bluuebunny/crossref_metadata_2025 huggingface dataset:
Heparin-Induced Thrombocytopenia and Graft Thrombosis following Endovascular Aneurysm Repair
Authors: Chuter Timothy A.M. , Pak Laura K. , Gordon Roy L. , Reilly Linda M. , Messina Louis M.
Published: March 2015

Purpose:

To report a case of heparin-induced thrombocytopenia (HIT) complicated by stent-graft thrombosis.

Case Report:

An 82-year-old woman underwent endovascular aortic aneurysm repair using a Zenith stent-graft. She returned 2 weeks later with an occluded graft limb, large quantities of thrombus lining the remainder of the stent-graft, thrombocytopenia, and antiplatelet antibodies. There were no signs of kinking or compression of the graft, nor was there any thrombosis of the native arteries downstream from the occluded graft limb. Thrombolysis restored graft patency. Anticoagulation was induced using hirudin and warfarin. The graft remains patent at 6-month follow-up.

Conclusion:

HIT is a rare cause of postoperative endograft thrombosis. In this case, the presumed source of the inciting heparin dosage was the stent-graft itself, which had been soaked in a concentrated heparin solution prior to insertion.
Endotension is Influenced by Aneurysm Volume: Experimental Findings
Authors: Gawenda Michael , Winter Stefan , Jaschke Gregor , Wassmer Gernot , Brunkwall Jan
Published: March 2015

Purpose:

To investigate in an in vitro model whether and to what extent pressure is influenced by aneurysm size.

Methods:

Latex aneurysms of 3 different volumes (24, 30, and 81 mL) were inserted into an in vitro circulation model. The systemic mean pressure (SPmean) was varied from 50 to 120 mmHg. The aneurysms were excluded using a woven polyethylene graft. Aneurysm sac mean pressure (ASPmean) was measured.

Results:

In the in vitro model, endovascular aneurysm repair created a closed chamber without endoleak but showed a relevant aneurysm sac pressure. At an SPmean of 80 mmHg, the ASPmean was 42.0 ± 0.6 mmHg in the 24-mL aneurysm, 40.5 ± 0.5 mmHg in the 30-mL model, and 19.3 ± 0.5 mmHg in the 81-mL aneurysm (p < 0.05). The ASPmean rose with increasing SPmean and was inversely dependent on the aneurysm volume.

Conclusions:

This in vitro model demonstrated that the sac mean pressure correlated to the systemic pressure and that a greater aneurysm volume reduced aneurysm sac pressure. These data highlight the need for further studies regarding endotension.
Non-Axisymmetrical (Life-Like) Abdominal Aortic Aneurysm Models: A Do-It-Yourself Approach
Authors: Chaudhuri Arindam , Ansdell Leslie E. , Richards Robin , Adiseshiah Mohan , Grass Anthony J.
Published: March 2015

Purpose:

To construct life-like non-axisymmetrical abdominal aortic aneurysm models from latex.

Technique:

A computed tomographic 3-dimensional reconstruction of an actual abdominal aortic aneurysm was cast in plastic to provide a core for a “chemical metal” mould. The mould was then coated with nonadhesive prevulcanized dipping latex and cured to provide an idealized hollow reconstruction of the aneurysm.

Conclusions:

Chemical metal can be manipulated quite easily to make a mould of any required size or surface character, which then allows the manufacture of a well-matched latex model for biophysical studies of non-axisymmetrical abdominal aortic aneurysms.
Vascular Occlusion by Ruptured Balloon after Percutaneous Transluminal Angioplasty
Authors: Gahlen Johannes , Koeppel Thomas , Prosst Ruediger L.
Published: March 2015

Purpose:

To report a rare case of chronic vascular occlusion by an undetected ruptured balloon fragment following percutaneous transluminal angioplasty.

Case Report:

A 79-year-old man suffered from calf claudication 1 year after angioplasty for a short stenosis in the superficial femoral artery. During the femoropopliteal bypass operation, a ruptured angioplasty balloon was retrieved.

Conclusions:

Endovascular treatment of arterial lesions always requires thorough pre and postinterventional check of the applied instrumentation. A damaged catheter must initiate an immediate search for lost intravascular objects.
Diagnostic Value of CT Virtual Intravascular Endoscopy in Aortic Stent-Grafting
Authors: Sun Zhonghua , Winder R. John , Kelly Barry E. , Ellis Peter K. , Kennedy Peter T. , Hirst David G.
Published: March 2015

Purpose:

To investigate the diagnostic value of postprocessing techniques for 3-dimensional (3D) computed tomography (CT), with emphasis on CT virtual intravascular endoscopy (VIE), in patients with abdominal aortic aneurysms (AAA) treated with suprarenal stent-grafts.

Methods:

The preprocedural and postprocedural CT datasets from 47 AAA patients (40 men; mean age 75 years, range 61–87) undergoing aortic stent-grafting with suprarenal fixation were examined. The CT datasets were processed to create various 3D reconstructions: shaded surface display (SSD), maximum intensity projection (MIP), and VIE. Three independent radiologists assessed various diagnostic parameters for each 3D reconstruction method and compared them to axial CT images.

