bluuebunny/crossref_metadata_2025 huggingface dataset:
Can Preoperative Spiral CT Scans Alone Determine the Feasibility of Endovascular AAA Repair? A Comparison to Angiographic Measurements
Authors: Shin Chung K. , Rodino William , Kirwin Jon D. , Wisselink Willem , Abruzzo Fredrick M. , Panetta Thomas F.
Published: March 2015

Purpose:

To determine whether computed tomography (CT) alone can be used for excluding patients from endovascular repair for abdominal aortic aneurysms (AAA).

Methods:

Among 71 patients evaluated for endovascular AAA repair using spiral CT imaging and angiography, 31 were selected who had both studies performed within 6 months of each other using a graduated measuring catheter or guidewire. Measurements of aneurysm neck diameter, neck length, and infrarenal aortic length were made from the CT and angiographic images using handheld calipers with calibration markers as guides. Infrarenal aortic length and neck length were determined from CT images by multiplying the width of the cuts by the number of slices between the lowest renal artery and the aortic bifurcation or the top of the aneurysm, respectively.

Results:

CT neck diameter measurements differed significantly from the angiographic dimensions (6.3 ± 5.1-mm mean difference, p < 0.001). In the majority of patients (25, 81%), CT neck diameters were larger (mean 7.3 ± 3.8 mm). The mean difference in neck length measurements was 0.5 ± 15.9 mm (p = NS). Twenty-two (71%) patients had aortic length measurements that were longer on the angiogram (mean 15.4 ± 17.2 mm, p = NS). Five patients who would have been excluded as candidates based on overestimated CT neck diameter measurements subsequently underwent successful endovascular aneurysm repair.

Conclusions:

Considerable discrepancies exist between preoperative neck diameter and infrarenal aortic length measurements obtained from CT scans and angiograms used to evaluate candidates for endovascular aortic aneurysm repair. CT alone may not be adequate for predicting the feasibility of endovascular AAA repair.
A Narrow-Waisted Abdominal Aortic Aneurysm Complicating Endovascular Repair
Authors: Heijmen Robin H. , Nolthenius Rudolf P. Tutein , van den Berg Jos C. , Overtoom Tim Th.C. , Moll Frans L.
Published: March 2015

Purpose:

To present a case in which a narrow waist in an abdominal aortic aneurysm (AAA) complicated endovascular repair using a modular bifurcated stent-graft.

Methods and Results:

A 68-year-old man underwent endovascular repair of a 5.9-cm asymptomatic AAA with a self-expanding modular bifurcated stent-graft. After insertion and deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected incomplete deployment of the contralateral iliac limb due to a narrow waist in the aortic aneurysm. Subsequent angioplasty did not increase iliac stent-graft diameter. At follow-up, a tapered course of the contralateral iliac leg persisted, without hemodynamic significance.

Conclusions:

A narrow waist in an AAA may be considered an additional important anatomical characteristic in assessing suitability for endovascular repair.
Endovascular Treatment of Atherosclerotic Lower Limb Lesions Using a PTFE-Collared Stent-Graft
Authors: Lundquist Per Birger , Kalin Bo , Olofsson Pär , Swedenborg Jesper
Published: March 2015

Purpose:

To assess the feasibility of a polytetrafluoroethylene-collared (PTFE) endoluminal graft in the treatment of lower limb atherosclerosis.

Methods:

We designed an endograft using a 3-mm-diameter balloon-expandable PTFE graft with terminal Palmaz stents placed on the outside of the graft, folding the PTFE back over the stents to form a collar at each end. Under protocol, this device was implanted in 8 symptomatic patients with lower limb ischemia. The lesions, ranging from 4 to 20 cm long, were located in the superficial femoral artery (n = 5), femoropopliteal segment (n = 1), and common (n = 1) and external (n = 1) iliac arteries. The device required a 14-F introducer system.

Results:

Graft lengths varied from 4 to 35 cm. Implantation was successful in all cases, but procedural complications occurred in 4 patients (2 access site hematomas, 1 leading to endograft occlusion; 1 arterial injury, and 1 distal thromboembolism). At a mean 14-month follow-up, 5 endografts were patent (2 after reintervention for restenosis or thrombosis). The common iliac endograft and 2 superficial femoral artery devices occluded after 3, 2, and 12 months, respectively.

Conclusions:

Although this endoluminal graft system is technically feasible and showed encouraging intermediate-term patency in a small pilot study, the early and late complications identified several shortcomings of this design, which needs refinement.
Stent-Graft Treatment for Bleeding from a Presumed Aortoenteric Fistula
Authors: Grabs Anthony J. , Irvine Craig D. , Lusby Robert J.
Published: March 2015

Purpose:

To describe a technique for the endovascular treatment of aortoenteric fistula.

Methods and Results:

A 67-year-old man who had undergone aortobi-iliac grafting for aneurysmal disease 8 years previously presented with life-threatening upper gastrointestinal hemorrhage. Endoscopy after resuscitation did not identify the source of the bleeding. Computed tomographic (CT) scanning and angiography revealed pseudoaneurysm formation at the upper anastomosis 1 cm below the renal arteries. Measurements were taken for endovascular repair. Uncomplicated emergency aortic endografting for exclusion of the pseudoaneurysm was performed using a 28-mm × 3.75-cm AneuRx device. Gastrointestinal hemorrhage ceased. CT scanning at 6 months confirmed the absence of a pseudoaneurysm, and the patient remains symptom free at 18 months.

