A systematic review of therapies for aortobronchial fistulae.

OBJECTIVE: The aim of the study was to summarize epidemiologic data about aortobronchial fistulae and compare outcomes (mortality, recurrence, reoperation) of open, staged, and endovascular repair of aortobronchial fistula. METHODS: A systematic literature review was conducted to identify eligible studies published between January 1999 and December 2019. The Cochrane Library, PubMed, and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series, and thus, only descriptive data with data heterogeneity were available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). RESULTS: Overall, 214 patients (90 studies) underwent 271 procedures (including redo procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae were located most often in the descending thoracic aorta (zone 3 or 4) (64.6%) and in zone 2 (23.8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43) patients. Recurrences were, to some extent, associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whereas 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61 patients, 3 received lifelong antibiotics and for 58 patients data were not available. Considering outcomes, the mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments. LIMITATIONS: Literature review has revealed only case reports and small case series, and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease, which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies that have not been conducted till today. CONCLUSIONS: Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and the recurrence process, and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal, and thus, surgeons should feel confident to apply the treatment of their choice, keeping in mind their experience, patient's age, and clinical condition.

TEVAR for Secondary Aortobronchial Fistulas: Two Cases with Favorable Long-term Outcomes.

Secondary aortobronchial fistula (ABF) is an uncommon clinical entity associated with increased mortality. Most common presentation is hemoptysis, ranging from repetitive self-limiting episodes to massive hematemesis. Mediastinitis (if present) and excessive blood loss burden the unfavorable case of ABF, whereas stent-graft contamination and sepsis are the main concerns regarding endovascular therapy. We are presenting two patients with secondary ABF treated with thoracic endovascular repair who completed long-term follow-up without complications or evidence of infection.

Immediate Change in Suprarenal Neck Angulation After Endovascular Aneurysm Repair: Comparison of the Ovation Stent-Graft Inflatable Sealing Rings to a Conventional Self-Expanding Stent-Graft.

PURPOSE: To compare the immediate suprarenal neck angulation change between the Ovation stent-graft, with its inflatable sealing rings, and a stent-graft with a conventional sealing mechanism. METHODS: A case-control study was conducted in which 30 consecutive patients (mean age 67 years; all men) with abdominal aortic aneurysm (AAA) treated with the Ovation stent-graft (group O) were retrospectively compared with 24 patients (mean age 77 years; all men) contemporaneously treated with the Endurant stent-graft (group E) at 3 high-volume tertiary vascular centers. The variables recorded were the aortic neck length, preoperative and postoperative angulation, minimum and maximum diameters of the infrarenal neck, as well as the maximum AAA diameter. All patients had undergone preoperative and postoperative (within 30 days) computed tomographic angiography. Multiple regression analysis compared the relative contribution to neck angulation change of each geometric parameter and the type of endograft. Data are presented as the mean ± standard deviation. RESULTS: The mean preoperative suprarenal neck angulation in group O was 23.2°±18.0° compared with 23.8°±22.9° in group E (t test, p=0.91). The neck lengths were 29.2±14.6 and 23.2±11.0 mm in groups O and E, respectively (p=0.1). Similarly, the minimum and maximum neck diameters were 22.4±2.6 and 25±3.5 mm, respectively, in group O vs 23.3±3.6 mm and 27.0±5.7 mm, respectively, in group E (p=0.3 and 0.12, respectively). The maximum transverse diameters of the AAA in the 2 groups were comparable, that is, 57.0±9.0 mm in group O vs 53.2±11.1 mm in group E (p=0.17). The Ovation stent-graft caused greater decrease in the aortic neck angulation postoperatively compared with the Endurant device (13.2°±16.1° vs 6.1°±5.9°, p=0.04). Multiple regression analysis revealed that preoperative neck angulation (ß coefficient 0.37, p<0.001) and the type of endograft (ß coefficient -7.91, p=0.01) had significant influence on the postoperative neck angulation change. The intraclass correlation coefficient ranged from 0.951 to 0.990 for the preoperative measurements and from 0.911 to 0.999 for the postoperative measurements for each examiner or the total of estimates at the measurement time points. CONCLUSION: The Ovation stent-graft induces greater postoperative reduction in the AAA neck angulation compared to an endograft with stent-supported graft seal. Expanded research to infrarenal angle as well to greater angles and correlation to clinical events is justified.

