bluuebunny/crossref_metadata_2025 huggingface dataset:
Institutional Economic Losses Associated with AAA Repair are Independent of Technique
Authors: Berman Scott S. , Gentile Andrew T. , Berens Eric S. , Haskell Jan
Published: March 2015

Purpose:

To investigate the perception of significant economic loss associated with endovascular abdominal aortic aneurysm (AAA) repair by comparing economic variables for the open and endovascular techniques.

Methods:

In a 1-year period, 20 consecutive patients (19 men; mean age 73.3 years, range 62–89) were treated for uncomplicated infrarenal AAAs using conventional open repair in 11 and endovascular repair (EVR) in 9. For the open repair, standard techniques were employed, including transperitoneal and retroperitoneal exposures; in EVR, both the AneuRx and Ancure systems were utilized. Length of stay and institutional costs were carefully tracked and compared.

Results:

The patients were similar with regard to comorbidities, but the endograft patients were older (p=0.02) Length of stay was significantly lower in the EVR group (1.9 ± 0.9 days) compared with the open group (8.4 ± 4.5 days, p=0.0004). However, total mean treatment costs (open: $17,576 ± $11,025 and EVR: $20,247 ± $5003; p=0.51) and subsequent losses (open: –$3949 ± $7095 and EVR: –$7572 ± $4488; p=0.20) were not significantly different between the groups.

Conclusions:

The costs associated with the care of AAA patients are independent of the technique used for repair. The economic loss associated with treatment is directly related to inadequate reimbursement on the part of Medicare and other carriers.
Single-Center Experience with Carotid Stent Restenosis
Authors: Willfort-Ehringer Andrea , Ahmadi Ramazanali , Gschwandtner Michael E. , Haumer Markus , Lang Wilfried , Minar Erich
Published: March 2015

Purpose:

To report the angiographic morphology of carotid stent restenosis and the possible therapies based on data from a single-center experience.

Methods:

In a 45-month period, 279 patients (196 men; mean age 70 ± 9 years, range 50–89) underwent successful Wallstent placement in 303 stenotic internal carotid arteries (ICA). Patients were followed with duplex sonography; angiography was used to confirm any significant (≥70%) recurrent lesions detected on the ultrasound scan. Further balloon dilation with or without stent placement was undertaken.

Results:

Over a median 12-month follow-up (interquartile range 6–24), there were 9 (3.0%) carotid stent restenoses found, all within 12 months after stent placement. Two types of restenosis were differentiated. In the more common form, “in-stent” stenoses (n = 6) were detected and treated with stent placement; lasting success (patency >12 months after retreatment) was achieved in 4. Early second and third recurrences arose in the other 2 stents within 3 months of the first retreatment; additional stents were placed at each recurrence. Both patients suffered a major cerebral event after 17 months. Less often, an “end of stent” stenosis (n = 3) developed at a kink in the ICA adjacent to the cephalad end of the stent. Lasting success was achieved by balloon dilation without additional stent placement in all 3 cases. No procedure-related complications were observed within 30 days after any treatment for restenosis.

Conclusions:

Carotid stent restenosis, which occurs rarely after 1 year, can be treated safely by further percutaneous interventions.
Coil Embolization Combined with Carotid-Subclavian Bypass for Treatment of Subclavian Artery Aneurysm
Authors: Bush Ruth L. , Lin Peter H. , Najibi Sasan , Dion Jacques E. , Smith Robert B.
Published: March 2015

Purpose:

To report 2 cases of proximal subclavian artery aneurysm treated with carotid-subclavian bypass and coil embolization.

Case Reports:

A subclavian artery aneurysm was discovered incidentally during presurgical coronary angiography in 2 men (72 and 63 years of age). Both patients underwent planned carotid endarterectomy, during which a carotid-subclavian bypass was created with a Dacron graft; the distal subclavian artery was also ligated. The aneurysm was completely excluded from the circulation by coil embolization in a separate procedure. The patients were discharged after 3 days with no adverse events. Magnetic resonance angiography at 6 months showed continued aneurysm exclusion in both cases. The patients continue to be well >1 year after treatment.

Conclusions:

Embolization with supraclavicular bypass represents a viable alternative to traditional thoracotomy and subclavian artery reconstruction for treatment of subclavian artery aneurysms.
Histological Changes in Canine Aorta 1 Year after Stent-Graft Implantation: Implications for the Long-term Stability of Device Anchoring Zones
Authors: Bashar Abul Hasan Muhammad , Kazui Teruhisa , Terada Hitoshi , Suzuki Kazuya , Washiyama Naoki , Yamashita Katsushi , Baba Satoshi
Published: March 2015

Purpose:

To examine aortic histology 1 year after stent-graft implantation in a canine model as a means of assessing the durability of endograft fixation.

Methods:

Fourteen mongrel dogs each received 1 stent-graft and 1 bare stent placed endoluminally in the abdominal aorta. Eight animals were followed for 1 year, 3 for 4 to 8 weeks, and the remaining 3 for 24 to 48 hours. Aortic specimens were stained with hematoxylin-eosin, elastica-van Gieson, and Masson's trichrome and examined with light and electron microscopy and immunohistochemistry to identify smooth muscle cells (SMC), endothelialization, aortic wall ultrastructure, and changes at the device anchoring sites.

