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Andrea Del Corso,
Irene Bargellini,
Antonio Cicorelli,
Orsola Perrone,
Michele Leo,
Alessandro Lunardi,
Aldo Alberti,
Francesca Tomei,
Roberto Cioni, Mauro Ferrari,
Carlo Bartolozzi
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ABSTRACT: PURPOSE: To prospectively evaluate safety and efficacy of a novel vascular closure device (Glubran 2 Seal) after peripheral angiography in patients with peripheral arterial occlusive disease (PAOD). METHODS: From December 2010 to June 2011, all consecutive patients with PAOD undergoing peripheral angiography were prospectively enrolled onto the study after percutaneous antegrade or retrograde puncture of the common femoral artery. After angiography, the Glubran 2 Seal device was used to achieve hemostasis. The following data were registered: technical success and manual compression duration, patients' discomfort (scale 0-5), operators' technical difficulty (scale 0-5), and vascular complications. The site of hemostasis was evaluated by clinical inspection and color-coded Duplex ultrasound performed 1 day and 1 month after the procedure. RESULTS: One hundred seventy-eight patients were enrolled (112 male, mean age 70.8 years) with a total of 206 puncture sites, including 104 (50.5 %) antegrade accesses. The device was successful in 198(96.1 %) of 206 procedures, with 8 cases of manual compression lasting longer than 5 min (maximum 20 min). No major vascular complications were observed, resulting in 100 % procedural success. Minor complications occurred in seven procedures (3.4 %), including two cases of pseudoaneurysms, successfully treated by ultrasound-guided glue injection. The mean ± standard deviation score for patients' discomfort was 0.9 ± 0.7, whereas the mean score for operators' difficulty was 1.2 ± 0.9. CONCLUSION: In patients with PAOD, the Glubran 2 Seal represents a simple, painless, and efficient vascular closure device, able to achieve hemostasis both in antegrade and retrograde accesses.
CardioVascular and Interventional Radiology 06/2012; · 2.09 Impact Factor
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ABSTRACT: The evolution of surgical robotics is following the progress of developments in Minimally Invasive Surgery (MIS), which is moving towards Single-Incision Laparoscopic Surgery (SILS) procedures. The complexity of these techniques has favored the introduction of robotic surgical systems. New bimanual robots, which are completely inserted into the patient's body, have been proposed in order to enhance the surgical gesture in SILS procedures. However, the limited laparoscopic view and the focus on the end-effectors, together with the use of complex robotic devices inside the patient's abdomen, may lead to unexpected collisions, e.g., between the surrounding anatomical organs not involved in the intervention and the surgical robot. This paper describes a computer guidance system, based on patient-specific data, designed to provide intraoperative navigation and assistance in SILS robotic interventions. The navigator has been tested in simulations of some of the surgical tasks involved in a cholecystectomy, using a synthetic anthropomorphic mannequin. The results demonstrate the usability and efficacy of the navigation system, underlining the importance of avoiding unwanted collisions between the robot arms and critical organs. The proposed computer guidance software is able to integrate any bimanual surgical robot design.