Initial single-center experience with the Ovation stent-graft system in the treatment of abdominal aortic aneurysms: application to challenging iliac access anatomies.

BACKGROUND: To present our preliminary results with the Ovation(™) abdominal stent-graft system in abdominal aortic aneurysms (AAA) with narrow (≤7 mm) or angulated iliac vessels. METHODS: From April 2012 to January 2014, 42 patients (97% men; mean age, 71 years; range, 55-89 years) with AAAs of 55.5 mm (50-79 mm) were treated with the Ovation device. Primary end points included technical success and freedom from early secondary interventions, any type of endoleak, and aneurysm-related death. Limb occlusion was studied with respect to iliac access diameter and angulation. Iliac angulation between 90° and 120° or <90° was considered moderate or severe, respectively. RESULTS: The postoperative follow-up was 7.8 ± 4.6 months (mean ± standard deviation). Infrarenal neck angulation was 26° ± 26°. AAA neck length and diameter were 27.3 ± 10.5 and 24.1 ± 3.2 mm, respectively. Forty-five percent of patients had at least 1 vessel of ≤7-mm diameter, and almost half of patients (24 of 44) had at least 1 iliac artery of moderate or severe angulation. Technical and treatment success were 100% and 95%, respectively. No stent-graft migration or type I, III, or IV endoleaks occurred. Type II endoleaks were identified in 5 patients, leading to sac enlargement in 2 and necessitating an embolization attempt that was unsuccessful in 1 case. No limb occlusion occurred, irrespective of the iliac diameter or angulation. CONCLUSIONS: Our 1-year results of the Ovation stent-graft system demonstrate excellent safety and effectiveness. The easy navigation through highly angulated and stenosed iliac vessels ensures high technical success in cases of challenging iliac anatomy. Follow-up is ongoing.

Technical challenges encountered during deployment of the ovation abdominal aortic stent-graft system.

PURPOSE: To describe technical challenges encountered using the Ovation endograft for abdominal aortic aneurysms and suggest tips and maneuvers for successful management. TECHNIQUE: Deployment of the Ovation's unsupported main body is often associated with the anteroposterior arrangement of the limb gates instead of the usual side-by-side configuration, rendering contralateral catheterization challenging. Successful catheterization of the contralateral limb can be confirmed by lateral deviation of the ipsilateral stiff guidewire caused by balloon inflation within the contralateral limb. Moreover, failure to cannulate the contralateral limb gate due to persistent impingement of the guidewire or compromise of the inflated rings can be overcome using the transbrachial antegrade approach. CONCLUSION: Awareness of certain aspects associated with the use of the Ovation device and adoption of the adjunctive techniques herein described helps the interventionist avoid unexpected challenges or manage technical difficulties to maximize the device's safety and effectiveness.

Impact of long-term warfarin treatment on EVAR durability: a meta-analysis.

PURPOSE: To evaluate whether postoperative long-term oral anticoagulation affects the durability of endovascular aneurysm repair (EVAR) and whether it is associated with an increased incidence of endoleak and subsequent need for reintervention. METHODS: A literature search was performed to identify studies of abdominal aortic aneurysm patients undergoing EVAR including an arm receiving warfarin postoperatively and reporting the frequency of any endoleaks and/or persistent type II endoleaks and reinterventions. The search identified 81 articles, of which 5 observational cohort studies ultimately met the inclusion criteria. RESULTS: Postoperative anticoagulation was required in 219 (14.6%) of the 1499 patients in the selected studies. The pooled effects analysis found that EVAR patients receiving long-term warfarin postoperatively had significantly more endoleaks of any type (OR 1.77, 95% CI 1.26 to 2.48, p=0.001) as well as persistent type II endoleaks (OR 1.58, 95% CI 1.05 to 2.37, p=0.03) compared with patients not on anticoagulation; however, there was no statistically significant difference in the reintervention rate between the groups. CONCLUSION: Long-term anticoagulation in EVAR patients was associated with a statistically significant increase in any endoleak and persisting type II endoleaks, although it was not linked to an increased risk of reintervention. Close monitoring for EVAR patients who require long-term oral anticoagulation is advised.

