bluuebunny/crossref_metadata_2025 huggingface dataset:
An Endovascular Model of Carotid Stenosis for the Evaluation of Thrombolysis and Angioplasty
Authors: Lin Peter H. , Surowiec Scott M. , Conklin Brian , Bush Ruth L. , Chen Changyi , Chaikof Elliot L. , Lumsden Alan B.
Published: March 2015

Purpose:

To develop a porcine carotid artery thrombosis model using a novel stent-graft device to evaluate the efficacy of thrombolytic therapy and angioplasty procedures.

Methods:

An endovascular device made from a tapered polytetrafluoroethylene graft inverted in a self-expanding nitinol stent was delivered to bilateral carotid arteries via a right femoral approach in 16 pigs. Carotid thrombotic occlusion ensued from flow stasis created by the intrastent stenosis. Via selective carotid catheterization from a femoral approach, urokinase (250,000 IU) was pulse-sprayed in one carotid artery while a control saline solution was infused in the contralateral vessel; delivery times were 1 hour, 8 hours, 3 days, or 6 days after carotid occlusion (4 animals per time period). After thrombolysis, balloon angioplasty was performed to maintain carotid patency. Arteriography and intravascular ultrasound were used to evaluate the efficacy of thrombolysis. Light microscopy was used for histological analysis of the thrombus.

Results:

Carotid artery occlusion occurred in 15 ± 8 minutes after stent-graft placement in all animals. Urokinase was effective in recanalizing all occluded arteries in the 1-hour, 4-hour, and 3-day groups (100%) but was effective in only 2 of 4 animals in the 6-day group (p < 0.05). Overall thrombolytic efficacy was 78% ± 7%. Control saline solution showed no thrombolytic effect (p < 0.001). Angioplasty successfully restored normal luminal diameter in all fully lysed arteries (100%). Histological analysis showed fibrin-predominant thrombus with a varying degree of platelet deposition.

Conclusions:

This endovascular approach, which creates a carotid stenosis using this novel stent-graft device, is reliable in producing carotid thrombosis. In our model, thrombolytic therapy was effective in restoring luminal patency, and the intraluminal stenosis is amenable to balloon angioplasty. The model is useful for the evaluation of antithrombotic therapy and adjunctive endovascular interventions.
Does Complete Aneurysm Exclusion Ensure Long-term Success after Endovascular Repair?
Authors: Lee W. Anthony , Wolf Yehuda G. , Fogarty Thomas J. , Zarins Christopher K.
Published: March 2015

Purpose:

To examine whether complete aneurysm exclusion is a reliable marker for successful long-term endovascular abdominal aortic aneurysm (AAA) repair.

Methods:

The medical records, computed tomographic (CT) scans, and duplex examinations of all the patients who underwent endovascular AAA repair at a single institution and had at least 12 months of follow-up were reviewed. Sixty-seven patients (58 men; mean age 74 years, range 57–87) were identified. Complete aneurysm exclusion was defined by the absence of an endoleak at any time before an adverse event. The primary endpoint included all major adverse events that occurred during the postoperative period, including aneurysm expansion, acute symptoms referable to the AAA, late secondary procedures, ruptures, and deaths from ruptures and all other causes.

Results:

There were 44 adverse events (8 expanding aneurysms, 4 acute symptoms, 17 secondary procedures, and 15 deaths from other causes) in 28 (42%) patients. Among 36 (54%) patients who had initial complete aneurysm exclusion (no endoleak), 12 (33%) experienced adverse events, compared with 16 (52%) events in 31 patients who had endoleak (χ2 = 1.59, p = 0.21).

Conclusions:

There was no statistically significant difference in adverse events based on the presence or absence of endoleak. Complete aneurysm exclusion as defined by absence of an endoleak does not indicate an event-free postoperative course. A better marker of clinical success of endovascular AAA repair is needed.
Transseptal Guidewire Stabilization Facilitates Stent-Graft Deployment for Persistent Proximal Ascending Aortic Dissection
Authors: Dorros Gerald , Dorros Ari M. , Planton Sara , O'Hair Daniel , Zayed Mahmoud
Published: March 2015

Purpose:

To report endovascular repair of a DeBakey type I ascending aortic dissection.

Case Report:

Five months after aortocoronary bypass grafting, a 56-year-old woman demonstrated a persistent ascending aortic type I dissection whose entry tear proximal to the innominate artery spiraled down the descending thoracic aorta into the iliofemoral arteries. Repair was facilitated with a guidewire passed through a transseptal sheath in the right femoral vein. The guidewire traversed the right and left atria and the left ventricle and then exited into the ascending aorta and was exteriorized through the right femoral artery. A right brachial catheter aided contrast visualization of the innominate artery. Adenosine-induced elective cardiac arrest promoted precise placement of a customized polyester-covered balloon-expandable stent, which closed the aortic rent.

Conclusions:

A transseptal approach enables the guidewire to follow the curvature of the aortic arch, providing precise control of the stent-graft delivery system. This case illustrates the applicability of endovascular techniques to repair ascending aortic pathologies using readily available techniques, equipment, and drugs.
An Endovascular System for Thoracoabdominal Aortic Aneurysm Repair
Authors: Chuter Timothy A.M. , Gordon Roy L. , Reilly Linda M. , Goodman Jay D. , Messina Louis M.
Published: March 2015

Purpose:

To describe a stent-graft system for endovascular repair of thoracoabdominal aortic aneurysm (TAAA) that preserves side branch perfusion.