Computer Aided Surgery 06/2012; 17(4):161-71. · 0.30 Impact Factor
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Alessia Scatena,
Pasquale Petruzzi, Mauro Ferrari,
Loredana Rizzo,
Antonello Cicorelli,
Raffaella Berchiolli,
Chiara Goretti,
Irene Bargellini,
Daniele Adami,
Elisabetta Iacopi,
Andrea Del Corso,
Roberto Cioni,
Alberto Piaggesi
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ABSTRACT: To evaluate the outcomes of a multidisciplinary team working on diabetic foot (DF) patients with critical limb ischemia (CLI) in a specialized center, the authors retrospectively traced all the patients admitted in their department in 3 consecutive years with a diagnosis of CLI. From January 2006 to December 2008, 245 consecutive DF patients with CLI according the TransAtlantic interSociety Consensus II criteria were included in the study. Treatment strategy was decided by a team of diabetologists, inteventional radiologists, and vascular surgeons. Technical and clinical success, mortality, and ulcer recurrence were evaluated at 6 months and at a mean follow-up of 19.5 ± 13.4 months. Percutaneous transluminal angioplasty (PTA) was performed in 189 (77%) patients, whereas medical treatment, open surgical revascularization (OSR), and primary amputation were performed in 44 (18.3%), 11 (4.3%), and 1 (0.5%) patients, respectively. Revascularization was successful in 227/233 (97.4%) patients. At follow-up, the overall clinical success rate was 60.4%; it was significantly (P = .001) higher after revascularization (75.9%) compared with medical treatment (48.3%). During follow-up, surgical interventions in the foot were 1.5 ± 0.4 in those treated with PTA, 1.6 ± 0.5 in those treated with OSR, and 0.3 ± 0.8 in those receiving medical therapy (P < .05 compared with the others). Ulcer recurrence occurred in 29 (11.8%) patients: 4 (1.6%) in PTA, 2 (0.8%) in OSR, and 23 (9.4%) in the medical therapy group (P < .05). Major amputation rate was 9.3%, being significantly (P = .04) lower after revascularization (5.2%) compared with medical therapy alone (13.8%). Cumulative mortality rate was 10.6%. In conclusion, this study confirms the positive role of a PTA-first approach for revascularizing the complex cases of DF with CLI in a teamwork management strategy.
The International Journal of Lower Extremity Wounds 06/2012; 11(2):113-9. · 1.20 Impact Factor
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ABSTRACT: The trend of surgical robotics is to follow the evolution of laparoscopy, which is now moving towards single-incision laparoscopic surgery. The main drawback of this approach is the limited maneuverability of the surgical tools. Promising solutions to improve the surgeon's dexterity are based on bimanual robots. However, since both robot arms are completely inserted into the patient's body, issues related to possible unwanted collisions with structures adjacent to the target organ may arise.
This paper presents a simulator based on patient-specific data for the positioning and workspace evaluation of bimanual surgical robots in the pre-operative planning of single-incision laparoscopic surgery.
The simulator, designed for the pre-operative planning of robotic laparoscopic interventions, was tested by five expert surgeons who evaluated its main functionalities and provided an overall rating for the system.
The proposed system demonstrated good performance and usability, and was designed to integrate both present and future bimanual surgical robots.
Computer Aided Surgery 01/2012; 17(3):103-12. · 0.30 Impact Factor
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ABSTRACT: Using practical examples, this report aims to highlight the clinical value of patient-specific three-dimensional (3D) models, obtained segmenting multidetector computed tomography (MDCT) images, for preoperative planning in general surgery.
In this study, segmentation and 3D model generation were performed using a semiautomatic tool developed in the authors' laboratory. Their segmentation procedure is based on the neighborhood connected region-growing algorithm that, appropriately parameterized for the anatomy of interest and combined with the optimal segmentation sequence, generates good-quality 3D images coupled with facility of use. Using a touch screen monitor, manual refining can be added to segment structures unsuitable for automatic reconstruction. Three-dimensional models of 10 candidates for major general surgery procedures were presented to the operating surgeons for evaluation. A questionnaire then was administered after surgery to assess the perceived added value of the new technology.
The questionnaire results were very positive. The authors recorded the diffuse opinion that planning the procedure using a segmented data set allows the surgeon to plan critical interventions with better awareness of the specific patient anatomy and consequently facilitates choosing the best surgical approach.
The benefit shown in this report supports a wider use of segmentation software in clinical practice, even taking into account the extra time and effort required to learn and use these systems.
