A Word of Caution for Extra Large Self-expandable Nitinol Stents.

BACKGROUND: To report an unsuccessful use of large nitinol stent to prevent proximal endoleak in endograft treatment for juxtarenal aortic aneurysm. CASE REPORT: An 82-year-old male presented coronary disease and severe chronic obstructive pulmonary disease requiring oxygen support. A large 80-mm juxtarenal aneurysm was found on routine urological examination. Neck features were as follows: 7 mm and high anterior-posterior angulation. ASA risk score IV was given. Patient wanted to be treated. We decided a 1-shot intervention based on self-expandable suprarenal fixation endograft with adjunctive extra large self-expandable (high radial force) nitinol stent. Control computed tomography scan demonstrates nitinol stent severe infolding and a possible perforation of the primary endograft. At 6-month follow-up, sac reveals enlargement of 5 mm and 6% volume increase. Patient does not want further treatments due to high risk of procedures. CONCLUSIONS: Extreme caution should be taken when using self-expandable extra large nitinol stents for preventive matters. Oversizing should be carefully considered, not necessarily reaching the endograft chosen size. When short and angulated neck morphology co-exists, other devices or procedures may be a better option.

Anticoagulation Alone for Aortic Segment Treatment in Symptomatic Primary Aortic Mural Thrombus Patients.

BACKGROUND: Primary aortic mural thrombus (AMT) is a rare entity. Asymptomatic AMT may be found in imaging studies for other disease studies. Symptomatic AMT as embolic events may localize in the arterial branches of the aorta; limb ischemia is the most usual clinical presentation, though. However, when proximal aorta is compromised, visceral branches occlusion and ischemia may determine morbidity and mortality in these patients. METHODS: We performed a retrospective study with collection of data from January 2011 to September 2016. Medical records of patients were reviewed for: demographic data, cardiovascular risk factors or any known prothrombotic predisposing condition, clinical presentation, vessel of embolism, localization of aortic thrombus, treatment of AMT and symptoms, follow-up, and computed tomography scan imaging findings. RESULTS: A total of 8 patients were included in the study. Mean age was 54.7 ± 11.5 years, with male/female ratio 3:1. Four (50%) patients had AMT at the arch or descending aorta, 3 (37.5%) patients in the infrarenal sector, and the remaining in the visceral aorta. All but one patient received anticoagulation alone for the aortic thrombus. Patient with femoral thromboembolectomy died in the early postoperative time due to severe massive embolism. Median follow-up was 23 months (range, 1-50). Five out of seven patients showed complete aortic thrombus resolution in imaging follow up. None of the patients presented recurrence of embolic events. CONCLUSIONS: An anticoagulation first-approach treatment may be reasonable if mild organ damage is encountered. This strategy may be continued if no recurrences in embolic events are encountered, as high percentage of thrombus resolution is expected. Open or endovascular may be saved for life-threatening visceral or arch branches damage.