Conclusions:

Endovascular treatment of aortoenteric fistula may represent a technique for treating gastrointestinal hemorrhage and for lessening the morbidity and mortality of open repair.
Endovascular Repair of an Innominate Artery False Aneurysm following Blunt Trauma
Authors: Axisa Benedict M. , Loftus Ian M. , Fishwick Guy , Spyt Tom , Bell Peter R. F.
Published: March 2015

Purpose:

To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma.

Methods and Results:

A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months.

Conclusions:

This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.
Aortic Stent-Grafts in Patients with Renal Transplants
Authors: Sawhney Rajiv , Chuter Timothy A. M. , Wall Susan D. , Reilly Linda M. , Kerlan Robert K. , Canto Catherine J. , Jean-Claude Jessie , Faruqi Rishad M.
Published: March 2015

Purpose:

To report the endovascular treatment of abdominal aortic aneurysms (AAA) in 2 patients with pelvic renal transplants.

Methods and Results:

Two men with multiple comorbidities and pelvic transplant kidneys underwent endovascular AAA repair using an aortomonoiliac system with femorofemoral bypass grafting. The arterial end-to-side anastomosis in both patients was to the external iliac artery. Tapered aortomonoiliac grafts were fashioned from Gianturco Z-stents covered with Dacron graft material and implanted with the distal attachment site in the iliac system ipsilateral to the transplant kidney arterial anastomosis. The body of the stent-graft was reinforcement with a Wallstent in each case before the contralateral common iliac artery was occluded and the cross-femoral bypass constructed. Both patients recovered uneventfully from the procedure and are free of endoleak or other complications related to their aneurysm repair at 7 and 34 months.

Conclusions:

The presence of a pelvic renal transplant in a patient undergoing endovascular AAA repair increases the complexity of procedural planning and endograft implantation, but a good outcome can be achieved.
Safety and Efficacy of High-Dose Adenosine-Induced Asystole during Endovascular AAA Repair
Authors: Kahn Ronald A. , Moskowitz David M. , Marin Michael L. , Hollier Larry H. , Parsons Richard , Teodorescu Victoria , McLaughlin Maryanne
Published: March 2015

Purpose:

To assess the safety and efficacy of high-dose adenosine administration to increase the precision of endovascular abdominal aortic aneurysm (AAA) repair using a balloon deployed stent-graft.

Methods:

From January 1997 to March 1999, 98 AAA patients (79 men; mean age 71 years, range 62–91) were treated with balloon-expandable stent-grafts under an approved protocol. After placing a temporary transvenous ventricular lead or an external transthoracic pacing electrode, adenosine (24 mg initially) was administered in an escalating dose fashion to induce at least 10 seconds of asystole, during which the proximal stent was expanded.

Results:

Adenosine dosages ranged from 24 to 90 mg (median 24 mg). Nine (9.2%) self-limiting cardiac events were observed: 2 (2.0%) episodes of transient myocardial ischemia, 2 (2.0%) cases of atrial fibrillation requiring cardioversion, 1 (1.0%) transient left bundle branch block lasting <10 seconds, and 4 (4.1%) prolonged periods of asystole requiring temporary pacemaker activation. There were no cases of bronchospasm or worsening obstructive pulmonary disease, and no patients required inotropic support after adenosine-induced asystole.

Conclusions:

Cardiac events following adenosine-induced asystole are infrequent, mild, and easily treated. The perioperative use of high-dose adenosine to ensure precise stent-graft placement appears to be a safe method of inducing temporary asystole during endovascular aortic repair.
Embolization of Type II Endoleaks Fed by the Inferior Mesenteric Artery: Using the Superior Mesenteric Artery Approach
Authors: Görich Johannes , Rilinger Norbert , Sokiranski Roman , Krämer Stefan , Schütz Ansgar , Sunder-Plassmann Ludger , Pamler Reinhard
Published: March 2015

Purpose:

To evaluate the use of a superior mesenteric artery (SMA) approach to embolize type II endoleaks arising from the inferior mesenteric artery (IMA).

Technique:

When reperfusion of the aneurysmal sac via the SMA occurs through the IMA, as shown by computed tomography (CT) and angiography, the IMA origin can be accessed via the marginal artery or the anastomosis of Riolan. The SMA is catheterized with a 5-F catheter, and a coaxial catheter is advanced to the leak to deliver 2- to 8-mm-diameter minicoils to embolize the IMA origin and entire aneurysmal sac. Embolization usually requires from 1 to 2 hours to complete. In our experience with this technique in 11 cases, complications have not occurred, and there has been only one very small residual leak that sealed the next day. Over a 24.5-month follow-up (range 12–39), the endoleaks have remained sealed according to serial color duplex scans.

Conclusions:

Successful percutaneous treatment of type II endoleak due to IMA inflow can be accomplished using an SMA access via the Riolan anastomosis or marginal artery. The procedure appears to be safe and has no adverse effects.
Endovascular in Situ Bypass Decreases Morbidity and Hospital Stay following Infrainguinal Arterial Reconstruction
Authors: Nelson Peter R. , Arous Elias J.
Published: March 2015

Purpose:

To report the early results of endovascular in situ saphenous vein bypass (EISVB) using side branch coil occlusion.