Technique:

The modular endograft system includes 3 components. The primary stent-graft is custom-made from conventional graft fabric and Gianturco Z-stents. Covered nitinol Smart Stents are used for the visceral and renal extensions, and the distal extension is made from a modified Zenith system. With the supine patient under general anesthesia, the components are delivered sequentially through surgically exposed femoral and right brachial arteries in an operation that requires prolonged periods of magnified high-resolution imaging. This system was first used in a 76-year-old man with a contained rupture of a supraceliac ulcer and a large abdominal aortic aneurysm ending proximally at the celiac artery. The endograft was implanted successfully, but the patient developed paraplegia on day 2; imaging documented an excluded aneurysm and excellent flow through the endograft and all prosthetic branches.

Discussion:

Endovascular repair of TAAA appears to be feasible. If there are no serious, specific, unavoidable complications, the potential advantages are enormous.
Sequential Coil Embolization of Bilateral Internal Iliac Artery Aneurysms Prior to Endovascular Abdominal Aortic Aneurysm Repair
Authors: Halloul Zuhir , Bürger Thomas , Grote Reinhard , Fahlke Jörg , Meyer Frank
Published: March 2015

Purpose:

To report the endovascular repair of concomitant aneurysms of the abdominal aorta and both internal iliac arteries.

Case Report:

A 72-year-old man with a 5.5-cm abdominal aortic aneurysm (AAA) extending to the right common iliac artery also presented with separate aneurysms of both internal iliac arteries. The patient refused conventional surgery, so an endovascular strategy was devised. Initially, the iliac aneurysms were sequentially coil embolized, allowing several weeks to elapse between the embolization sessions to encourage collateral development. A bifurcated Talent endograft was inserted successfully 8 months after the initial intervention; no evidence of endoleaks or mesenteric ischemia has been seen over a 1-year follow-up.

Conclusions:

This case illustrates the feasibility of inducing collateralization prior to endovascular AAA repair that would jeopardize internal iliac artery circulation bilaterally. Sequential embolization of the internal iliac arteries over several months initiates this response, paving the way for eventual endovascular repair of the primary aortic aneurysm.
Management of Neurological Complications of Carotid Artery Stenting
Authors: Wholey Michael H. , Wholey Mark H. , Tan Walter A. , Toursarkissian Boulis , Bailey Steven , Eles Gustave , Jarmolowski Chester
Published: March 2015

Purpose:

To review the neurological complications associated with extracranial carotid artery stenting and to preliminarily assess techniques used to manage these complications.

Methods:

Between April 1994 and August 2000, 450 patients (270 men; mean age 70.2 years, range 27–89) had stents implanted to treat 472 cervical carotid artery stenoses. Over half (257, 57%) of the patients were symptomatic. A variety of stents were implanted percutaneously after predilation of the lesion; a third of the patients received glycoprotein IIb/IIIa inhibitors intraprocedurally in addition to a standard oral antiplatelet regimen (aspirin and ticlopidine or clopidogrel). Occurrence and management of neurological complications within the 30-day periprocedural period were reviewed.

Results:

There were 14 (3.1%) transient ischemic attacks (TIAs), 10 (2.2%) minor strokes, and 3 (0.7%) major strokes. Among 6 (1.3%) procedure-related deaths, 4 had neurological causes. The total stroke and death rate was 4.2% (n =19). All the TIAs, 4 of which occurred between 1 and 14 days poststenting, were treated medically, as were the minor strokes, 3 of which occurred >24 hours after stenting. Only 2 minor stroke patients had mild residual upper extremity motor deficits. Intra-arterial thrombolytic therapy was administered in 5 cases (2 major strokes survivors and 3 patients who suffered a neurologically-related death); occlusions were identified in the proximal middle cerebral artery (MCA) in 3 and the distal MCA in 2. Angiographic improvement was noted in 4 (80%), but only the 2 (40%) with distal MCA occlusions did well clinically.

Conclusions:

Neurological complications following carotid artery stenting are inevitable. The occurrence of minor strokes >24 hours following stenting may indicate a possible late embolic phenomenon, which warrants investigation. Likewise, the marginal efficacy of intra-arterial thrombolytic therapy demonstrates an inability to lyse embolic plaque and underscores the need for effective distal protection.
Serial CT Volume Measurements after Endovascular Aortic Aneurysm Repair
Authors: Czermak Benedikt V. , Fraedrich Gustav , Schocke Michael F. , Steingruber Iris E. , Waldenberger Peter , Perkmann Reinhold , Rieger Michael , Jaschke Werner R.
Published: March 2015

Purpose:

To evaluate the efficacy of transluminal stent-graft placement in aortic aneurysms using postoperative enhanced spiral computed tomographic (CT) volumetric measurements of the aneurysm sac, the intra-aneurysmal vascular channel (IAVC), the thrombus, and the stent-graft.

Methods:

Among 53 patients (45 men; mean age 74 years, range 59–85) who underwent elective endovascular aortic aneurysm repair, 37 patients with 27 abdominal and 10 thoracic aortic aneurysms completed at least a 6-month follow-up that included computerized CT volumetric analysis prior to discharge and at 3, 6, 12, 24, and 36 months. A variety of bifurcated (n = 23) and tube (n = 14) stent-grafts were observed for signs of endoleak and aneurysm enlargement.

Results:

Mean follow-up was 16 months (range 6–48). Total aneurysm volumes and thrombus volumes decreased, whereas IAVC and stent-graft volumes increased over time. Between the postoperative and 12-month imaging studies, reductions in total aneurysm (p = 0.011) and thrombus (p < 0.001) volumes were significant. No statistically significant difference in volume changes for the aneurysm sac (p = 0.555) or the thrombus (p = 0.920) was found when comparing the 24 patients without primary leak to the 12 with primary type-II leak. In all 5 cases with secondary leak, the volume of the aneurysm sac increased after initial shrinkage.

