Andrea Siani

Policlinico Casilino, Romeno, Trentino-Alto Adige, Italy

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Publications (68)57.14 Total impact

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    ABSTRACT: Objectives To evaluate the outcome of acute popliteal artery aneurysm (PAA) thrombosis and leg ischemia after preoperative or intraoperative use of intra-arterial urokinase thrombolysis. Materials and Methods From 2000 to 2009, 86 patients with acute leg ischemia (Rutherford grade IB to IIA) from PAA thrombosis were treated by immediate surgery including intraoperative thrombolysis (group A: 47 cases) or preoperative thrombolysis (group B: 39 cases) followed by acute (<24 hours) or elective surgery. Chi-square tests for categorical data and time to event provided two-sided p values with a level of significance at 0.05 and all confidence intervals (CIs) at the 95% level. Results The mean follow-up was 45 months. The 2-year primary patency was 61.7% (29/47) for group A and 43.6% (17/39) for group B (hazard ratio [HR] 1.85; 95% CI: 0.96 to 3.54; p = 0.06). The 2-year secondary patency was 70.2% (33/47) for group A and 53% (21/39) for group B (HR 1.86; 95% CI: 0.91 to 3.81; p = 0.08). One-month amputation rate was 18% in group A and 29% in group B (p < 0.001), and 12-month amputation rate was 19% (9/47) in group A and 44% (17/39) in B (p = 0.05). In group A, 28% of patients required fasciotomy and in group B, 59% (p < 0.05). Effective thrombolysis allowed 82% limb salvage patency in group B. No systemic or locoregional complications during thrombolysis were recorded, but four cases of worsening ischemia were recorded. Conclusion Our results suggest that the immediate surgery with intraoperative thrombolysis improved the outcome of patients with acute leg ischemia due to PAA thrombosis in terms of limb salvage.
    The Thoracic and cardiovascular surgeon. 06/2014;
  • Journal of vascular surgery. 06/2014; 59(6):1707-8.
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    ABSTRACT: The chimney graft (CG) technique, based on the deployment of a covered stent parallel to the aortic endograft, has been proposed to achieve a safe proximal fixation extending the sealing zone. We report our experience with the CG technique in an emergency setting. Between December 2010 and April 2012, 4 patients underwent the CG technique. The mean age was 79 (range 76-82 years) and 3 patients were men. The median aneurysm diameter was 64.7 mm (range 63-68 mm). Indications for CG were painful proximal para-anastomotic aneurysm in 2 cases and symptomatic juxtarenal aneurysm in the other 2. Target vessels were both the renal arteries. Technical success was achieved in 100% and no intraoperative complications occurred. No stent-related complications, or Type I endoleak, were detected. No death occurred during the postoperative course. Creatinine elevation was observed in 2 cases. At follow-up, no endoleaks or rupture occurred. One patient died of myocardial infarction 3 months after the procedure. The primary patency rate of covered stents was 100%. The CG technique seems to be safe and feasible with an excellent patency rate of covered stents and a low incidence of endoleaks. More evidence in the literature is needed to carry out a validation of this technique in an emergency.
    Interactive Cardiovascular and Thoracic Surgery 01/2013; · 1.11 Impact Factor
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    ABSTRACT: AIM:Carotid artery angioplasty and stenting (CAS) has emerged as an alternative treatment for extra cranial carotid artery stenosis in stroke prevention. Nevertheless concerns are remaining about the long-term durability as hemodynamic in-stent restenosis (ISR) after CAS are increasing and usually treated again by endovascular approach. This preliminary study, instead, albeit in a limited series, reports our safe and successful experience of the surgical correction of carotid ISR after CAS. METHODS: From January 2003 to June 2011 seven patients with severe hemodynamic carotid ISR (three symptomatic, four asymptomatic, mean age 76±2), were submitted to surgical operation to remove the carotid stent. The indications for CAS were primary in five cases, secondary to restenosis after carotid endarterectomy (CEA) in two patients. Standard CEA with complete removal of the stent and the entire atherosclerotic plaque was carried out easy and without technical difficulty in the five primary ISR. In the two patients of ISR in post-CEA restenosis, a common carotid to the distal internal carotid artery (ICA) bypass with polytetrafluoroethylene (PTFE) graft was carried out. Mean operation time was 88±26 min. All interventions were performed under general anesthesia with remifentanil preserved consciousness. RESULTS:No death or major complications occurred. Temporary vocal cord impairment by deficit of recurrent inferior laryngeal nerve in one patient with ISR after CAS performed to treat post-CEA restenosis was observed. Intimal hyperplasia was the predominant mechanism to ISR. The mean follow-up of 18 months (range, 4 to 36 months) showed a normal patency of the surgical correction without recurrent restenosis on color-coded duplex ultrasounds (US) examinations. CONCLUSION: The surgical management of carotid ISR appears feasible and effective leading to good long-term outcome.