Methods:

Between September 1997 and November 1998, 25 patients (15 men; mean age 70.9 years, range 53–85) with lower limb ischemia were treated with endovascular femorodistal bypass. The saphenous vein was prepared using retrograde valvulotomy and endoscopic cannulation with coil occlusion of the side branches. Duplex graft surveillance was performed at 1, 3, 6, and 12 months.

Results:

The 25 EISVB procedures consisted of 15 femorodistal popliteal, 7 femorotibial, 2 femoroperoneal, and 1 femorodorsalis pedis in situ saphenous vein reconstructions. Mean operative time was 202 ± 40 minutes, mean number of side branch coils per case was 5.1 ± 1.3, and mean number of incisions per case was 2.9 ± 0.6. Mean hospital length of stay (LOS) was 35 ± 13 hours (1.4 ± 0.6 days); 19 (76%) patients were discharged on the first postoperative day. Short-term follow-up (mean 6.2 months, range 2–15) was notable for 2 graft thromboses and 1 graft stenosis; primary and secondary patency rates were 88% and 92%, respectively. Three asymptomatic, persistent arteriovenous fistulas discovered on routine duplex were ligated in the outpatient setting. Only 1 (4%) minor wound complication was encountered.

Conclusions:

EISVB provides early patency comparable to conventional in situ infrainguinal bypass. Its distinct advantages, however, are the ability to minimize incision length with resultant reductions in wound-related complications, hospital LOS, and recovery time. EISVB promises to be a useful adjunct in the approach to peripheral vascular insufficiency.
Intravascular Ultrasound Assessment of Iliac Stent Procedures
Authors: Navarro Felipe , Sullivan Timothy M. , Bacharach J. Michael
Published: March 2015

Purpose:

To determine whether intravascular ultrasound (IVUS) is more sensitive in identifying incomplete stent deployment or mechanical disruption compared to angiography.

Methods:

Over a 9-month period, 44 patients (25 men; mean age 63 years, range 36–88) treated for common or external iliac artery stenoses with balloon angioplasty and stenting underwent IVUS interrogation following completion arteriography.

Results:

One hundred nine stents were deployed in the 44 patients. Of these, 29 (27%) stents (in 45% of patients) were found by IVUS to be incompletely deployed or to have an associated mechanical disruption despite a normal completion arteriogram. Further treatment (repeat dilation or additional stenting) was performed in 28 cases; 1 hemodynamically insignificant dissection was not treated. Twenty-six (93%) of these interventions were successful as determined by IVUS; 2 underexpanded stents did not respond to redilation.

Conclusions:

Incomplete stent deployment or mechanical problems associated with stenting were common in this study, occurring in nearly half of the patients. IVUS has clinical utility in identifying incomplete deployment or mechanical problems in stents with an increased sensitivity compared to contrast angiography.
Stent Implantation for Mesenteric Bypass Graft Stenosis
Authors: Phipp Laura H. , Scott D. Julian , Kessel David , Robertson Iain
Published: March 2015

Purpose:

To present a case of symptomatic mesenteric bypass graft stenosis treated with Palmaz stent implantation.

Methods and Results:

A 65-year-old man with a history of mesenteric ischemia and superior mesenteric artery (SMA) occlusion presented with recurrent symptoms 3 years after Dacron graft revision surgery for occlusion of a venous aorto-SMA bypass graft. Graft thrombectomy revealed a tortuous segment of narrowed graft proximally, and a Palmaz stent was deployed across the defect. Adequate flow was restored through the conduit, and the patient has remained asymptomatic for 2 years.

Conclusions:

Mesenteric ischemia is a rare and potentially fatal condition requiring major vascular intervention. Revision surgery may be avoided by angioplasty and stent insertion across flow-limiting stenoses, even in prosthetic grafts.
Emergency Stent-Graft Repair of a Ruptured Hepatic Artery Secondary to Local Postoperative Peritonitis
Authors: Bürger Thomas , Halloul Zuhir , Meyer Frank , Grote Reinhard , Lippert Hans
Published: March 2015

Purpose:

To describe the use of a stent-graft for emergent repair of life-threatening hepatic artery hemorrhage.

Methods and Results:

A 57-year-old man with a 17-year history of myxoid liposarcoma underwent surgery for a recurrent abdominal mass. Multivisceral resection including a Kausch-Whipple procedure with an extended right hemicolectomy was performed. Three weeks later, an episode of gastrointestinal bleeding prompted surgical repair of the hepatic artery, which had been eroded by infection due to a leaking bilioenteric anastomosis. After 3 weeks of programmed abdominal lavage, bleeding recurred. Angiography documented another rupture of the proximal hepatic artery. After an unsuccessful attempt at coil embolization, a Hemobahn stent-graft was implanted percutaneously during simultaneous cardiopulmonary resuscitation. Hemostasis was secured, and the patient recovered. Over the 10-month follow-up, no bleeding or infection has been observed at the site of the repair, and flow through the hepatic artery endograft remains satisfactory.

Conclusions:

Percutaneous stent-graft placement can be employed for emergent treatment of visceral artery rupture in patients at high risk for conventional surgical repair.
Endovascular Repair of an Aortoduodenal Fistula
Authors: Eskandari Mark K. , Makaroun Michel S. , Abu-Elmagd Kareem M. , Billiar Timothy R.
Published: March 2015

Purpose:

To demonstrate the utility of endovascular stent-graft repair for the management of an unusual aortoduodenal fistula.

Methods and Results:

A 23-year-old man with an aortoduodenal fistula secondary to tumor necrosis was treated with a Corvita endoluminal stent-graft after several failed surgical attempts to repair the defect. At 2-year follow-up, the patient was clinically and radiographically devoid of any evidence of occult stent-graft infection.

Conclusions:

This case illustrates the usefulness of endovascular repair for the treatment of a primary aortoduodenal fistula. Endovascular repair should be included in the armamentarium for the management of difficult aortoduodenal fistulas.
Primary Stenting for Chronic Total Occlusion of the Infrarenal Aorta
Authors: Karkos Christos D. , D'Souza Stephen P. , Hughes Robert
Published: March 2015

Purpose:

To present a rare case of chronic total occlusion of the infrarenal aorta treated with a self-expanding endoluminal stent implanted without preliminary dilation.

Methods and Results:

A 68-year-old woman presented with severe bilateral buttock and thigh claudication. Angiography revealed total occlusion of the infrarenal abdominal aorta and relatively normal iliac vessels. Via a right groin puncture and a 9-F sheath, a 14-mm × 5-cm self-expanding Wallstent was deployed in the abdominal aorta and expanded with an angioplasty balloon. Completion angiography showed successful recanalization of the aorta with satisfactory distal flow. Palpable distal pulses were restored, and the patient's symptoms were alleviated. She remained asymptomatic until her death from a major stroke 11 months after aortic stent implantation.

Conclusions:

Primary stenting may be considered a viable alternative to conventional surgery in selected patients with total infrarenal aortic occlusion.
Endovascular Repair of Perisplanchnic Abdominal Aortic Aneurysm with Visceral Vessel Transposition
Authors: Macierewicz Jan A. , Jameel Mohamed M. M. , Whitaker Simon C. , Ludman Catherine N. , Davidson Ian R. , Hopkinson Brian R.
Published: March 2015

Purpose:

To report a combined endoluminal and open surgical approach for a suprarenal abdominal aortic aneurysm (AAA) with coexistent splanchnic vessel stenoses.

Methods and Results:

A 64-year-old man presented with an aneurysm of the proximal abdominal aorta and severe stenoses of the celiac axis and superior mesenteric artery (SMA). An initial 2-stage plan to stent the visceral vessel stenoses and exclude the aneurysm with a fenestrated stent-graft failed when the celiac lesion could not be crossed. The approach was changed to restore visceral perfusion with a bifurcated left iliosplenic and ilio-SMA bypass graft. Exclusion of the aneurysm was achieved with a custom-made suprarenal aortic tube stent-graft (Ivancev-Malmö) system. The patient is free of symptoms at 22 months, and there was no aneurysm visible on the 14-month CT scan.

Conclusions:

Hybrid techniques are an alternative treatment for complex perivisceral aortic aneurysms when total endovascular reconstruction is not possible.
Endovascular Management of Rare Sciatic Artery Aneurysm
Authors: Sultan Sherif A.H. , Pacainowski John P. , Madhavan Prakash , McDermott Ronan , Molloy Martin , Colgan Mary-Paula , Moore Dermot J. , Shanik Gregor D.
Published: March 2015

Purpose:

To present a rare case of complete persistent sciatic artery aneurysm successfully treated by coil embolization and to suggest a new classification for this anomaly that encompasses both clinical and pathological factors.

Methods and Results:

A 77-year-old female presented with sudden onset of sharp, throbbing left thigh and foot pain. A nontender 10.0- × 7.0-cm pulsatile mass was found over the inferolateral aspect of the left buttock on examination in the right lateral decubitus position. Angiography demonstrated a 6.9-cm sciatic artery aneurysm with the distal sciatic artery completely thrombosed. Before planned bypass grafting, the aneurysm and distal segment of the internal iliac artery were successfully embolized with coils through a left percutaneous approach. The patient's symptoms resolved with no deterioration in limb perfusion, and further revascularization was unnecessary. Postembolization imaging showed complete occlusion of the aneurysm, which has continued for 19 months.

Conclusions:

The application of endovascular techniques and surgical revascularization procedures provides numerous management options for the treatment of an aneurysmal persistent sciatic artery. This case demonstrates that clinical evaluation between staged procedures may obviate the need for further intervention.
A Retrospective Comparative Study of Open and Endoscopic Saphenous Vein Harvesting
Authors: Galbraith Gervis F. , Pica-Furey Wendy
Published: March 2015

Purpose:

To compare the operative variables, complications, and potential benefits of endoscopic saphenous vein harvesting (ESVH) with traditional open vein retrieval for coronary artery bypass grafting (CABG).

Methods:

Data were collected retrospectively on 212 consecutive CABG patients from whom saphenous veins were harvested by one surgeon using either an open saphenous vein harvesting (OSVH) technique (n = 135) or ESVH (n = 77) performed with the ENDOSAPH Vein Harvest System. Fifty-three patients underwent a purely endoscopic procedure, whereas 24 patients had either a combined endo-open procedure (n = 13) or were converted to an open technique (n = 11) because of equipment failure or adverse anatomical characteristics. Harvest time was measured from initial leg incision to aortic cross-clamping. Leg wound complications were evaluated on the basis of progressive severity.