Surgical Endoscopy 09/2011; 26(3):616-26. · 4.01 Impact Factor
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ABSTRACT: Surgical simulation requires to have an operating scenario as similar as possible to the real conditions that the surgeon is going to face. Not only visual and geometric patient properties are needed to be reproduced, but also physical and biomechanical properties are theoretically required. In this paper a physically based patient specific simulator for solid organs is described, recalling the underlying theory and providing simulation results and comparisons. The main biomechanical parameters (Young's modulus and density) have been integrated in a Mass-Spring-Damper model (MSDm) based on a tetrahedral structured network. The proposed algorithms allow the automatic setting of node mass and spring stiffness, while the damping coefficient have been modeled using the Rayleigh approach. Moreover, the method automatically detects the organ external layer, allowing the usage of both the surface and internal Young's moduli: for the capsule (or stroma) and for the internal part (or parenchyma). Finally the model can be manually tuned to represent lesions with specific biomechanical properties. The method has beed tested with various material samples. The results have shown a good visual realism ensuring the performance required by an interactive simulation.
Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference 08/2011; 2011:4550-4.
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ABSTRACT: This work presents a simulator based on patient specific data for bimanual surgical robots. Given a bimanual robot with a particular geometry and kinematics, and a patient specific virtual anatomy, the aim of this simulator was to evaluate if a dexterous movability was obtainable to avoid collisions with the surrounding virtual anatomy in order to prevent potential damages to the tissues during the real surgical procedure. In addition, it could help surgeons to find the optimal positioning of the robot before entering the operative room. This application was tested using a haptic device to reproduce the interactions of the robot with deformable organs. The results showed good performances in terms of frame rate for the graphic, haptic, and dynamic processes.
Studies in health technology and informatics 01/2011; 163:379-85.
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ABSTRACT: In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS).
Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses.
In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock.
TBS seems to complete the information given by the parameter "presence of shock," and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA.
Annals of Vascular Surgery 11/2009; 24(3):315-20. · 1.03 Impact Factor
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ABSTRACT: Hand-assisted laparoscopic surgery (HALS) was previously employed to treat patients with infrarenal abdominal aortic aneurysm (IAAA). The use of HALS for juxtarenal abdominal aortic aneurysm (JAAA) has never been validated. In this study, we report our experience with this technique to demonstrate its feasibility and prove its safety in dealing with JAAA.
From October 2000 to October 2008, we have selectively treated 271 patients with abdominal aortic aneurysm with the HALS technique. Of these, 83 were JAAAs which required a suprarenal aortic clamping (group A), and 188 were IAAA (group B). General data of the two groups were analyzed for comparability purposes and operative and postoperative data were prospectively collected. Additionally, patients in group A were stratified in three classes according to their pre-existing degree of renal function impairment. Statistical significance was defined at the P < .05 level.
Mean operative time was 220 minutes +/- 66 in group A and 231 minutes +/- 64 in group B (P > .05). The mean duration of suprarenal clamping was 28 minutes +/- 6; whereas infrarenal clamping lasted an average of 25 minutes +/- 5 (P > .05). Mean intraoperative blood loss was 1023 +/- 584 mL for group A and 961 +/- 633 mL for group B (P > .05). No conversion or 30-day postoperative mortality was recorded in either group. Sixteen percent of the patients in group A developed a postoperative complication, vs 11% in group B (P > .05). Mean postoperative stay for group A and B was 4.2 +/- 1.5 and 4.2 +/- 1.9 days, respectively (P > .05). Postoperative kidney function significantly worsened in 5 patients in group A (6%). A prolonged warm ischemia time (>40), pre-existing renal dysfunction, and diabetes, correlated to the development of postoperative renal insufficiency. Follow-up of patients averaged 37.9 +/- 20 months. The incidence of incisional hernias in group A and B was 15.5% vs 11.1%, respectively (P > .05).
The HALS technique proved to be feasible and safe not only for patients with IAAA, but also for the management of patients with JAAA. No significant difference could be shown in the comparison between the two groups, apart from the expected higher rate of postoperative renal dysfunction after suprarenal clamping. In view of the demonstrated benefit of this minimally invasive approach, we believe that it should be included among the alternative options of treatment for these patients.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2009; 50(5):1006-11. · 3.52 Impact Factor
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ABSTRACT: Techniques of mixed reality can successfully be used in preoperative planning of laparoscopic and robotic procedures and to guide surgical dissection and enhance its accuracy.
