Pioneer re-entry into covered stent graft to recanalize occluded, jailed external iliac artery.

Aortoiliac occlusive disease in patients who are poor surgical candidates requires innovative strategies in endovascular surgery. We present a case of a 59-year-old gentleman with significant medical comorbidities and chronic limb-threatening ischemia secondary to a chronically occluded left-to-right cross-femoral bypass, as well as an occluded right iliac system owing to a jailed right external iliac artery from a prior common-to-internal iliac covered stent, originally done for buttock claudication. He was treated successfully from an endovascular approach with kissing stents in the right internal and external iliac arteries after gaining access to the old right common iliac stent via an ipsilateral access and use of a Pioneer intravascular ultrasound-guided re-entry catheter. Use of this strategy to treat complex aortoiliac occlusions in patients that are not suitable surgical candidates can be achieved effectively, even in the setting of existing prior ipsilateral stent grafts.

Successful endovascular salvage of a maldeployed iliac limb extension during complex aortic reconstruction.

PURPOSE: The worst complication during cannulation of the contralateral gate during complex endovascular aortic repair is deployment of the limb extension behind the main graft body. CASE REPORT: A patient with a 5.7 cm juxtarenal abdominal aortic aneurysm was taken to the operating room for fenestrated endovascular aortic repair and iliac branch device. Percutaneous femoral access was used to deploy a Gore Iliac Branch Endoprosthesis, followed by a physician modified Cook Alpha thoracic stent graft with four fenestrations. Next a Gore Excluder was deployed to bridge the fenestrated component to the iliac branch and native left common iliac artery creating distal seal. Due to the severe tortuosity, a buddy wire technique, using a stiff lunderquist wire, was used to cannulate the contralateral gate. Unfortunately, after cannulation, the limb was advanced over the buddy lunderquist wire instead of the luminal wire. We used a backtable modified guide catheter to provide the necessary pushability to navigate wires between the aberrantly deployed limb extension and the iliac branch device. Using through-and-through access, we then successfully deployed a parallel flared limb in the correct plane. CONCLUSION: Careful communication, wire marking, and attention to intraoperative flow can minimize risks of complication, but knowledge of bail out techniques remains imperative.

Endovascular salvage of thrombosed haemodialysis vascular access.

Background: Haemodialysis access thrombosis is associated with significant morbidity and access abandonment rates, for which endovascular salvage is a well described treatment option. This study aimed to evaluate the outcomes of endovascular salvage procedures of thrombosed vascular access circuits and identify factors influencing outcomes. Patients and methods: Retrospective review of 328 consecutive procedures performed over 10 years at our institution between January 2010 and December 2019. Patient demographics, access circuit characteristics, procedure details and outcome data were collected. Kaplan-Meier survival curves were used to estimate patency rates and Cox multivariate regression analysis to identify factors affecting outcomes. Results: Technical and clinical success rates were 87.8% and 75.9% respectively. The primary, primary assisted and secondary patency rates at 6 months were 42.2%, 46.7% and 59.1%; and at 12 months were 23.4%, 28.3% and 41.8% respectively. Median access circuit survival was 9.2 months. Major complication rate was 5.2% including 3 procedure-related deaths. Native AVF, lower time from thrombosis to intervention and pharmacomechanical thrombectomy using AngioJetTM predicted positive outcomes. Previous thrombectomy within 3 months and residual thrombus at completion were associated with poorer outcomes. Age and hypertension predicted higher complication rates. Conclusions: This is one of the largest single center series of endovascular salvage of thrombosed haemodialysis access and demonstrates that endovascular treatment is effective and provides durable access circuit survival. Careful patient screening is essential to optimize outcomes.

A Novel Solution to Concomitant Type Ia/Type IIIa Endoleak Using the Cook Zenith Fenestrated Device and Endologix AFX®2.

Failing EVAR is typically treated with open explant or conversion to fenestrated endovascular repair. Novel solutions for EVAR salvage may be required in patients unable to tolerate explant or travel to centers with custom-fenestrated capabilities. However, strategies utilizing commercially available devices are often limited by anatomic constraints such as short renal artery to endograft bifurcation length. We present a case of progressive sac expansion due to late, concomitant type Ia and type IIIa endoleaks. The patient was successfully treated by proximal extension into the visceral segment using a Cook Zenith Fenestrated device and graft relining using the Endologix AFX®2.

Comparison of Outcomes of Hybrid and Surgical Correction for De Novo Arteriovenous Graft Occlusion.

PURPOSE: This study aimed to compare surgical revisions and balloon angioplasty after surgical thrombectomy on thrombosed dialysis access as a first event. MATERIALS AND METHODS: Records of patients undergoing creation of arteriovenous grafts (AVGs) at the Gachon University Gil Medical Center between March 2008 and February 2016 were reviewed. Among them, patients who underwent treatment on first-time thrombotic occlusion after AVG creation were identified. Outcomes were primary, primary-assisted, and secondary patency. The patency was generated using the Kaplan-Meier method, and patency rates were compared by log-rank test. RESULTS: A total of 59 de novo interventions (n=26, hybrid interventions; n=33, surgical revisions) for occlusive AVGs were identified. The estimated 1-year primary patency rates were 47% and 30% in the surgery and hybrid groups, respectively. The estimated primary patency rates were not different between the two groups (log-rank test, P=0.73). The Kaplan-Meier estimates of 6 and 12 months for primary-assisted patency rates were 68% and 57% in the surgery group and 56% and 56% in the hybrid group. The Kaplan-Meier estimates of 12 and 24 months secondary patency rates were 90% and 71% in the surgery group and 79% and 62% in the hybrid group. There were no differences in the estimated primary-assisted and secondary patency rates between the two groups. CONCLUSION: Our results showed no significant difference between the two groups in terms of primary patency (P=0.73), primary-assisted patency (P=0.85), and secondary patency (P=0.78). However, percutaneous transluminal angioplasty can give more therapeutic options for both surgeons and patients.