Results:

Harvest and procedural times were longer for the ESVH group (111 and 313 minutes, respectively) than for the OSVH patients (63 and 252 minutes, respectively, p < 0.001). Mean length of stay was not appreciably different: 11.7 ± 6.2 days (range 3–52) for the OSVH group, compared with 11.0 ± 6.0 days (range 3–41) for the ESVH patients (p = 0.40). Fewer complications occurred in the ESVH group when a purely endoscopic procedure was performed (17% versus 35% for OSVH, p = 0.012). Infection occurred in 1 OSVH and in 4 ESVH patients, but 3 of the endoscopic patients had a combined procedure. Bivariate correlational analysis showed that an increased number of incisions ( r = 0.29, p < 0.01), obesity ( r = 0.18, p < 0.01), and short stature ( r = −0.16, p < 0.05) were associated with leg wound complications, but hierarchial stepwise regression analysis determined only short stature to be a predictive variable (β = 0.17, R2 = 0.03).

Conclusions:

Despite increased operating time, ESVH results in fewer complications when a purely endoscopic procedure is performed.
Does Prosthetic Covering of Nitinol Stents Alter Healing Characteristics or Hemodynamics?
Authors: Avino Anthony , Johnson Brad , Bandyk Dennis , Back Martin , Roth Steven , Kudryk Bruce , Cantor Alan
Published: March 2015

Purpose:

To evaluate placement of polyester (Dacron) coverings on nitinol stents implanted in the canine aorta to determine the effect on cross-sectional lumen area, development of intimal hyperplasia, device endothelialization, and flow hemodynamics.

Methods:

Ten polyester-covered and 10 uncovered nitinol stents (60-mm length, 10- or 12-mm diameter) were deployed percutaneously in the normal infrarenal aorta of 20 adult mongrel dogs using random assignment. Angiography, intravascular ultrasound (IVUS), and duplex ultrasound performed at device deployment and before explantation at 6 weeks were used to measure aorta/device diameter and cross-sectional area. Pressure-perfusion-fixed aortic segments were compared for surface endothelialization (CD31 staining) and for thickness of neointimal formation.

Results:

All 20 endoluminal devices were accurately positioned in the infrarenal aorta without early or delayed evidence of device thrombosis, significant lumen narrowing, or device deformity. IVUS and duplex scanning identified no anatomical stenosis in either the covered or the bare devices by duplex ultrasound; peak systolic velocity measurements were similar (106 ± 25 cm/s in the covered stent versus 96 ± 25 cm/s for bare stents, p > 0.05). Mean neointimal thickness was significantly greater (p < 0.005) in the covered (326 ± 145 µm) compared with the bare (219 ± 62 µm) stents. Intima-to-media height ratios were greater in the covered stents (3.0 ± 1.1 compared with 1.1 ± 0.2, p < 0.003). Mean surface area endothelialization in the proximal, middle, and distal sections of each device was similar (p > 0.05) in covered (59%, 56%, and 69%) and bare (59%, 65%, and 53%) stents.

Conclusions:

Deployment and balloon dilation of a covered nitinol stent in a nondiseased canine aorta increased neointimal development compared with an uncovered stent, but overall lumen cross-sectional area was preserved. No differences in device patency, intradevice thrombus formation, flow hemodynamics, or luminal endothelialization were demonstrated, despite a thicker intradevice neointima induced by the polyester covering.
Differing Morphological Changes following Endovascular AAA Repair Using Balloon-Expandable or Self-Expanding Endografts
Authors: Singh-Ranger Ravinder , Adiseshiah Mohan
Published: March 2015

Purpose:

To determine whether changes in aneurysm morphology after endovascular abdominal aortic aneurysm (AAA) repair differ according to the type of endograft (self-expanding versus balloon-expandable).

Methods:

Among 88 patients with AAA treated with either homemade polytetrafluoroethylene (PTFE) aortomonoiliac endografts or Talent stent-grafts, 30 patients (24 males; mean age 73 years, range 55–93) were selected for this study based on a >2-year follow-up and freedom from endoleak or conversion. Of these, 12 had PTFE endografts and 18 Talent devices. All patients had spiral computed tomographic angiography with 3-dimensional reconstruction at 5 days post-treatment and 6-month intervals thereafter. Neck dimensions (length and diameters at 3 levels) were measured, along with volumes and maximal diameters of the sac and lengths of the aneurysm and endograft. Intra- and interobserver errors were <5% for linear and volume measurements.

Results:

Both groups had an initial 20-mL increase in median volume (p = 0.02) followed, only in Talent patients, by marked shrinkage at 6 months (–87.4 mL; p = 0.09). PTFE patients had no further changes in sac volume. Maximal sac diameters reflected volumes, but only after day 5. PTFE patients had an immediate increase (p = 0.03) in aneurysm neck diameters, which then remained stable. Talent patients had continuing increases in diameter to 6 months (p < 0.05), with no change thereafter. Length changes were not significant in either group. PTFE patients had an increase in median aneurysm length at day 5 (+3.2 mm, p = 0.04) and again at 1.5 years (+6.4 mm, p = 0.03). Endograft length slowly increased (+18.7 mm) over 1.5 years (p = 0.02). Talent patients had no length changes in the device or aneurysm.