Results:

Scores for VIE reconstructions were inferior to axial CT images in the visualization of normal arterial branches, measurement of the aneurysm diameter and neck length, as well as assessment of vessel patency and presence of endoleaks. VIE was rated superior to axial CT and other 3D imaging methods in visualizing the configuration of stent struts relative to the aortic branch ostia and the number of stent wires crossing the ostia in >80% of cases.

Conclusions:

VIE was not found to play a role in most preoperative situations compared to axial CT images. However, VIE provided additional postgrafting information on the 3D relationship of the suprarenal stent struts to the aortic branch ostia (in particular the renal and superior mesenteric arteries). VIE findings might aid clinicians in accurately assessing the effect of suprarenal stent-grafting on the renal arteries.
Carotid Stenting for Radiation-Induced Extracranial Carotid Artery Occlusive Disease: Efficacy and Midterm Outcomes
Authors: Ting Albert C.W. , Cheng Stephen W.K. , Yeung Kai-Ming Au , Cheng Pui-Wai , Lui Wai-Man , Ho Pei , Tso Wai-Kuen
Published: March 2015

Purpose:

To investigate the immediate and midterm results of carotid stenting for severe radiation-induced extracranial carotid artery disease.

Methods:

Between April 1998 and May 2002, 16 patients (15 men; mean age 64±8 years, range 48–72) presented with 18 severe radiation-induced carotid stenoses in the internal carotid artery (n=3), common carotid artery (n=7), and both vessels (n=8). Thirteen (76%) patients were symptomatic; the mean degree of carotid stenosis was 85%±10% (range 70%–95%). An independent neurological specialist assessed perioperative neurological complications before and after treatment. The patients were followed prospectively for at least 12 months by clinical examination and serial duplex ultrasound scanning. Restenosis was defined as a diameter reduction >50%.

Results:

Of 18 stent procedures attempted (2 staged), 1 was abandoned owing to failure to pass the guidewire across a tight lesion (94% technical success by intent to treat). In the 17 successfully completed procedures, 17 Wallstents and 4 SMART stents were deployed with satisfactory anatomical results. One postoperative stroke occurred as a result of thromboembolism to the ipsilateral middle cerebral artery and led to hospital death (5.9% combined stroke and death rate). One transient ischemic attack occurred (11.6% neurological event rate). With a median 30-month follow-up (range 5–55), 3 (17.6%) recurrent stenoses (>50%) were detected on duplex scan; 1 repeat angioplasty was performed. No new neurological event has been detected.

Conclusions:

Carotid stenting may be performed in patients with irradiation-induced carotid stenosis with acceptable risks and midterm durability.
Comparison of Surgical versus Endovascular Occlusion Models in Pig Femoral Arteries
Authors: Engelmann Markus G. , Shimizu Masumi , Pelisek Jaroslav , Fuchs Alexandra , Golda Adam , Mekkaoui Choukri , Fraunberger Peter , Rolland Pierre H. , Nikol Sigrid
Published: March 2015

Purpose:

To compare an endovascular technique with a well established surgical approach to achieve long-term occlusions of large porcine arteries while preserving the integrity of periarterial tissue.

Methods:

The femoral arteries in 11 pigs were occluded using surgical techniques on one side and blinded stent-grafts in the contralateral vessel. Feasibility, safety, primary and long-term success, and the extent of vascularization were determined over a 3-month period by conventional angiography and histological analysis. A subgroup of animals (n=5) was treated with a locally administered plasmid coding for vascular endothelial growth factor (pVEGF165) to compare both occlusion techniques under conditions of collateral growth induction.

Results:

The primary and long-term success rates for both occlusion models were 100%. Surgical occlusion of arteries resulted in a significant amount of scar dehiscence and local groin infection compared to the endograft-occluded side. There was no significant difference in capillary densities and collateralization of periarterial areas in a comparison of the occlusion technique: the cross-sectional area of the superficial femoral artery (SFA) was 300±24 mm2 for endovascular occlusion versus 320±23 mm2 for surgical occlusion (p=0.559). In the profunda femoris artery, respective values were 418±35 and 448±18 mm2 (p=0.474). The local delivery of pVEGF165 resulted in a significant increase in collateral growth in both occlusion models with comparable neovascularization: cross-sectional SFA area increased from 310±16 to 428±13 mm2 (p<0.0001); in the PFA, the area increased from 422±19 to 658±49 mm2 (p<0.0001).

Conclusions:

Endovascular arterial occlusions using blinded stent-grafts allow easy and safe creation of long-term occlusions. Previously described collateralization following surgical occlusions was not observed, indicating that those collaterals may be associated with wound healing rather than ischemia. The occlusion of arteries using blinded stent-grafts in pigs may therefore be an appropriate model for assessing the effects of angiogenic factors in vivo.
Endovascular Techniques in the Management of Acute Arterioenteric Fistulas
Authors: Knape Susanne , Van Nieuwenhove Yves , van Tussenbroek Frank , Van den Brande Pierre , Delvaux Georges
Published: March 2015

Purpose:

To report the use of endovascular techniques to emergently treat hemorrhagic complications of rare arterioenteric fistulas.

Case Reports:

Two patients, a 71-year-old man and a 61-year-old woman, presented with acute bleeding arising from primary arterioenteric fistulas. In the first patient, a fistula between the iliac artery and the small intestine complicated laparoscopic treatment of acute appendicitis. In the second patient, irradiation of a metastatic cervical carcinoma led to a fistula between the right iliac artery and the terminal ileum. In both patients, the hemorrhage was controlled with implantation of a Jostent Peripheral Stent-Graft. The man is alive at 3 years with a patent endograft, but the woman died 1 month after treatment from complications of tumor progression.

Conclusions:

Endovascular application of covered stents provides an alternative treatment, avoiding extensive surgery. In cases of neoplastic erosion of a large vessel, endovascular stenting can offer a palliative solution.
Update on Endovascular Treatment of Cerebrovascular Diseases
Authors: Hussain M. Shazam , Qureshi Adnan I. , Kirmani Jawad F. , Divani Afshin A. , Hopkins L. Nelson
Published: March 2015

Several developments in endovascular technology have greatly expanded the application of these techniques to treat extra- and intracranial cerebrovascular diseases. This review explores the indications, techniques, and clinical results for endovascular treatment of ischemic stroke and intracranial stenoses, aneurysms, and arteriovenous malformations.
Management of Abdominal Aortic Aneurysm: A Decade of Progress
Authors: Chuter Timothy A.M. , Parodi Juan C. , Lawrence-Brown Michael
Published: March 2015

Since the world was first introduced to the concept of endovascular aneurysm repair by Parodi's landmark procedures in 1990, stent-grafts have assumed a prominent role in the management of abdominal aortic aneurysm. Most modern systems are trackable, accurate, and secure. The resulting endovascular procedure is safe, durable, effective, and versatile. Perhaps the most significant increment in the applicability of the endovascular technique was achieved by the development of bifurcated stent-grafts, which dispensed with inadequate distal aortic implantation sites. Additional branches and fenestrations now permit endovascular repair in cases of thoracoabdominal, pararenal, juxtarenal, and bilateral iliac aneurysms. These advances in device performance have been accompanied by a rapid dissemination of necessary skills, leading to the development of a new superspecialty of vascular therapy, with elements of vascular surgery, interventional radiology, and interventional cardiology.
Percutaneous Endovascular Therapy of Renal Artery Stenosis: Technical and Clinical Developments in the past Decade
Authors: Zeller Thomas
Published: March 2015

Renal artery stenosis may initiate or exacerbate arterial hypertension and/or renal insufficiency. During the last decade, technical improvements of diagnostic and interventional endovascular tools have led to more widespread use of endoluminal renal artery revascularization and broader indications for this type of therapy. Since the first renal artery angioplasties performed by Felix Mahler and Andreas Grüntzig in 1978, numerous single-center studies have documented the benefits of percutaneous renal revascularization. In the early 1990s, stent implantation was added to the interventionist's armamentarium for treating renal artery stenosis due to atherosclerosis or fibromuscular dysplasia. The metaanalysis of 3 randomized studies comparing balloon angioplasty with best medical therapy found intervention to be beneficial for blood pressure control but not for preservation of renal function. Despite the absence of randomized studies, there is mounting evidence that stenting of hemodynamically relevant atherosclerotic renal artery stenosis has a positive impact on blood pressure control and renal function. This article summarizes the technical improvements in these endovascular tools during the last decade and gives an overview concerning their clinical impact on renal artery revascularization.
An Update on Endovascular Therapy of the Lower Extremities
Authors: Bates Mark C. , AbuRahma Ali F.
Published: March 2015

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.
A History of Thrombolytic Therapy
Authors: Ouriel Kenneth
Published: March 2015

Thrombolytic therapy has been available for the last 5 decades, but the modern era of thrombolysis began in the early 1990s, with the execution of 3 multicenter trials designed to compare this potentially less invasive therapy to the then standard of care for acute limb ischemia, open surgical revascularization. Even with the development of several bioengineered lytic agents, the major risk of thrombolytic therapy continues to be bleeding complications. Nevertheless, data exist to suggest that thrombolysis should be considered as an adjunct to open surgery, percutaneous interventions, or, occasionally, as sole therapy for acute vascular occlusion. This review summarizes the developmental milestones in the history of thrombolysis and reviews data supporting its use in acute arterial occlusions.
Advances in Vascular Brachytherapy over the Last 10 Years: Focus on Femoropopliteal Applications
Authors: Schillinger Martin , Minar Erich
Published: March 2015

Restenosis and the need for repeated interventions after percutaneous transluminal angioplasty (PTA) remain major drawbacks limiting a widespread application of this minimally invasive technique in the femoropopliteal segment. During the last decade, vascular brachytherapy (BT) emerged as a promising, novel technology with the potential to reduce the rates of restenosis. Meanwhile, several randomized controlled trials have suggested beneficial short and midterm effects of BT in the femoropopliteal arteries. However, despite substantial advances, many questions remain regarding the utility of vascular BT and its dissemination as a practical tool to prevent restenosis. The risk of complications, such as late stent thrombosis, edge effect, catch-up late restenosis, and potential aneurysm formation, as well as the logistical issues associated with the use of this technology in the catheterization laboratory, are delaying the acceptance of BT for routine use. This article reviews the developments of BT for restenosis prevention during the past decade, focusing on implications for peripheral endovascular treatment.
Impact of Gender on the Outcome of Endovascular Aortic Aneurysm Repair Using the Zenith Stent-Graft: Midterm Results
Authors: Hugl Beate , Hakaim Albert G. , Biebl Matthias , Oldenburg W. Andrew , McKinney J. Mark , Nolte Lorraine A. , Greenberg Roy K. , Chuter Timothy A. M.
Published: March 2015

Purpose:

To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft.

