Background and objectives: Abdominal aortic aneurysm (AAA) growth is unpredictable after the endovascular aneurysm repair (EVAR). Continuing aortic wall degradation and weakening due to hypoxia may have a role in post-EVAR aneurysm sac growth. We aimed to assess the association of aortic wall density on computed tomography angiography (CTA) with aneurysm growth following EVAR. Materials and Methods: A total of 78 patients were included in the study. The control group consisted of 39 randomly assigned patients without aortic pathology. Post-EVAR aneurysm sac volumes on CTA were measured twice during the follow-up period to estimate aneurysm sac behavior. A maximum AAA sac diameter, aortic wall and lumen densities in Hounsfield units (HU) on CTA were measured. A relative aortic wall density (the ratio of aortic wall to lumen densities) was calculated. A statistical data analysis was performed using standard methods. Results: An increase in the AAA sac volume was observed in 12 (30.8%) cases. Median relative aortic wall density on CTA scores in both the patient and the control group at the level of the diaphragm were similar: 0.15 (interquartile range (IQR), 0.11-0.18) and 0.16 (IQR 0.11-0.18), p = 0.5378, respectively. The median (IQR) relative aortic wall density score at the level of the maximum AAA diameter in the patient group was lower than at the level below renal arteries in the control group: 0.10 (0.07-0.12) and 0.17 (0.12-0.23), p < 0.0001, respectively. The median (IQR) relative growing AAA sac wall density score was lower than a relative stable/shrinking AAA sac wall density score: 0.09 (0.06-0.10) and 0.11 (0.09-0.13), p = 0.0096, respectively. Conclusions: A lower aortic aneurysm wall density on CTA may be associated with AAA growth after EVAR.
Background: The primary approach for treating ischemic wounds is restoring oxygen supply to the ischemic region. While direct angiosomal revascularization is often associated with better post-operative wound healing and limb salvage, its superiority over non-angiosomal revascularization remains controversial. This study aimed to compare intraoperative tissue oxygen saturation changes in ischemic zones following either direct or indirect revascularization in below-the-knee arteries. Methods: This prospective observational study included patients undergoing direct and indirect below-the-knee endovascular revascularizations. Assignment to the groups was not randomized. Near-infrared spectroscopy was used to monitor rSO2 changes near the ischemic wounds intraoperatively. The changes were compared between the groups. Results: 15 patients (50%) underwent direct angiosomal revascularization, while an equal number of patients underwent indirect revascularization. Overall, a statistically significant increase in regional oxygen saturation was observed after revascularization (p = 0.001). No statistically significant difference was found between the direct and indirect revascularization groups (p = 0.619). Conclusions: This study revealed a minor difference in the oxygen saturation increase between the angiosomal and non-angiosomal revascularization groups. Such a finding indicates that the clinical significance of angiosomal revascularization is negligible and might be concealed by confounding factors, such as the vessel diameter and outflow impact on the restenosis rate.
Objectives: Current methods evaluating tissue ischemia are based mainly on evaluating blood flow and not tissue perfusion. However, diabetes mainly affects small vessels and blood flow evaluation is insufficient. The aim of the trial was to evaluate the feasibility of NIRS in measuring perfusion changes during chronic total occlusion (CTO) revascularization in below the knee (BTK) arteries. Methods and Material: A prospective observational study was performed. During the endovascular revascularization procedure, tissue oxygenation changes were measured using three NIRS sensors. Postoperative angiographies and 30 days wound healing was evaluated. Results: The study enrolled 30 patients with chronic limb threatening ischemia, occluded below the knee arteries, Rutherford 5. Mean age 74.7 ± 11.2 years, 16 (53%) of the patients had diabetes mellitus, 10 (33%) had end-stage renal disease. A statistically significant NIRS rSO2 increase was observed on sensors near the wound after the revascularization, p = 0.001. Thirty days follow-up visits included 27 patients, because 3 patients had died. Comparing good wound healing group with poor wound healing group intraoperative NIRS rSO2 increase difference was statistically significant, p = 0.017. Conclusions: The study confirmed tissue perfusion increase could be detected using NIRS during revascularization of below the knee arteries. An intraoperative increase of NIRS rSO2 proved to predict wound healing results.
