Ultrasound Coded-Excitation Imaging for Endoleak Detection After Complex Endovascular Aortic Repair.

OBJECTIVES: Several imaging modalities have been suggested for surveillance after fenestrated endovascular aortic repair in general and endoleak detection in specific. In the present project a coded excitation-based ultrasound (B-Flow) was investigated for endoleak detection after complex endovascular aortic repair. METHODS: Patients post complex endovascular aortic repair (FEVAR or T/FEVAR) undergoing follow-up appointments including ultrasonography of the aorta at a vascular and endovascular surgery outpatient center were included in the study. B-Flow was compared with computed tomography angiography (CTA), Duplex ultrasound (DUS), and contrast-enhanced ultrasound (CEUS) regarding agreement and reliability for endoleak detection and characterization. RESULTS: In total, 47 follow-ups were included. They accumulated in a total of 149 imaging investigations. Endoleaks were discovered in 44.7% of B-Flow studies and a majority of these endoleaks were classified as type II. Agreement between B-Flow and other imaging modalities was good (>80.0%) in general. However, with B-Flow 6 and 2 endoleaks would have been missed compared with CEUS and CTA, respectively. Regarding endoleak classification, B-Flow had a strong agreement (94.5%) with CEUS in detected cases. Furthermore, in a limited subset analysis, imaging findings were externally validated using findings from angiography. CONCLUSIONS: Ultrasonography allows for endoleak detection and characterization without an invasive procedure or the use of potentially nephrotoxic contrast medium and can reduce radiation exposure. While CEUS mitigates issues of radiation and nephrotoxicity it still requires the intravenous application of contrast enhancers. Ultrasound coded-excitation imaging such as B-Flow could therefore further simplify endoleak surveillance after fenestrated endovascular aortic repair.

Fenestrated Endovascular Aortic Repair After Failed Endovascular Aortic Repair.

PURPOSE: Fenestrated endovascular aortic repair (FEVAR) is technically more challenging when performed after a failing EVAR procedure (FEVAR after EVAR). This study aims to assess the technical outcome of FEVAR after EVAR and to identify factors that may influence complication rates. METHODS: A retrospective observational study was conducted at a single department of vascular and endovascular surgery. The rate of FEVAR after EVAR compared to primary FEVAR is reported. Complication and primary unconnected fenestration (PUF) rates as well as survival were assessed for the FEVAR after EVAR cohort. PUF rates and operating time were also compared to all primary FEVAR patients. Patient characteristics and technical factors such as number of fenestrations or use of a steerable sheath were assessed as possible influencers on technical success when performing FEVAR after EVAR. RESULTS: Two hundred and nine fenestrated devices were implanted during the study period (2013 to April 2020). Thirty-five patients (16.7% of all FEVAR patients) had undergone FEVAR after EVAR and were included in the study. Overall survival at last follow-up (20.2±19.1 months) was 82.9% in FEVAR after EVAR patients. Rates of technical failure dropped significantly after 14 procedures (42.9% vs. 9.5%; p=0.03). Primary unconnected fenestrations were seen in 3 cases of FEVAR after EVAR (8.6%) and 14 of 174 primary FEVAR cases (8.0%; p>0.99). Operating time for FEVAR after EVAR was significantly higher than for primary FEVAR (301.1±110.5 minutes vs. 253.9±103.4 minutes; p=0.02). The availability of a steerable sheath was a significant predictor of reduced risk of PUFs, whereas age and gender, number of fenestrations or suprarenal fixation of the failed EVAR did not significantly influence PUF rates. CONCLUSION: Fewer technical complications were seen over the study period in FEVAR after EVAR patients. While rates of PUFs were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR can be a valuable and safe tool to treat patients with progression of aortic disease or type Ia endoleak after EVAR but may be more complex to achieve than primary FEVAR. CLINICAL IMPACT: This retrospective study assesses the technical outcome of fenestrated endovascular aortic repair (fenestrated EVAR; FEVAR) after prior EVAR. While rates of primary unconnected fenestrations were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR after prior EVAR may be technically more challenging than primary FEVAR procedures, but could be performed with equally good results in this patient cohort. FEVAR offers a feasible treatment option for patients with progression of aortic disease or type Ia endoleak after EVAR.

Multicentre experience with an iliac fenestrated device.