Methods:

A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05.

Results:

Overall rates of mortality (12.5% for women versus 13.2% for men, p=0.94) and aneurysm rupture (2.5% for women versus 0% for men, p=0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p=0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p=0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p=0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p=0.10). None of the patients developed device migration .10 mm or required intervention for migration.

Conclusion:

While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.
Computational Fluid Dynamics within Bifurcated Abdominal Aortic Stent-Grafts
Authors: Howell Benjamin A. , Kim Tom , Cheer Angela , Dwyer Harry , Saloner David , Chuter Timothy A. M.
Published: March 2015

Purpose:

To assess the hemodynamic forces on a bifurcated abdominal aortic stent-graft under realistic conditions of flow, blood pressure, and sac pressure.

Methods:

Computational fluid dynamics was used to study the temporal and spatial variations in surface pressure and shear through the cardiac cycle on models of bifurcated stent-grafts derived from computed tomography in 4 patients who had previously undergone endovascular repair of abdominal aortic aneurysm (AAA). The trunk, bifurcation, and limbs of the graft were analyzed separately and as parts of a unified whole. Analyses were repeated under varying conditions of sac pressure, reflecting different conditions of perigraft flow and sac diameter change.

Results:

Pressure-related forces were far larger than flow-related forces in all 3 segments of all 4 cases. The largest forces acted at the bifurcation of the stent-graft. High sac pressures, seen in patients with endoleak or aneurysm dilatation, were associated with reduced transmural pressure and low-pressure—derived forces.

Conclusion:

Several parameters of stent-graft design affect the magnitude and distribution of forces on a bifurcated stent-graft. The forces on a stent-graft are also affected by the pressure within the aneurysm sac, which depends on stent-graft performance.
Results of Thoracic Endovascular Grafting in Different Aortic Segments
Authors: Melissano Germano , Bertoglio Luca , Civilini Efrem , Marone Enrico Maria , Calori Giliola , Setacci Francesco , Chiesa Roberto
Published: March 2015

Purpose:

To compare the results of thoracic endovascular grafting of different aortic segments performed with commercially available stent-grafts.

Methods:

Between January 1999 and October 2006, 178 patients (150 men; mean age 69.4±10.2 years) underwent endovascular grafting of the thoracic aorta (68 hybrid procedures) with commercially produced stent-grafts from 4 manufacturers. Patients were divided into 3 groups according to the aortic segment involved: 64 aortic arch cases (37 hybrids for supra-aortic trunks revascularization), 100 descending thoracic aorta (DTA) cases (17 hybrid: 12 for access and 5 for associated abdominal aortic aneurysm), and 14 thoracoabdominal aorta (TaA) patients excluded from conventional repair (14 hybrids for renal and splanchnic revascularization).

Results:

The technical success was 93.8% (167/178). Overall 30-day mortality was 5.6% (10/178). There were 10 (5.6%) type I endoleaks. Initial clinical success was 88.2% (157/178). At a mean follow-up of 29.3±21.2 months, the midterm clinical success was 89.9% (160/178). In the arch group, the technical success was 85.9% (55/64). Thirty-day mortality was 6.3% (4/64). There were 8 (12.5%) type I endoleaks. Initial and midterm clinical success rates were 79.7% (51/64) and 85.9% (55/64), respectively. In the 100-patient DTA group, the technical success was 98.0%. Thirty-day mortality was 2.0%. The type I endoleak rate was 2.0%. Clinical success was 96.0% initially and 95.0% at midterm. All 14 of the TaA cases were completed successfully, but 30-day mortality was 28.6% (4/14). There were no type I endoleaks. Clinical success rates initially and at midterm were both 71.4% (10/14).

Conclusion:

Over the last 6 years, synergy between endovascular and surgical procedures allowed treatment of all segments of the thoracic aorta. Overall perioperative and medium-term results were reasonably favorable; however, they were more satisfactory when the descending thoracic aorta alone was involved. Hybrid procedures allowed treatment of all aortic segments, but they decreased the success rates significantly. Endovascular grafting is currently our preferred method of treating pathologies involving the DTA and aortic arch, while our data suggest limiting the use of stent-grafts to high-risk patients or compassionate indications when the thoracoabdominal aorta is involved.
Comparison of the Fixation Strength of Standard and Fenestrated Stent-Grafts for Endovascular Abdominal Aortic Aneurysm Repair
Authors: Zhou Samuel S. N. , How Thien V. , Vallabhaneni S. Rao , Gilling-Smith Geoffrey L. , Brennan John A. , Harris Peter L. , McWilliams Richard
Published: March 2015

Purpose:

To determine whether fenestrated stent-grafts provide better stability to resist migration than standard non-fenestrated stent-grafts.

