Mid-term Results of Chimney and Periscope Grafts in Supra-aortic Branches in High Risk Patients.

PURPOSE: Report mid-term outcomes of thoracic endovascular aneurysm repair (TEVAR) with chimney and periscope grafts (CPG) in supra-aortic branches (SAB). METHODS: Retrospective analysis, from October 2009 to May 2014, of patients with aneurysms requiring TEVAR with zone 0/1/2 proximal landing in association with at least one CPG in the SAB. All patients were considered at high risk for conventional surgery. Peri-operative mortality and morbidity, retrograde type A dissection, maximum aortic transverse diameter (TD) and its post-operative evolution, endoleak, survival, freedom from cardiovascular re-interventions, and CPG freedom from occlusion during the follow-up were analysed. RESULTS: Forty-one patients (28.05% EuroScore II) with thoraco-abdominal aortic aneurysm (17%), arch aneurysm (39%), descending aneurysm (34%), and aneurysm extending from the arch to the visceral aorta (10%) were included. Fifteen (37%) patients were treated non-electively. Fifty-nine SABs were treated with the CPG technique: one, two, three, and four CPG were employed in 71%, 19%, 5%, and 5% of patients, respectively. The proximal landing was in zone 0 in 49% of patients, zone 1 in 17%, and zone 2 in 34%. Technical success was 95%. Peri-operative complications and neurological events were registered in six (14.6%) patients and there were 5 deaths (12%). At a median follow-up of 21.2 (mean 22, SD 18; range 0-65) months, type I/III endoleaks were registered in three (7%) cases and re-intervention in six (15%) patients. A significant aneurysm sac shrinkage (p<.001) was reported at mean follow-up and no significant aneurysm sac increase (>5 mm). The estimated 2 year survival, freedom from re-intervention, freedom from endoleak, and freedom from branch occlusion were 75%, 77%, 86%, and 96%, respectively. CONCLUSION: The chimney and periscope grafts technique was shown to be safe in aortic aneurysm disease involving the supra aortic branches, even in an emergency setting using off the shelf devices. Mid-term follow-up results in this high risk population are good, but longer follow-up is mandatory before this technique is used in intermediate-risk patients.

The coronary technique for complex carotid artery stenting in the setting of complex aortic arch anatomy.

Carotid artery stenting (CAS) remains a viable option for treating carotid artery lesions in high surgical risk patients. We retrospectively reviewed our experience in performing CAS in patients with complex aortic arch anatomy. The ''coronary technique'' uses an AL1 guiding catheter to engage the origin of the common carotid artery permitting delivery of protection device and stent. In total, 12 patients had complex arch anatomy which precluded access using the standard technique as determined on preoperative imaging. A total of 8 patients with such anatomy underwent femoral artery catheterization with placement of an Amplatz AL1 guide catheter into the common carotid artery. All were able to be successfully treated, with no dissection, neurovascular deficit, or other major complication. Based on this case series, we describe the coronary technique as a safe and viable method for CAS in the setting of complex anatomy which might otherwise preclude CAS.

Access complications during endovascular aortic repair.

Endovascular repair is becoming the mainstay of treatment for aneurysmal disease of the abdominal and thoracic aorta. Access related issues comprise a major reason for failure or conversion to open repair and can contribute to a significant amount of morbidity and mortality. This article will discuss a multitude of access related complications and their treatment. Preoperative imaging is paramount to the success of endovascular procedures. Intraoperative adjuncts, such as iliac artery angioplasty/stenting, the "pull-down" technique, and aorto mono iliac/femoral systems will be discussed. Occasionally, challenging iliac or femoral anatomy may preclude access through these vessels and the endovascular specialist may need to gain direct access through the aorta or via the carotid artery. In addition, the advantages and disadvantages of an entirely percutaneous technique will be discussed. Finally, peri-operative complications such as rupture, dissection, pseudoaneurysm and infection will be discussed and various treatment modalities reviewed. As stent graft technology and our own skill sets and experience continue to improve, fewer patients will be refused an endovascular repair based on access issues alone.

Experience and technique for the endovascular management of iatrogenic subclavian artery injury.

BACKGROUND: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. CONCLUSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair.

Multidimensional characterization of carotid artery stenosis using CT imaging: a comparison with ultrasound grading and peak flow measurement.

PURPOSE: Clinical decision making for carotid surgery depends largely upon stenosis grade. While digital subtraction angiography remains the gold standard for stenosis grading, many physicians use less invasive modalities. The purpose of this study was to compare the results of multidimensional Computed tomography (CTA) with ultrasound (US) grading and peak flow velocity (PSV). METHODS: 37 stenosed carotid arteries were studied retrospectively in 36 consecutive patients. US grading and PSV were compared to multidimensional CTA analysis (diameter, area and volumetric measurements), performed by a medical software company. Calculations of stenosis percentage on CTA were made using the NASCET and ECST methodology. Diameter measurements were also performed by a neuroradiologist. RESULTS: All CTA diameter, area and volume measurements had only modest correlation with PSV (r<0.5) and ultrasound grading (p<0.5). There was concordant classification of stenosis grades in only 40-60% of cases. CTA diameter, area and volume measurements had good correlation (0.69

Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation.

Durable vascular access for hemodialysis remains a critical issue in end-stage renal disease patients. Creation of an autogenous arteriovenous (AV) fistula in the most distal location of the nondominant extremity is the preferred technique and provides superior patency over an AV graft. Others have shown that regional anesthesia in the form of axillary block results in the dilatation of the native veins and allows for their increased utilization in creating AV fistulae. We report on 26 patients undergoing creation of a vascular access for hemodialysis. Regional anesthesia consisting of axillary nerve block was used in all cases. All surgical plans with regard to the site and type of access were made based on the physical exam and ultrasound vein measurements taken prior to surgery. On the day of surgery patients were reevaluated with venous ultrasound using tourniquet before and after administration of the regional block. The previously determined operative plan either remained unchanged or was modified depending on the venous dilatation noted after administration of regional block. Among 26 patients, average vein diameter increased from 0.29 +/- 0.12 cm to 0.34 +/- 0.11 cm (P = 0.008). Twenty-one of 26 patients had no modification in operative plan (group 1). Five had some modification of the original operative plan (group 2): AV graft to a brachial vein transposition (n = 2), AV graft to a Cimino fistula (n = 2), and brachiocephalic to a Cimino (n = 1). The average follow-up for all patients was 82.6 +/- 75.6 days and did not differ between the groups. There was one failure in a patient from group 1, and there was no significant difference in the patency rate between study groups (P = 0.29). Following regional nerve block, operative plans in patients undergoing AV access surgery were modified in 29.4% of patients undergoing creation of an AV access for hemodialysis; either from graft to fistula creation or from the proximal to more distal fistula site. The routine use of regional anesthesia as well as intraoperative ultrasound during AV access surgery can lead to improved site selection and increased opportunity for AV fistula creation.

Relationship of proximal fixation to renal dysfunction in patients undergoing endovascular aneurysm repair.

Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (= or <1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P<0.03), and 1.5 +/- 0.8 mg/dl for TRF (P<0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m2 for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m2 for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m2 for IRF, p<0.02: and 48+/-16 ml/min/1.73 m2 for TRF, P<0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p<0.05), and larger contrast volume was associated with an increase in serum Cr (p<0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents.

Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience.

OBJECTIVE: To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992. SUMMARY BACKGROUND DATA: Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy. METHODS: During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded. RESULTS: The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3). CONCLUSION: With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair.