The presence of long and heavily calcified lesions predisposes for fracture in patients undergoing stenting of the first part of the subclavian artery.

OBJECTIVE: To determine the prevalence and risk factors of subclavian artery stent fractures and to investigate their impact on in-stent restenosis development. METHODS: One hundred eight patients (65 females; median age, 58.3 years [interquartile range, 53.4-65.5 years]) with steno-occlusive disease of the first part of the subclavian artery who underwent stenting (N = 108 stents; balloon-expandable, 83.3%; self-expandable, 16.7%) between 2005 and 2015 and returned for a fluoroscopic examination of the implanted stents in 2017 were included in our study. Fractures were type I (single strut fracture), type II (multiple strut fractures without deformation), type III (multiple strut fractures with deformation), type IV (multiple strut fractures with acquired transection but without gap), or type V (multiple strut fractures with acquired transection with gap in the stent body). Stent patency was monitored by duplex ultrasound imaging. The Mann-Whitney U and Fisher's exact tests; Kaplan-Meier, receiver operating characteristic, and logistic regression analyses; as well as a log-rank test were used as statistical methods. RESULTS: The median follow-up was 73.8 months (interquartile range, 35.6-104.2 months). Thirty-eight fractures (35.2%) were detected; fractures were type I in 13, type II in 12, type III in 6, type IV in 4, and type V in 3 cases. Multivariable logistic regression analysis revealed the presence of long (≥20 mm) lesions (odds ratio, 3.3; 95% confidence interval, 1.3-8.4; P = .012) and heavy calcification (odds ratio, 4.7; 95% confidence interval, 1.7-12.7; P = .002) to be significant independent predictors of stent fracture. The primary patency rates were significantly worse (P = .035) in patients with stent fracture compared with those without stent fracture. CONCLUSIONS: Stent fractures frequently occur. Patients with long and/or heavily calcified lesions require closer follow-up.

Stent Protrusion >20 mm Into the Aorta: A New Predictor for Restenosis After Kissing Stent Reconstruction of the Aortoiliac Bifurcation.

PURPOSE: To determine the long-term patency of aortoiliac kissing stents and to identify predisposing factors for the development of in-stent restenosis (ISR). METHODS: A retrospective analysis was conducted of 105 patients (median age 60.9 years; 64 women) with symptomatic aortoiliac occlusive disease who had kissing stents implanted between 2001 and 2015. The indication for kissing stents was severe claudication in 91 (86.7%) patients and critical limb ischemia in 14 (13.3%). Lesions were TASC A in 52 (49.5%), B in 29 (27.6%), C in 4 (3.8%), and D in 20 (19%) patients. Twenty-five (23.8%) patients had heavily calcified lesions. In all, 210 stents were deployed [180 (85.7%) self-expanding and 30 (14.3%) balloon-expandable]. Follow-up included clinical evaluation, ankle-brachial index measurement, and duplex ultrasonography. RESULTS: The median follow-up was 45 months. The primary patency rates were 93%, 86%, and 77% at 12, 24, and 60 months, respectively. Significant ISR developed in 23 (21.9%) patients (12 unilateral and 11 bilateral). Univariate Cox regression analysis revealed older age [hazard ratio (HR) 0.5, 95% confidence interval (CI) 0.31 to 0.81, p=0.004] and larger aortic diameter (HR 0.42, 95% CI 0.25 to 0.7, p<0.001) to be variables favoring long-term patency, while a longer aortic stent segment (HR 1.56, 95% CI 1.16 to 2.09, p=0.003) and a larger discrepancy between the summed stent diameters and the aortic diameter (HR 1.64, 95% CI 1.01 to 2.65, p=0.043) were associated with ISR development. Multivariate analysis showed a longer aortic stent segment to be the only significant determinant of ISR (HR 1.44, 95% CI 1.02 to 2.01, p=0.035). CONCLUSION: The kissing stent technique can be performed with good long-term patency. Patients whose iliac stents protrude too far into the aorta need closer follow-up.

Comparison of the Snare Loop Technique and the Hungaroring Reinforcement for Physician-Modified Endograft Fenestrations-An In Vitro Study.

BACKGROUND: We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation. MATERIALS AND METHODS: The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration. RESULTS: Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010-1090) compared to 760 s (IQR:685-784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8-27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3-20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm. CONCLUSION: Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.

The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses-a randomized controlled trial.

