Total Endovascular Aortic arch Replacement with Chimney/Sandwich Techniques.

Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30-40%) and mortality (8-20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angio-computed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.

The sandwich technique to treat complex aortoiliac or isolated iliac aneurysms: results of midterm follow-up.

OBJECTIVE: To ascertain midterm outcomes of the sandwich technique (ST) for internal iliac artery endorevascularization (ER). METHODS: All consecutive patients with complex aortoiliac aneurysms, isolated common iliac artery aneurysms, and abdominal aortic aneurysms with bilateral short, nondiseased common iliac artery undergoing elective endovascular aneurysm repair (EVAR) with the ST at our center, between October 2008 and March 2011, were invited to participate in the present study. Patients were considered eligible for this procedure only when their aneurysm features did not fulfill the requirements for standard EVAR. Follow-up assessments were carried out at 1 month and every 6 months thereafter and included computed tomographic angiography or duplex ultrasound. The study was approved by the Institutional Review Board, and all patients gave written informed consent. RESULTS: A cohort of 40 patients (95% male; mean age, 72.2 years) was followed over a mean follow-up period of 12 ± 4.4 months (range: 6-30 months); 48 internal iliac artery (IIA) ER with ST were undertaken. Internal iliac artery aneurysm (IIAA) ER technical success rate was 100%. Primary patency rate was 93.8% on account of three IIA ER occlusions, occurring early in the study. Early and late related mortality rate was 0% and late unrelated mortality rate was 2.5%. Iliac aneurysm sac evolution demonstrated a significant (at least 5 mm) decrease in diameter in 16 (34.8%) common iliac artery aneurysms, no change in 29 (63%) common iliac artery aneurysms, and an increase in one patient (2.2%). Statistical significance was reached only for comparisons between baseline and 30 months (P = .039). Late buttock claudication rate was 0% after IIA ER with ST and 14.3% after IIA coil embolization. CONCLUSIONS: The ST expands the limits of EVAR for complex aortoiliac aneurysms or IIAA in a safe, easy to perform, and cost-effective manner.

Endovascular treatment of complex aortic aneurysms using the sandwich technique.

PURPOSE: To assess the safety and efficacy of the sandwich technique for complex aortic aneurysms. METHODS: Between October 2008 and March 2012, 78 patients (70 men; mean age 73.3 years) undergoing complex thoracic or abdominal endovascular aneurysm repairs were treated with the sandwich technique when the aneurysm features did not fulfill the requirements for standard endovascular techniques or total aortic arch replacement. Two thirds of the population was treated for aortoiliac aneurysm (52, 66.7%). There were 15 (19.2%) thoracoabdominal aneurysms, 6 (7.7%) isolated iliac artery aneurysms, 3 (3.8%) arch aneurysms, and 2 (2.6%) abdominal aortic aneurysm with non-diseased, short common iliac arteries bilaterally. Five (6.4%) symptomatic patients were submitted to endovascular repair in the urgent setting. RESULTS: Technical success was 98.7%; one procedure was aborted when both renal arteries could not be cannulated. Over a mean 17-month follow-up (range 1-42), primary patency was high (96.7%) and mortality low (early: 5.1%, late: 1.3%). Overall, only 4 (5.1%) type II endoleaks persisted: 3 early with no sac increase and 1 late with sac increase that was managed conservatively on patient demand (stable at 9 months). In all other aneurysms except the 3 in the arch, there was a 5-mm reduction in size achieved by the end of the second year of follow-up, though this was significant only in the aortoiliac aneurysm group (p<0.005). CONCLUSION: The sandwich technique facilitates safe and effective aneurysm exclusion and target vessel revascularization in adverse anatomical scenarios, with sustained durability in midterm follow-up.

Lobato technique for acute type B aortic dissection complicated by thoracoabdominal aortic aneurysm and total true lumen occlusion of the infrarenal aorta.

A 63-year-old man had presented for emergency endovascular treatment of acute type B aortic dissection complicated by acute occlusion of the true lumen of the infrarenal aorta and a Crawford type III thoracoabdominal aortic aneurysm. These findings precluded the use of a conventional endovascular approach. A novel technique was developed with the insertion of guidewires through the left femoral and subclavian arteries to deliver stent grafts to cover the dissection entry tear and exclude the thoracoabdominal aortic aneurysm. A femorofemoral bypass was performed to preserve the circulation. The procedure and follow-up course were uneventful. This technique appears to be a promising tool for thoracic endovascular aortic repair in emergency setting. More experience with the method is warranted.

Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation.

PURPOSE: To describe a new endovascular approach to preserve internal iliac artery (IIA) flow in patients with abdominal aortic aneurysm (AAA) involving the common iliac artery(ies) (CIA) or in cases of isolated CIA/IIA aneurysm. TECHNIQUE: The sandwich technique for isolated CIA/IIA aneurysms or aortoiliac aneurysms extending to the IIA includes 5 steps: (1) bifurcated stent-graft main body insertion through an ipsilateral femoral approach and positioned such that the distal end of the iliac limb is 1 cm above the IIA origin; (2) catheterization of the ipsilateral IIA through a left brachial access with a long 5-F multipurpose catheter and a 0.035-inch extra stiff floppy tip guidewire; (3) placement of a covered self-expanding stent 2 cm inside the IIA with a 6-cm overlap into the iliac limb, followed by positioning of an iliac limb extension 1 cm below the covered stent's proximal end (the iliac limb extension is deployed first and then the covered stent); (4) modeling of the iliac limb stent-grafts using a latex balloon and dilation of the covered stent with an angioplasty balloon; and (5) deployment of the contralateral iliac limb. For bilateral CIA aneurysms extending to both IIAs, repeat steps 2-4. CONCLUSION: This technique was developed to overcome current anatomical and device constraints, expanding the limits of endovascular aneurysm repair (EVAR) in a safe, easy to perform, and cost-effective manner. The sandwich technique appears a promising tool in the EVAR armamentarium, but more experience with the method is warranted.

Parallel Graft Technique in a Complex Aortic Aneurysm: The Value of Intra-operative Flexibility from The Original Operative Plan.

INTRODUCTION: The parallel grafting technique (PGT) is a valuable alternative to prefabricated branched or fenestrated endovascular aortic repair. An often overlooked advantage of PGT is its unique adaptability to different anatomical challenges that might appear intra-operatively. REPORT: A 72 year old male patient presented with a 60 mm thoracic aneurysm, 59 mm juxtarenal abdominal aortic aneurysm, and 32 mm common iliac aneurysm (CIAA). Thoracic endovascular aortic repair plus endovascular aortic repair with bilateral renal artery chimneys and CIAA exclusion applying the sandwich technique was proposed. Because of unfavourable angulation it was not possible to achieve selective left renal catheterisation via axillary access. Changing to a femoral approach allowed successful retrograde catheterisation. The procedure ended with a chimney for the right renal artery and a periscope for the left renal artery. The final angiogram showed no endoleaks and renal and hypogastric patency. The patient was discharged three days after the procedure and remains under ultrasound surveillance after 40 months because of a small type two endoleak. CONCLUSION: When using a prefabricated branched device, the possibility of selectively catheterising a visceral branch often has no straightforward solution. However, parallel grafting is an extremely flexible technique, which was of paramount importance for the surgical outcome of the present case.

Aortic disease in the young: genetic aneurysm syndromes, connective tissue disorders, and familial aortic aneurysms and dissections.

There are many genetic syndromes associated with the aortic aneurysmal disease which include Marfan syndrome (MFS), Ehlers-Danlos syndrome (EDS), Loeys-Dietz syndrome (LDS), familial thoracic aortic aneurysms and dissections (TAAD), bicuspid aortic valve disease (BAV), and autosomal dominant polycystic kidney disease (ADPKD). In the absence of familial history and other clinical findings, the proportion of thoracic and abdominal aortic aneurysms and dissections resulting from a genetic predisposition is still unknown. In this study, we propose the review of the current genetic knowledge in the aortic disease, observing, in the results that the causative genes and molecular pathways involved in the pathophysiology of aortic aneurysm disease remain undiscovered and continue to be an area of intensive research.

A new technique to enhance endovascular thoracoabdominal aortic aneurysm therapy--the sandwich procedure.

