The Cupidon's Strike Technique: How to Never Miss a Rendezvous While Going on SAFARI.

One of the difficulties of the subintimal arterial flossing with antegrade-retrograde intervention technique (SAFARI) technique is to properly achieve a rendezvous between both antegrade and retrograde accesses. We propose a new technique to overcome this difficulty. It consists of directly percutaneously puncturing 2 loop snares, placed via each access, which are then both used to snare an externally introduced guidewire introduced through the needle. The snares are then moved en bloc, bringing both snares and the wire into the same channel.

Chronic abdominal aortic dissection, endovascular treatment using a new Stent-graft for in situ Fenestration.

BACKGROUND: Although endovascular treatment of the thoracic aorta (TEVAR) has become an elective procedure for treatment of complicated type B aortic dissection, its role in treating post dissection thoraco-abdominal aortic aneurysm (TAAA), is still limited. This is a case of aortic vascular disease, which reports the use of a new endovascular device. CASE PRESENTATION: We present the case of a 62 year old male patient with a history of hypertension, active smoker, who presented penetrating descending thoracic aortic ulcer in the setting of a chronic abdominal aortic dissection. The patient was treated using a new stent graft capable of in situ fenestration that allowed crossing the stent-graft membrane, implanting a covered stent to exclude the re-entry at the level of the left renal artery and redirecting the blood flow through the true lumen. CONCLUSIONS: This case report demonstrates the feasibility of a novel stent-graft concept. Larger studies with longer follow-up are essential to fully evaluate the safety and effectiveness of this new design.

Comparison of contrast-enhanced MR angiography to intraarterial digital subtraction angiography for evaluation of peripheral arterial occlusive disease: results of a phase III multicenter trial.

PURPOSE: To evaluate the efficacy and safety of 0.1 mmol/kg gadodiamide administration for contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting hemodynamically relevant main stenosis (ie, > or = 50% or occlusion) of aortoiliac arteries. MATERIALS AND METHODS: In a multicenter, phase 3, controlled study, patients with suspected or proven peripheral arterial occlusive disease (PAOD) underwent CE-MRA with administration of gadodiamide. Intraarterial digital subtraction angiography (IA-DSA) was used as the reference. The study was approved by all Institutional Review Boards or Institutional Ethic Committees prior to commencement of patient recruitment and written informed consent was obtained from all patients. RESULTS: Independent readers rated 25%-45% of CE-MRA images as excellent compared with 0.3%-6% of noncontrast MRA images. Mean imaging acquisition time for CE-MRA was <1 minute (0.7 +/- 1.9 minutes) versus 10 minutes (10.8 +/- 3.0) for noncontrast MRA. Sensitivity, specificity, and accuracy of CE-MRA were superior compared with those of noncontrast MRA in detecting significant arterial stenoses. Compared with IA-DSA, the sensitivity of CE-MRA ranged from 80%-88% and the specificity from 73% to 92% for the three blinded readers, at the patient level. CONCLUSION: Diagnostic results with CE-MRA were superior and more consistent compared with noncontrast MRA for detecting hemodynamically relevant main stenoses in patients with suspected or proven PAOD and compared favorably with IA-DSA as a reference standard.

Radiofrequency perforation system for in vivo antegrade fenestration of aortic stent-grafts.

PURPOSE: To evaluate the ability to create in vivo antegrade fenestrations (IVAF) using a radiofrequency probe in juxtarenal aortic stent-grafts to preserve the patency of renal arteries. METHODS: Modified stent-grafts with an unsupported fenestration area were deployed in the juxtarenal aorta of 2 25-kg dogs. Prior to deployment, both renal arteries were marked with detachable coils that were later removed (dog 1) or with hydrophilic catheters (dog 2). After deployment, a radiofrequency probe was used to perforate the graft. If puncture was successful, attempts were made to pass guidewires into the renal arteries for balloon dilation and stenting of the graft perforation. Doppler ultrasound scans of the renal arteries were taken after 1 week. Doppler ultrasound and angiography were repeated prior to autopsy and macroscopic analysis at 1 month. RESULTS: Fenestration was attempted in 3 renal arteries (1 in dog 1 and 2 in dog 2). It was successful in 2 renal arteries but required 6 attempts in dog 1 and 3 in dog 2. The failed case was related to the position of a stent-graft strut close to the fenestration area. One stent thrombosis was seen during follow-up, while the other fenestrated artery remained patent. No stent fracture was encountered during follow-up. CONCLUSION: This radiofrequency device allowed successful fenestration but was difficult to control. Technical improvements are required to improve clinical success and patency.

In vivo antegrade fenestration of abdominal aortic stent-grafts.

PURPOSE: To examine in a canine model the feasibility of antegrade fenestration of abdominal aortic stent-grafts to preserve the patency of the renal arteries. METHODS: Two large dogs underwent antegrade fenestration of stent-grafts in the perirenal aorta. Before fenestration, bare stents were inserted in both renal arteries as fluoroscopic landmarks. A 12-mm iliac extension served as the canine aortic endograft. The first procedure was done under ultrasound and fluoroscopic guidance, using an intravascular ultrasound (IVUS) probe inserted in the vena cava and a Pioneer IVUS catheter. The second was performed exclusively under fluoroscopic guidance with a Brockenbrough needle. Angiograms and duplex ultrasound were planned for 1 month, after which the dogs would be sacrificed for autopsy. The explanted endograft was subjected to biomaterials analysis, with a focus on fabric tear. RESULTS: Perforation of the aortic graft and catheterization of the renal arteries with a floppy guidewire were possible in both animals. In dog 1, aortic graft dilation and subsequent fenestration were not possible, and the experiment was terminated. However, the procedure was successful in both renal arteries of dog 2. At 1-month follow-up in this dog, both renal arteries were patent. Stent fractures were observed bilaterally. There was no extension of the damage to the fabric beyond the area of fenestration. CONCLUSION: In vivo antegrade fenestration of aortic endografts is technically feasible. However, improvements in technique, instrumentation, and materials are required to make it a reliable and reproducible way of allowing stent-graft vascularization of aortic side branches.