Conclusions:

Postoperative CT volumetric analysis is an effective tool for evaluating the outcome of endovascular aortic aneurysm repair. Thrombus volume measurements are more accurate than total aneurysm volumes. In patients in whom contrast agents are contraindicated, volume measurements can also be obtained without the use of contrast.
Aneurysm Sac Hygroma: A Cause of Endotension
Authors: Risberg Bo , Delle Martin , Eriksson Elsa , Klingenstierna Hans , Lönn Lars
Published: March 2015

Purpose:

To describe a new pathophysiological mechanism for endotension.

Case Reports:

Four patients developed aneurysm sac expansion after repair of abdominal aortic aneurysms, one with a conventional polytetrafluoroethylene (PTFE) graft and the others with a variety of commercially made endografts (2 PTFE, 1 Dacron). Pressures within the sacs were nonpulsatile and approximately half the systemic blood pressure. Attenuation on computed tomography (CT) was significantly less in the sac than in the graft in 3 of the patients. A clear, highly viscous fluid was aspirated from all 4 sacs, supporting the diagnosis of aneurysm sac hygroma. Prominent local hyperfibrinolysis in the sac was combined with signs of local coagulation activation.

Conclusions:

A new mechanism for continued sac expansion based on aneurysm sac hygroma is proposed. Measurement of attenuation may be of diagnostic value. It is further proposed that local hyperfibrinolysis/coagulation may promote rebleeding, liquefaction, and continued expansion analogous to the chronic subdural hematoma.
Evaluation of Patient Selection Guidelines for Endoluminal AAA Repair with the Zenith Stent-Graft: The Australasian Experience
Authors: Stanley Brendan M. , Semmens James B. , Mai Qun , Goodman Marcel A. , Hartley David E. , Wilkinson Catherine , Lawrence-Brown Michael M.D.
Published: March 2015

Purpose:

To review the patient selection guidelines for endovascular repair of abdominal aortic aneurysms (AAA) using the Zenith Endovascular Graft and establish an order of importance for each criterion.

Methods:

The Zenith Endovascular Graft Research Database was interrogated for information on 238 patients (209 men; mean age 74.9 ± 0.9 years, range 50–94) treated with a Zenith bifurcated graft from 1994 to 1998. The common complications of endoluminal AAA repair (endoleak, migration, graft occlusion, graft kinking, conversion, and deployment failure) were analyzed to determine any associations with selection criteria.

Results:

By 1998, 69% of endograft patients did not meet the recommended guidelines; however, primary and secondary aneurysm exclusion rates were 87% and 94%, respectively. Over a median follow-up of 13.4 months (interquartile range 2.8–24.0), 38 (16%) patients developed 28 (74%) early and 10 (26%) late type-I endoleaks. The endoleak rate in necks ≤10 mm long was 57% (8/14). Endoleak was associated with a neck contour change >3 mm (p = 0.003) and neck length <20 mm (p = 0.045). The risk of proximal endoleak was 4 times greater if at least one of the proximal neck guidelines was breached; combined guideline deviations of “contour change and large diameter” (p = 0.0004), “contour change and short length” (p = 0.006), “large diameter and short length” (p = 0.01), and “contour change and angle” (p = 0.03) also increased the risk of endoleak. Endograft migration was seen in 10 (4.2%) cases; only neck diameter >28 mm (p = 0.0024) was associated with this complication.

Conclusions:

Proximal neck contour, length, and diameter are the most important criteria in terms of endoleak development. Breaching the proximal neck length criterion resulted in a 4-fold increase in endoleak, and combined deviations from the guidelines multiplied the effect. Necks ≤10 mm long are unsuitable for the standard Zenith graft.
Angioplasty and Stenting in the Posterior Cerebral Circulation
Authors: Barakate Michael S. , Snook Kylie L. , Harrington Timothy J. , Sorby William , Pik Justin , Morgan Michael K.
Published: March 2015

Purpose:

To report initial experience with intracranial vertebral artery (VA) and basilar artery (BA) percutaneous transluminal angioplasty (PTA) and stenting.

Methods:

Eleven patients (10 men; mean age 66 years, range 56–75) with intracranial 14 VA and 3 BA stenoses were managed from December 1997 through November 1999. All patients presented with vertebrobasilar ischemia (VBI) despite antiplatelet and anticoagulant therapy. Clinical presentations included visual disturbance (n = 8), dysarthria/dysphasia (n = 5), and vertigo (n = 5).

Results:

Five patients underwent PTA only of 7 lesions with a mean preprocedural stenosis of 80% (range 50%–90%) that was reduced to 54% (range 30%–70%) after dilation. Six patients received 9 stents, 2 for VA dissections, 3 for tandem lesions, and 1 for a BA lesion. There were no embolic strokes. Patients were followed by clinical evaluation and personal or telephone interviews. Over a mean 18-month follow-up (range 12–35), 8 (73%) patients remained asymptomatic, while 3 (27%) had permanent deficits, 2 related to the procedure and 1 owing to distal disease

Conclusions:

Intracranial VA or BA angioplasty and stenting alleviated symptoms in patients with vertebrobasilar ischemia despite best medical management and may prevent stroke.
Carotid Stenting with Distal-Balloon Protection via the Transbrachial Approach
Authors: Al-Mubarak Nadim , Vitek Jiri J. , Iyer Sriram S. , New Gishel , Roubin Gary S.
Published: March 2015

Purpose:

To document the feasibility of brachial artery access for carotid stenting with distal-balloon protection of the internal carotid artery (ICA).

