Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation.

OBJECTIVE: The aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). METHODS: All consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients' baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. RESULTS: Overall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. CONCLUSIONS: Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation.

OBJECTIVE: The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS: IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS: IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.

Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone.

BACKGROUND: Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting. METHODS: This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1 cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon. RESULTS: Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28 min; the median fluoroscopy time was 9 min and a median 70 mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1 year. DISCUSSION: Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10 mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Outcomes From the Multicenter Italian Registry on Primary Endovascular Treatment of Aortoiliac Occlusive Disease.

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Results: Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0-42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Conclusion: Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.

Endovascular repair of subclavian artery aneurysms: results from a single-center experience.

OBJECTIVE: To present our experience of the endovascular treatment of subclavian artery aneurysms (SAAs) and analyze the clinical manifestations, imaging findings and treatment outcomes. METHODS: In this retrospective study, nine patients with SAAs underwent endovascular stent placement in our center between July 2011 and June 2016. Clinical features, imaging findings, treatment outcomes and follow-up results of these SAA patients were retrospectively analyzed. RESULTS: Nine patients were diagnosed with SAAs by computer tomography angiography (CTA). Five patients underwent percutaneous endovascular stent placement in the subclavian artery. Three patients underwent endovascular repair of the SAAs with coil embolization and stent graft. One patient underwent stent graft implantation by the simultaneous kissing stent technique. Five patients had their symptoms relieved and thrombosis occurred in one case. The mean follow-up period was 17 months, ranging from 8 to 40 months. CONCLUSION: For patients with SAAs, endovascular treatment is a feasible choice, with a high success rate, few complications and good clinical outcomes.

Utility of Intra-operative Cone Beam Computed Tomography in Endovascular Treatment of Aorto-iliac Occlusive Disease.

OBJECTIVE: Endovascular treatment of aorto-iliac occlusive disease (AIOD) is well established, but to maintain long-term patency, secondary interventions are common. Multiple stents and iliac artery tortuosity often make it difficult to evaluate stent compression intra-operatively and this might be a cause for later failure. Completion angiography (CA) and pressure gradient (PG) measurement are often used to assess the final intra-operative result. The purpose of this study was to evaluate the role of intra-operative cone beam computed tomography (CBCT) to optimize the primary operation results. METHOD: Fifty-three patients (28 females) were enrolled in a prospective study. All patients underwent endovascular aorto-iliac revascularization. Final intra-operative results were evaluated with additional CBCT, after CA and PG were found to be satisfactory. Imaging findings and imaging based adjunctive procedures were recorded. RESULTS: One hundred and sixty five stents were placed because of AIOD. Twenty patients underwent adjunctive procedures after the primary stenting. In 24.5% (13/53) cases, adjunctive procedures were indicated solely by the CBCT findings, as both standard CA and PG were normal. Twenty-six of the 53 patients had kissing stents placed at the aortic bifurcation. Of the kissing stent patients, 34.6% required adjunctive procedures and in two thirds these stent compressions were detected only by CBCT. CONCLUSION: The use of CBCT revealed a significant number of stent compressions that were not found with CA and PG. When performing endovascular procedures at the aortic bifurcation, CBCT is an excellent intra-operative evaluation method to assess the configuration of deployed stents. In this study, CBCT improved the technical results intra-operatively, which might influence the long-term patency positively.

Simultaneous kissing stent in a patient with severe bifurcation pulmonary vein stenosis.

Pulmonary vein stenosis (PVS) is a late and rare complication of pulmonary vein isolation for the treatment of atrial fibrillation. The ideal approach to the management of PVS has not yet been established, however, corrective procedures may include both surgical and percutaneous techniques. We describe the case of a complex bifurcation lesion involving the left superior pulmonary vein. The condition required percutaneous intervention using a modified kissing stent technique with bare metal stents that resulted in an excellent post-operative course, sustained symptomatic relief, and uncomplicated 1-year follow-up. © 2014 Wiley Periodicals, Inc.