Methods:

Truncated fenestrated stent-grafts with a single fenestration were deployed in bovine aortic segments with a side branch. Balloon-expandable stents were then delivered into the branches. Similarly, standard stent-grafts of the same dimensions were deployed for comparison. The aorta was pressurized to achieve stent-graft oversizing of 5%, 10%, or 20%. The force required to cause distal migration was recorded by a digital force gauge attached to the stent-graft.

Results:

Displacement of the stent-grafts occurred in 2 distinct phases: an initial yield during which the barbs embedded in the aortic wall and a final displacement leading to significant migration and dislodgement of the device. The displacement force that initiated each phase was dependent upon the degree of oversizing of the stent-graft relative to the aortic diameter. For 5%, 10%, and 20% oversizing, the mean displacement forces in the initial displacement phase were 3.39±0.37, 4.32±0.63, and 7.69±1.18 N, respectively, in non-fenestrated grafts and 10.48±1.23, 11.45±1.48, 12.12±1.42 N in fenestrated grafts. The displacement forces in the final displacement phase were 8.10±0.92, 10.76±1.74, and 16.82±0.92 N for non-fenestrated and 22.56±1.60, 28.24±1.56, and 33.01±1.75 N for fenestrated stent-grafts. The differences in displacement forces between standard and fenestrated stent-grafts were significant for both phases (p<0.001) at all oversizing levels.

Conclusion:

Improvement in fixation strength was noted with increasing stent-graft oversizing of up to 20%. Fenestrated stent-grafts offer higher ultimate fixation compared to standard devices. However, the ultimate fixation strength was not recruited until an initial phase of short migration occurred as the barbs engaged. While this movement is inconsequential with standard stent-grafts, it has the potential to crush the stents placed into aortic side branches with fenestrated endografts.
Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak after Endovascular Abdominal Aortic Aneurysm Repair
Authors: Zanchetta Mario , Faresin Francesca , Pedon Luigi , Ronsivalle Salvatore
Published: March 2015

Purpose:

To report a prospective, nonrandomized pilot study to determine whether fibrin glue aneurysm sac embolization at the time of endovascular aneurysm repair (EVAR) is a safe and effective procedure to primarily prevent type II endoleaks.

Methods:

Between June 2003 and December 2005, 84 consecutive patients (79 men; mean age 73.8±7.8 years, range 64–86) with degenerative infrarenal abdominal aortic aneurysm underwent EVAR with bifurcated stent-grafts and fibrin glue injection into the aneurysm sac at the conclusion of the endovascular procedure. A total of 424 imaging studies and 348 visits were recorded during the study period and reviewed.

Results:

Selective catheterization of the aneurysm sac and fibrin glue injection immediately after initial stent-graft deployment was successful in 83 (99%) of 84 cases; there was one failure to access the excluded aneurysm sac due to severe iliac artery calcification. The estimated primary and assisted clinical success rates at 2 years were 91.3% and 98.8%, respectively, but the major findings were the low rate of delayed type II endoleak (2.4%) and the statistically significant decrease in the maximum transverse aneurysm diameter (50.40±6.70 versus 42.03±6.50 mm, p=0.0001) at follow-up. In addition, of 31 patients available for 24-month follow-up, 14 (45.2%) patients showed a reduction in maximum transverse aneurysm diameter by ≥5 mm; 16 (51.6%) patients had no significant changes, whereas only 1 patient showed a >5-mm enlargement.

Conclusion:

This clot engineering approach to aneurysm sac embolization at the time of endografting appears to be safe and may spare the patient a repeated catheter-based intervention or surgical procedure.
Total Percutaneous Endovascular Repair of Abdominal Aortic Aneurysms Using Perclose ProGlide Closure Devices
Authors: Dosluoglu Hasan H. , Cherr Gregory S. , Harris Linda M. , Dryjski Maciej L.
Published: March 2015

Purpose:

To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device.

Technique:

After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90° to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65–85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites).

Conclusion:

We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.
Brain Injury Secondary to Carotid Intervention
Authors: MacDonald Sumaira
Published: March 2015

Causes of brain injury during endovascular carotid intervention are protean. Mechanisms of injury include embolic and hemodynamic events, acute carotid occlusions occurring through a variety of means, and the relatively rare contrast-induced encephalopathy.

Embolic injury may result from micro- and macroembolization and most commonly causes ischemic stroke when sufficiently severe. Hemodynamic injury may proceed from hemodynamic depression and hypoperfusion (which may result in watershed infarction) or the hyperperfusion syndrome, which may, if severe, result in hemorrhagic stroke.

Embolic and dynamic causes of stroke may either occur intraprocedurally or at a variable time after stent placement and may be co-related. Impaired clearance of emboli due to relative hypoperfusion may exacerbate their clinical relevance. Other causes of stroke include acute carotid occlusions, which most commonly occur procedurally due to flow-limiting spasm, acute dissection, and, if a filter-type cerebral protection device has been used, filter occlusion due to a large trapped embolic load. These scenarios may result in stroke if not recognized and dealt with appropriately. Acute stent thrombosis may occur within 24 hours of the procedure as a result of adverse hemodynamic factors or suboptimal patient response to procedural heparin and antiplatelet agents, or it may occur after the procedure, again perhaps as a result of suboptimal response to antiaggregate drugs.
Two-Year Results after Directional Atherectomy of Infrapopliteal Arteries with the SilverHawk Device
Authors: Zeller Thomas , Sixt Sebastian , Schwarzwälder Uwe , Schwarz Thomas , Frank Ulrich , Bürgelin Karlheinz , Pochert Volker , Müller Christian , Noory Elias , Krankenberg Hans , Hauswald Kirsten , Neumann Franz-Josef , Rastan Aljoscha
Published: March 2015

Purpose:

To report the 12- and 24-month results after directional atherectomy (DA) of below-the-knee (BTK) arterial lesions with the SilverHawk device.