Technique:

Via percutaneous access to the brachial artery, a large double-curve catheter is advanced into the aortic arch over a hydrophilic guidewire to cannulate the left common carotid artery. Following sheath exchange, a GuardWire distal-protection balloon is positioned within the left ICA distal to the stenosis. The lesion is dilated, followed by deployment and dilation of a self-expanding stent. Transcranial Doppler monitoring shows only scarce microembolic signals during the procedure.

Conclusions:

Carotid stenting with distal balloon protection via the brachial artery appears feasible as an alternative to standard femoral access.
Modified Technique for Using Vascular Sheaths in Carotid Artery Stent Placement
Authors: Wholey Michael H. , Toursarkissian Boulos , Bailey Steven
Published: March 2015

Purpose:

To report a technical modification that will prevent sheath kinking in acutely angled vessels during carotid stent placement.

Technique:

If a long vascular sheath kinks when engaging an acutely angled common carotid or innominate artery, the sheath is pulled caudally approximately 2 cm while a 0.014-inch guidewire, supported by a coronary balloon catheter, is advanced toward the internal carotid artery (ICA). Alternatively, to avoid kinking, the original 0.035-inch super stiff wire is maintained within the sheath until the 0.014-inch wire and coronary balloon have exited the sheath's distal tip.

Conclusions:

If an aortic arch is tortuous and the angle of the common carotid artery is unfavorable, a guiding catheter is preferable to a long vascular sheath for accessing the ICA during carotid stent procedures.
Endovascular Stenting for the Nutcracker Phenomenon
Authors: Chiesa Roberto , Anzuini Angelo , Marone Enrico Maria , Briguori Carlo , Moura Marcelo R.L. , Melissano Germano , Colombo Antonio , Rosanio Salvatore
Published: March 2015

Purpose:

To present a case highlighting the efficacy of stent implantation for left renal vein (LRV) entrapment, otherwise known as the nutcracker phenomenon.

Case Report:

A 17-year-old boy presented with a history of gross hematuria and left flank pain. Magnetic resonance angiography documented compression of the LRV between the superior mesenteric artery and aorta. A Memotherm stent was successfully placed across the LRV to restore adequate luminal flow after a Wallstent failed to adequately span the narrowed segment. Spiral CT angiography at 6 months confirmed LRV patency; the patient remains asymptomatic and free of hematuria at 12 months.

Conclusions:

Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures.
Autologous Thrombin: A New Embolization Treatment for Traumatic Intrasplenic Pseudoaneurysm
Authors: Engelke Christoph , Quarmby John , Ubhayakar Gaurang , Morgan Robert , Holmes Keith , Belli Anna-Maria
Published: March 2015

Purpose:

To report the use of autologous thrombin for transcatheter embolization of a traumatic parenchymal splenic pseudoaneurysm.

Case Report:

A 15-year-old boy presented with a splenic parenchymal laceration after blunt abdominal trauma. The patient was managed conservatively but developed an intrasplenic pseudoaneurysm (grade III AAST scale) with subcapsular contrast extravasation after 3 weeks. Autologous thrombin was isolated from the patient's blood and subsequently delivered to the lesion by transcatheter superselective injection into the aneurysm neck. The patient was asymptomatic after the procedure. Nine months' follow-up demonstrated a normal spleen with completely homogenous parenchyma.

Conclusions:

Autologous thrombin injection to induce thrombosis of intrasplenic pseudoaneurysm represents a new treatment option for traumatic abdominal organ injuries. Intrasac thrombosis can be safely induced to successfully restore the splenic parenchymal integrity without introduction of foreign material and associated risks of adverse reactions or infection that might accompany the use of commercial thrombin preparations.
Delayed Pseudoaneurysm after Renal Artery Angioplasty
Authors: McWilliams Richard G. , Godfrey Hugh , Bakran Ali , Kool Leo J. Schultze , van Bockel J. Hajo , van Oostayen Jacques A.
Published: March 2015

Purpose:

To report delayed pseudoaneurysm formation after percutaneous renal artery angioplasty.

Case Reports:

A 56-year-old woman succumbed to complications of a ruptured right juxtarenal aortic pseudoaneurysm 2 years after right renal artery stenting for renal impairment. The juxtarenal aorta had been normal on aortography at the time of angioplasty. She gave a history of right-sided back pain that started within 8 months of the angioplasty. A 21-year-old woman with left renal artery stenosis due to fibromuscular dysplasia was treated with balloon angioplasty, after which there was evidence of active extravasation. The completion angiogram, after a period of observation, documented cessation of the leak. Follow-up angiography because of persisting hypertension disclosed a large, asymptomatic, intrarenal pseudoaneurysm that was repaired with bench surgery and autotransplantation.

Conclusions:

We advise that patients with symptoms referable to the site of renal artery intervention and those who have had complicated interventions should have follow-up imaging to exclude pseudoaneurysm formation.
Outcome after Endovascular Abdominal Aortic Aneurysm Repair: A Meta-Analysis
Authors: Walschot Luc H. B. , Laheij Robert J. F. , Verbeek André L. M.
Published: March 2015

Purpose:

To determine the frequencies of complications and risk factors for complications following endovascular abdominal aortic aneurysm (AAA) repair (EVAR).

Methods:

Thirty-nine articles published between October 1995 and October 1999 in English, German, French, or Dutch were identified in electronic databases. All articles reported perioperative (30-day) complications on 2387 patients, while postoperative complications (>30 days) were reported on 1645 patients in 30 of 39 studies. Data were pooled and subjected to multivariable logistic regression analysis to identify risk factors for death, endoleak, rupture, conversion, and local and systemic complications. Effects of risk factors were expressed as odds ratios (OR) with 95% confidence interval (CI).

Results:

Mean follow-up was 13.9 months (range 4–29). The perioperative death rate (3.7%) was lower than postoperative mortality (5.0% per annum). The risks for both endoleak (13.1%) and conversion (5.0%) were higher in the perioperative period than postoperatively (5.4% and 1.4% per annum, respectively). Independent risk factors for perioperative complications were: general anesthesia (death: OR = 5.1, 95% CI 1.9–13.3); EVT graft (endoleak: OR = 3.0, 95% CI 1.3–7.0); female sex (rupture: OR = 2.8, 95% CI 1.4–5.8); hypertension (conversion: OR = 0.03, 95% CI 0.0–0.3); age >70 years (conversion: OR = 3.5, 95% CI 1.3–9.2); and team experience >30 patients (conversion: OR = 3.0, 95% CI 1.2–7.6). Independent risk factors for postoperative complications were: predischarge examination (death: OR = 0.2, 95% CI 0.0–0.7); follow-up 30 days after operation (death: OR = 0.3, 95% CI 0.1–1.0); and female sex (rupture: OR = 1.4, 95% CI 0.5–4.4; conversion: OR 6.8, 95% CI 2.0–23.4; and systemic complications: OR = 2.9, 95% CI 1.1–7.5).

Conclusions:

The risk of complications after EVAR is high, supporting the cautious use of EVAR. Both patient characteristics and procedural variables were independent risk factors for complications. To avoid the limitations of this study, the results of randomized clinical trials must determine if EVAR offers a safe and durable alternative to open AAA repair.
Surgical Conversion after Endovascular Grafting for Abdominal Aortic Aneurysms
Authors: Böckler Dittmar , Probst Thomas , Weber Heinz , Raithel Dieter
Published: March 2015

Purpose:

To analyze the indications, results, and technical problems associated with conversion after endoluminal repair of abdominal aortic aneurysms (AAA) based on a 6-year experience in endovascular grafting.

Methods:

From August 1994 to May 2000, 520 patients with AAA were deemed candidates for endovascular therapy based on data from contrast-enhanced computed tomography and aortography. Any conversions were performed using an open operation modified according to the indication for conversion, elapsed time from the endoluminal repair, and type of endograft (tube, bifurcated, infra-/suprarenal fixation).

Results:

Conversion to open repair was required in 37 (7.1%) cases: 23 tube grafts and 14 bifurcated devices. Seventeen (3.2%) conversions occurred at the original operation and 20 (3.8%) were performed secondarily. Indications for primary conversion were mainly device defects (n = 5) or access problems (n = 5), while secondary conversion was primarily owing to type I endoleak (n = 16). The conversion rate was significantly higher in modular devices (5.9%) than unibody designs (1.4%) (p = 0.003). The rate of primary conversions diminished from 10.9% in 1994–1995 to 2.4% between 1996 and 2000, as did the overall mortality rate, from 8.3% in the first time period to 0% in the second for elective conversions, but emergency operations had 40% mortality.

Conclusions:

Most AAAs require bifurcated devices for complete exclusion, and older model modular grafts have higher conversion rates. Primary conversion decreases as more experience in endoluminal grafting is acquired. Emergency open repair results in a high mortality rate.
Emergent Axillary Artery Stent-Graft Placement for Massive Hemorrhage from an Avulsed Subscapular Artery
Authors: Dinkel Hans-Peter , Eckstein Friedrich S. , Triller Jürgen , Do Dai-Do
Published: March 2015

Purpose:

To report the successful endovascular repair of an acute axillary artery hemorrhage.

Case Report:

An 87-year-old woman with Charcot-Marie-Tooth ataxia presented with an enormous shoulder hematoma and clinical signs of exsanguination after a fall. Angiography demonstrated complete avulsion of the right subscapular artery from the axillary artery, and active bleeding into a hematoma of at least 1500 mL. Endovascular repair with a balloon-mounted covered stent-graft was performed percutaneously, which controlled the bleeding and averted surgery. The patient recovered uneventfully and was without signs of recurrent bleeding or ischemia on the 6-month ultrasound examination; she reports no symptoms referable to her upper extremity after 14 months.

Conclusions:

Endovascular repair with stent-grafts is effective in controlling arterial bleeding from supra-aortic vessels even under emergency conditions.
Efficacy of a Nitinol Filter Device in the Prevention of Embolic Events during Carotid Interventions
Authors: Cremonesi Alberto , Castriota Fausto
Published: March 2015

Purpose:

To evaluate the feasibility, safety, and efficacy of the TRAP Vascular Filtration System (VFS) during carotid interventions as a deterrent to embolic complications.

Methods:

Thirty-one consecutive patients (18 men; mean age 72 ± 8 years) gave informed consent to undergo elective percutaneous angioplasty and stenting of the extracranial carotid artery protected by the TRAP VFS, a nitinol basket filter system.

Results:

The TRAP VFS was delivered and retrieved safely in all patients; procedural success for carotid stenting was 100%. In 3 (9.7%) cases, the filters were positioned after lesion predilation. Nearly half (13, 41.9%) of the retrieved filters contained visible plaque debris that histology identified as cholesterol crystals, fibrin material, atheromatous plaque, and macrophage foam cells. There were no symptomatic major or minor neurological complications encountered in this cohort during hospitalization.