Results:

No dilatation or dissection was noted at any of the device anchoring sites. The aortic media at 1 year was remarkably decreased in thickness: 891 ± 196 µm in the control tissue versus 388 ± 70 µm for the proximal stent-grafted aorta and 457 ± 148 µm for the bare-stented aortic segment. Other important histological features were reduced elastic lamellae in the stent-grafted aorta versus control (p<0.0001), increased SMC density in the stent-grafted aortic region (p<0.0001 versus control), and absence of inflammatory infiltrate. Complete neointimal covering and endothelialization of the luminal endograft surface were found. SMCs generally showed no ultrastructural features of necrosis.

Conclusions:

Aortic stent-grafts induce distinctive histological changes in the aortic wall at 1 year, even when implanted in a healthy aorta. Although there is considerable medial elastin loss, an increased medial SMC density, an exuberant neointima, and a general absence of perigraft inflammation suggest an ongoing process of structural restoration at the device anchoring sites.
Abdominal Aortic Healing Associated with a Thin-Walled Dacron—Covered Endovascular Graft in a Canine Model
Authors: Dal Ponte Donny B. , Berman Scott S. , Patula Vangie , Kleinert Leigh , Williams Stuart K.
Published: March 2015

Purpose:

To characterize the healing response associated with an experimental endovascular graft (EVG) by examining the lumen of the prosthesis and the native vessel wall responses after implantation in a canine model.

Methods:

An endovascular graft (EVG) constructed of hookless self-expanding nitinol springs covered by an ultrathin Dacron fabric was placed in the abdominal aorta of 8 dogs following femoral artery catheterization. After 12 weeks, specimens were subjected to histological and immunocytochemical testing to quantitatively and qualitatively analyze the cellular makeup of the luminal and abluminal tissues.

Results:

Gross examination revealed a glistening, thrombus-free luminal surface on all prostheses, which was confirmed by scanning electron microscopy. The EVGs were well incorporated into the aortic wall, leaving a concentric, smooth flow surface. Immunocytochemistry-verified the presence of von Willebrand factor—positive endothelial cells on the luminal surface and α-smooth muscle cell actin—positive smooth muscle and/or fibroblast cells in the subendothelial space. A sparse inflammatory response and a paucity of proliferating nuclear cell antigen—positive cells were noted within the neomedial lining adjacent to the graft material. In addition, a rich vaso vasorum—like plexus of microvessels was evident within the neomedial tissue. The native vessel wall upon which the EVG impinged was largely unaffected.

Conclusions:

These data demonstrate that placement of an experimental EVG in the canine abdominal aorta elicits a healing response that is distinct from interpositional vascular grafts. Results from this study have particular relevance to the proximal and distal anastomotic neck regions.
Endovascular Management of Blunt Traumatic Renal Artery Dissection
Authors: Lee James T. , White Rodney A.
Published: March 2015

Purpose:

To describe the importance of accurate diagnosis and successful emergent endovascular repair of intimal injury to the renal artery from sudden deceleration.

Case Report:

A 22-year-old man was evaluated after jumping head first out of a fourth floor window. Gross hematuria was detected at the initial assessment. Contrast-enhanced computed tomography (CT) revealed diminished uptake in the right kidney. Arteriographic examination of the renal artery demonstrated 2 areas of intimal disruption, which a team of physicians decided to treat with angioplasty and stent placement owing to the associated intracranial injuries. Two balloon-expandable stents were successfully deployed to exclude the intimal defects. Once the associated injuries were also addressed, the patient made an uneventful recovery.

Conclusions:

Management of blunt traumatic injuries to the renal vasculature involves timely assessment to maximize preservation of renal function. In the setting of multiple concomitant injuries, recent experience supports the consideration of endoluminal intervention for traumatic renal artery dissections.
Percutaneous Reconstruction of the Aortoiliac Bifurcation with the “Kissing Stents” Technique: Long-term Follow-up in 106 Patients
Authors: Haulon Stéphan , Mounier-Véhier Claire , Gaxotte Virginia , Koussa Mohamad , Lions Christophe , Haouari Ben Ahmed , Beregi Jean-Paul
Published: March 2015

Purpose:

To evaluate the long-term results using the kissing stents technique for treatment of occlusive disease involving the aortoiliac bifurcation.

Methods:

One hundred six patients (97 men; mean age 52.5 ± 10.2 years, range 33–78) were treated with the kissing stents technique for bilateral aortoiliac stenosis (55, 51.9%), unilateral occlusion of the common iliac artery (CIA) with contralateral stenosis (47, 44.3%), and bilateral CIA occlusion (4, 3.8%). Clinical examination and duplex scans were performed prior to discharge and at 1, 6, and 12 months, followed by yearly examinations thereafter.

Results:

Bilateral stent implantation was successful in all patients. No major procedure-related complications were observed. Self-expanding stents were deployed in 62 (58.5%) patients and balloon-expandable devices in 44 (41.5%). Fifteen (7.1%) hematomas were observed at the 212 access sites. Mean follow-up was 30.1 ± 11.1 months (range 12–137). Duplex imaging diagnosed significant (>50%) restenosis in 15 (14.8%) of 101 patients and reocclusion in 4 (4%); 17 (89.5%) of these patients had recurrent symptoms and all were retreated (endovascular procedure in 18 and an aortobifemoral bypass in 1). Primary and secondary cumulative patency rates at 36 months were 79.4% and 97.7%, respectively. Balloon-expandable stents had a nonsignificantly higher patency rate compared to self-expanding stents.

Conclusions:

Based on our experience, aortoiliac endovascular reconstruction with the kissing stents technique is a safe and effective procedure, representing an alternative to conventional surgery in selected patients.
Rheolytic Thrombectomy in the Management of Limb Ischemia: 30-Day Results from a Multicenter Registry
Authors: Ansel Gary M. , George Barry S. , Botti Charles F. , McNamara Thomas O. , Jenkins J. Stephen , Ramee Steven R. , Rosenfield Kenneth , Noethen Alice A. , Mehta Tejas
Published: March 2015

Purpose:

To evaluate the use of rheolytic thrombectomy (RT) with the AngioJet catheter for treatment of lower extremity ischemia due to arterial/graft thrombotic occlusion.

Methods:

A retrospective multicenter review was performed of 99 consecutive patients (52 men; mean age 67 ± 13 years, range 30–90) who underwent RT for thrombotic occlusions in native arteries (n=80) or bypass grafts (n=19). Pre- and postprocedural limb ischemia and in-hospital events were evaluated. Amputation and mortality rates at 30 days were determined.

Results:

The majority of patients (78.8%) presented within 14 days of symptom onset. RT resulted in substantial to complete thrombus removal in 70 (70.7%) patients and partial in 22 (22.2%); there was no angiographic change in 7 (7.1%). Adjunctive post RT thrombolysis was used in 37 patients. Underlying stenoses found in 81 limbs were treated with one or more of the following procedures: balloon angioplasty (n=62), stenting (n=35), or non-emergent surgical revision (n=5). In-hospital complications included 2 major amputations, 5 cases of minor tissue loss, 7 rethromboses, and 3 cases of transient renal insufficiency. Four (4.0% patients died in-hospital; the 95 surviving patients all had viable limbs at discharge. Mortality and amputation rates at 30 days were 7.1% and 4.0%, respectively.

Conclusions:

Percutaneous treatment of thrombotic occlusions with RT, followed by definitive treatment of the underlying stenosis, is a promising therapeutic option for patients with limb-threatening ischemia.
Emergency Treatment of Symptomatic or Ruptured Abdominal Aortic Aneurysms: The Role of Endovascular Repair
Authors: Yilmaz Neval , Peppelenbosch Noud , Cuypers Philippe W.M. , Tielbeek Alexander V. , Duijm Luciën E.M. , Buth Jacob
Published: March 2015

Purpose:

To report the initial experience with endovascular aortic repair (EVAR) in patients with ruptured or symptomatic abdominal aortic aneurysms (AAA) and to compare the results with conventional open surgery.

Methods:

Between May 1999 and December 2001, 24 patients (21 men; mean age 75 years, range 56–89) with ruptured or symptomatic AAA underwent EVAR using a specially designed aortomonoiliac endograft. Six patients were selected based on device and operator availability; the subsequent 18 patients were treated under a modified management protocol that offered stent-graft repair to all symptomatic AAA patients. The results of this new treatment protocol were analyzed on an intention-to-treat basis for the last 8 months of the study. The 30-day outcomes in all patients treated with emergency EVAR were compared with 40 consecutive, contemporaneous patients undergoing open surgery for symptomatic or ruptured AAA.

Results:

No early conversions to open surgery were performed. Significantly decreased operative blood loss and intensive care stay (p<0.05 for both) were observed in EVAR patients. The mortality rate for EVAR patients was 17% compared to 32% in conventionally treated patients (NS). Among patients with ruptured AAA, the 30-day mortality rates were 24% (4/17) and 41% (12/29) for EVAR and open surgery, respectively (NS). Of 26 unselected patients who were treated prospectively under the modified protocol, the majority (81%, 21/26) had anatomy suitable for endovascular repair; however, only 18 (69%) underwent EVAR owing to a short infrarenal neck (n=2) or device/operator unavailability (n=6).

Conclusions:

EVAR is a feasible treatment in the majority of patients with ruptured or symptomatic AAA. The 30-day mortality appears to be similar between conventionally treated patients and those undergoing endovascular repair.
Does Fresh Clot Shrink Faster Than Preexistent Mural Thrombus after Endovascular AAA Repair?
Authors: Blankensteijn Jan D. , Prinssen Monique
Published: March 2015

Purpose:

To correlate the amount of preexistent thrombus in abdominal aortic aneurysms (AAA) to sac shrinkage after endovascular repair.

Methods:

From January 1993 through April 2000, 76 patients underwent endovascular AAA repair and were examined at 12 months to identify aneurysms that had decreased in size by >10%. Volume measurements were performed using a standardized spiral computed tomographic angiography (CTA) protocol with 3-dimensional postprocessing. Volume measurements were unavailable or incomplete in 16 patients, and another 16 did not have sac shrinkage >10%, leaving 44 patients in the study group. The percentage of preexistent mural thrombus in shrinking sacs (OldThr%) was calculated by dividing the preoperative thrombus volume by the postoperative nonluminal thrombus volume. The 12-month volume change, expressed as a percentage of the postoperative thrombus volume and as an absolute value, was correlated with OldThr% using the Pearson product moment test.

Results:

The median proportional shrinkage at 12 months was 56% (range 15%–89%) and the absolute nonluminal thrombus volume shrinkage was 49 mL (range 6–186). The median OldThr% was 53% (range 6%–94%). The correlation coefficients of OldThr% were 0.130 (p=0.40) with the proportional shrinkage in thrombus volume and 0.235 (p=0.13) with the absolute volume change.

Conclusions:

The rate of shrinkage of successfully excluded aneurysm sacs after endovascular repair is independent of the preoperative mural thrombus volume in the aneurysm. Other factors are responsible for the large variation in shrinkage.
The AneuRx Stent-Graft since FDA Approval: Single-Center Experience of 230 Cases
Authors: Ramaiah Venkatesh G. , Westerband Alex , Thompson Charles , Ravi Rajagopalan , Rodriguez Julio A. , DiMugno Leanne , Shafique Shoaib , Olsen Dawn , Diethrich Edward B.
Published: March 2015

Purpose:

To compare a single-center experience with the AneuRx stent-graft system before and after FDA approval to results from the multicenter phase II clinical trial.