    The Journal of cardiovascular surgery 11/2012; · 1.51 Impact Factor
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    ABSTRACT: OBJECTIVE: This study evaluated outcomes of remote endarterectomy (RE) vs endovascular (ENDO) interventions on Trans-Atlantic Inter-Societal Consensus (TASC) II D femoropopliteal lesions and identified factors predictive of restenosis. METHODS: From October 2004 to December 2008, 95 patients with TASC-II D lesions were randomized 1:1 to receive RE of the superficial femoral artery (SFA) with end point stenting (51 patients) or ENDO, consisting of subintimal angioplasty with stenting (44 patients). The groups were balanced for age, sex, atherosclerotic risk factors, and comorbidities. Categoric data were analyzed with χ(2) tests, and time to event provided two-sided P values with a level of significance at .05 and 95% confidence intervals (CIs). Survival curves for primary patency were plotted using the Kaplan-Meier method. Univariate analysis for diabetes, hypertension, dyslipidemia, smoking, and critical ischemia was performed according to the Cox proportional hazards model. RESULTS: The mean follow-up was 52.5 months (range, 35-75 months). Five RE patients and four ENDO patients were lost to follow-up (censored). Primary patency was 76.5% (39 of 51) in RE and 56.8% (25 of 44) in ENDO (hazard ratio [HR], 2.6; 95% CI, 0.99-4.2; P = .05) at 24 months and was 62.7% (32 of 46) in RE and 47.7% (21 of 40) in ENDO (HR, 1.89; 95% CI, 0.94-3.78; P = .07) at 36 months. Assisted primary patency was 70.6% (36 of 51) in RE and 52.3% (23 of 44) in ENDO (HR, 2.45; 95% CI, 1.20-5.02; P = .01). Secondary patency overlapped the primary comparison data at 12 and 24 months; at 36 months, there was a slight but significative advantage for RE (HR, 2.26; 95% CI, 1.05-4.86; P = .03). Univariate analysis demonstrated that hypercholesterolemia and critical limb ischemia (CLI) were significantly related to patency failure, whereas diabetes was significant only in ENDO. These factors (hypercholesterolemia and CLI) were independent predictors of patency on Cox multivariate analysis. CONCLUSIONS: RE is a safe, effective, and durable procedure for TASC II D lesions. Our data demonstrate a significantly higher primary, assisted primary, and secondary patency of RE vs ENDO procedures. Furthermore, overall secondary patency rates remain within the standard limits, although preoperative CLI and dyslipidemia continue to be associated with worse outcomes. Taken together, these data suggest that remote endarterectomy should be considered better than an endovascular procedure in SFA long-segment occlusion treatment.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2012; · 3.52 Impact Factor
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    ABSTRACT: Venous hypertension and outflow stenosis of arteriovenous hemodialysis access managed using endovascular procedures usually present a high technical success rate, with few complications. We reported a rare and fatal complication of superior vena cava perforation with pericardial tamponade 3 months after subclavian vein stenting. Interventional recanalization with stenting for the management of superior vena cava syndrome or central vein stenosis is a safe procedure with a low complication rate. Stent misplacement, reocclusion, migration, or access-related complications appear to occur most frequently.
