Background This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on ...postoperative survival. Methods Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria. Results The study included 171 patients (80% men) who were a mean age of 69 ± 14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications ( P = .001), longer hospitalization ( P = .008), and higher hospital mortality (29% vs 4%; P < .001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI ( P = .001). Conclusions Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We report the treatment of a patient who had presented with hemoptysis due to an aortobronchial fistula from an anastomotic pseudoaneurysm after extra-anatomic bypass for aortic coarctation. An ...aortobronchial fistula can often result from an aortic pseudoaneurysm and is associated with high mortality if not treated. We decided to use combined endovascular and open surgical treatment and obtained a satisfactory intraoperative result. The perioperative outcome and first follow-up visit were favorable. In recent years, endovascular repair of pathologic aortic conditions has increased; thus, we have placed the present case within the context of the relevant medical literature.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Aim
Conversion to open repair becomes the last option in case of endovascular repair of abdominal aneurysm failure, when radiological interventional procedures are unfeasible. While early conversion ...to open repair generally derives from technical errors, aetiopathogenesis and results of late conversion to open repair often remain unclear.
Methods
We report data from our Institute’s experience on late conversion to open repair. Twenty-two late conversion to open repairs out of 435 consecutive patients treated during a 18 years period, plus two endovascular repair of abdominal aneurysms performed in other centres, are analysed. The indication for conversion to open repair was aneurysm enlargement because of type I, type III, type II endoleak and endotension. Even if seven cases (23%) had shown an initial aneurysmal shrinkage, in a later phase, the sac began to enlarge again. In 12 patients, conversion to open repair was the last chance after unsuccessful secondary endovascular procedures.
Results
Three cases (12.5%) were treated in emergency. Aortic cross-clamping was only infrarenal in 10 cases, only or temporarily suprarenal in 14 and temporarily supraceliac in 9 cases, for 19 total and 5 partial endograft excisions. Two patients died for Multiple Organ Failure (MOF), on 42nd (endovascular repair of abdominal aneurysm infection) and 66th postoperative day. No other conversion to open repair-related deaths or major complications were revealed by follow-up post-conversion to open repair (mean: 68 months ranging from 24 to 180 months).
Conclusion
Late conversion to open repair is often an unpredictable event. It represents a technical challenge: specifically, the most critical point is the proximal aortic clamping that often temporarily excludes the renal circulation. In our series, conversion to open repair can be performed with a low rate of complications. In response to an endovascular repair of abdominal aneurysm failure, before applying complex procedures of endovascular treatment, conversion to open repair should be taken into account.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Some studies consider the different physical properties of the stent graft when compared with the blood vessel on the basis of vascular lesions that may require further intervention. We present a ...case in which a patient developed an intramural hematoma at the distal landing of previous thoracic endovascular aortic repair (TEVAR) that required the relining with a flared prosthesis. During follow-up, we observed the appearance of more caudal hematoma. We decided to observe this lesion with close radiological controls. In order to prevent serious complication after the induction of TEVAR, accurate planning of the procedure is very important to study the impact of the prosthesis implanted in the cardiovascular system. In particular, oversize, radial forces and length of coverage have been taken into account. The adherence to follow-up is very important to precociously detect the lesions to avoid the onset of complication.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The goal of this study was to analyze our 10-year experience in the treatment of aneurysms of the collateral circulation secondary to steno-occlusions of the celiac trunk (CT) or superior mesenteric ...artery (SMA).
In the last 10 years, 32 celiac-mesenteric aneurysms were detected (25 true aneurysms and seven pseudoaneurysms) in 25 patients with steno-occlusion of the CT or SMA. All cases were diagnosed and treated at our center, with either surgical or endovascular approach. As open surgery, we performed aneurysmectomy and revascularization; as endovascular treatment we performed both the embolization (or graft exclusion) of the aneurysm sac, and embolization of afferent and efferent arteries.
Sixteen patients (64%) underwent endovascular treatment, accounting for 66% of aneurysms (21/32). Six patients (24%) and seven associated aneurysms (22%) underwent open surgery. Three asymptomatic patients (12%), representing a total of four aneurysms (12%), were not treated. For endovascular procedures, the technical success rate was 90%, with a 56% clinical success rate. For open surgery, clinical and technical success were achieved in five patients (83%) and six procedures (86%), respectively. Sixty-eight percent of patients (17/25) were treated in an emergency setting, using either endovascular (88%) or open (12%) approaches. Although technical success was achieved in more than 85% of these procedures for both approaches, clinical success was reached less frequently among patients with an acute presentation (P = .041). Regardless of the type of treatment, CT or SMA revascularization during the first procedure did not show an increased rate of clinical success (P = .531). However, we reported four cases of visceral ischemia after an endovascular approach without revascularization, with three open surgical corrections required. The mean follow-up was 41 months (range, 0-136 months).
Neither of the approaches described qualifies as a standard optimal choice. We suggest a tailored therapeutic approach based on the clinical condition at the time of diagnosis and specific vascular anatomy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract
Background and Aims
In renal transplant field, the progressive increase both of donor and recipient age has led further challenges in patient management. In this setting, the personalization ...of immunosuppressive therapies (IT) has been strongly suggested. We have investigated renal histology at 12 months after transplantation to assess whether surveillance biopsies (SB) could be considered an additional tool to further improve management of immunosuppression.
Method
Monocentric retrospective analysis of SB performed 12 months post-transplant (Tx) between 2009-2018. For each SB were collected recipient and donor demographic data, HLA mismatch, induction and maintenance IT, DGF, cold ischemia time, PRA, DSA and nDSA, previous episodes of acute rejection (AR), serum creatinine (Cr) at the time of SB and 1, 3 and 5 years later, histological score according to Banff classification in force at the time of SB. Statistics included comparison between groups and Cox regression.
Results
We analyzed 209 SB in as many pts, most of them at low immunological risk (first Tx in 94.3%, PRA <30% in 88%, DSA at time of Tx in 5.4%). All pts received induction therapy; maintenance IT included calcineurine inhibitors in 97%, mycophenolate mofetil in 49%, mTOR inhibitors in 30%, azathioprine in 10% and corticosteroids in 33%.
SB showed normal histology in only 26.3% of cases. There were no differences in renal function between normal and pathological biopsies (Cr 1.40 vs 1.46 mg/dl, p=NS). Major histologic findings, isolated or associated with each other Fig. 1, were vascular lesions (VL, 40%), IFTA (33%) and inflammatory lesions (IL, 32%).
VL correlated with donor age (OR 1.07, p<0.001), whereas IFTA with both donor age (OR 1.03, p=0.04) and DGF (OR 1.07, p=0.04). IFTA was the only histological pattern associated with a lower renal function (Cr 1.58 vs 1.39 mg/dl, p=0.016). IL included interstitial infiltrates (14.8% of specimens), tubulitis (9.6%), glomerulitis (19.6%) and capillaritis (ptc, 13.9%). Both glomerulitis and capillaritis were associated with the presence of DSA, both at Tx (OR 4.35, p=0.037) and at biopsy (OR 5.45, p<0.001).
All types of lesions were found to be related with previous AR (VL with OR 3.08, p= 0.003, IFTA with OR 2.15, p=0.04, IL with OR 4.71, p<0.001) and to be more frequent in the last 5 year biopsies, according to an older donor age (59.5 vs. 52.3 ys, p< 0.001) and a lower HLA-matching (mismatch AB >2: 50.5% vs 32%, p=0.045).
Indipendent histological variables that predicted a worsening of renal function were glomerulitis/capillaritis (HR 6.996, P<0.001) and VL (HR 2.229, p=0.038).
Conclusion
Our data confirm that stable renal function does not exclude the presence of subclinical histological lesions, even in patients at low immunological risk. Abnormal findings are present in 73.7% of our SB. Glomerulitis/capillaritis and VL can affected renal function, so their recognition should be considered for immunosuppression optimization. Patients with previous AR are at higher risk for all types of histologic lesions and may require a closer monitoring.