Chimney and periscope technique for emergent treatment of spontaneous aortic rupture.

Aortic rupture comprises a potentially fatal condition necessitating emergent treatment. Endovascular sealing of the rupture site is often combined with the use of chimney- and periscope stent placement to preserve perfusion of aortic branches. We present a case of successful endovascular management of contained aortic rupture in a 78-year-old patient. The left brachial access facilitated stenting of the celiac and superior mesenteric arteries, whereas the left femoral route served stenting of the renal artery. One-month follow-up confirmed complete sealing, stent patency, and absence of endograft migration. The combined periscope and chimney technique is feasible and effective in the emergency setting.

Clinical outcomes after crossed-limb vs. conventional endograft configuration in endovascular AAA repair.

PURPOSE: To report a case controlled analysis of endovascular aneurysm repair (EVAR) outcomes using the crossed-limb (CxL) endovascular configuration vs. the straight-limb configuration (SLC). METHODS: From January 2007 to July 2012, 27 patients (25 men; mean age 73.7±7.2 years, range 53-82) were treated by EVAR with the CxL technique. These patients were matched anatomically with 27 patients (27 men; mean age 72.4±7.4 years, range 52-86) who underwent EVAR using the same endograft and the standard SLC within a ±6-month period. Primary outcome measures included technical and clinical success and freedom from graft limb thrombosis, any type of endoleak, early or late secondary interventions, and aneurysm-related death estimated using the Kaplan-Meier method. RESULTS: The median follow-up periods for the CxL and SLC groups were 29.9 (range 6-54) and 33.5 (range 6-59) months, respectively (p=0.81). The technical success rate was 100% in both groups, but mean procedure times were significantly longer in the CxL group (116.3 vs. 90.7 minutes, p=0.035). Twelve intraoperative endoleaks (3 each for types Ia, Ib, II, and IV) occurred but without any difference between groups (p=0.51). One CxL group patient died in the early postoperative period (aneurysm-related) and another had an early graft limb thrombosis. One late type Ib intraoperative endoleak was recorded in the SLC group (p=0.51). For the CxL vs. SLC groups, the 1-year rates for freedom from endograft limb thrombosis (94% vs. 96%), any type of endoleak (96% vs. 96%), early or late reintervention (94% vs. 96%), and aneurysm-related death (94% vs. 96%) were not significantly different. Respective values at 36 months were 82% vs. 82%, 85% vs. 84%, 81% vs. 78%, and 83% vs. 84% (p>0.05). Clinical success rates at 12 months for the CxL and SLC groups were 91% and 100% (p>0.05), respectively, whereas at 36 months, the rates were 83% and 90% (p>0.05). CONCLUSION: No difference was found between the crossed-limb technique and the conventional endograft position as regards short- or midterm clinical outcomes.

Surgical or endovascular therapy of abdominal penetrating aortic ulcers and their natural history: a systematic review.

Little is known regarding the outcomes of endovascular and surgical treatment of penetrating ulcers in the abdominal aorta. The potential benefit of conservative management of asymptomatic disease is also debatable. A systematic review of the literature was undertaken to investigate these issues.

Aneurysm sac shrinkage after endovascular treatment of the aorta: beyond sac pressure and endoleaks.

The isolation of the aneurysm sac from systemic pressure and its consequent shrinkage are considered criteria of success after endovascular repair (EVAR). However, the process of shrinkage does not solely depend on the intrasac pressure, the predictive role of which remains ambiguous. This brief review summarizes the additional pathophysiological mechanisms that regulate the biomechanical properties of the aneurysm wall and may interfere with the process of aneurysm sac shrinkage.

Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy.