Conclusions:

Aneurysm morphology appeared to alter according to the type of endograft deployed. With PTFE endografts, aneurysm volume does not change, whereas impressive sac shrinkage occurs in conjunction with the Talent system. Aneurysm/graft lengths increase with unsupported stent-grafts. Neck diameter increases immediately with balloon-expandable endografts and then remains constant. In the self-expanding models, neck diameter increases at 6 months but not thereafter.
Percutaneous Stenting of an Iatrogenic Superior Mesenteric Artery Dissection Complicating Suprarenal Aortic Aneurysm Repair
Authors: Desgranges Pascal , Bourriez Armand , d'Audiffret Alexandre , Zubilewicz Thomas , Mathieu Didier , Becquemin Jean-Pierre , Kobeiter Hicham
Published: March 2015

Purpose:

To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter.

Case Report:

A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year.

Conclusions:

Iatrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.
Fenestration in Endovascular Grafts for Aortic Aneurysm Repair: New Horizons for Preserving Blood Flow in Branch Vessels
Authors: Stanley Brendan M. , Semmens James B. , Lawrence-Brown Michael M.D. , Goodman Marcel A. , Hartley David E.
Published: March 2015

Purpose:

To describe techniques for deploying fenestrated stent-grafts that use partial graft deployment and guided tracking of the fenestration to the arterial orifice.

Technique:

Fenestrations have been added to custom-made tube grafts and commercially manufactured Zenith stent-graft systems to preserve perfusion of aortic side branches. Partial device deployment, orientation markers on the endograft, and intraoperative angiography enable maneuvering of the fenestration over the orifice of the target vessel with the aid of guiding catheters. Placement of a Palmaz stent overlapping the fenestration and vessel orifice secures the junction. Two variations of fenestration have preserved blood flow in renal arteries during endovascular repair of abdominal aortic aneurysms (AAAs); similar techniques have maintained flow to the celiac axis in a thoracic aortic aneurysm.

Conclusions:

Accurate placement of a fenestration over the orifice of a target vessel is feasible, but long-term maintenance of position is dependent on secure graft fixation. This capability brings us a step closer to overcoming the problem of inadequate necks in infrarenal AAAs, especially when the neck is foreshortened by asymmetry of the renal origins. It may also pave the way for the eventual replacement of the entire aorta with an endoluminal graft.
Geometric Changes in Aortic Endografts over a 2-Year Observation Period
Authors: Krämer Stefan C. , Seifarth Harald , Pamler Reinhard , Fleiter Thorsten , Görich Johannes
Published: March 2015

Purpose:

To report geometric changes in bifurcated aortic endografts observed over a 2-year follow-up period.

Methods:

Twenty-two patients (21 men; mean age 68 years, range 57–83) with abdominal aortic aneurysms were treated with an endovascular stent-graft. Follow-up examinations included spiral computed tomographic scanning postoperatively and at 3, 6, 9, 12, 18, and 24 months after treatment. Geometric changes were measured using 3-dimensional reconstructed images in anteroposterior (AP) and lateral projections. Locations for the measurements were the proximal neck, the midportion of the endograft, and the graft limbs at the origin of the iliac arteries.

Results:

Lateral changes predominated, demonstrating maximum angles on the side of the inserted left limb. For the proximal neck, the stent angle changed by a mean −0.71° in the AP and 4.0° in the lateral projection. At the midgraft, changes were −0.56° for AP and 12.5° for lateral. The right limb showed an angle of 6.43° in AP and −0.43° in lateral, whereas the left limb angles changed 1.38° in AP and 11.71° in the lateral plane after 2 years. There was no statistically significance difference in these changes from baseline.

Conclusions:

Aortic endografts are exposed to a significant amount of movement after insertion, but the resultant changes are very inhomogeneous, unpredictable, and ongoing even after 2 years. The most vulnerable location seems to be the attachment zone of the modular graft limb. These geometric changes might be one cause for late complications, including leaks and limb dislocations.
Carotid Artery Stenting in Patients with High-Risk Anatomy for Carotid Endarterectomy
Authors: Dangas George , Laird John R. , Mehran Roxana , Satler Lowell F. , Lansky Alexandra J. , Mintz Gary , Monsein Lee H. , Laureno Robert , Leon Martin B.
Published: March 2015

Purpose:

To report the results of carotid artery stenting (CAS) in patients considered to have high-risk anatomical characteristics for carotid endarterectomy.

Methods:

CAS was performed in 39 carotid arteries of 37 consecutive patients (26 men; mean age 72 ± 8 years, range 56–88) who met the criteria for high-risk surgical anatomy: previous ipsilateral carotid endarterectomy (20/39, 51.3%), common carotid bifurcation above the mandibular angle (5/39, 12.8%), contralateral carotid artery occlusion (15/39, 38.5%), or previous radiation therapy to the neck (1/39, 2.6%). Palmaz, Integra, or Wallstents were deployed via a percutaneous femoral artery access. Independent neurological evaluation was performed at specified time points, and a dedicated committee adjudicated all clinical events.

Results:

Procedural success was 100%, with no major in-hospital complications. Neurological events were rare. Only 1 (2.6%) transient ischemic attack occurred prior to discharge; at 30 days, 1 (2.6%) additional minor stroke had been observed, giving a 2.6% cumulative 30-day “death plus any stroke” rate. Over a mean 11 ± 6-month follow-up, 2 (5.4%) patients died of nonneurological causes, but there were no strokes.