OBJECTIVES: The aim of this study was to present a multicentre experience of technical results and mid-term follow-up using a custom-made iliac fenestrated device (Terumo Aortic, Inchinnan, Renfrewshire, UK) for the treatment of iliac aneurysms and endoleaks. METHODS: A multicentre retrospective evaluation of 22 patients (3-12 per institution) with either an iliac artery aneurysm or endoleak treated with an iliac fenestrated device was performed. Data were gathered from 3 departments of vascular and endovascular surgery at 3 European institutions. RESULTS: Ten of the included patients (45.5%) were treated for an endoleak and 12 had aorto-iliac aneurysms (54.5%). Two patients underwent bilateral fenestrated device implantation for a total of 24 devices included in this analysis. Primary technical success was 91.7% (22 of 24 implanted devices). One of the 24 internal iliac arteries could not be cannulated and was covered (primary assisted technical success rate 95.8%) and 1 patient required a relining of the stent graft due to a mid-grade stenosis opposite the internal iliac artery fenestration. Survival at the last available follow-up (mean 15.2 ± 12.0 months, range 0.5-36.6 months) was 90.9%. CONCLUSIONS: The present investigation adds to a growing body of literature on custom-made endografts and their usefulness in achieving endovascular repair without compromising blood flow via important arterial branch vessels, such as the internal iliac artery. It presents encouraging technical and mid-term follow-up data from consecutive patients treated for iliac aneurysms or endoleaks using this custom-made device. The technique may help avoid adverse sequelae associated to a coil-and-cover approach when iliac branch devices are not feasible.

Decrease of peripheral resistance after intraoperative administration of iloprost in patients with and without type 2 diabetes mellitus and with peripheral arterial occlusive disease.

BACKGROUND: In many cases, Ilomedin® infusions are applied as part of a perioperative measure in patients with peripheral arterial occlusive disease because it makes a relevant vasodilatatory effect in patients with type 2 diabetes mellitus and with/without peripheral neuropathy. AIMS: A prospective case-control study was performed to investigate the effect of prostanoids on peripheral resistance in patients with type 2 diabetes mellitus and patients without type 2 diabetes mellitus, as well as the role of peripheral neuropathy in patients undergoing arterial reconstruction. METHODS: Sixty patients undergoing arterial reconstruction were enrolled. Sufficient data were collected on 38 patients. Prior to surgery, peripheral nerve conduction velocity was measured. Blood flow volume at the common femoral artery was assessed intraoperatively using a Doppler flowmeter at four time points: at baseline before arterial reconstruction (T0), after reconstruction (T1), after 5 (T2) and 10 min (T3) after intra-arterial application of 3000 ng of Ilomedin. Peripheral resistance units were calculated as a function of mean arterial pressure and flow volume using the following formula: peripheral resistance unit = mean arterial pressure (mm Hg) / flow volume (mL/min). RESULTS: Ilomedin produced an immediate and significant drop of peripheral resistance in patients without type 2 diabetes mellitus as well as in patients with type 2 diabetes mellitus. Patients with peripheral neuropathy showed a less pronounced effect to Ilomedin compared to individuals with normal nerve conduction velocity.

Ultrasound-Guided Percutaneous Arterial Puncture and Closure Device Training in a Pulsatile Model.

OBJECTIVE: The current study assesses the feasibility of in vitro practice of percutaneous puncture techniques in a pulsatile flow-model. DESIGN: Prospective, controlled, randomized study. SETTING: The percutaneous access to endovascular aortic repair is considered safe, but success rates may be dependent on surgeon experience with the technique. PARTICIPANTS: Fourteen vascular surgery trainees and consultants were enrolled and randomized to a study or control group with both groups receiving instructions by a tutor on how to perform ultrasound guided percutaneous puncture and closure using a suture-mediated closure device. The study group received additional hands-on training on a pulsatile flowmodel of the groin and the performance of both groups was then graded. Study group participants were timed during and after their training on the model. RESULTS: The study group achieved higher overall grading than the control group on a 5-point scale with higher scores indicating a better performance (mean overall scores 4.0 ± 0.7 versus 2.8 ± 1.0, respectively; p = 0.03). Experienced participants (more than 20 punctures performed before the study) achieved higher overall scores than trainees (3.8 ± 0.4 versus 2.5 ± 0.8, respectively; p = 0.01). Five participants in the study group could deploy and close the ProGlide closure device correctly without the help of a tutor while being graded (71% in the study versus 0% in the control group; p = 0.02). Study group participants improved their overall score from 3.2 ± 0.9 to 4.0 ± 0.7 during training (p = 0.02). Time needed to complete the puncture and closure reduced from 456 seconds on average before, to 302 seconds after training (p < 0.001). CONCLUSIONS: Study group participants could improve their overall score while working on the simulator. More experienced participants performed better during the simulation, which may indicate the model to be life-like and a potential skills assessment tool. Simulation training may be a valuable adjunct to traditional forms of training when teaching an endovascular technique but is limited by its reliance on simulators and demo devices.