Placement of stent grafts with different calibers into the true and false lumens of anastomotic aneurysms after descending aortic replacement for aortic dissection.

Anastomotic aneurysms present as a life-threatening emergency after descending aortic replacement for aortic dissection. Thoracic endovascular aneurysm repair (TEVAR) has been performed since the early 2000s for complicated cases in which re-thoracotomy cannot be adopted. We report the case of a 57-year-old male patient, during a 5-year follow-up after descending aortic replacement for aortic dissection, developed aneurysm expansion around the false lumen on the peripheral side of the artificial graft. Considering the risk and the patient's desires, we opted to perform TEVAR with different calibers into the true and false lumens "modified kissing stents technique". His postoperative course was uneventful without any complications. This case highlights the utility of the modified kissing stents technique for anastomotic aneurysms after descending aortic replacement for aortic dissection using stent grafts with different calibers into the true and false lumens.

Membranous diaphragm formation after simultaneous kissing stenting with sirolimus-eluting stents for the left main bifurcation: insight from optical coherence tomography findings.

Two patients who underwent simultaneous kissing stenting with sirolimus-eluting stents in the left main coronary artery were investigated with optical coherence tomography (OCT) at just more than 1 year postoperatively. In both cases, follow-up angiogram indicated complete coverage of the new metal carina with a membranous diaphragm, yet OCT showed varying tissue-coverage patterns transitioning from stent inflow to stent outflow. These patterns included single-strut coverage, bridge-like membrane formation between more than 1 strut, and end-to-end coverage of the carina; no uncovered stent struts were detected. OCT also demonstrated mixed patterns of tissue characteristics on the metal carina, ranging from poor endothelialization to modest neointima formation. These varying tissue characteristics suggest that the process of tissue coverage in the metal carina is different from that occurring on the vessel wall; this may indicate delayed healing in the carina.

Case report: A hybrid open and endovascular approach for repairing a life-threatening innominate artery dissection using the simultaneous kissing stent technique.

Managing acute innominate artery (IA) dissection associated with severe stenosis is challenging due to its rarity, possible complex dissection patterns, and compromised blood flow to the brain and upper extremities. This report describes our treatment strategy for this challenging disease using the kissing stent technique. A 61-year-old man had worsening of an acute IA dissection secondary to an extension of a treated aortic dissection. Four possible treatment strategies for kissing stent placement were proposed based on different approaches (open surgical or endovascular) and accesses (trans-femoral, trans-brachial, or trans-carotid access). We chose to place two stents simultaneously via a percutaneous retrograde endovascular approach through the right brachial artery and a combined open surgical distal clamping of the common carotid artery with a retrograde endovascular approach through the carotid artery. This hybrid approach strategy highlights the three key points for maintaining safety and efficacy: (1) good guiding catheter support is obtainable through retrograde, rather than antegrade, access to the lesion, (2) concomitant cerebral and upper extremity reperfusion is guaranteed by placing kissing stents into the IA, and (3) peri-procedural cerebral emboli are prevented by surgical exposure of the common carotid artery with distal clamping.

Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

Objectives: The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation. Methods: Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded. Results: The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up. Conclusions: Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

Upside-down and kissing stent graft techniques for late extravasation of a prosthetic graft implanted in the abdominal aorta.

Extravasation of prosthetic grafts is rare. Various anatomical problems after graft replacement might make standard endovascular treatment difficult. Use of a commercially available main body requires an adequate distance of the flow divider. An 86-year-old man developed extravasation of a graft that had been implanted in the infrarenal abdominal aorta 24 years previously. Endovascular repair with upside-down and kissing stent graft techniques using the contralateral leg was successfully performed.

Midterm outcomes of endovascular treatment with bare metal stents for Leriche syndrome patients.

