Purpose: To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after ...thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. Methods: The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the I2 statistic (low 25%, medium 50%, high 75%). Results: Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI −0.1% to 22.3%, p=0.052). There was significant heterogeneity (I2=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; I2=69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI −3.5% to 11.1%, p=0.308; I2=10.2%). Conclusion: At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.
Imaging software has become critical tools in the diagnosis and decision making for the treatment of abdominal aortic aneurysms (AAA). However, the interobserver reproducibility of the maximum ...cross-section diameter is poor. This study aimed to present and assess the quality of a new fully automated software (PRAEVAorta) that enables fast and robust detection of the aortic lumen and the infrarenal AAA characteristics including the presence of thrombus.
To evaluate the segmentation obtained with this new software, we performed a quantitative comparison with the results obtained from a semiautomatic segmentation manually corrected by a senior and a junior surgeon on a dataset of 100 preoperative computed tomography angiographies from patients with infrarenal AAAs (13,465 slices). The Dice similarity coefficient (DSC), Jaccard index, sensitivity, specificity, volumetric similarity (VS), Hausdorff distance, maximum aortic transverse diameter, and the duration of segmentation were calculated between the two methods and, for the semiautomatic software, also between the two observers.
The analyses demonstrated an excellent correlation of the volumes, surfaces, and diameters measured with the fully automatic and manually corrected segmentation methods, with a Pearson's coefficient correlation of greater than 0.90 (P < .0001). Overall, a comparison between the fully automatic and manually corrected segmentation method by the senior surgeon revealed a mean Dice similarity coefficient of 0.95 ± 0.01, a Jaccard index of 0.91 ± 0.02, sensitivity of 0.94 ± 0.02, specificity of 0.97 ± 0.01, VS of 0.98 ± 0.01, and mean Hausdorff distance per slice of 4.61 ± 7.26 mm. The mean VS reached 0.95 ± 0.04 for the lumen and 0.91 ± 0.07 for the thrombus. For the fully automatic method, the segmentation time varied from 27 seconds to 4 minutes per patient vs 5 minutes to 80 minutes for the manually corrected methods (P < .0001).
By enabling a fast and fully automated detailed analysis of the anatomic characteristics of infrarenal AAAs, this software could have strong applications in daily clinical practice and clinical research.
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.
Our case illustrates the concomitant presence of a giant aneurysm of the left renal artery at the ostium and an abdominal aortic aneurysm, in presence of a complex aortic anatomy. Type of approach ...and timing of the treatment is still not well established for the rare coexistence of these 2 pathologies. In case of surgical high-risk patients, endovascular therapy is considered now the best choice to exclude arterial and aortic aneurysms although there are chances to do further interventions in the follow-up. For this reason, we simultaneously treated both the aneurysms through an embolization with plugs and coils of renal aneurysm and endovascular exclusion of aortic aneurysm; in the follow-up, renal function of the patient worsened until hemodialysis and we saw the reperfusion of renal aneurysm and the onset of endoleak I type A from above the aortic and renal aneurysm and B from iliac legs of the previous endograft. We performed a parallel graft technique on visceral vessels to exclude the refilling of both aneurysms and preserve visceral vascularization. Follow-up at 12 months showed the complete exclusion of the aneurysms and the patency of stents in celiac trunk and superior mesenteric artery.
Our goal was to assess the value of the Modified Arch Landing Areas Nomenclature (MALAN) for thoracic endovascular aortic repair (TEVAR), in which each landing area (LA) is identified by a proximal ...landing zone and the type of arch (e.g. 0/I), as predictors of postoperative proximal endograft performance.
A multicentre retrospective analysis was performed of patients treated with arch TEVAR (i.e. proximal landing zone 0-3) for various indications between 2007 and 2017. Patients were stratified by the MALAN classification into hostile LAs (i.e. 2/III and 3/III) and favourable LAs (i.e. 0/I-III, 1/I-III, 2/I-II and 3/I-II). Outcome criteria included composite proximal endograft failure (including type Ia endoleak, persistent false lumen perfusion at the level of the most proximal communication between the lumina in aortic dissections, endograft migration and retrograde dissection) and deaths from all causes. Competing risk analyses were performed.
A total of 359 patients (hostile LAs 133; favourable LAs 226) were identified. The median age was 71.0 (62.0-77.0); 78.3% were men. Proximal endograft failure occurred in 28/133 patients (21.1%) in the hostile LA group and in 12/226 (5.3%) in the favourable LA group. On multivariate analysis, hostile LAs were independently associated with proximal endograft failure (P < 0.0001). There was no other independent risk factor. Favourable LAs were associated with an increased mortality rate (P = 0.006), which could be attributed to the proximal LA subgroup (i.e. 0/I-III and 1/I-III) (P < 0.0001), in addition to age (P < 0.0001).
The MALAN classification identifies hostile proximal landing zones for TEVAR, namely 2/III and 3/III LAs, which are associated with dismal proximal endograft performance. The MALAN appears to be an intuitive and valuable tool to improve the preoperative decision-making process.
Imaging softwares have become critical tools in the diagnosis and decision making for the treatment of abdominal aortic aneurysms (AAA). However, the inter-observer reproducibility of maximum ...cross-section diameter is poor. This study aimed to present and assess the quality of a new fully automated software (PRAEVAorta) that enables fast and robust detection of the aortic lumen and the infra-renal AAA characteristics including the presence of thrombus.
To evaluate the segmentation obtained with this new software, we performed a quantitative comparison with the results obtained from a semi-automatic segmentation manually corrected by a senior and a junior surgeon on a dataset of 100 pre-operative CTAs from patients with infrarenal AAAs (i.e. 13465 slices). The Dice Similarity Coefficient (DSC), Jaccard index (JAC), Sensitivity, Specificity, volumetric similarity (VS), Hausdorff distance (HD), maximum aortic transverse diameter, and the duration of segmentation were calculated between the two methods and, for the semi-automatic software, also between the two observers.
The analyses demonstrated an excellent correlation of the volumes, surfaces, and diameters measured with the fully automatic and manually corrected segmentation methods, with a Pearson's coefficient correlation >0.90, P<0.0001. Overall, comparison between the fully automatic and manually corrected segmentation method by the senior surgeon revealed a mean DSC of 0.95±0.01, JAC of 0.91±0.02, sensitivity of 0.94±0.02, specificity of 0.97±0.01, VS of 0.98±0.01, and mean HD/slice of 4.61±7.26mm. The mean VS reached 0.95±0.04 for the lumen and 0.91±0.07 for the thrombus. For the fully automatic method, the segmentation time varied from 27 seconds to 4 minutes per patient vs 5 minutes to 80 minutes for the manually corrected methods (P<0.0001).
By enabling a fast and fully automated detailed analysis of the anatomic characteristics of infra-renal AAAs, this software could have strong applications in daily clinical practice and clinical research.
Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of ...treatment for this insidious condition.
PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023.
The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis.
The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.
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