Thoracoabdominal aortic aneurysm (TAAA) is a life-threatening condition with a potentially high risk of rupture (46% to 74%) when left untreated. Mean elective surgical mortality rate is 6.6% at best, rising to 47% for emergency operations. Standard thoracic endovascular repair alone is not currently considered an adequate approach to treat TAAA because of the visceral arteries involved by the aneurysm sac. A hybrid procedure and other complex endovascular techniques (eg, chimney graft, fenestrated and side-branched modular endograft systems) have been developed, but results are still conflicting; the procedures are not feasible for all patients and cost is still a concern. The sandwich technique was developed to address these aneurysms and dissection that still cannot be repaired in a safe, efficient, and cost-wise manner. From October 2008 to March 2012, elective and/or emergency sandwich technique repair was undertaken in 15 consecutive patients (80% male, mean age 70.3 years) with TAAA at our institution, with a mean follow-up period of 16.2 (range 1 to 36) months. Technical success rate was 92.3% and, in one patient (TAAA), both renal arteries could not be cannulated by guide wire and the procedure was aborted. Total, elective, and emergency 30-day mortality rates were 20% (3/15), 7.7% (1/13), and 100% (2 of 2), respectively. Two other deaths were unrelated to the procedure and due to hemorrhagic stroke (10 months) and lymphoma (12 months). Forty-eight visceral arteries (mean 3.4 arteries/patient) were successfully endorevascularized (22 renal arteries, 14 superior mesenteric arteries and 12 celiac trunks) with self-expandable covered stents and bare stents inside it in 14 patients. Three right and two left renal arteries could not be cannulated (5 of 54), comprising 9.2% failure to treat target vessels. Primary patency rate was 97.9%, with only 1 of 48 with endorevascularized target vessel occlusion. No spinal cord ischemia events were observed during the follow-up period. Three transient renal function impairments (20%) and one type III endoleak (11%), which sealed spontaneously at the 1-month assessment, were detected. Sandwich technique for TAAA repair is a safe, well-tolerated, feasible alternative using ready-to-use endoprosthesis to provide efficient visceral revascularization in types I, II, III, and IV TAAAs. The sandwich technique appears to be a promising tool in the endovascular repair of TAAA, but more experience with the method is warranted.

Superior mesenteric artery syndrome: an uncommon complication of abdominal aortic aneurysm repair.

The superior mesenteric artery syndrome (SMAS) is an uncommon finding, especially when occurring after open abdominal aortic aneurysm (AAA) repair. Very few cases have been previously reported in the literature. The underlying anatomic mechanism as well as a better way to manage this complication remains controversial. We report a case of well-documented duodenum obstruction occurring after an elective, uneventful open AAA repair in an 83-year-old white male. The patient was initially discharged from hospital on the fifth postoperative (PO) day but was readmitted on the seventh PO day with suspicion of intestinal obstruction caused either by adhesions or extrinsic pressure by a retroperitoneal hematoma. A laparotomy carried out on the 10th PO day was unremarkable and the patient continued vomiting until a left lateral decubitus positioning was assumed. The patient was discharged home on the 19th PO day and has remained well since.

Learning curve for endovascular abdominal aortic aneurysm repair: evaluation of a 277-patient single-center experience.

PURPOSE: To determine the minimum number of stent-graft deployments that an interventional team with endovascular skills must do to be considered well trained in endovascular abdominal aortic aneurysm (AAA) exclusion. METHODS: The records of 277 consecutive patients (236 men; median age 73 years, range 49-91) undergoing endovascular AAA repair at a single institution between 1994 and 1998 were reviewed. Information was collected on procedural success, conversion, time interval between procedures, operative complications, operative mortality, contrast volume, blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS. A first-order differential equation was used to calculate a learning curve based on the success rate. Patients were subsequently divided into 5 sequential groups of 55 patients (the last group had 57 patients). RESULTS: Analyzing the pattern of procedural success to failures, a sharp change in the slope was observed between 50 and 65 trials. The number 55 was arbitrarily chosen to represent the point after which the incremental change in the success rate never exceeded 0.01 (<1 failure per 100 attempts). In the intergroup comparisons, success rate (p<0.04), conversion rate (p<0.0001), and procedural frequency (p<0.0001) were statistically significant when the first 55-patient group was compared to the others. Operative complications (p=0.08) and operative mortality (p=0.16) were numerically but not significantly different. Contrast volume was significantly reduced for the last group (p<0.0001). A Cox regression model identified only procedural frequency (p=0.03) and procedural volume (p=0.04) as predictive of technical success. Performing endovascular AAA repairs at a < or =10-day interval was associated with a >80% success rate. CONCLUSIONS: This study shows that not only is the number of procedures important to outcome, but also the frequency with which they are performed. Based on our team's performance data, 55 cases would appear to be the minimum volume and 1 case every 10 days the minimum frequency to obtain good operative results with aortic endografting.