    Annals of Vascular Surgery 07/2012; 26(5):733.e9-12. · 0.99 Impact Factor
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    ABSTRACT: The syndrome of inappropriate secretion of antidiuretic hormone after carotid endarterectomy is very rare; only two cases have been reported in medical literature. We describe the case of an 82-year-old woman presenting with lethargy and drowsiness due to severe hyponatremia with urine hyperosmolarity and plasma hypo-osmolarity after carotid endarterectomy.
    Annals of Vascular Surgery 06/2012; 26(6):859.e7-8. · 0.99 Impact Factor
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    ABSTRACT: The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death. A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant. The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present. CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.
    The Journal of cardiovascular surgery 06/2012; 53(3):333-43. · 1.51 Impact Factor
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    ABSTRACT: AIM:The purpose of our study was to determine the efficacy of percutaneous thrombin treatment for iatrogenic femoral artery pseudoaneurysms (FAP) and to identify those criteria that may help to predict increased treatment failure risk and complications. METHODS: A number of 32 iatrogenic femoral pseudoaneurysms were treated with US-guided thrombin injection (group A), while four elderly patient with complex femoral pseudoaneurysm underwent compression assisted by removable "guidewire" (group B). Twenty-five were classified as simple (single lobe) and 11 as complex (at least two lobes with a single neck to the native vessel). Pseudoaneurysm volume, classification, thrombin dose, anticoagulation therapy status, and sheath size were considered independent prognostic factors. RESULTS: All the 36 patients (pts) had initial complete femoral pseudoaneurysms thrombosis. The aneurysm was thrombosed on a Doppler ultrasound (US) follow-up in all the cases but four (group A), those who required the additional thrombin injection. A fatal complication occurred in one patient with complex FAP (group A). CONCLUSION: Preliminary data suggest that US-guided percutaneous thrombin injection is a safe and effective method to treat iatrogenic pseudoaneurysms. Simple iatrogenic femoral pseudoaneurysms benefit a single injection of up to 500 units of topical thrombin. We recommend more caution in complex pseudoaneurysms treatment; it is preferable to perform thrombin injection first into the lobe which is not directly joined to the femoral artery. A longer bed rest and closer observation are mandatory during the subsequent 24 hours. If the lobe communicating with the femoral artery is still patent, it can be retreated. Alternatively, we propose a new strategy approach through compression assisted removable "guidewire".
    The Journal of cardiovascular surgery 05/2012; · 1.51 Impact Factor
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    ABSTRACT: Carotid artery stenting (CAS) is the treatment of choice for recurrent stenosis after carotid endarterectomy (CEA). However a significative incidence of in-stent restenosis could be occurred. Despite classical CEA leads to good results, in selective cases bypass graft may be the best treatment of in-stent restenosis. We describe two cases of carotid bypass graft performed to treat a recurrent in-stent stenosis after CAS for post-CEA restenosis. No death and cardiac complication occurred and no cranial nerves impairment was detected. Prosthetic bypass graft is safe and effective in treatment of in-stent recurrent restenosis after CEA restenosis.
    Il Giornale di chirurgia 03/2012; 33(3):95-7.
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    ABSTRACT: Venous aneurysms (VAs) have been described in quite of all the major veins. They represent uncommon events but often life-threatening because of pulmonary or paradoxical embolism. We describe our twelve patients' series with acute pulmonary emboli due to venous aneurysm thrombosis. Our experience underlines the importance of a multilevel case-by-case approach and the immediate venous lower limbs duplex scan evaluation in pulmonary embolism events. Our data confirm that anticoagulant alone is not effective in preventing pulmonary embolism. We believe that all the VAs of the deep venous system of the extremities should be treated with surgery as well as symptomatic superficial venous aneurysm. A simple excision can significantly improve symptoms and prevent pulmonary embolism.
    The Scientific World Journal 01/2012; 2012:386478. · 1.73 Impact Factor
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    ABSTRACT: Celiac trunk aneurysm is one of the rarest forms of splanchnic artery aneurysm. Conventional open vascular surgery is associated with increased rates of morbidity and mortality and can require complex vascular reconstruction.We describe the case of a 42-year-old patient with celiac trunk aneurysm whom we treated by means of a hybrid surgical-endovascular procedure. We performed a left reno-splenic bypass, after which we used a direct splenic artery approach to deploy a self-expandable 6 × 50-mm stent-graft across the splenic and hepatic arteries. One year later, the stability of the repair was confirmed.
    Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 01/2012; 39(3):408-11. · 0.67 Impact Factor
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    ABSTRACT: We report a case of acute limb ischaemia due to unusual upstream stent migration into the aorta 2 years after successful kissing stenting. Angiography showed a misplacement of both common iliac stent into the aorta, upstream migration with a fracture on the left external iliac stent into the iliac common artery, occlusion of the left iliac and femoral artery, dilatation of aortic bifurcation and stent separation on the right side. The patient underwent a successful axillo-bifemoral bypass graft. Vessel wall remodelling due to overestimation of stent size, aortic turbulence and rebound effect may explain this complication.
    Interactive Cardiovascular and Thoracic Surgery 11/2011; 14(2):231-3. · 1.11 Impact Factor
  • The journal of vascular access 09/2011; 13(1):126-7. · 1.02 Impact Factor
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    ABSTRACT: We prospectively evaluated safety and efficacy from our six-year results of general anesthesia (GA) using remifentanil conscious sedation in carotid endarterectomy (CEA). From January 2005 to December 2010, 625 consecutive CEAs were performed on 545 patients (male/female 336/209, age 75 ± 7 years). After a superficial plexus block with ropavacaine, GA was induced with an intravenous infusion of propofol, using local lidocaine during tracheal intubation and a high-dose of remifentanil, in all cases reducing and then stopping the remifentanil infusion at the clamping time so that the patient would be awake and collaborating within a few minutes, as in local anesthesia. Data on postoperative morbidity and mortality, neurological complications, shunt insertions and the responses to one-day and three-month questionnaires on satisfaction were collected for all patients. The 30-day mortality was 0.32% (two patients). Only one major stroke (0.16%) and two minor strokes (0.32%) occurred. A shunt was deployed in 83 cases (13.3%). Eight patients (1.28%) reported cranial nerve injuries, and surgical drainage for postoperative hematoma was performed in 11 patients (1.8%). Thirty-one patients (4.6%) suffered postoperative nausea/vomiting. Almost all patients were satisfied at the 24-h (94.6%) and three-month (>98%) follow-up questionnaire. The six-year results for GA using remifentanil conscious sedation were very satisfactory and highlighted the advantages of both GA (hemodynamic stability and excellent control of ventilation) and local anesthesia (ease of evaluation of neurological status) in a calm and relaxed environment for both patient and surgeon.
    Interactive Cardiovascular and Thoracic Surgery 09/2011; 13(6):601-5. · 1.11 Impact Factor
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    ABSTRACT: The internal carotid artery (ICA) usually, lies posterolaterally to the external carotid artery (ECA). Sometimes a complete carotid transposition can occur, with the ECA in a lateral position and the ICA on the medial side can occur. Our study evaluated the significance and impact that this anomaly may have on cranial nerve injuries. From January 2008 to November 2010, 296 patients underwent 360 consecutive primary carotid endarterectomy (CEA) procedures. During carotid isolation, we detected an unexpected lateral position of the ECA in 11 cases (3.6%). χ(2) analysis and the Student's t-test were used to compare the incidence of cranial nerve injuries between the 11 patients with the lateral ECA who underwent CEA (group A) and 11 randomized patients with a normal bifurcation (group B). Statistical significance was inferred at χ(2)>3.84 and P<0.05. A statistical difference in the incidence of superior laryngeal nerve paralysis was detected between groups A and B (18.1%, 2/11 in group A vs. 0%, 0/11 in group B; χ(2)>3.84; P<0.05). No differences in incidence of injury were detected for the other cranial nerves. A very meticulous mobilization of the ECA and ICA is needed to perform CEA, but superior laryngeal nerve injury can occur despite the use of a safe and meticulous surgical technique.
    Interactive Cardiovascular and Thoracic Surgery 08/2011; 13(5):471-4. · 1.11 Impact Factor
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    ABSTRACT: La thrombopénie induite à l'héparine de type II est un syndrome immun qui peut survenir d'une façon dépendant du temps après traitement par l'héparine. Une thrombopénie et la thrombose chez les patients exposés à l'héparine sont suggestives de ce syndrome.
    Annales de Chirurgie Vasculaire. 08/2011; 25(6):896.e9–896.e12.
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    ABSTRACT: Venous aneurysms are uncommon but they can have devastating consequences, including pulmonary embolism, other thromboembolic events and death. We report six cases of venous aneurysm of the extremities, in which the first sign of presence was acute pulmonary embolism. Surgical resection is recommended whenever possible. Our experience suggests that prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for extremity deep and superficial venous aneurysms for their potential risk of developing thromboembolic complications despite adequate anticoagulation. Other venous aneurysms should be excised only if they are symptomatic or enlarging.
    VASA.: Zeitschrift für Gefässkrankheiten. Journal for vascular diseases 07/2011; 40(4):327-32. · 1.01 Impact Factor
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    ABSTRACT: Heparin-induced thrombocytopenia type II is an immune-mediated syndrome that may arise in a time-dependent manner after heparin therapy. Thrombocytopenia and thrombosis in patients exposed to heparin are suggestive of this syndrome.
    Annals of Vascular Surgery 05/2011; 25(6):840.e9-12. · 0.99 Impact Factor
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    ABSTRACT: The association of open and endovascular procedures in patients with obstructive disease of the lower limbs gives the opportunity to treat in a single step multi-segmental lesions which were currently treated in the past by more demanding open procedures. From January 2003 to May 2009, 52 patients with peripheral occlusive chronic arterial disease of the lower limbs were submitted to combined open and endovascular procedures. In 37 patients (71.2%) a femoro-popliteal/pedidial bypass was carried out after Percutaneous Transublimal Arterio (PTA)/stenting of the iliac/femoral arteries, while in the remaining 15 patients (28.8%) the endovascular procedures were performed following open approach, that consisted in a femoro-popliteal bypass. Iliac stenting interested the common iliac artery in 19 patients (51.3%), the common and external iliac artery in 11 patients (29.7%) and the external artery in 7 (19%). In this same group a fem-pop bypass below knee was carried out in 28 (75.6), a fem-pop above knee in 6 (16.2%), a fem-pop and jump on the posterior tibial in 2 (5.4%) and a superficial femoral-pedal in the last one (2.8%). In the other group the fem-pop bypass below knee was followed by a PTA of the tibial vessel in 12 cases (80%) and by a stenting in only 3 cases (20%). Three patient was lost to follow-up. Three (8.1%) iliac stents became occluded and the sudden onset of an acute ischemia of the limb required in all cases an aorto-femoral bypass. The occlusion of tibial stent in 2 patient (13.3%) was no clinical relevant, and the failure of the PTA procedure in other 4 patients with the reocclusion of the tibial arteries was followed by thight amputation. Occlusion of the femoro-popliteal bypass occurred in 9 of 37 patients (24.3%) submitted to iliac stenting and in 4 of 15 (26.6%) patients with PTA of the tibial vessels. The overall patency rate was 69.2%. Limb salvage was 77.5% Combination of the open and endovascular procedures to treat lesions of the lower limbs is effective and durable in terms of patency and complication rate. For validation this new approach needs the recruitment of much more patients and prospective protocol studies.
    Il Giornale di chirurgia 05/2011; 32(5):275-8.

Publication Stats

75 Citations
57.14 Total Impact Points

Institutions

  • 2011–2014
    • Policlinico Casilino
      Romeno, Trentino-Alto Adige, Italy
  • 2008–2013
    • Azienda Ospedaliera San Paolo - Polo Universitario
      Milano, Lombardy, Italy
  • 2009–2011
    • Sapienza University of Rome
      Roma, Latium, Italy
  • 2006–2008
    • Ospedale San Pietro Fatebenefratelli
      Roma, Latium, Italy