Conclusions:

Our data indicate that percutaneous dilation and stenting of the carotid artery protected by TRAP VFS appears to be feasible, safe, and effective in preventing cerebral embolization.
Simultaneous Stent-Graft Repair of Thoracic and Infrarenal Abdominal Aortic Aneurysms
Authors: Meguid Ahmed A. , Bove Paul G. , Long Graham W. , Kirsch Matthias J. , Bendick Phillip J. , Zelenock Gerald B.
Published: March 2015

Purpose:

To describe a technique for concomitant endovascular stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms.

Case Report:

A 68-year-old man was found to have concomitant thoracic and abdominal aortic aneurysms. Both of the aneurysms were excluded successfully in one procedure using Talent stent-grafts. The patient tolerated the procedure well and was discharged on postoperative day 4. Aside from an infected groin wound, the patient did not have any complications. Computed tomographic scans at 6, 12, and 18 months showed proper position of both stents without evidence of endoleak.

Conclusions:

Simultaneous endovascular treatment of thoracic and infrarenal abdominal aortic aneurysms may represent a viable alternative for therapy in some patients.
Endograft Fabric Disintegration Simulating a Type II Endoleak
Authors: Becquemin Jean-Pierre , Poussier Bertrand , Allaire Eric , Kobeiter Hischam , Desgranges Pascal
Published: March 2015

Purpose:

To report a case of endograft disintegration misinterpreted as a type II endoleak.

Case Report:

An 86-year-old man underwent successful Vanguard stent-graft implantation for a 49-mm abdominal aortic aneurysm. At 1 month, a distal type I endoleak was repaired, but another endoleak thought to arise from the lumbar or inferior mesenteric arteries remained. Multiple interventions to embolize the feeding arteries were unsuccessful, and the endoleak persisted. At 1 year, the leak was still present, and the aneurysm had increased to 69 mm. After failing to demonstrate the source of the leak radiographically, surgery was performed. At operation, the endoleak was traced to small holes in the graft fabric. The endograft was removed without difficulty, and the flow was re-established with an aortobiiliac woven graft.

Conclusions:

Chronically implanted stent-grafts can show signs of failure that are confusing or misleading. Correct diagnosis of endoleaks may be difficult, but every effort must be made to identify their source. It is vital that no enlarging aneurysm be left untreated.
Endovascular Management of a Pancreaticoduodenal Aneurysm: A Clinical Dilemma
Authors: Sultan Sherif , Molloy Martin , Evoy Denis , Colgan Mary-Paula , Madhavan Prakash , Moore Dermot , Shanik Gregor
Published: March 2015

Purpose:

To report the successful endovascular embolization of a pancreaticoduodenal aneurysm (PDA).

Case Report:

A 56-year-old man with a history of pancreatitis presented with insidious, progressive epigastric pain for the preceding 6 months. Contrast-enhanced computed tomography (CT) and selective hepatic digital subtraction angiography identified a 7.7-cm aneurysm that arose from the pancreaticoduodenal branch of the gastroduodenal artery. Through a percutaneous common femoral approach, 10 stainless steel coils were delivered to occlude the aneurysm. A single coil detached and became lodged in a small branch of the right hepatic artery without sequelae. At 26 months, duplex and CT scans show continued occlusion of the aneurysm.

Conclusions:

Transcatheter coil embolization should be the first choice treatment for aneurysms of the pancreaticoduodenal artery.
Preliminary Experience with the Xtrak Debulking Device in the Treatment of Peripheral Occlusions
Authors: Yoffe Boris , Yavnel Leonty , Altshuler Alexander , Scheinowitz Mickey , Lebovici Octavian
Published: March 2015

Purpose:

To report our initial experience with a new rotary debulking device designed for treating long, diffusely diseased arterial segments.

Methods:

Ten symptomatic patients (8 men; mean age 63 years, range 34–76) with occluded superficial femoral (n = 6) or popliteal (n = 4) arteries were enrolled into a study to evaluate the debulking capabilities of a rotational atherectomy device. Occlusion length ranged from 4.0 to 16.1 cm (mean 11.1 ± 4.10). The occlusions were treated with a low-speed, over-the-wire rotary device featuring a flexible, spiral “corkscrew” that embeds itself in the obstructive material while a rotary cutting catheter simultaneously cuts and captures the obstruction in a single pass.

Results:

The device cut and retrieved material in a single pass from all segments without device-related complications. The captured material consisted of a mixture of atherosclerotic plaque and thrombus. Minimum lumen diameters (MLD) increased from 0.0 to 2.2 ± 1.09 mm (p<0.05) after Xtrak treatment and to 4.09 ± 1.20 mm (p<0.05) after adjunctive balloon dilation, which was used in 8 of 10 segments. All patients improved clinically after the procedure, with an increased the mean ankle-brachial index sustained at 6 months (0.69 ± 0.32, p<0.05 compared to baseline and 1-month measurements). Six months after the procedure, 7 patients remained free of clinical symptoms, while 3 patients required a subsequent intervention.

Conclusions:

These initial results demonstrate that the Xtrak device can safely debulk long segments of diffusely diseased arteries in a single pass while simultaneously retrieving the occluding material. Supplementary angioplasty may be required in the majority of cases. Larger studies are required to determine whether debulking followed by balloon dilation improves the long-term prognosis in patients with chronic lower limb occlusions.
Open versus Endovascular AAA Repair in Patients Who are Morphological Candidates for Endovascular Treatment
Authors: Hill Bradley B. , Wolf Yehuda G. , Lee W. Anthony , Arko Frank R. , Olcott Cornelius , Schubart Peter J. , Dalman Ronald L. , Harris E. John , Fogarty Thomas J. , Zarins Christopher K.
Published: March 2015

Purpose:

To compare the outcomes of open versus endovascular repair of abdominal aortic aneurysm (AAA) in a cohort of patients who fulfill morphological criteria for endovascular repair.