OBJECTIVES: This study was undertaken to evaluate the acute and midterm results of endovascular treatment with bare metal stents (BMS) for Leriche syndrome patients. METHODS: Patients with Leriche syndrome treated with BMS from August 2008 to May 2017 were included in the study and followed up. The primary endpoints were primary restenosis-free survival rates at 1, 2 and 3 years. The secondary endpoints were secondary restenosis-free and freedom from target lesion revascularization survival rates at 1, 2 and 3 years; technical success rate; complication rate; procedure-related mortality rate; and clinical status improvement at follow-up. RESULTS: Twenty patients were included and the follow-up duration was 34.7 ± 18.7 months (0-86 months). The 1-, 2- and 3-year primary restenosis-free survival rates were 94.4%, 88.1% and 73.5% and the secondary patency rates were 94.4%, 94.4% and 86.6%, respectively. The freedom from target lesion revascularization survival rates of patients at 1, 2 and 3 years were 94.4%, 88.1% and 79.3%, respectively. The aortoiliac lesions were successfully treated with BMS bilaterally in 17 patients (85.0%) and unilaterally in another 3 patients (15.0%). The complication rate was 10.0% and the procedure-related mortality rate was 0%. Mean ankle-brachial index increased significantly from 0.43 ± 0.20 before the procedure to 0.95 ± 0.21 after the procedure (P < 0.001), and to 1.00 ± 0.19 at the end of the follow-up (P < 0.001). Improvement in symptoms occurred in most patients soon after the endovascular procedure (95.0%) and at follow-up (88.2%). CONCLUSIONS: Endovascular treatment with BMS is effective and safe for patients with Leriche syndrome according to 3-year follow-up results.

Comparison of results between kissing stent and aortic bifurcated bypass in aortoiliac occlusive disease.

OBJECTIVE: Kissing stent (KS) technique has been used as an alternative to aortic bifurcated bypass surgery (ABBS) for aortoiliac occlusive disease (AIOD). We aimed to compare the results of ABBS and KS in AIOD. METHODS: Medical records of patients treated with ABBS and KS between March 2011 and December 2016 in a single center were retrospectively analyzed. The patients' characteristics and clinical outcomes were evaluated. RESULTS: Patients who underwent ABBS had a more common history of smoking (P = 0.04) and lower body mass index (P = 0.02). A significant difference was observed between the two groups in terms of the TransAtlantic Inter-Society Consensus II classification (P < 0.01). A significant difference was observed between the two groups of improvement in postoperative mean ankle-brachial indexes (ABI) (ABBS: 0.57 ± 0.24 vs KS: 0.41 ± 0.18, P = 0.01). A significant difference was observed between the combined treatments of the two groups (P < 0.01). Primary patency rates of the ABBS and KS groups at 1, 2, and 3 years were 90.1% and 100%, 82.6% and 90.6%, and 82.6% and 90.6%, respectively (P = 0.637). Primary assisted patency rates of the ABBS and KS groups at 1, 2, and 3 years were 90.1% and 100%, 82.6% and 95.7%, and 82.6% and 95.7%, respectively (P = 0.110). Secondary patency rates of the ABBS and KS groups at 1, 2, and 3 years were 93.8% and 100%, 93.8% and 95.7%, and 93.8% and 95.7%, respectively (P = 0.512). CONCLUSION: ABBS in AIOD remains an important revascularization option whenever endovascular treatment is not feasible.

Kissing stent management of stenosis of two branches of left renal artery bifurcation: a case report.

BACKGROUND: Secondary hypertension accounts for 5% of all cases of hypertension. Renal artery stenosis is one of the common causes of secondary hypertension. Atherosclerosis and fibromuscular dysplasia are the commonest types of stenosis associated with renal vascular hypertension, with the former accounting for 70-80% of all cases and the latter accounting for 10% of the incidence. The greatest incidence atherosclerosis is in men over the age of 40 years, mostly affecting the proximal part of the renal arteries, whereas fibromuscular dysplasia affects women ranging in age from 30 to 50 years. Currently, possible treatments are medical treatment using blood pressure-lowering drugs, balloon angioplasty with or without stent insertion, and surgery to reconstruct the artery. CASE PRESENTATION: We report a case of a 46-year-old Asian woman with stenosis of two branches of renal artery bifurcation treated by percutaneous balloon dilatation and stenting of both branches after referral to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She was a known nonsmoker, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable. Laboratory investigations revealed normal serum cholesterol, lipid profile, and serum creatinine. She had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indicated left renal artery stenosis, and the patient was referred to our department. CONCLUSIONS: For patients with uncontrolled hypertension despite receiving medications, renal Doppler ultrasound should be included in the diagnostic workup for secondary hypertension. Once renal artery stenosis is suspected, renal angiography is highly recommended because the technique is able to accurately diagnose stenosis in the branch arteries, unlike computed tomographic angiography and magnetic resonance angiography. Percutaneous transluminal renal angioplasty is the treatment of choice for renal artery stenosis in patients with renovascular hypertension or renal dysfunction.