A computer-generated three-dimensional (3D) model of the vascular anatomy of the spleen was obtained from the computed tomography (CT) dataset of a patient with a 3-cm splenic artery aneurysm. Using an environmental infrared localizer and a stereoscopic helmet, the surgeon can see the patient's anatomy in transparency (augmented or mixed reality). This arrangement simplifies correct positioning of trocars and locates surgical dissection directly on top of the aneurysm. In this way the surgeon limits unnecessary dissection, leaving intact the blood supply from the short gastric vessels and other collaterals. Based on preoperative planning, we were able to anticipate that the vascular exclusion of the aneurysm would result in partial splenic ischemia. To re-establish the flow to the spleen, end-to-end robotic anastomosis of the splenic artery with the Da Vinci surgical system was then performed. Finally, the aneurysm was fenestrated to exclude arterial refilling.
The postoperative course was uneventful. A control CT scan 4 weeks after surgery showed a well-perfused and homogeneous splenic parenchyma. The final 3D model showed the fenestrated calcified aneurysm and patency of the re-anastomosed splenic artery.
The described technique of robotic vascular exclusion of a splenic artery aneurysm, followed by re-anastomosis of the vessel, clearly demonstrates how this technology can reduce the invasiveness of the procedure, obviating an otherwise necessary splenectomy. Also, the use of intraoperative mixed-reality technology proved very useful in this case and is expected to play an increasing role in the operating room of the future.
Surgical Endoscopy 10/2009; 24(5):1204. · 4.01 Impact Factor
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ABSTRACT: The purpose of this study was to report a series of 16 consecutive patients who underwent laparoscopic treatment of splenic artery aneurysms.
Over a period of 8 years, patients were selected for the laparoscopic option by a team of specialists that included the vascular surgeon, the interventional radiologist, and the laparoscopic surgeon. The mean size of the aneurysm was 32 mm and most was located at the splenic hilum. They were twice as common in females as in males. Ultrasonography with color Doppler function was used to define intraoperative strategy.
The laparoscopic treatment entailed excision of the aneurysm or its exclusion, usually reserved for distally located lesions. In one patient, laparoscopic resection and robotic anastomosis of the splenic artery was performed to re-establish flow to the spleen. In two patients, the intraoperative decision was added to combine a laparoscopic splenectomy due to insufficient residual arterial flow to the spleen. There was no conversion, or need for re-operation or related mortality. Analysis of intraoperative arterial flow data avoided unnecessary splenectomy following noncritical reduction of flow to the spleen.
The use of intraoperative color Doppler ultrasonography is essential in deciding the appropriate procedure and whether the spleen should be removed or saved. Early control of the splenic artery proximal to the aneurysm can limit the risk of conversion due to intraoperative bleeding. Distally located aneurysms are more difficult to manage and entail a higher risk of associated splenectomy. The laparoscopic option offers some advantages over the endovascular treatment in selected patients. A multidisciplinary approach is the key to a successful treatment of this uncommon disease.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2009; 50(2):275-9. · 3.52 Impact Factor
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ABSTRACT: To evaluate the agreement between color-coded duplex ultrasound (US) and computed tomographic angiography (CTA) in monitoring aneurysm diameter and detecting endoleaks after endovascular aneurysm repair (EVAR).
From November 1998 to January 2007, 196 patients (191 men; mean age 72.4 years, range 52-88) underwent EVAR and were followed by CTA and US over a mean 3.9+/-2.4 years (range 0-8.9, median 3.4). Annual paired CTA and US examinations were reviewed to assess agreement in measuring maximum aneurysm transverse diameter and to evaluate diagnostic accuracy of US in detecting endoleak.