Methods:

A retrospective review of 229 consecutive AAA patients treated over a 3-year period identified 149 patients who were candidates for endovascular repair based on preoperative computed tomography and angiography. Of the 149 patients, 79 (68 men; mean age 74 ± 8 years) underwent endovascular repair with the AneuRx stent-graft; the remaining 70 (56 men; mean age 72 ± 8 years) had open repair. Short-term outcome measures were 30-day mortality and procedure-related morbidity, length of stay in the intensive care unit and hospital, intraoperative blood loss, interval to oral diet, and time to ambulation. Long-term outcome measures included death and secondary procedures.

Results:

There was no difference in the 30-day mortality between endovascular repair (2, 2.5%) and open repair (2, 2.9%), even though endovascular patients had more comorbidities (p<0.05). Overall length of stay was reduced for endovascular patients (3.9 ± 2.4 days versus 7.7 ± 3.1 days for surgical patients, p<0.0001). Fewer endograft patients had complications (24% versus 40% for open repair, p<0.05), and the severity of these complications was less, as evidenced by the shorter hospital stays for endovascular patients with complications compared to conventionally treated patients with complications (6.7 ± 2.4 days versus 22.5 ± 35.2 days, p<0.05). There were no aneurysm ruptures or late surgical conversions in either group.

Conclusions:

Patients with AAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. Despite increased comorbidities in the endograft patients, there was no increase in mortality compared to open repair. Both treatments required secondary procedures and appeared to be equally effective in preventing aneurysm rupture up to 3 years.
Learning Curve for Endovascular Abdominal Aortic Aneurysm Repair: Evaluation of a 277-Patient Single-Center Experience
Authors: Lobato Armando C. , Rodriguez-Lopez Julio , Diethrich Edward B.
Published: March 2015

Purpose:

To determine the minimum number of stent-graft deployments that an interventional team with endovascular skills must do to be considered well trained in endovascular abdominal aortic aneurysm (AAA) exclusion.

Methods:

The records of 277 consecutive patients (236 men; median age 73 years, range 49–91) undergoing endovascular AAA repair at a single institution between 1994 and 1998 were reviewed. Information was collected on procedural success, conversion, time interval between procedures, operative complications, operative mortality, contrast volume, blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS. A first-order differential equation was used to calculate a learning curve based on the success rate. Patients were subsequently divided into 5 sequential groups of 55 patients (the last group had 57 patients).

Results:

Analyzing the pattern of procedural success to failures, a sharp change in the slope was observed between 50 and 65 trials. The number 55 was arbitrarily chosen to represent the point after which the incremental change in the success rate never exceeded 0.01 (<1 failure per 100 attempts). In the intergroup comparisons, success rate (p<0.04), conversion rate (p<0.0001), and procedural frequency (p<0.0001) were statistically significant when the first 55-patient group was compared to the others. Operative complications (p=0.08) and operative mortality (p=0.16) were numerically but not significantly different. Contrast volume was significantly reduced for the last group (p<0.0001). A Cox regression model identified only procedural frequency (p=0.03) and procedural volume (p=0.04) as predictive of technical success. Performing endovascular AAA repairs at a ≤10-day interval was associated with a >80% success rate.

Conclusions:

This study shows that not only is the number of procedures important to outcome, but also the frequency with which they are performed. Based on our team's performance data, 55 cases would appear to be the minimum volume and 1 case every 10 days the minimum frequency to obtain good operative results with aortic endografting.
Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms
Authors: Hinchliffe Robert J. , Macierewicz Jan A. , Hopkinson Brian R.
Published: March 2015

Purpose:

To report a single-center experience with endovascular repair of inflammatory abdominal aortic aneurysm (IAAA), with particular attention to the fate of the aneurysm sac, perianeurysmal fibrosis (PAF), and renal function.

Methods:

A retrospective review of 350 patients undergoing endovascular aortic aneurysm repair during a 7-year period at University Hospital, Nottingham, identified 14 (4%) cases of IAAA confirmed either on preoperative spiral computed tomography (CT) or at laparotomy in attempted open aneurysm repair. All data were reviewed from a prospectively maintained database, hospital notes, and serial CT studies.

Results:

Endovascular repair was successfully completed in all 14 IAAA patients, but 2 (14%) died in the perioperative period. One patient referred from another center was lost to imaging follow-up, leaving 11 patients who were followed for a mean 29 months (range 1–73). All 11 IAAAs remained excluded, but 1 patient required a secondary transabdominal intervention for a type III endoleak. There was no CT evidence of PAF progression in any patient. Postoperative renal complications were not encountered where there had been none preoperatively.

Conclusions:

IAAA may be successfully excluded by the endovascular technique, and EVAR is particularly useful where open repair has failed. The impact of endograft placement on perianeurysmal fibrosis is less clear. In this study, there was no suggestion that the degree of PAF worsens following endovascular repair.
Endovascular Exclusion of Saccular AAAs Using “Stacked” AneuRx Aortic Cuffs
Authors: York John W. , Sternbergh W. Charles , Lepore Michael R. , Yoselevitz Moises , Money Samuel R.
Published: March 2015

Purpose:

To show that AneuRx aortic cuffs might be used in a “stacked” configuration to effectively treat saccular abdominal aortic aneurysm (AAA).

Methods:

In a recent 1-year period, 147 patients underwent endovascular AAA repair. Of these, 5 (4 men; mean age 61.6 years, range 55–69) had saccular AAAs with a mean diameter of 3.7 ± 0.2 cm (range 3.0–4.7). AneuRx aortic cuff prostheses (3.75-cm length) were deployed sequentially in these 5 patients via a right femoral approach; the devices were overlapped ∼1.5 to 2.0 cm until complete exclusion of the aneurysm was achieved. Endograft surveillance was performed using computed tomography at 4 weeks postoperatively and then every 6 months.