Background: Air embolism is a known risk during thoracic endovascular aortic repair (TEVAR) and is associated with an incomplete deairing of the delivery system despite the saline lavage recommended by the instructions for use (IFU). As the delivery systems are identical and residual air remains frequently in the abdominal aortic aneurysm sac, endovascular aortic repair (EVAR) can be used to examine the effectiveness of deairing maneuvers. We aimed to evaluate whether increasing the flush volume can result in a more complete deairing. Methods: Patients undergoing EVAR were randomly assigned according to flushing volume (Group A, 1× IFU; Group B, 4× IFU). The Terumo Aortic Anaconda and Treo and Cook Zenith Alpha Abdominal stent grafts were randomly implanted in equal distribution (10-10-10). The quantity of air trapped in the aneurysm sac was measured using a pre-discharge computed tomography angiography (CTA). Thirty patients were enrolled and equally distributed between the two groups, with no differences observed in any demographic or anatomical factors. Results: The presence of air was less frequent in Group A compared to that in Group B [7 (47%) vs. 13 (87%), p = .02], and the air volume was less in Group A compared to that in Group B (103.5 ± 210.4 vs. 175.5 ± 175.0 mm3, p = .04). Additionally, the volume of trapped air was higher with the Anaconda graft type (p = .025). Discussion: These findings suggest that increased flushing volume is associated with a higher amount of trapped air; thus, following the IFU might be associated with a reduced risk of air embolization. Furthermore, significant differences were identified between devices in terms of the amount of trapped air. Clinical trial registration: [NCT04909190], [ClinicalTrials.gov].

[Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]. / Hasi aorta aneurysma másodlagos rupturáinak kezelése orvos által módosított fenesztrált grafttal, endocsavarozással, majd nyitott mutéttel.

Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.

[Complex endovascular repairs of the aortic arch.] / Komplex endovascularis rekonstrukciók az aortaíven.

Thoracic endovascular aneurysm repair (TEVAR) of the aortic arch has started to spread in recent years. We present our initial experience with TEVAR involving supra-aortic branches using parallel and branched grafts. Parallel grafts are typically used in emergency cases. In the case of Z0 proximal fixation, we can perform a combined hybrid surgery with Z1 debranching and securing of the innominate artery with chimney graft, which can also be used instead of Z0 debranching when the patient is unfit for sternotomy. In the case of TEVAR with planned Z2 position with inadvertent covering of the left common carotid artery, we can perform chimney conversion to rapidly recover the circulation of the left common carotid artery (LCCA). Instead of prior revascularization of the left subclavian artery, chimney graft can be used to recover the lumen, in the case of left upper limb ischemia after Z2 TEVAR. Exclusion of penetrating aortic ulcers located in the lesser curvature can be facilitated by use of a custom-made graft, where a scallop is placed around the origin of the supra-aortic vessel, thus increasing the length of the proximal neck. For elective interventions, custom-made branching grafts can be allowed to save all three branches with Z0 fixation. Technical success was obtained in all cases. Orv Hetil. 2023; 164(11): 426-431.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting.

Background: Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS. Methods: A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up. Results: There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04). Conclusion: The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

Combined Transradial and Transpedal Approach for Femoral Artery Interventions.

OBJECTIVES: The purpose of this prospective study was to evaluate the acute success and complication rates of combined transradial and transpedal access for femoral artery intervention. BACKGROUND: Improved equipment and techniques have resulted in transition from transfemoral to transradial access for intervention of superficial femoral artery. METHODS: Between 2014 and 2016, clinical and angiographic data from 145 consecutive patients with symptomatic superficial femoral stenosis, treated via primary radial access using the 6-F SheathLess Eaucath PV guiding catheter were evaluated in a pilot study. Secondary access was achieved through the pedal or popliteal artery. The primary endpoints were major adverse events, target lesion revascularization, and rates of major and minor access-site complications. Secondary endpoints included angiographic outcome, procedural factors, crossover rate to femoral access site, and duration of hospitalization. RESULTS: Technical success was achieved in 138 patients (95.2%). Combined radial and pedal access was obtained in 22 patients (15.1%). The crossover rate to a femoral access site was 2%. Stent implantation was necessary in 23.4% of patients. Chronic total occlusion recanalization was performed in 63 patients, with a 90.4% technical success rate. The mean contrast consumption, radiation dose, and procedure time were 112.9 ml (101.8 to 123.9 ml), 21.84 Gy/cm2 (9.95 to 33.72 Gy/cm2), and 34.9 min (31.02 to 38.77 min), respectively. The cumulative rate of access-site complications was 4.8% (0% major, 4.8% minor). The cumulative incidence rates of major adverse events at 3 and 12 months follow-up was 8.3% and 19.2%. The cumulative incidence rates of death at 3- and 12-month follow-up were 2.8% and 5.6%. CONCLUSIONS: Femoral artery intervention can be safely and effectively performed using radial and pedal access with acceptable morbidity and a high technical success rate.