Conclusions:

CAS is a viable endovascular revascularization technique that can be performed safely and effectively in patients with high-risk anatomy for carotid endarterectomy.
The ICAROS Registry of Carotid Artery Stenting
Authors: Biasi Giorgio M. , Ferrari Stefano A. , Nicolaides Andrew N. , Mingazzini Paolo M. , Reid Donald
Published: March 2015

ICAROS (Imaging in Carotid Angioplasties and Risk Of Stroke) is a multicenter international registry of carotid artery stenting designed to determine the criteria for identifying patients at higher or lower risk of periprocedural stroke and restenosis at 1 year. The aim of the registry is to improve patient selection and consequently reduce the risk of cerebral embolization during carotid stenting. The registry is open to all interventionists performing carotid stenting, and the participants are free to apply their own endovascular techniques and devices, including cerebral protection mechanisms. All cerebral ischemic events following the procedure will be reported. Follow-up surveillance to 1 year will include periodic duplex scanning and neurological examinations. Echographic plaque images will be standardized for comparison, processed for echodensity, and analyzed by computer at the Registry Center. Correlation will be investigated between the echographic index (gray-scale median) and the risk of embolism and outcome of carotid stenting.
Endoluminal Stent Placement and Coil Embolization for the Management of Carotid Artery Pseudoaneurysms
Authors: Bush Ruth L. , Lin Peter H. , Dodson Thomas F. , Dion Jacques E. , Lumsden Alan B.
Published: March 2015

Purpose:

To present a series of carotid artery pseudoaneurysms treated successfully using an endovascular approach.

Methods:

From April 1995 to November 1999, 5 patients with neurological symptoms not explained by computed tomography of the head were identified by carotid angiography as having internal carotid artery (ICA) pseudoaneurysms. Three patients had sustained blunt trauma, and 2 had previous elective carotid endarterectomies for atherosclerotic disease. The time between injury and treatment ranged from 3 days to 10 years. The patients were treated with endovascular stent placement for exclusion of the pseudoaneurysm, followed by filling of the cavity with multiple detachable coils. Patients were maintained on oral antiplatelet agents or anticoagulant therapy after the procedure.

Results:

Primary technical success was 100%. No patient suffered permanent neurological sequelae. Postprocedure angiography demonstrated a patent ICA in all cases, with complete obliteration of the pseudoaneurysm. At a mean 8.4-month follow-up (range 2–21), all patients remained symptom free; angiograms in 3 patients at a mean 11.7 months demonstrated continued ICA patency. One patient had a 60% focal narrowing of the distal common carotid artery, which was treated successfully with balloon dilation and stenting.

Conclusions:

Endovascular treatment of carotid artery pseudoaneurysms is a useful alternative to standard surgical repair. This modality avoids the necessity for surgical exposure at the skull base with its inherent morbidity.
Combined Endovascular and Open Surgery for Four-Vessel Cerebrovascular Occlusive Disease
Authors: Barakate Michael S. , Fisher Charles M. , Appleberg Michael , Farrar Michelle A. , Tse Regina V. , Harrington Timothy J. , Sorby William
Published: March 2015

Purpose:

To report a case of bilateral simultaneous percutaneous transluminal angioplasty and stenting of the intracranial vertebral arteries prior to staged bilateral carotid endarterectomy. Case Report: A 68-year-old man presented with a 3-month history of recurrent, intermittent left-sided weakness and diplopia. Imaging defined bilateral 80% to 99% internal carotid artery stenoses and >90% stenoses of both distal vertebral arteries at the level of the foramen magnum. Bilateral intracranial vertebral artery stenting was performed, followed by staged carotid endarterectomies. No complications occurred, and the patient recovered uneventfully from all 3 procedures. He remains symptom- and event-free 20 months later.

Conclusions:

Our initial success in this case indicates a role for percutaneous transluminal angioplasty and stenting as an alternative to open surgery for intracranial vertebral artery stenosis.
Percutaneous Access and Closure of Femoral Artery Access Sites Associated with Endoluminal Repair of Abdominal Aortic Aneurysms
Authors: Howell Marcus , Villareal Rollo , Krajcer Zvonimir
Published: March 2015

Purpose:

To report longer follow-up and further experience using the Prostar XL Percutaneous Vascular Surgery (PVS) device for access and closure of large bore femoral artery access sites during endovascular repair of abdominal aortic aneurysms (AAAs).

Methods:

One hundred forty-four patients (128 men; mean age 72 years, range 56–89) undergoing endovascular AAA repair had percutaneous access and closure of their 16-F femoral artery access sites using a 10-F PVS device. The first 54 patients were enrolled in the phase III trial of the AneuRx stent-graft for AAA treatment.

Results:

The femoral artery access site was successfully closed in 136 (94.4%) patients, with only 8 patients in whom adequate hemostasis could not be obtained. One-month follow-up was available in 144 patients, 6-month in 100, and 1-year in 59. No groin or lower extremity complications have been observed in any patient who had successful closure of the femoral artery access site.

Conclusions:

Large-bore femoral artery access sites can be percutaneously repaired using this device, which minimizes the invasiveness of the endograft procedure.
Analytical Modeling and Numerical Simulation of Forces in an Endoluminal Graft
Authors: Liffman Kurt , Lawrence-Brown Michael M.D. , Semmens James B. , Bui Anh , Rudman Murray , Hartley David E.
Published: March 2015

Purpose:

To utilize mathematical analysis and computational fluid dynamics (CFD) to investigate the forces acting within the pressurized aorta and upon a stent-graft and how these forces may affect the ongoing performance of the stent-graft.