The 5-year cumulative endoleak incidence was 43.8% (72 patients). At first diagnosis, US detected 55/72 (76.4%) endoleaks; of the remaining 17, only 3 (4.3%) were clinically significant in terms of aneurysm enlargement. Pairing 709 annual CTA and US examinations from 184 patients showed a high agreement (k = 0.96) between examinations in measuring maximum transverse diameter, with a mean difference between US and CTA of -2.5 mm.
After the first year of follow-up, EVAR surveillance costs can be reduced by performing annual US examinations only. Keeping in mind that US underestimates diameter measurements, CTA can be reserved for patients with increasing or persistently stable aneurysm diameters.
Journal of Endovascular Therapy 03/2009; 16(1):93-104. · 2.86 Impact Factor
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Chiara Armani,
Michele Curcio,
Maria Chiara Barsotti,
Tatiana Santoni,
Rossella Di Stefano,
Matteo Dell'omodarme,
Maria Luisa Brandi, Mauro Ferrari,
Fabrizio Scatena,
Angelo Carpi,
Alberto Balbarini
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ABSTRACT: Abdominal aortic aneurysm (AAA) has a multifactorial aetiology and the importance of genetic components is getting increasing interest. Alteration in the structure of the vascular extracellular matrix has been described in AAA. Matrix metalloproteinases (MMPs) degrade extracellular matrix proteins which alter the vessel wall stability. We evaluated two different polymorphisms, a CA repeat and a cytosine to thymidine transition in the promoter sequence of MMP-9 gene for frequency in 146 patients with AAA. We compared the results with those of 156 healthy subjects. No difference was found in the allelic distribution of either polymorphisms. We therefore found no evidence that MMP-9 is a marker of susceptibility for AAA.
Biomedecine [?] Pharmacotherapy 07/2007; 61(5):268-71. · 2.00 Impact Factor
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ABSTRACT: Endoaneurysmorrhaphy with intraluminal graft placement, described by Creech, is the gold standard for abdominal aortic aneurysm (AAA) repair. Endovascular aneurysm repair has gained popularity for its minimal invasiveness and satisfying short-term results, but there are still many concerns about the long-term success of the procedure. Since 1998, laparoscopic surgery has been proposed for AAA treatment. The potential benefits of a minimally invasive procedure reproducing the endoaneurysmorrhaphy results over time have been advocated. In our experience, hand-assisted laparoscopic surgery (HALS) has been routinely used for the open-surgery transperitoneal/retroperitoneal approach and for endovascular aneurysm repair. After 4 years, we are able to define the early and middle-term results of such laparoscopic-assisted treatment.
From October 2000 to March 2004, 604 consecutive nonurgent AAAs were treated at our institution. Of these, 122 (20.2%) were treated by HALS. Exclusion criteria for HALS were hostile abdomen (previous major abdominal or aortic surgery), bilateral diffuse common iliac and/or hypogastric aneurysms, massive aortoiliac calcifications, and severe cardiac (ejection fraction <35%) and respiratory (P(O2) <60 mm Hg or carbon dioxide >50 mm Hg) insufficiency. Juxtarenal and proximal iliac aneurysms were not a contraindication, nor was obesity. In all patients, we performed a minilaparotomy (7-8 cm) both for laparoscopic hand-assisted dissection and for endoaneurysmorrhaphy. All perioperative data were prospectively recorded. Follow-up consisted of ultrasonography and clinical evaluation after 6 and 12 months and then every year after surgery.