Figure:
The ergotamine tartrate associated with certain categories of drugs can lead to critical ischemia of the extremities. Discontinuation of taking ergotamine is usually sufficient for the total ...regression of ischemia, but in some cases it could be necessary thrombolytic and anticoagulant therapy to avoid amputation.
A woman of 62 years presented with a severe pain left forearm appeared 10 days ago, with a worsening trend. The same symptoms appeared after 5 days also in the right forearm. Physical examination showed the right arm slightly hypothermic, with radial reduced pulse in presence of reduced sensitivity. The left arm was frankly hypothermic, pulse less on radial and with an ulnar humeral reduced pulse, associated to a decreased sensitivity and motility.Clinical history shows a chronic headache for which the patient took a daily basis for years Cafergot suppository (equivalent to 3.2 mg of ergotamine).From about ten days had begun therapy with itraconazole for vaginal candidiasis. The Color-Doppler ultrasound shown arterial thrombosis of the upper limbs (humeral and radial bilateral), with minimal residual flow to the right and no signal on the humeral and radial left artery.
Angiography revealed progressive reduction in size of the axillary artery and right humeral artery stenosis with right segmental occlusions and multiple hypertrophic collateral circulations at the elbow joint. At the level of the right forearm was recognizable only the radial artery, decreased in size. Does not recognize the ulnar, interosseous artery was thin. To the left showed progressive reduction in size of the distal subclavian and humeral artery, determined by multiple segmental steno-occlusion with collateral vessels serving only a thin hypotrophic interosseous artery.Arteriographic findings were compatible with systemic drug-induced disease. The immediate implementation of thrombolysis, continued for 26 hours, with heparin in continuous intravenous infusion and subsequent anticoagulant therapy allowed the gradual disappearance of the symptoms with the reappearance of peripheral pulses.
Angiography showed regression of vasospasm and the resumption of flow in distal vessels. The patient had regained sensitivity and motility in the upper limbs and bilaterally radial and ulnar were present.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
The residual stump after excision of an infected aortic graft may be subject to acute blowout due to chronic mechanical stress on a weak arterial wall. We present a case of late aortic stump ...disruption that required revision after 12 months from graft removal. Our strategy consisted of avoiding reexposure of the pararenal aorta by creating a new supraceliac stump with healthy aortic wall after antegrade visceral debranching. This case confirms the need for long-term surveillance of aortic stumps. The use of a supraceliac approach minimizes the risk of intraoperative blowout and postoperative disruption.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
: The aim of this retrospective study was to assess the impact of steroid therapy on cardiovascular disease (CVD) and patient mortality, in 486 on‐CsA renal transplant recipients, with a follow‐up ...of 9.5 ± 4.3 yr. Two hundred and one patients had their steroids permanently withdrawn at sixth month after transplantation (G1); 285 patients did not (G2) as they were unable (acute rejection after suspension) or unsuitable (because of clinical criteria or immunosuppressive protocols). The CVD considered were coronary artery disease diagnosed by angiography and myocardial infarction. G1 and G2 patients were well‐matched regarding CVD risk factors, except for age (G1: 44 ± 14 yr; G2: 40 ± 12 yr; p < 0.003), incidence of male (G1: 62%; G2: 72%, p < 0.02) incidence of acute rejection (G1: 39%; G2: 83%, p < 0.0001). Both CVD and deaths occurring during the first year of transplantation were excluded from the analysis. At 20 yr, the cumulative probability of developing a CVD, was 3.8% in G1; 23.8% in G2 (p < 0.0005). Patient survival rate was 95% in G1; 62% in G2 (p < 0.003). Mortality caused by CVD was higher in G2 (4.2% vs. 0.5%; p < 0.03). The Cox analysis identified in steroid therapy the main independent risk factors for both CVD (hazard ratio 9.56 p < 0.0001) and patient mortality (hazard ratio 5.99, p < 0.0001). At 10th and 15th year after transplantation, the mean‐daily dose of steroids was 4.2 mg.
In the long‐term, steroid therapy, even in low‐doses, increases significantly both the rate of CVD and patient mortality. This retrospective study suggests that steroid‐free regime should always be recommended for the prevention of post‐transplant CVD. This relevant statement should be followed by a long‐term prospective study.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
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