Methods:

The medical records of 230 consecutive patients (218 men; mean age 74 years) undergoing AneuRx stent-graft implantation for abdominal aortic aneurysm (AAA) exclusion since September 1999 were reviewed to collect patient characteristics, aneurysm morphology, procedure variables, perioperative morbidity, mortality, and short-term outcome. These data were compared to the 30 patients treated at our institution during the AneuRx phase II clinical trial and to the overall multicenter trial data. Stent-graft difficulty was categorized from 1 (straight neck and access of appropriate size) to 4 (proximal neck <10 mm long or angulated >60° and/or difficult access) based on aneurysm morphology.

Results:

Data from the 30 patients enrolled in the phase II trial at our institution were comparable in terms of patient characteristics and procedure variables to patients treated after FDA approval and to the multicenter data. However, the proportion of cases involving aneurysms with a more complex morphology (levels 3 and 4) rose 22% after FDA approval, reflecting a change in referral patterns. Our postoperative endoleak and morbidity rates increased nonsignificantly with respect to our own phase II experience (17% versus 6%, 18% versus 11%, respectively);however, they were not significantly different from the multicenter data. Reintervention was performed in 15 of 38 endoleak cases, mostly type I. Only 5 (2.1%) cases had a persistent endoleak at the time of discharge.

Conclusions:

Since FDA approval of the AneuRx device, our endovascular practice has changed toward the management of increasingly more complex AAAs. Although we are attempting more challenging cases, we are able to maintain similarly high short-term success rates while offering stent-grafting to an increasing number of patients. These results suggest that more patients may be candidates for endoluminal graft placement than determined by the clinical trial selection criteria, provided that strict surveillance and long-term follow-up is maintained.
Long-term Results of Endovascular AAA Repair Using a Homemade Aortomonoiliac PTFE Device
Authors: Ingle Hemant , Fishwick Guy , Garnham Andrew , Thompson Matthew M. , Bell Peter R.F.
Published: March 2015

Purpose:

To assess the long-term results of a homemade aortomonoiliac polytetrafluoroethylene (PTFE) device used for endovascular abdominal aortic aneurysm (AAA) repair.

Methods:

A vascular audit database was interrogated to identify 58 consecutive AAA patients (all men; median age 73 years, range 56–88) who underwent aortomonoiliac stent-graft repair. AAAs were eligible for endovascular treatment if the infrarenal neck was ≥15 mm long and ≤28 mm in diameter.

Results:

Nine (15.5%) procedures failed, 8 during the procedure and 1 on the 7th postoperative day; 8(13.8%) patients were converted, but one was unfit for surgery. There was one intraprocedural stroke, and 3 (5.2%) patients died within 30 days. The primary success rate (no conversion or mortality) was 79.3%. Over a median follow-up of 45 months (range 23–80), there were 3 (5.2%) graft occlusions, 1 kink requiring stent implantation, and 1 expanding sac without identifiable endoleak. There were 11 (19.0%) endoleaks in 10 patients, 9 type I leaks (2 proximal) and 1 type II. One patient with a distal type I endoleak (treated) also exhibited a type III leak at 2 years, but the sac size had not increased. There was a 40% incidence of bilateral buttock claudication, which was serious in only 1 patient. The long-term survival rate by Kaplan-Meier life-table analysis was 57% at 4 years.

Conclusions:

Implantation of an aortomonoiliac PTFE device can be achieved with good primary success, and the stent-graft seems durable over the long term. Proximal type I endoleaks are rare, but distal endoleaks from the contralateral common iliac artery can be solved by using a different covered stent.
A Hybrid Endovascular Procedure to Preserve Internal Iliac Artery Patency during Endovascular Repair of Aortoiliac Aneurysms
Authors: Hinchliffe Robert J. , Hopkinson Brian R.
Published: March 2015

Purpose:

To demonstrate the feasibility of a hybrid endovascular procedure to preserve blood flow in the internal iliac arteries (IIA) during aortoiliac endografting.

Technique:

When aneurysmal dilatation makes the distal neck in the common iliac artery (CIA) too short for an adequate seal, the CIA bifurcation is exposed via an extraperitoneal approach after endograft deployment. Via an arteriotomy in the CIA, the distal end of the stent-graft is sutured to the CIA bifurcation under direct vision to preserve IIA blood flow. This approach has been successful in preserving IIA blood flow in 5 of 7 endograft procedures; in the other 2, IIA occlusion was a predictable event.

Conclusions:

Direct suturing of an aortoiliac stent-graft to the CIA bifurcation via an extraperitoneal approach is a useful method of maintaining IIA perfusion. However, further study is required to identify patients at high risk of pelvic ischemia who would benefit from such intervention.
Predictors for Clinical Success at One Year following Renal Artery Stent Placement
Authors: Gill-Leertouwer Trude C. , Gussenhoven Elma J. , Bosch Johanna L. , Deinum Jaap , van Overhagen Hans , Derkx Frans H.M. , Pattynama Peter M.T.
Published: March 2015

Purpose:

To determine pretreatment variables that may predict 1-year clinical outcome of stent placement for renal artery stenosis.

Methods:

In a prospective study, 40 consecutive patients (29 men; mean age 60 ± 9.1 years) with angiographically proven atherosclerotic renal artery stenosis were treated with stent placement because of drug resistant hypertension (n=14), renal function impairment (n=14), or both (n=12). Clinical success at 1 year was defined as a decrease of diastolic blood pressure ≥10 mmHg or a decrease in serum creatinine ≥20%, depending on the indication for treatment. Regression analysis was performed using anatomical parameters from angiography and intravascular ultrasound, estimates of renal blood flow from renal scintigraphy, and single-kidney renal function measurements.