OBJECTIVE: To evaluate and compare the outcome after endovascular abdominal aortic aneurysm repair (EVAR) with the newly released Endurant endograft system in patients with different aortoiliac anatomic characteristics. METHODS: We conducted a prospective observational study assigning patients with infrarenal abdominal aortic aneurysm (AAA) treated with the Endurant endoprosthesis from February 2009 to March 2010. Two groups were studied, according to the presence of a friendly (group I [GI] = 43) or hostile (group II [GII] = 34) infrarenal aortoiliac anatomy. Hostile profile was defined as any (or combination) of the following measurements: 5 mm ≤ proximal neck length (Lpr) ≤ 12 mm, 60° < proximal neck angle (A°pr) ≤ 90° and 60° < any iliac axis angle (A°iliac) ≤ 90°. Primary end points included technical and clinical success, freedom from early or late secondary interventions, any type of endoleak, and aneurysm-related death. All outcome measures were calculated using the Kaplan-Meier method and the log rank test was applied for comparisons between the groups. RESULTS: The mean comorbid severity scoring was higher in GII (P = .018). The mean follow-up period in GI and GII was 12.9 ± 3.9 months (± SD, range: 6.4-19.8) and 12.4 ± 4 months (range: 4.2-19.6), respectively. Two unplanned conversions to aortouniiliac configurations were required in GI. The technical success rate in GI and GII was 95.4% and 100%, respectively. The requirement for intentional occlusion of the internal iliac artery, the requirement for cross-limb technique, the necessity of troubleshooting techniques, the procedure and radiation times, the frequency of postimplantation syndrome, and mean hospital stay were significantly higher in GII (P = .028, P = .013, P = .005, P = .037, P < .001, P = .032, P = .021, respectively). Two patients of GI died in the early postoperative period (one aneurysm but not device-related death), whereas no deaths in GII were recorded, yielding an overall 30-day mortality rate of 2.3%. No type I/III endoleaks were recorded up to the end of the study. Freedom from any type of endoleak, early or late secondary interventions, and aneurysm-related death at 12 months were found in 93.2%, 87.1%, and 93.3% of GI patients; respective values for GII were 86% (P = .21), 93.4% (P = .066), and 93.4%. The clinical success rate was 82.1% and 100% at 12 months for GI and GII, respectively. CONCLUSIONS: Early (12 months) results suggest similar clinical performance of the Endurant stent graft system in endovascular treatment of AAAs with friendly and hostile anatomies, however, demonstrating more intra- and perioperative adversities for the last group. Larger prospective studies or even randomized trials comparing different new generation graft models are required to evaluate the comparable long-term results and possible expansion of EVAR indications for this specific endograft in adverse anatomies.

A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or endograft delivery systems.

PURPOSE: To determine via a meta-analysis if the success rates for percutaneous EVAR using the "preclose" technique with suture-mediated vascular closure devices (SMCDs) are higher for smaller sheaths [≤ 18-F outer diameter (OD)] than for larger sheaths (≥20-F). METHODS: All English-language studies on percutaneous EVAR outcomes related to sheath sizes published between 1999 and August 30, 2010, were searched using MEDLINE and SCOPUS. Randomized trials, retrospective or prospective observational studies, and original articles (including a review) were included. The search identified 32 relevant full-text studies; data on percutaneous EVAR outcomes per sheath size category (≤ 18-F and ≥ 20-F OD) were included in the final meta-analysis of data from 17 studies (1 randomized controlled trial and 8 retrospective and 8 prospective cohort observational studies). The final analysis included 1440 patients and 2447 femoral access sites. Primary success was defined as closure of a common femoral artery arteriotomy without the need for any adjunctive surgical or endovascular procedure. RESULTS: Pooled data revealed that success rates were significantly better when percutaneous EVAR was performed with ≤ 18-F sheaths than with ≥ 20-F sheaths (odds ratio 1.78, 95% confidence interval 1.24 to 2.54, p = 0.002). This benefit, although not significant, was more pronounced when multiple rather than single pre-applied SMCDs were deployed (odds ratio 2.16 vs. 1.64, respectively; p = 0.353). CONCLUSION: When considering primary success, it appears that larger-bore femoral access sheaths (≥ 20-F) introduced for percutaneous EVAR after pre-application of SMCDs are predictors of primary failure and the need for conversion to a femoral cutdown. More advanced large-bore SMCDs are required to further reduce the necessity for conversion. Planned use of multiple SMCDs might be more beneficial when ≤ 18-F sheaths are required.