Double D Technique: An Innovative Modified Bifurcated Stent Graft Deployment Strategy for an Isolated Common Iliac Artery Aneurysm With a Challenging Renal Artery Anatomy.

PURPOSE: Endovascular aneurysm repair (EVAR) for an isolated common iliac artery aneurysm (iCIAA) sometimes requires a bifurcated stent graft (SG). In EVAR, it is essential to preserve the renal artery (RA). However, this is challenging in cases of anatomical variation. The double D technique (DDT) can be used in anatomically inadequate cases with a commercially approved bifurcated SG. Here, we report the repair of iCIAA in the presence of a challenging RA anatomy, through EVAR using the DDT. CASE REPORT: An 84-year-old woman was diagnosed with a maximal 35-mm diameter left iCIAA and a nonaneurysmal aorta by computed tomography (CT), which also showed that the right RA arose 50-mm above the aortic bifurcation. The DDT was chosen because commercially approved bifurcated SGs typically require a distance of >70 mm from the proximal position to the aortic bifurcation. Postoperative CT showed excellent results with no endoleaks or SG kinking and occlusion, as well as preservation of robust blood flow to the right RA. CONCLUSION: Endovascular aneurysm repair using the DDT can be an alternative option for treatment of iCIAA with a challenging RA anatomy.

Innominate artery bifurcation pseudoaneurysm repair by "kissing stent-grafts technique": a case report.

BACKGROUND: We introduce the "kissing stent-grafts technique" for a patient who suffered from a pseudoaneurysm in bifurcation of innominate artery. This technique repaired an innominate artery bifurcation pseudoaneurysm; it successfully isolated the pseudoaneurysm and preserved both right subclavian and right common carotid artery. CASE PRESENTATION: A 60-year-old Asian (Chinese) woman complained of discovering a cervical pulsatile mass. A pseudoaneurysm at the location of innominate artery bifurcation is a rare and difficult situation that should be treated by vascular surgeons. To our knowledge, this is the first case to use the "kissing stent-grafts technique" in treating innominate bifurcation pseudoaneurysm. With this minimally invasive endovascular treatment, our patient avoided open surgery and recovered quickly. CONCLUSIONS: When treating vascular lesions with complicated anatomy, endovascular treatment always has the merit of being minimally invasive. "Kissing stent-grafts technique" can be useful in locations other than coronary and aortic bifurcation.

Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery.

BACKGROUND: Endovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation. CASE PRESENTATION: An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15-30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient's symptoms. CONCLUSIONS: CMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.

Successful Treatment Using a Kissing Stent for Blunt Abdominal Aortic Injury: A Case Report.

Blunt abdominal aortic injury (BAAI) is extremely rare. Three known treatments of BAAI exist: medical treatment, conventional surgical treatment, and endovascular treatment. Outcomes of medical and conventional surgical treatments, such as bypass graft, thrombectomy, and intimal suture, were not satisfactory. A 47-year-old man presented with multiple injuries after a high-speed vehicular accident. He was diagnosed with the traumatic aortic injury to be an intra-mural hematoma in the bifurcation of the terminal aorta. Endovascular repair with a kissing stent was performed after exploratory laparotomy. At 12 months postoperatively, the kissing stents were patent and intact, and there was no late complication. The findings indicate that the kissing stent could be useful for the treatment of BAAI in the terminal aorta.