Purpose Abdominal aortic aneurysm (AAA) growth after endovascular aneurysm repair (EVAR) is still unpredictable. The issue of optimal frequency of computed tomography angiography for surveillance and its measurement method accuracy remain unclear. We aimed to assess the value of abdominal aneurysm sac volume measurement for detecting expansions and the association of preprocedural intraluminal thrombus (ILT) volume with aneurysm sac growth following EVAR. Material and methods A total of 107 patients underwent elective EVAR. Inclusion criteria provided a cohort of 39 patients. Changes of postoperative maximum aneurysm sac diameter and AAA volume were calculated. Volumetric AAA changes and demographic data of the cases with clinically irrelevant AAA diameter enlargement were evaluated. Preoperative ILT volumes were collected. ILT and AAA sac volume ratio was calculated. Statistical data analysis was performed using standard methods. Results The mean changes of maximum AAA diameter and volume in percentage after EVAR were –5.08 ± 8.20 mm and –13.39 ± 23.32%, respectively. A moderate positive linear correlation between those changes was found (R<sup>2</sup> = 0.731; p < 0.0001). The mean relative AAA volume increase in cases without clinically relevant diameter enlargement was 11.50 ± 8.27%. The means of ILT and AAA sac ratios were 0.59 ± 0.17 and 0.52 ± 1.8 in growing AAA sac and in stable or shrinking AAA sac groups, respectively (p = 0.308). Conclusions Volumetric AAA measurement may be useful as an additional method to diameter measurement after EVAR to identify clinically relevant sac growth. Preoperative volume of ILT may not significantly affect the growth rate of AAA after EVAR.
Objectives. We hypothesized, that patients with peripheral arterial disease (PAD) are less aware of risk factors and possible outcomes of the disease compared to patients with coronary artery disease (CAD), which are similar. Hence, the aim of this study was to evaluate awareness of and attitudes towards PAD and CAD among patients, who are already diagnosed with either disease. Design. A cross-sectional descriptive study was performed. Basic demographics, the presence and awareness of risk factors for PAD and CAD; perceived systemic and limb consequences, severity of PAD and CAD, self-reported knowledge about other non-vascular illnesses were assessed using an anonymous questionnaire. Results. 203 were invited and 157 (77%), 63 with PAD and 94 with CAD, patients agreed to take part in and completed the survey. Basic demographic characteristics were similar in both groups, except for the level of education: PAD patients were less educated compared to CAD patients (p = .002). Only 35% of PAD patients were familiar with the definition of PAD (key words were registered) in contrast to 52% CAD definition awareness among CAD patients (p = .034). PAD patients were significantly less familiar with other common diseases (p = .002) and risk factors for both PAD (p < .001) and CAD (p = .003) in comparison to equivalent CAD group parameters. Conclusions. PAD patients are less aware of risk factors for PAD and atherosclerosis in general, other illnesses and have lower level of education, which may negatively affect overall management of this complex disease.
Uretero-arterial fistula (UAF) poses major challenges in management and diagnosis due to the rarity of this condition and associated high morbidity/mortality rates.We describe a case of a UAF associated with previous aorto-biiliac grafting, ureteric stenting and right nephrectomy because of chronic pielonephritis and complicated by surgical site infection. This case illustrates a very complex pathology, with a challenging diagnosis and multiple treatment options.A 72 year-old woman was referred to Vilnius Vascular Unit for open UAF repair. The patient had a history of open abdominal aortic aneurysm repair using a bifurcated graft 25 years ago. The right ureter was injured during the operation and a rigid indwelling ureteric stent was inserted. Six months prior to referral, she underwent a right nephrectomy due to a chronic pyelonephritis, complicated by surgical site infection, which was still present at the time of admission. Initial CTA demonstrated bilateral iliac aneurysms, but no signs of UAF. A further CTA revealed a UAF between the right ureteral stump and the right common iliac artery (CIA) para-anastomotic aneurysm. After unsuccessful attempts to embolize the UAF using both coils and glue, the patient was referred to Vilnius Vascular Unit for open repair. Left axillo-bifemoral bypass reconstruction was performed followed by UAF repair and bifurcated graft explantation. Follow-up after 2 years showed no recurrence of haematuria, good function of the remaining kidney and patent axillo-bifemoral bypass with no signs of infection around the prosthetic aortic stump.Uretero-arterial fistula is a uncommon condition in everyday clinical practice. The rarity of this condition may lead to delayed or missed diagnosis which can result in life-threating consequences. A multidisciplinary approach involving urologists, vascular surgeon and radiologist are crucial to both the diagnosis and managment of this rare entity.