Results:

Patients treated for hypertension had better outcome than those treated for renal function impairment, with clinical success rates of 85% and 35%, respectively. Preserved renal function, with low serum creatinine and high 2-kidney glomerular filtration rate at baseline, was associated with clinical success in the entire patient group at follow-up (p=0.02 and p=0.03, respectively). An elevated vein-to-artery renin ratio on the affected side was borderline predictive (p=0.06). In patients treated for renal impairment, lateralization to the affected kidney (affected kidney—to–2-kidney count ratio ≤0.45) on the scintigram emerged as a significant predictor for clinical success, with an odds ratio of 15 (p=0.048).

Conclusions:

Clinical success of renal artery stent placement is better for the treatment of hypertension than for preserving renal function. In patients with renal function impairment, lateralization to the affected kidney on the scintigram appears to be a predictor of clinical success.
Contrast-Enhanced 3D MRA of the Aortoiliac and Infrainguinal Arteries When Conventional Transfemoral Arteriography is Not Feasible
Authors: Fenchel Sabine , Wisianowsky Christian , Schams Silvia , Nuessle Karin , Krämer Stefan C. , Görich Johannes , Merkle Elmar M.
Published: March 2015

Purpose:

To evaluate whether contrast-enhanced 3-dimensional (3D) magnetic resonance angiography (MRA) can substitute for transaxillary or transbrachial catheter access when angiography via the transfemoral route is not possible.

Methods:

Contrast-enhanced 3D MRA was performed in 14 patients (12 men; mean 66.1 ± 12.4 years, range 48–98) with atherosclerotic disease of the aorta or lower extremities in whom conventional transfemoral arteriography was not feasible. The images were evaluated for their ability to identify and characterize lesions directly responsible for the patient's symptoms, adequately depict the vascular anatomy for therapy planning, and identify additional lesions not directly responsible for the patient's symptoms. The arterial system was divided into 15 segments, and image quality and the presence of occlusive disease were determined.

Results:

MRA adequately depicted 387 (95%) of 406 arterial segments in 14 patients. Nineteen (5%) arterial segments were inadequately delineated because of low signal intensity distal from severe stenoses (n = 11), venous overlap (n = 6), or metallic clip—induced signal voids (n = 2). The lesions directly responsible for the patients' symptoms were identified in all 14 patients (2 aortic occlusions [Leriche's syndrome] and 12 iliac occlusions or severe stenoses). Visualization of the vascular anatomy was adequate for therapy planning in 13 of 14 patients, and 3D MRA satisfactorily identified other lesions not directly responsible for the current symptoms.

Conclusions:

When transfemoral catheter angiography of the aortoiliac and lower extremities is not feasible, contrast-enhanced 3D MRA is suitable for determining and planning therapy and can be used instead of angiography via the transaxillary or transbrachial routes.
Computerized Modeling Based on Spiral CT Data for Noninvasive Determination of Aortic Stent-Graft Length
Authors: Rott Albert , Boehm Thomas , Söldner Joachim , Reichenbach Jürgen R. , Heyne Jürgen , Bartel Martin , Kaiser Werner A.
Published: March 2015

Purpose:

To preprocedurally determine the correct length of a nonbifurcated endovascular prosthesis for abdominal aortic aneurysm (AAA) repair using a computerized model.

Methods:

A computer program was implemented to calculate the optimal intraluminal course of nonbifurcated stent-grafts from spiral computed tomographic (CT) images of the aortic lumen reconstructed at 2.5, 5, and 10-mm slice thicknesses. The algorithm was tested using 10 phantoms fabricated from 150-mm-long, 10-mm-diameter copper rods that were bent into shapes mimicking different aortic configurations. Midpoint coordinates and rod diameters were determined from each CT image by 3 independent observers and served as input parameters to the program. The influence of the different CT reconstructions on the calculated lengths and possible observer dependence were assessed using calculated length estimation errors. Spiral CT images from 20 consecutive AAA patients scanned before stent-graft implantation were also processed to evaluate the algorithm under clinical conditions.

Results:

Length estimation errors of the phantoms depended on the degree of bending as well as on the CT reconstruction slice thickness but were observer independent. Maximum errors were 7% for the 10-mm slices, 3.5% for the 5-mm slices, and 1.2% for a 2.5-mm reconstruction. The mean longitudinal shortening of the aorta due to vessel tortuosity was 9.1% ± 4.8% among the 20 patients. Based on the results of the phantom study, errors of the calculated stent-graft lengths in patients were estimated to be ∼1% for a 5-mm CT reconstruction increment and <2% for a 10-mm increment.

Conclusions:

The proposed algorithm makes it possible to calculate noninvasively the correct length of straight stent-grafts under clinical conditions with a 1% to 2% error.
Type III Endoleak from a Thoracic Aortic Stent-Graft
Authors: Lange Conrad , Ødegård Asbjørn , Lundbom Jan , Hatlinghus Staal , Myhre Hans O.
Published: March 2015

Purpose:

To present an as yet unreported late complication of an Excluder thoracic endograft.