Methods:

Forty-nine BTK lesions in 36 patients (58% men; mean age 70611 years) with peripheral occlusive disease of the lower limbs were treated with DA; 19 (53%) of the limbs were classified with Rutherford-Becker 4 or 5 ischemia. Target lesions were in the popliteal artery (n=6, 12%), tibioperoneal trunk (n=25, 51%), peroneal artery (n=10, 20%), anterior tibial artery (n=5, 10%), and posterior tibial artery (n=3, 6%). Nine (18%) lesions were located in a stent. Twelve lesions extended to 2 artery segments. The average degree of diameter stenosis was 89%±10% (range 70%–100%); there were 11 (22%) occlusions. The mean lesion length was 48±28 mm.

Results:

Sixteen (33%) lesions were treated after predilation; 33 (67%) lesions were treated with primary DA. All but 1 (2%) lesion could be treated with DA. In 19 (39%) lesions, additional balloon angioplasty was performed, and 2 (4%) lesions required stent implantation as a result of dissection. The mean stenosis diameter after DA was 12%±18% (range 0%–100%). After additional therapy, the mean stenosis diameter was 8%±9% (range 0%–100%). A residual stenosis ≤30% was achieved in 48 (98%) lesions. The mean ankle-brachial index significantly increased from 0.48±0.26 to 0.81±0.32 (p<0.05) before discharge and remained improved during follow-up. Primary and secondary patency rates were 67% and 91% after 1 year and 60% and 80% after 24 months. The 12-and 24-month cumulative event-free survival rates (primary patency) by Kaplan-Meier analysis were 58%±8% and 46%±9%; at the same time intervals, the cumulative survival rates (secondary patency) were 88%±6% and 73%±9%, respectively.

Conclusion:

BTK lesions can be treated successfully and safely with DA. Midterm clinical results are encouraging.
Sirolimus-Eluting versus Bare Stents after Suboptimal Infrapopliteal Angioplasty for Critical Limb Ischemia: Enduring 1-Year Angiographic and Clinical Benefit
Authors: Siablis Dimitris , Karnabatidis Dimitris , Katsanos Konstantinos , Kagadis George C. , Kraniotis Pantelis , Diamantopoulos Athanassios , Tsolakis John
Published: March 2015

Purpose:

To report the 1-year angiographic and clinical outcome from a prospective single-center study investigating the infrapopliteal application of sirolimus-eluting versus bare metal stents in patients with critical limb ischemia (CLI) who underwent below-the-knee endovascular revascularization.

Methods:

Stenting was performed as a bailout procedure for suboptimal angioplasty results (flow-limiting dissection, elastic recoil, or postangioplasty residual stenosis >30%). In the first 29 patients, infrapopliteal stenting was performed with bare metal stents (group B) and with sirolimus-eluting stents in the other 29 patients (group S).

Results:

Below-the-knee angioplasty and stenting involved 65 lesions in 40 infrapopliteal arteries of 29 limbs in group B and 66 lesions in 41 infrapopliteal arteries of 29 limbs in group S. Baseline comorbidities (hyperlipidemia and symptomatic cardiac and carotid disease) were more pronounced in group S (p<0.05). At 6 months, sirolimus-eluting stents demonstrated significantly higher primary patency (OR 5.625, 95% CI 1.711 to 18.493, p=0.004) and decreased in-stent binary restenosis (OR 0.067, 95% CI 0.021 to 0.017, p<0.001) and in-segment binary restenosis (OR 0.229, 95% CI 0.099 to 0.533, p=0.001). After 1 year, sirolimus-eluting stents were steadily associated with increased primary patency (OR 10.401, 95% CI 3.425 to 31.589, p<0.001) and significantly less in-stent (OR 0.156, 95% CI 0.060 to 0.407, p<0.001) and in-segment (OR 0.089, 95% CI 0.023 to 0.349, p=0.001) binary restenosis. In addition, sirolimus-eluting stents were associated with significantly fewer cumulative target lesion reinterventions at 6 months (OR 0.057, 95% CI 0.008 to 0.426, p=0.005) and 1 year (OR 0.238, 95% CI 0.067 to 0.841, p=0.026). No significant differences between groups B and S were noted at 1 year with respect to mortality (10.3% versus 13.8%, respectively), minor amputation (17.2% versus 10.3%), or limb salvage (100% versus 96%).