Emergency endovascular treatment of early spontaneous nonaneurysmal popliteal artery rupture in a patient with Salmonella bacteremia.

Rupture of a nonaneurysmal popliteal artery and subsequent pseudoaneurysm formation is an exceedingly rare event after bacteremia caused by Salmonella spp. Only a few cases have been reported in the literature. Moreover, spontaneous popliteal artery rupture resulting from this pathology, to our knowledge, has not been reported. We describe an early spontaneous rupture of the popliteal artery complicated by acute compartment syndrome in a 67-year-old man who had recently experienced fever, chills, and diarrheal syndrome and had sustained episodes of bacteremia infection, with isolation of S enteritidis. Immediate endovascular sealing of the bleeding site was achieved with a covered stent, and his recovery was uneventful. The long-term durability of endovascular repair in this type of pathology remains to be determined, however.

Total Endovascular Therapy of Abdominal Aortic Aneurysm, Peripheral Artery Disease, and Chronic Mesenteric Ischemia: A Challenging Case.

We presented a challenging case of a patient diagnosed with abdominal aortic aneurysm (AAA), peripheral artery disease, and chronic mesenteric ischemia (CMI). Herein, we describe the treatment in this high-risk patient diagnosed with CMI who also had critical limb ischemia and his AAA had rapidly expanded. First we performed angioplasty and celiac arterial stenting. Afterwards, we proceeded to perform balloon angioplasty of the iliac arteries and chimney endovascular aneurysm repair (Ch-EVAR) preserving the inferior mesenteric artery (IMA). The patient was discharged three days later and his IMA remained patent eighteen months post-operation. A thorough pre-operative assessment is essential in such challenging cases. Minimally invasive procedures like endovascular therapy and the chimney technique extend the prognoses in high-risk patients.

Successful management of acute thromboembolic disease complicated with heparin induced thrombocytopenia type II (HIT II): a case series.

Heparin-induced thrombocytopenia type II (HIT II) is a rare immune-mediated complication of heparin. The diagnosis of HIT is considered in patients exposed to heparin, presenting with thrombocytopenia and thrombosis.We present two cases with massive pulmonary embolism and HIT, successfully treated with the administration of fondaparinux, an alternative anticoagulant, combined with the insertion of an inferior vena cava filter for the prevention of new thromboembolic events. The two cases supplement the available data of the use of fondaparinux in patients with HIT and pulmonary embolism, before further large studies establish its efficacy and safety in this group of patients. Moreover, the management of these patients reveals the need for future evaluation of the combined therapy of alternative anticoagulant agents with the placement of vena cava filters.

The ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives.

The Ovation Abdominal Stent Graft System is a trimodular endoprosthesis recently introduced for the endovascular repair of abdominal aortic aneurysm (AAA). It uncouples the stages of stent-graft fixation and sealing with the suprarenal fixation achieved with a long, rigid anchored stent while the sealing onto the neck is accomplished via a pair of polymer-filled inflatable rings that accommodate to each patient's individual anatomy. Moreover, the lack of Nitinol support enables lower profiles of the endograft's delivery system, thus facilitating the navigation through angulated and stenosed iliac vessels. Ovation's novel design expands further the AAA eligibility to endovascular repair. This article discusses the clinical and hemodynamic consequences of the Ovation design and contributes to better understanding of current and future implications.

Troubleshooting techniques for the Endurant™ device in endovascular aortic aneurysm repair.

Endovascular aortic aneurysm repair with the Endurant™ stent-graft system has been shown to be safe and effective in high-risk surgical patients with complex suprarenal and/or infrarenal abdominal aortic aneurysm anatomy. The wireformed M-shaped stent architecture and proximal springs with anchoring pins theoretically permit optimal sealing in shorter and more angulated proximal aneurysm necks even under off-label conditions. Nonetheless, extremely difficult anatomical situations and inherent graft system-related limitations must be anticipated. Herein, we describe our techniques to overcome the capture of the tip sleeve within the suprarenal bare-stent anchoring pins, other endograft segments, and native vessels.