The mean laparoscopic and total operative times were respectively 64 +/- 32 minutes and 257 +/- 70 minutes, the mean aortic cross-clamping time was 76 +/- 26 minutes, and the mean autotransfused blood volume was 1136 +/- 711 mL. The overall mortality and morbidity were respectively 0% and 12.2%. Morbidity was surgery related in only two cases (bleeding from an ipogastric artery lesion and a leg graft thrombosis). The mean intensive care unit stay was 14.3 +/- 13 hours. Oral food intake was resumed after 27.4 +/- 15 hours, and patients were discharged after a mean of 4.4 +/- 1.7 days. Operative times were not affected by obesity, suprarenal aortic cross-clamping, or aneurysm size. Both concomitant iliac aneurysms and bifurcated graft implantation (related to longer vascular reconstruction) involved significantly longer operative times. The learning curve of the procedure (comparing the first 30 patients with the last 92 patients) led to significantly shorter endoscopic, cross-clamping, and total operative times (P = .000). The mean follow-up was 28.6 +/- 16 months. Three incisional hernias and one case of bowel occlusion were detected. All these cases (3.4%) required laparoscopic treatment.
The HALS technique is a safe and minimally invasive treatment for AAA; it is useful for limiting the need for conventional open surgery and reducing the length of hospital stay. Despite the lack of randomized studies, HALS seems to be associated with a better postoperative course than standard open surgery. HALS can also be considered as an equivalent of a well-established procedure and as a bridge between open and total laparoscopic surgery.
Journal of Vascular Surgery 05/2006; 43(4):695-700. · 3.21 Impact Factor
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Mauro Ferrari,
Raffaella Berchiolli,
Savino G Sardella,
Roberto Cioni,
Pasquale Petruzzi,
Andrea Del Corso,
Roberto Di Mitri,
Chiara Croce,
Francesco Romagnani,
Daniele Adami,
Franco Mosca
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ABSTRACT: To report an unusual late complication of endovascular aneurysm repair: an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein following sac expansion due to a type III endoleak.
A 79-year-old man developed an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein 67 months after endovascular aneurysm exclusion (EVAR). Aneurysm rupture was due to disconnection between the right iliac limb and an extender cuff. The problem was repaired percutaneously with another endograft bridging the two prostheses. At 16 months, the aneurysm sac diameter was decreased; there was no evidence of the AV fistula, and the patient was free from any complication related to the EVAR.
This case emphasizes the need of close surveillance even in the late postoperative course of these patients. Moreover, this rare event confirmed that endovascular techniques can play an important role in treating emergent complications.
Journal of Endovascular Therapy 09/2005; 12(4):512-5. · 2.86 Impact Factor
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ABSTRACT: The objective of this study was to differentiate type II lumbar endoleaks on the basis of dynamic features identified by contrast-enhanced ultrasound scanning (CUS) and to evaluate the role of this differentiation in detecting abdominal aortic aneurysm (AAA) enlargement > or =1 mL/mo.
Eighteen male patients (mean age, 71.8 years) with type II lumbar endoleak suspected at CUS underwent computed tomography angiography (CTA) and digital subtraction angiography (DSA). On CTA, AAA volumes and endoleak visualization and volume were assessed. At CUS, performed after a bolus of 1.5 to 2.4 mL of a second generation blood pool contrast agent, the following parameters were evaluated: presence of contrast material within the aneurysmal sac (endoleak), delay of endoleak detection (wash-in) and disappearance (washout) from the beginning of contrast injection, visualization of inflow and outflow vessels, and presence of cavity filling. Statistical analysis was performed regarding endoleak features at CUS, endoleak detection at CTA, and rate of AAA enlargement.
DSA confirmed all the endoleaks. Mean +/- standard deviation wash-in and washout times were 121.9 +/- 132.6 and 337.2 +/- 193.7 seconds, respectively; a significant relation was observed between these two parameters (P < .01, analysis of variance). By Youden plots, endoleaks were classified as hyperdynamic when wash-in was <100 seconds (n = 10, 55.5%) and/or washout was <520 seconds (n = 13, 72.2%). A slower washout was associated with nonvisualized outflow (66.7%) and/or inflow arteries (66.7%) ( P < .05). Eight endoleaks (44.4%) were missed at CTA; it occurred in hypodynamic endoleaks, absence of detectable inflow or outflow vessels, and absence of cavity filling at CUS (P < .05). Overall mean AAA volume increase rate was 1.1 +/- 1.7 mL/mo. By multiple logistic regression model, the washout time > or = 520 seconds was the only independent predictor of AAA volume increase > or = 1 mL/mo (8 patients, 44.4%).