Case Report:

A 78-year-old man underwent surgery for a ruptured type V thoracoabdominal aortic aneurysm in 1996. Four years later, an aneurysm was detected in the proximal thoracic aorta and repaired with 2 Excluder endoprostheses. At 12 months, computed tomography showed an increase in the aneurysm sac diameter and a type III endoleak, which was traced to a hole in the stent-graft fabric on arteriography. No fracture of the metal components was detected in the stent-grafts. Another Excluder device was implanted within the distal endograft. Satisfactory exclusion of the leak has been maintained for 6 months.

Conclusions:

The risk of type III leaks must be minimized before stent-grafting can be regarded as a routine procedure in the treatment of thoracic aortic aneurysms.
Endovascular Treatment and Complete Regression of an Infected Abdominal Aortic Aneurysm
Authors: Berchtold Christoph , Eibl Charis , Seelig Matthias H. , Jakob Pedi , Schönleben Klaus
Published: March 2015

Purpose:

To report a case of successful endovascular treatment of an infected abdominal aortic aneurysm (AAA) following Salmonella septicemia.

Case Report:

A 60-year-old man was admitted for rapid onset of urinary frequency, fever, and suprapubic pain extending to the flanks. Blood cultures were positive for Salmonella enteritidis, and appropriate antibiotic treatment was started. After 4 weeks, fever ceased and the C-reactive protein fell to 5.8 mg/dL, but the erythrocyte sedimentation rate remained unchanged. Back pain prompted computed tomography, which showed a large AAA with a very irregular aortic wall suspicious of impending rupture. A tube stent-graft was introduced under general anesthesia from a left groin incision and deployed immediately below the renal arteries; a proximal type I endoleak was suspected but not repaired. Oral antibiotic therapy was continued for 2 months after discharge. By 6 months, the endoleak had sealed with a concomitant decrease in the maximal diameter of the aneurysm from 7.4 to 5.6 cm. At 4 years, the aneurysm sac was no longer visible.

Conclusions:

Although experience is limited, endovascular grafting in combination with antibiotic therapy in selected infected aneurysms might represent an effective low-risk alternative to conventional surgery with the potential to restore normal vascular anatomy.
Endovascular Repair of a Type B Aortic Dissection with Transposition of a Coexistent Aberrant Subclavian (Lusorian) Artery
Authors: Vos A.W. Floris , Wisselink Willem , Rijbroek Abraham , Avontuur Jurgen A. , Manoliu Radu A. , Rauwerda Jan A.
Published: March 2015

Purpose:

To report the endovascular treatment of a relatively uncommon entity: an aortic type B dissection combined with an aberrant subclavian artery (SA).

Case Report:

A 59-year-old patient was admitted with chest pain and interscapular back pain. A transesophageal ultrasound and magnetic resonance angiography revealed a type B aortic dissection originating at the level of an aberrant SA orifice. After failure of medical therapy, the dissection was treated by transluminal implantation of an Excluder stent-graft covering the entry site of the dissection at the aberrant SA orifice. Prior to the endovascular procedure, a transposition of the aberrant SA to the right carotid artery was performed through a supraclavicular approach. The patient remains asymptomatic at 19 months after the endovascular repair.

Conclusions:

Endovascular repair of a type B aortic dissection in the presence of a lusorian artery appears to be a feasible, safe, and less invasive alternative to conventional surgery. The need for concurrent transposition of the SA remains to be determined.
Endovascular Repair of Traumatic Descending Aortic Transection
Authors: Orend Karl Heinz , Pamler Reinhard , Kapfer Xaver , Liewald Florian , Görich Johannes , Sunder-Plassmann Ludger
Published: March 2015

Purpose:

To present the results of endovascular repair of acute traumatic descending aortic transection.

Methods:

Among 66 thoracic stent-graft repairs performed between 1995 and 2001, 11 patients (9 men; mean age 34 years, range 12–73) underwent emergent endovascular repair of acute traumatic descending aortic transection following traffic accidents. Immediate treatment of aortic rupture was indicated in all patients because of a marked fresh hematoma with hemothorax; the spiral computed tomographic (CT) scans showed circular or semicircular descending thoracic aortic injuries. The devices used included 11 thoracic Excluders and 1 Talent stent-graft.

Results:

No patient required conversion to an open transthoracic operation. No patient developed temporary or permanent neurological deficit after endovascular treatment. Two type I endoleaks required periprocedural treatment: a second stent-graft was deployed in one and the existing stent-graft was balloon dilated in the other. Two patients underwent secondary procedures (iliac access complication and revascularization of the left subclavian artery). One patient died 22 days postoperatively secondary to injuries unrelated to the aortic repair. Over a mean 14-month follow-up (range 1–26), the surveillance CT scans have shown the stent-graft to be correctly positioned in all patients.

Conclusions:

The treatment of acute traumatic descending aortic transection with an endovascular approach is feasible and safe and may offer the best means of therapy. Mortality and the risk of neurological deficit are low compared with open operations.
Crossing the Limbs: A Useful Adjunct for Successful Deployment of the AneuRx Stent-Graft
Authors: Ramaiah Venkatesh G. , Thompson Charles S. , Shafique Shoaib , Rodriguez Julio A. , Ravi Rajagopalan , DiMugno Leanne , Diethrich Edward B.
Published: March 2015

Purpose:

To describe a technique for deploying an AneuRx stent-graft in an abdominal aortic aneurysm (AAA) with an acutely angled aortic neck.

Technique:

In routine cases, the AneuRx stent-graft main body is positioned with the nose cone notch facing the contralateral side. In severely angulated aortic necks, however, the main body of the AneuRx stent-graft can be positioned with the nose cone notch and iliac limb gate facing the ipsilateral side; this dramatically reduces the acuity of the angle at the aortic neck and the iliac gate. This technique of “crossing the limbs” has been successfully used in 7 cases since FDA approval of the AneuRx device.