Conclusion:

The application of sirolimus-eluting stents reduces the restenosis rate in the infrapopliteal arteries and the rate of repeat endovascular procedures the first year after treatment.
Transfemoral Stent-Graft Placement to Treat a Complication of the Frozen Elephant Trunk Procedure
Authors: Easo Jerry , Dapunt Otto , Natour Ehsan , Hoelzl Philipp , Dangel Gerd , Chavan Ajay
Published: March 2015

Purpose:

To report a novel complication of a hybrid “frozen elephant trunk” endograft used in the treatment of a multisegmentally diseased aorta.

Case Report:

A 53-year-old man with chronic type A aortic dissection and previous replacement of the supracoronary ascending aorta underwent a “frozen elephant trunk” procedure using a hybrid endograft. The stent-graft was placed deep in the descending aorta to cover the multiple distal re-entries. Due to ineffective covering of the re-entries, a patent false lumen led to rapid repressurization of the false lumen immediately distal to the circumferential elephant trunk anastomosis. Compression of the non-stented portion of the hybrid endograft caused a functional aortic stenosis, with severe hemodynamic consequences. Endovascular treatment of the compression by retrograde transfemoral placement of a stent-graft in the non-stented portion of the hybrid endograft achieved free flow in the distal aorta.

Conclusion:

This case documents a new complication of the frozen elephant trunk procedure; a pseudocoarctation from a repressurized proximal false lumen was successfully managed with a stent-graft to support the non-stented segment of the hybrid endograft.
Quality of Life after Balloon Angioplasty versus Stent Implantation in the Superficial Femoral Artery: Findings from a Randomized Controlled Trial
Authors: Sabeti Schila , Czerwenka-Wenkstetten Alfa , Dick Petra , Schlager Oliver , Amighi Jasmin , Mlekusch Irene , Mlekusch Wolfgang , Loewe Christian , Cejna Manfred , Lammer Johannes , Minar Erich , Schillinger Martin
Published: March 2015

Purpose:

To investigate whether primary nitinol stenting in the superficial femoral artery (SFA) is beneficial to patients' quality of life (QoL).

Methods:

One hundred four patients (55 men; mean age 66±19 years) with chronic limb ischemia and SFA disease were randomly assigned to primary stent implantation (n=51) or balloon angioplasty (n=53) with optional stenting for a suboptimal angioplasty result (17 of 53). QoL was measured by the SF-36 questionnaire at baseline and at 3, 6, and 12 months post intervention.

Results:

QoL was significantly improved post intervention and up to 12 months in both treatment groups. Significant inverse associations were observed between QoL parameters and restenosis. Comparing primary stenting (n=51) versus balloon angioplasty with optional stenting (n=53) by the intention to treat, no significant differences in QoL were observed. Analyses of stented patients (n=68) versus balloon angioplasty (n=36) patients, however, demonstrated significantly improved measures of QoL after stenting.

Conclusion:

Endovascular revascularization of SFA disease improves QoL, and restenosis negatively affects QoL outcomes. After stent implantation, whether primary or secondary, QoL was significantly ameliorated compared to balloon angioplasty alone. However, it remains to be proven in larger cohorts whether primary stenting yields a QoL benefit compared to balloon angioplasty with optional secondary stenting.
Subintimal Angioplasty of Infrainguinal Arterial Occlusions for Critical Limb Ischemia: Long-Term Patency and Clinical Efficacy
Authors: Åkesson Michael , Riva Lorenzo , Ivancev Krassi , Uher Petr , Lundell Anders , Malina Martin
Published: March 2015

Purpose:

To evaluate long-term patency and clinical efficacy of subintimal angioplasty (SAP) of occluded infrainguinal arteries 3 years post procedure.

Methods:

One hundred eighty-one patients (92 men; median age 79 years) underwent attempted SAP in 193 limbs with occluded infrainguinal arteries during the period 1999 to 2001. Nearly half (83, 46%) of the patients had diabetes. Most (172, 95%) had critical ischemia (Fontaine classification >II). All patients surviving at least 3 years after the procedures were followed in January 2005 with questionnaires, clinical examinations, ankle-brachial index measurements, and duplex ultrasonography. All data were collected prospectively and analyzed retrospectively.

Results:

The primary technical success in the entire cohort was 77% (148/193). Thirty-day mortality was 10% (19/181); 113 (62%) patients died before the 3-year follow-up. In the 68 (38%) survivors (71 limbs), patency at 49.2 months (IQR 40.8–57.6) was 40% (26/65 limbs imaged by duplex). The TASC classification did not affect technical or clinical outcomes. Forty-six (68%) of the survivors presented with clinical improvement (lower Fontaine classification at postoperative follow-up versus baseline). The limb salvage at >3 years was 86% in the 58 primarily successful SAPs and 38% in the 13 procedures that failed initially.

Conclusion:

SAP is a minimally invasive option for patients with critical limb ischemia. A primary technical success is essential for good clinical outcome and primary technical failure is more devastating than late occlusion. TASC classification and length of the SAP are of poor predictive value. More data are needed to confirm the efficacy of SAP.
Duplex Sonography versus Angiography for Assessment of Femoropopliteal Arterial Disease in a “Real-World” Setting
Authors: Schlager Oliver , Francesconi Marcel , Haumer Markus , Dick Petra , Sabeti Schila , Amighi Jasmin , Mlekusch Wolfgang , Koppensteiner Renate , Minar Erich , Schillinger Martin
Published: March 2015

Purpose:

To evaluate the agreement of duplex ultrasound (DUS) versus digital subtraction angiography (DSA) for assessment of femoropopliteal arterial disease in a real-world clinical setting.