Type II lumbar endoleaks show different hemodynamic features at CUS, which might influence the rate of aneurysm enlargement, addressing the need for treatment.
Journal of Vascular Surgery 01/2005; 41(1):10-8. · 3.21 Impact Factor
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ABSTRACT: Vascular smooth muscle cells (VSMCs) synthesize elastin (ELN), major protein of aortic tunica media which confers strength and elasticity to aortic wall. Protein loss or distortion is typical in aneurysm tunica media. Transforming growth factor beta1 (TGFbeta1) inhibits growth and connective protein expression of abdominal VSMCs cultures. Also, in atherogenic studies, estrogen (but not estrogen plus progestin) treatments inhibit aortic collagen accumulation and elastic loss, risk factors to subsequent aortic enlargement. Therefore, polymorphisms of ELN, estrogen receptor alpha (ERalpha) and beta (ERbeta), progesterone receptor (PR) and TGFbeta1 genes and their products may be involved in the abdominal aortic aneurysm (AAA) development. Using PCR-RFLP method, we analyzed ELN RmaI (exon 16), ERalphaPvuII-XbaI (intron 1), ERbetaAluI (exon 8), PR TaqI (intron 7) and TGFbeta1 Bsu36I (-509 bp, promoter) polymorphisms in 324 Caucasian male subjects: 225 healthy controls (mean age 71.20 +/- 6.85 years) and 99 unrelated AAA patients (mean age 69.8 +/- 7.1 years). No difference in ELN, ERalpha, PR and TGFbeta1 allele frequencies was observed in AAA patients versus controls (P > 0.05). However, because possessing at least an ERbetaAluI restriction site was statistically associated to AAA onset (chi(2) = 5.220; OR = 1.82, P < 0.05), ERbeta polymorphism was proposed as genetic determinant in the AAA susceptibility.
The Journal of Steroid Biochemistry and Molecular Biology 12/2004; 92(5):413-8. · 3.05 Impact Factor
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ABSTRACT: To evaluate contrast material-enhanced ultrasonography (US) for depiction of endoleaks after endovascular abdominal aortic aneurysm repair (or endovascular aneurysm repair [EVAR]) in patients with aneurysm enlargement and no evidence of endoleak.
From November 1998 to February 2003, 112 patients underwent EVAR. At follow-up, duplex US and biphasic multi-detector row computed tomographic (CT) angiography were performed. In 10 patients (group A), evident aneurysm enlargement was observed, with no evidence of complications, at both CT angiography and duplex US. Group A patients, 10 men (mean age, 69.6 years +/- 10 [standard deviation]), underwent US after intravenous bolus injection of a second-generation contrast agent, with continuous low-mechanical index (0.01-0.04) real-time tissue harmonic imaging. Group B patients, 10 men (mean age, 71.3 years +/- 8.2) with aneurysm shrinkage and no evidence of complications, and group C patients, 10 men (mean age, 73.2 years +/- 6) with CT angiographic evidence of endoleak, underwent contrast-enhanced US. Digital subtraction angiography (DSA) was performed in groups A and C. Endoleak detection and characterization were assessed with imaging modalities used in groups A-C; at contrast-enhanced US, time of detection of endoleak, persistence of sac enhancement, and morphology of enhancement were evaluated.
In group A, contrast-enhanced US depicted one type I, six type II, one type III, and two undefined endoleaks that were not detected at CT angiography. All leakages were characterized by slow and delayed echo enhancement detected at longer than 150 seconds after contrast agent administration. DSA results confirmed findings in all patients; percutaneous treatment was performed. In group B, contrast-enhanced US did not show echo enhancement; in group C, results with this modality confirmed findings at CT angiography and DSA.