Carotid artery endarterectomy (CAE) is a treatment of choice for symptomatic and asymptomatic high-grade carotid stenosis, showing great results in reducing stroke morbidity. The optimal technique of the arterial closure is, however, still under discussion, with both patch angioplasty and primary closure having numerous advantages and pitfalls. The definite evidence is still lacking. The aim of this study was to evaluate the results of the modified primary closure technique during CEA. Incidence of restenosis more than 8 months after the surgery was measured. A retrospective observational study to evaluate modified primary internal carotid artery closure was conducted in Republican Vilnius University Hospital from January 1st, 2014 to December 31st, 2018. The patients were enrolled in the trial during their routine follow-up by their surgeon. During the visit, after an informed consent was signed, a qualified investigator performed carotid duplex ultrasound scan, documenting the restenosis rates. Patients also filled in the comorbidity assessment questionnaire, which included their smoking habits, history of hypertension and their adherence to antihypertensive medication as well as cholesterol levels and statin therapy, additional related comorbidities. Out of 342 patients that underwent CAE with primary closure in the Republican Vilnius university hospital from 2014 to 2018, 42 patients were identified as deceased, therefore a follow-up was impossible. Out of planned 150 (50%) consequently selected patients, 125 gave an informed consent to be enrolled into the study. Out of those 6 pre-occlusions were established during the review of the patient medical data and therefore were excluded from the study. In general, we analyzed the data of 119 patients and 125 CAE with a modified primary suture closure. The mean follow-up time was 35.78 months (SE 0.992; SD 11,046). At the time of a follow up, 3 (2,4%) carotid artery occlusions were identified and promptly evaluated. Restenosis rates varied: 5,6% of patients had low grade (<50%), 5,6% had moderate grade (50-69%) and 1,6% had high grade (70-99%) stenosis. The modified lateral CAE with primary closure technique, used in our hospital’s contemporary practice has shown to be a promising alternative to the classical primary suture, due to reduced restenosis rates. More prospective and randomized studies are needed to evaluate this technique in comparison to other CAE closure techniques.
Background. Blood flow restore in critical limb ischemia according to angiosomes is becoming very popular. This method allows to restore blood flow precisely to the artery supplying the ischemic zone, based on the angiosome concept. However, angiosome revascularization is not a gold standard because of the lack of evidence supporting this approach. The aim of this study was to compare tissue oxygenation changes in ischemic zone during endovascular revascularization procedure either following angiosome concept or performing indirect revascularization. Methods. A prospective observational study was performed. Patients with critical limb ischemia and tissue loss due to chronic total occlusion of below the knee arteries were included. Endovascular revascularization was performed in all cases. Tissue oxygen saturation was observed intraoperatively using near-infrared spectroscopy. Tissue oxygenation changes near the ischemic wound were compared between direct and indirect revascularization groups. Results. This clinical trial included 30 patients with critical limb ischemia (Rutherford 5) and occluded below the knee arteries intended to treat. In 15 patients the procedure was performed according to angiosome, while the other half underwent indirect revascularization. Tissue oxygenation near the wound was monitored during the intervention. Greater oxygen saturation increase was observed in the group with direct revascularization (29% and 23% accordingly), however the difference between groups was not statistically significant (t-test for independent group, p = 0,544). Conclusions. The increase in tissue oxygen saturation differed very slightly in direct and indirect revascularization groups and the difference was statistically insignificant.