Methods:

Consecutive patients with peripheral artery disease who were scheduled for a percutaneous intervention were included in this retrospective study. During an 18-month period, 491 patients (276 men; median age 73 years, interquartile range 64–81) were enrolled. A peak systolic velocity ratio (PSVR) >2.4 was the optimal cutoff for detecting a >50% stenosis by DSA. Findings of preprocedural DUS in the proximal, middle, and distal ipsilateral superficial femoral artery and in the popliteal segment were analyzed for agreement with preprocedural femoropopliteal DSA using kappa statistics. Only the target limb in each patient was analyzed, for a total of 1964 vascular segments.

Results:

Agreement for the degree of stenosis in 10% increments was only moderate (weighted kappa 0.67, 95% CI 0.65 to 0.69). Using the PSVR >2.4 cutoff, agreement between DUS and DSA for a >50% stenosis was good (kappa 0.79, 95% CI 0.77 to 0.81). Sensitivity, specificity, positive predictive value, and negative predictive value for correctly detecting a >50% stenosis by DUS were 0.81 (0.78 to 0.84), 0.93 (0.91 to 0.94), 0.84 (0.81 to 0.87), and 0.91 (0.87 to 0.95), respectively. Comparable findings were observed within different patient subgroups.

Conclusion:

Agreement between DUS and DSA in the femoropopliteal segment is only moderate with respect to the absolute degree of stenosis. However, detection of a >50% stenosis can be done with acceptable precision in routine clinical practice using PSVR >2.4 as a threshold.
Angiographic Analysis of Intravascular Thrombus Volume in Patients with Acute Ischemic Stroke
Authors: Qureshi Adnan I. , Alkawi Ammar , Hussein Haitham M. , Divani Afshin A.
Published: March 2015

Purpose:

To investigate the role that intravascular thrombus volume plays in mechanical thrombectomy and dose-titrated algorithms using pharmaceutical thrombolytic therapies.

Methods:

The angiographic studies of 33 consecutive patients (19 women; mean age 66±11 years) who underwent endovascular treatment for acute ischemic stroke were reviewed. A double-injection technique was utilized that involved 2 catheters for simultaneous injection of contrast proximal and distal to the thrombus to delineate its boundaries. The thrombus volume was calculated using the formula for cylindrical objects after measuring its length and diameter.

Results:

The volume of the 36 thrombi measured in the study group was 46±59 mm3. The mean length and diameter were 10±6 and 2±1 mm, respectively. The time between symptom onset and acquisition of angiographic images ranged from 167 to 589 minutes (mean 336±109). In a multivariate analysis, thrombus volume was not associated with any recanalization (odds ratio 2.4, 95% CI 0.02–191) after adjusting for initial occlusion grade, time between symptom onset and angiography, and previous intravenous use of thrombolytic agents. Volume capacities for retrieval devices to retain 50% and 75% of the thrombi were estimated as 29.2 mm3 and 55.3 mm3, respectively.

Conclusion:

The large variation in thrombi volume must be considered in designing retrieval devices to optimize their performance.
CT Angiography of Stented Carotid Arteries: Comparison with Doppler Ultrasonography
Authors: Kwon Bae Ju , Jung Cheolkyu , Sheen Seung Hun , Cho Jae Hoon , Han Moon Hee
Published: March 2015

Purpose:

To determine whether computed tomographic angiography (CTA) is a feasible modality for assessing stented carotid arteries and whether in-stent restenosis based on CTA concurs with ultrasonography (US).

Methods:

A retrospective review was conducted of 37 follow-up CTA and US images from 27 patients (23 men; median age 70 years, range 56–77) who received 34 nitinol carotid stents. CTA and US images were compared with respect to assessability and percent stenosis. Both visual estimation (≥50% or not) and the NASCET method were used to determine percent stenosis in CTA images. For US, a determination of ≥50% stenosis was based on peak systolic velocity (≥200 cm/s) and an internal carotid artery to common carotid artery ratio ≥2.5. Percent stenosis values by CTA were also compared to values (n=7, 21%) determined by catheter angiography.

Results:

CTA and US images were “totally assessable” in 27 (73%) and 15 (41%), “totally non-assessable” in 0 (0%) and 3 (8%), and “partially assessable” in 10 (27%) and 19 (51%), respectively. Assessability of CTA images was equal to or better than that of US images in 33 (89%). The percent stenoses by CTA and US were comparable in 20 cases. CTA found ≥50% stenosis using the NASCET method in 4 of 20 stents; none of these showed ≥50% stenosis by visual estimation of CTA or by spectral Doppler US. Compared with catheter angiography, CTA overestimated percent stenosis from 34% to 66% (mean 53%). US confirmed 2 angiographically proven restenoses, but CTA identified only 1.

Conclusion:

CTA provides better image quality for stented carotid arteries than US, but it might be inferior to US in determining restenosis in assessable cases. Therefore, CTA is likely to be an alternative to US in cases of non-assessability. A large-scale study including more restenosis cases is warranted to reveal which modality is more reliable for diagnosis of restenosis.