Contrast-enhanced US depicts endoleaks after EVAR, particularly when depiction fails with other imaging modalities.
Radiology 11/2004; 233(1):217-25. · 5.73 Impact Factor
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ABSTRACT: The aim of this study was to evaluate incidence, potential risk factors and effects on stent-graft migration of proximal neck dilatation after endoluminal repair of abdominal aortic aneurysm (EVAR), and the role of ultrasound (US) in detecting neck enlargement. From November 1998 to October 2001, 90 patients underwent EVAR. On follow-up, US and CT angiography (CTA) were performed, and diameters of the suprarenal and infrarenal aortic necks were monitored. Incidence of significant neck enlargement (> or =2.5 mm) and distal stent-graft migration (>10 mm) was calculated. Several factors were evaluated as predictive of neck enlargement. Ultrasound and CTA measurements were compared. The US and CTA examinations were available in 68, 39, and 11 patients at 1, 2, and 3 years follow-up (mean follow-up 15 months). Incidence of significant neck dilatation was 21.8% at the infrarenal level (13, 33, and 36% at 1, 2, and 3 years follow-up) and 13.8% at the suprarenal level (9, 18, and 27% at 1, 2, and 3 years follow-up). Significant stent-graft migration occurred in 14 of 87 patients (16%) and was associated with neck dilatation in 8 (2 suprarenal and 6 infrarenal). No risk factors were identified. Ultrasound was less accurate than CT in measuring neck diameter, in particular at the suprarenal level. Proximal aortic neck enlargement occurs in up to 30% of patients after EVAR and represents the main risk factor for stent-graft migration. The risk of infrarenal neck dilatation is higher at 2 years follow-up, whereas the suprarenal neck enlarges later. Ultrasound is not useful in monitoring neck diameter.
European Radiology 08/2003; 13(8):1962-71. · 3.22 Impact Factor
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ABSTRACT: To test the hypothesis that D-dimer (D-D), a cross-linked fibrin degradation product of an ongoing thrombotic event, could be a marker for incomplete aneurysm exclusion after endovascular abdominal aortic aneurysm (AAA) repair.
In a multicenter study, 83 venous blood samples were collected from 74 AAA endograft patients and controls. Twenty subjects who were >6 months postimplantation and had evidence of an endoleak and/or an unmodified or increasing AAA sac diameter formed the test group. Controls were 10 nondiseased subjects >65 years old, 18 AAA surgical candidates, and 26 postoperative endograft patients with no endoleak and a shrinking aneurysm. Blood samples were analyzed for D-D through a latex turbidimetric immunoassay. The endograft patients were stratified into 5 clinical groups for analysis: no endoleak and decreasing sac diameter, no endoleak and increasing/unchanged sac diameter, type II endoleak and decreasing sac diameter, type II endoleak and increasing/unchanged sac diameter, and type I endoleak.
Individual D-D values were highly variable, but differences among clinical groups were statistically significant (p < 0.0001). D-D values did not vary significantly between patients with stable, untreated AAAs and age-matched controls (238 +/- 180 ng/mL versus 421 +/- 400 ng/mL, p > 0.05). Median D-D values increased at 4 days postoperatively (963 ng/mL versus 382 ng/mL, p > 0.05) and did not vary thereafter if there was no endoleak and the aneurysm sac decreased. D-D mean values were higher in patients with type I endoleak (1931 +/- 924 ng/mL, p < 0.005) and those with unchanged/increasing sac diameters (1272 +/- 728 ng/mL) than in cases with decreasing diameters (median 638 +/- 238 ng/mL) despite the presence of endoleak (p < 0.0005).
Elevated D-D may prove to be a useful marker for fixation problems after endovascular AAA repair and may help rule out type I endoleak, thus excluding patients from unnecessary invasive tests.
Journal of Endovascular Therapy 02/2002; 9(1):90-7. · 2.86 Impact Factor