Conclusions:

Proximal neck angulation is an important factor for successful endovascular AAA repair. Crossing the graft limbs reduces the effect of neck angulation on the proximal main body and may decrease the stress upon the contralateral limb gate, which may avoid graft gate disconnection and endoleak.
Initial Clinical Results of Tenecteplase (TNK) in Catheter-Directed Thrombolytic Therapy
Authors: Razavi Mahmood K. , Wong Humberto , Kee Stephen T. , Sze Daniel Y. , Semba Charles P. , Dake Michael D.
Published: March 2015

Purpose:

To investigate the safety and immediate efficacy of 2 different doses of tenecteplase (TNK) in peripheral catheter-directed thrombolytic therapy of arterial occlusions and deep vein thrombosis (DVT).

Methods:

Over a 20-month period, 63 nonconsecutive patients underwent catheter-directed thrombolytic therapy with either 0.25 mg/h or 0.50 mg/h of TNK in a nonrandomized, open-label study. Of these, 55 patients (60 limbs) were treated for DVT (36 limbs in 16 men and 15 women; mean age 41 years, range 21–73) or peripheral arterial occlusions (24 limbs in 16 men and 8 women; mean age 63 years, range 32–91). The primary endpoints were major bleeding complications and angiographic reduction in clot burden.

Results:

The mean duration of infusion was 18 ± 4 hours in patients with arterial occlusions and 30 ± 13 in those with DVT. Twenty-one (87.5%) patients with occlusive disease had marked or complete lysis of clot. Thirty (83.3%) limbs with DVT had either marked or complete resolution of thrombus. There were 4 (7.3%) episodes of minor bleeding with 1 (1.8%) major hemorrhagic event. Fibrinogen levels dropped by an average of 23%.

Conclusions:

Preliminary evidence suggests that TNK doses of 0.25 mg/h to 0.50 mg/h appear to be safe and effective. The potential benefits of TNK therapy warrant further investigation.
Complex Endovascular Treatment for Critical Limb Ischemia in Poor Surgical Candidates: A Pilot Study
Authors: Gray Bruce H. , Laird John R. , Ansel Gary M. , Shuck John W.
Published: March 2015

Purpose:

To evaluate the effectiveness of complex endovascular treatment for limb salvage in patients with critical limb ischemia.

Methods:

In a prospective study, 23 patients (13 men; mean age 70 ± 11 years, range 44–87) with ischemic ulceration or gangrene of 25 lower limbs were enrolled at 4 sites to evaluate treatment with excimer laser recanalization followed by balloon angioplasty with optional stenting in the superficial femoral, popliteal, and/or tibial arteries.

Results:

Multiple lesions (mean 3.1, range 1–8) were treated in most cases. Reduction of stenosis/occlusion to <50% was achieved in 22 (88%) limbs. Individual cases of vessel perforation, inability to cross the lesion, and excessive residual stenosis accounted for the 3 failures. Over a 6-month period, 4 patients died of cardiac comorbidity and 1 was lost to follow-up. Adverse events included 4 minor and 2 below-knee amputations, 4 secondary angioplasties, and 4 femorodistal bypasses. The mean wound area reduction was 70% at 3 months, increasing to 89% at 6 months. According to life table analysis, the limb salvage rate was 90% with bypass and 69% without in the successfully treated patients (corresponding intention-to-treat rates were 79% and 61%).

Conclusions:

Complex endovascular treatment combining laser debulking and angioplasty/stenting offers an alternative for patients with critical limb ischemia who lack good surgical options.
Renal Atrophy Outcome after Revascularization in Fibromuscular Dysplasia Disease
Authors: Mounier-Véhier Claire , Haulon Stéphan , Devos Patrick , Lions Christophe , Jaboureck Olivier , Gaxotte Virginia , Carré Alain , Beregi Jean-Paul
Published: March 2015

Purpose:

To assess clinical, biological, and kidney parameters before and 6 months after revascularization of renal artery stenosis due to fibromuscular dysplasia (FMD).

Methods:

Twenty hypertensive patients (18 women; mean age 48.7 ± 15.4 years) with unilateral de novo FMD stenosis were studied before and 6 months after revascularization (balloon angioplasty 19; bypass surgery 1). Blood pressure and creatinine clearance were measured, and renal length, cortical thickness, cortical area (CA), and medullary length (ML) were evaluated by spiral computed tomographic angiography (CTA) in 20 poststenotic and 20 contralateral kidneys.

Results:

Six months after revascularization, the systolic and diastolic blood pressures decreased by 19 mmHg and 10 mmHg, respectively (p=0.02), the number of antihypertensive drugs decreased by 1 (p=0.01), but the increase in creatinine clearance was not significant. At baseline, the poststenotic kidneys were significantly more atrophied than the contralateral normal kidney (ML in normal kidney 89 ± 9 mm versus 81 ± 10 mm in poststenotic kidney, p<0.001; CA in normal kidney 824 ± 149 mm versus 703 ± 156 mm in poststenotic kidney, p<0.01), which persisted at 6 months (ML in normal kidney 89 ± 10 versus 80 ± 11 in poststenotic kidney, p<0.001; CA in normal kidney 807 ± 145 mm versus 696 ± 157 mm in poststenotic kidney, p<0.01). Renal length was still within normal range in all kidneys, and the morphological parameters remained stable after revascularization.