Methods:

Analytical force balance analysis and CFD simulations using the Fluent code were used to mimic blood flow through a bifurcated stent-graft in a person at rest. Steadystate blood flow was assumed in which the inlet pressure approximated the mean blood pressure (100 mm Hg) and the blood flow velocity was an approximation of the peak systolic flow rate (0.6 m/s). Two sizes of endoluminal grafts were analyzed: the larger graft had an inlet diameter of 3 cm and outlet diameters of 1 cm; the smaller graft diameters measured 2.4 cm proximally and 1.2 cm distally. The endografts were studied in 2 configurations: with the limbs straight and with one bent.

Results:

For the larger graft model, the normal peak blood flow induced a downward force of 7 to 9 N on the bifurcated grafts. Bending one of the limbs of the graft produced a sideways force of 1.3 N. For the smaller endograft, the downward force was in the range of 3.1 to 5.1 N and the sideways force on a curved limb was ∼1.5 N. The magnitude of the forces given by the analytical formulae and the CFD results agreed to within 2 significant figures.

Conclusions:

These results suggest that the downward force on a bifurcated stent-graft, which may exceed the force required to dislodge it when relying on radial attachment alone, is determined mostly by the proximal graft diameter. Curvature of the graft limbs creates an additional sideways force that works to displace the distal limbs of the graft from the iliac arteries.
Thrombus Formation in Aortic Endografts
Authors: Wegener Martin , Görich Johannes , Krämer Stefan , Fleiter Thorsten , Tomczak Reinhard , Scharrer-Pamler Reinhard , Kapfer Xaver , Brambs Hans-Jürgen
Published: March 2015

Purpose:

To examine the incidence of intraprosthetic thrombotic deposits in aortic endografts.

Methods:

Transfemoral implantation of tube or bifurcated stent-grafts was performed in 82 patients (75 men; average age 67.7 years, range 25–88) for treatment of aneurysms of the abdominal (n = 73) or thoracic (n = 9) aorta in a 3.5-year period. Patients underwent 3-phase helical computed tomographic (CT) examinations at 3-month intervals. The length and cross-sectional area of any thrombotic deposits were measured from axial and 3-dimensional CT images.

Results:

Over a 12.1-month mean follow-up, intraluminal deposits of thrombotic material were observed in 19 (23.2%) patients, all with infrarenal endografts that were predominately of a bifurcated design. The first signs of thrombus formation occurred on average 7 months postoperatively (range 1 week to 20 months). In 16 patients, nonocclusive deposits of thrombotic material were seen in the aortic segment of the endograft; a graft limb was involved in 5 patients. Three graft limbs occluded owing to kinking; no thrombus was seen on CT scans taken prior to occlusion. In 3 cases the thrombotic deposits disappeared completely from the prosthesis lumen during follow-up.

Conclusions:

Based on this small experience, nearly 1 in 5 patients may experience some degree of intraluminal thrombus following endovascular treatment of aortic aneurysms. Whether the deposition of thrombus is influenced by the geometry of the aortic stent-graft or by flow conditions within the prosthetic lumen must be determined in future studies.
Endovascular Repair of Iatrogenic Subclavian Artery Perforations Using the Hemobahn Stent-Graft
Authors: Bartorelli Antonio L. , Trabattoni Daniela , Agrifoglio Marco , Galli Stefano , Grancini Luca , Spirito Rita
Published: March 2015

Purpose:

To report the use of a new self-expanding endograft for percutaneous treatment of iatrogenic subclavian artery perforations.

Case Reports:

The subclavian artery of 2 patients was inadvertently cannulated during percutaneous attempts to implant a permanent pacemaker in one and catheterize the subclavian vein in the other. Because both patients had serious comorbidities, endovascular repair of the subclavian perforations was performed using the Hemobahn endograft, a nitinol stent covered internally with expanded polytetrafluoroethylene. The endoprostheses were successfully deployed via an ipsilateral brachial artery access. No signs of endograft occlusion, migration, deformation, or fracture have been observed during follow-up at 12 and 10 months, respectively, in these patients.

Conclusions:

The Hemobahn stent-graft appears well suited to repairing subclavian artery injuries. Longer follow-up will determine if the design of this endograft will resist compression in this vascular location.
Pseudoaneurysm and Aortobronchial Fistula after Surgical Bypass for Aortic Coarctation: Management with Endovascular Stent-Graft
Authors: Smayra Tarek , Otal Philippe , Soula Pierre , Chabbert Valérie , Cérène Alain , Joffre Francis , Rousseau Hervé
Published: March 2015

Purpose:

To report the endovascular repair of an aortobronchial fistula at the distal anastomosis of a complex thoracic graft.

Case Report:

A 61-year-old man operated 18 years prior for aortic coarctation presented with hemoptysis. An aortobronchial fistula was suspected, but spiral computed tomography and angiography showed only a small pseudoaneurysm at the distal anastomosis without revealing the fistulous tract. A Talent stent-graft was successfully deployed through a femoral access, but the large delivery system injured the external iliac artery, producing a retroperitoneal hemorrhage. Prompt balloon occlusion of the aorta and subsequent bypass graft repair of the arterial injury prevented serious sequelae. The patient recovered without further complications. Follow-up imaging to 2 years has documented exclusion of the pseudoaneurysm with no hemoptysis or signs of new false aneurysm formation.

Conclusions:

Endovascular exclusion of anastomotic pseudoaneurysms even in complicated cases can be an efficient treatment option, but the procedure must be carefully planned and executed in order to achieve good results.