Results:

Successful exclusion of the saccular infrarenal aortic aneurysms was achieved in all 5 patients using 2 or 3 “stacked” stent-graft extensions. Four of the 5 procedures were performed under spinal anesthesia; the average procedural time was 96 ± 41 minutes. The average hospital length of stay was 1.6 days; no major morbidity or mortality was encountered. There were no early or late endoleaks, aneurysm expansion, or device migration over a follow-up that ranged to 12 months.

Conclusions:

Saccular AAA provides ideal anatomy for endovascular repair with a “tube” endograft. “Stacked” aortic cuffs create a customized stent-graft that is not otherwise commercially available.
A Laparoscopic Approach to the Abdominal Aorta for Thoracic Stent-Graft Deployment: Evaluation in a Porcine Model
Authors: Formichi Maxime , Renier Jean-François
Published: March 2015

Purpose:

To develop laparoscopic techniques for aortic stent-graft placement as an alternative to the femoral approach.

Methods:

Endovascular stent-grafts were placed in 8 pigs via a totally laparoscopic retroperitoneal approach. After needle puncture, a guidewire was inserted into the abdominal aorta, followed by an 18-F sheath through which a Talent stent-graft was deployed in the descending thoracic aorta without aortic clamping. All the endovascular tools were inserted into the retroperitoneal area via the ports. After the sheath was withdrawn, hemostasis was achieved by suturing the aortic puncture under aortic cross-clamping. After sacrificing the animals, the thoracic aorta was removed to verify the position and deployment of the stent-grafts.

Results:

Seven (87.5%) of 8 procedures were successfully completed; the first animal died from hemorrhage due to inadvertent injury to the posterior infrarenal aortic wall. The accurate deployment and position of the stent-grafts were verified visually after sacrifice. Mean (± SD) procedural, implantation, and aortic cross-clamping times were 205 ± 56, 22 ± 9, and 30 ± 19 minutes, respectively. Mean blood loss was 120 ± 56 mL.

Conclusions:

Thoracic aortic stent-grafting using a laparoscopic approach to the infrarenal aorta is feasible. More studies will be required to define the place of combined endovascular and laparoscopic procedures as an alternative to the femoral surgical approach for stent-graft placement.
Diameter of Occluded Superficial Femoral Arteries Limits Percutaneous Recanalization: Preliminary Results
Authors: Kröger Knut , Buss Carsten , Goyen Matthias , Santosa Frans , Rudofsky Gottfried
Published: March 2015

Purpose:

To explore if the diameter of an occluded superficial femoral artery (SFA) can predict the technical success of percutaneous recanalization.

Methods:

Two hundred patients (151 men; mean age 57 ± 16 years) suffering from peripheral arterial occlusive disease were evaluated with duplex ultrasonography to measure arterial diameters and percent diameter reduction. Seventy-nine (39.5%) patients had segmental or complete SFA occlusions that ranged in age from 2 to 26 months (median 11). The majority of occlusions (45, 57.0%) were ≤10 cm long (range 10–35). Percutaneous recanalization was performed in 71 patients using either conventional angioplasty or local low-dose thrombolysis with rtPA.

Results:

Diameters of 79 unilaterally occluded SFAs at the level of occlusion were 4.5 ± 1.4 mm versus 5.7 ± 1.3 mm for the patent contralateral artery (p=0.055). None of the 121 patent SFAs had diameters ≤3.5 mm, but 12 (15%) of the 79 occluded SFAs did, and none of these could be recanalized. The sensitivity of the 3.5-mm cut point to predict recanalization failure was 44% (specificity 100%).

Conclusions:

Our data suggest that occluded SFAs with a diameter reduction to ≤3.5 mm are not suitable for percutaneous recanalization, as the original arterial lumen cannot be reconstructed.
Midterm Follow-up of Balloon-Expandable ePTFE Endografts in the Femoropopliteal Segment
Authors: Hagenaars Tjebbe , Gussenhoven Elma J. , Smeets Luuk , Moll Frans L. , Buth Jacob , Nevelsteen Andre , van Dijk Lukas C. , van Sambeek Marc R.H.M. , van Urk Hero
Published: March 2015

Purpose:

To evaluate the midterm clinical outcome of patients treated with a balloon-expandable polytetrafluoroethylene (ePTFE) endograft for long-segment occlusive disease of the femoropopliteal segment.

Methods:

Eighty-nine patients (68 men; median age 69 years, range 43–81) with disabling claudication (n=73) or critical ischemia (n=16) were treated with an ePTFE endograft (mean length 29 cm) for 7 stenosis (mean length 9 cm) and 82 occlusions (mean length 19 cm) in the femoropopliteal segment. The follow-up protocol included Doppler ankle-brachial pressure measurement and duplex scanning or angiography of the endograft at 6-month intervals. Primary and secondary patency rates were analyzed.

Results:

At the last examination, the endograft was patent in 52 patients (median 17 months, range 7–50) and occluded in 35 (median 7 months, range 0–40);2 patients died of nonvascular causes with a patent endograft at 6.5 and 7 months. At follow-up, the primary and secondary endograft patency rates were 71% and 83% at 6 months, 57% and 69% at 1 year, 45% and 49% at 2 years, and 30% and 44% at 3 years, respectively.

Conclusions:

The midterm success of this new ePTFE endograft is limited; therefore, the device needs to be refined if this minimally invasive technique is to compete with conventional bypass surgery.