Conclusions:

We demonstrated significant cortical/medullary atrophy in poststenotic kidneys compared to contralateral normal kidneys. Despite intraparenchymal disease, clinical outcome was favorable after revascularization. Cortical/medullary thinning appears to be an early marker of renal ischemia that could support revascularization in FMD disease.
Stent-Graft Migration following Endovascular Repair of Aneurysms with Large Proximal Necks: Anatomical Risk Factors and Long-term Sequelae
Authors: Lee James T. , Lee Jason , Aziz Ihab , Donayre Carlos E. , Walot Irwin , Kopchok George E. , Heilbron Mauricio , Lippmann Maurice , White Rodney A.
Published: March 2015

Purpose:

To evaluate the outcome of aortic endografts deployed in large infrarenal necks and to identify any association of preoperative aneurysm characteristics and postoperative morphological changes with the incidence of neck dilatation and device migration in this patient subset.

Methods:

The records of 47 patients (41 men; mean age 74, range 55–84) with large aortic neck diameters treated with Talent stent-grafts from 1998 to 2001 were reviewed. Patients with anatomical criteria that precluded aneurysm exclusion with currently available devices were preferentially selected. Mean baseline aneurysm morphology included 27.6-mm (range 18–33.4) suprarenal and 28.1-mm (range 24–34) infrarenal neck diameters; the infrarenal neck length was 26 ± 16 mm with angulation of 37° ± 18°. Computed tomographic (CT) angiograms up to 3 years were analyzed using specialized interactive software; migration was defined as >1-cm change in the distance from the lower renal artery to the top of the device. Pre- and postoperative morphological characteristics of the aneurysm were compared between patients with and without migration.

Results:

Of the 45 patients successfully treated, 40 had complete CT data for analysis. During a mean 17-month follow-up, 7 (17.5%) of the 40 devices exhibited distal migration. Six patients required secondary procedures; 5 were in the migration cohort. No preoperative anatomical characteristic or degree of neck dilatation over time was predictive of stent-graft migration. Aneurysm sac regression was significant at 1 (–0.09 ± 4.90 mm) and 2 (–1.48 ± 2.56 mm) years in endografts without migration (p<0.001). Distal endograft migration >1 cm predicted the need for secondary interventions (p<0.001), with 83% sensitivity and 94% specificity.

Conclusions:

Endovascular repair is successful in patients with large infrarenal necks and complex neck morphology. Changes in aneurysm remodeling over time were similar to reported observations in patients with more favorable neck criteria. Although no anatomical factor associated with migration could be identified from this analysis, distal displacement >1 cm correlated with the need for a secondary intervention.
Percutaneous Stent-Graft Repair of Mycotic Common Femoral Artery Aneurysm
Authors: Kwon Kihwan , Choi Donghoon , Choi Seung-Hyuk , Koo Bon Kwon , Ko Young-Guk , Jang Yangsoo , Shim Won-Heum , Cho Seung-Yun
Published: March 2015

Purpose:

To report successful percutaneous repair of a peripheral mycotic aneurysm as a bridge to standard surgical therapy.

Case Report:

An aneurysm of the left common femoral artery was diagnosed in a 43-year-old man with subacute infective endocarditis. A Jostent stent-graft was percutaneously deployed to exclude the mycotic lesion. Computed tomography at 8 months after the procedure documented aneurysm regression and stent-graft patency without evidence of infection. Arteriography at 18 months has confirmed continued stent-graft patency and the patient remains asymptomatic.

Conclusions:

The standard management of mycotic aneurysms is usually by surgical resection and repair. However, this case suggests that percutaneous stent-graft implantation may be an option for the treatment of mycotic aneurysms.
Endovascular Aneurysm Exclusion along a Femorodistal Venous Bypass in Active Behçet's Disease
Authors: Gretener Silvia B. , Do Dai-Do , Baumgartner Iris , Dinkel Hans-Peter , Schmidli Jürg , Birrer Manuela
Published: March 2015

Purpose:

To report the endovascular repair of dual aneurysms along a femorodistal venous bypass graft in a patient with Behçet's disease.

Case Report:

A 55-year-old man of middle European ancestry with Behçet's disease had dual aneurysms evolve along the proximal segment of a femorodistal venous bypass that had been implanted 2.5 years earlier for recurrent false aneurysm formation. Owing to the lack of suitable venous conduits and the active nature of the disease, the aneurysms were successfully excluded with overlapping Hemobahn and Jostent endografts; the immunosuppressive therapy was intensified. Rupture of the aneurysms was successfully prevented, but the stent-grafts thrombosed 6 weeks later owing to exacerbation of the underlying disease.

Conclusions:

Endovascular exclusion of aneurysm in venous bypass grafts in Behçet's disease is feasible. Although the stent-grafts thrombosed, they did prevent rupture of the aneurysms.
Twin Pregnancy following Endoluminal Exclusion of an Iliac Arteriovenous Fistula
Authors: Frego Mauro , Kontothanassis Dimitrios , Miotto Diego , Chiesura-Corona Matteo , Verlato Fabio
Published: March 2015

Purpose:

To demonstrate the sustained efficacy of stent-graft exclusion of a pelvic arteriovenous fistula (AVF) in a woman who became pregnant after treatment.

Case Report:

An iatrogenic iliac arteriovenous fistula caused by redo surgery for a herniated disk in a 23-year-old woman was successfully treated with percutaneous endoluminal exclusion. Intravascular ultrasound was particularly useful for localization of the fistula during the procedure. The patient subsequently became pregnant, and serial Doppler studies were used to monitor the stent-graft until the uneventful delivery of twins by Caesarian section. At 36 months after endograft implantation, the patient has no complaints relative to the device.

Conclusions:

Uncomplicated twin pregnancy following stent-graft repair of an AVF in the pelvis appears feasible.