Assessment of Pull-out Forces in TEVAR and ANACONDA FEVAR Combination and Early Clinical Results: Creation of a Proximal Landing Zone for FEVAR in Patients with Extent I and Extent IV TAAAs.

BACKGROUND: Although recent data on the treatment of thoracoabdominal aortic aneurysms (TAAAs) are promising, in some cases, the paravisceral segment of the aorta may not be suitable for a branched endograft due to space restrictions. A combination of a fenestrated aneurysm repair (FEVAR) with a thoracic aneurysm repair (TEVAR) may represent a feasible treatment option. The current investigation was performed to assess the stability of a fenestrated Anaconda device implanted into a set of thoracic endografts from different manufacturers. We then assessed our clinical results with the FEVAR/TEVAR combination. METHODS: Pull-out forces were measured in vitro after docking a fenestrated Anaconda graft within the distal end of different TEVAR devices. Anaconda devices were implanted in 28- or 30-mm thoracic tube grafts (oversizing of at least 2 mm: 13.3-21.4; minimum overlap of 15 mm). Continuously increasing longitudinal pull forces of up to 100 N were applied on an Instron Tensile Tester. Initial break point and damage to the endografts were documented. Clinical results of patients treated with such an FEVAR/TEVAR combination at our institution are presented as a second part of this study. RESULTS: Median pull-out forces ranged from 2.38 N to 55.0 N. The highest stability was achieved with 34-mm Anaconda devices in 28-mm thoracic tube grafts. Grafts with either thinner Dacron material or those featuring a polytetrafluorethylene membrane seemed especially vulnerable to punctures and tears caused by the downward-looking hooks of the Anaconda device. Between April 1, 2013 and December 31, 2018, in 28 of 172 patients treated with a fenestrated Anaconda device, prior implantation of a thoracic tube graft was necessary to create a sufficient proximal landing zone. In 25 cases (89.3%), the aneurysm was successfully treated. Although the 30-day reintervention rate in this subgroup was relatively high at 28.6%, none of these was due to a failure of the FEVAR/TEVAR combination. Upon an average follow-up of 15 months, no failure of the graft connection and no type III endoleak due to membrane damage were observed. CONCLUSIONS: The combination of a thoracic tube graft and a fenestrated Anaconda device is a viable option for the treatment of patients with Extent I or IV TAAAs with no adequate landing zone above the celiac trunk. Although pull-out testing has shown good stability with most assessed grafts, the thoracic devices with thicker Dacron membranes seemed to be especially suitable.

Endovascular treatment of hypogastric artery aneurysms.

OBJECTIVE: Internal iliac artery aneurysm (IIAA) is a rare entity. Its treatment can be technically challenging. The aim of this study was to evaluate the treatment possibilities in an era of advanced endovascular techniques and their potential to preserve iliac blood flow while reliably excluding the aneurysm. METHODS: A retrospective analysis of 46 consecutive patients with endovascularly treated IIAA was performed. Data were collected from a single-institution aortoiliac database. The following end points were recorded: technique of aneurysm exclusion, technical success rates, perioperative morbidity and mortality, primary patency, and midterm follow-up. RESULTS: Between September 2009 and May 2016, a total of 46 patients with 55 IIAAs were identified. The majority of patients (n = 39 [84.8%]) had aortoiliac aneurysms and seven had isolated IIAAs (15.2%). The following surgical techniques were used: implantation of iliac branch devices (IBDs; n = 29), occlusion of the internal iliac artery (IIA) by ostium coverage with or without prior coil embolization (n = 23), and other endovascular techniques (n = 3). Primary assisted technical success was achieved in 93.1% of IBD implantations and in 100% of occlusions by ostium coverage and other techniques. Overall 30-day mortality was 4.3% (n = 2) and 0% in electively treated patients. Assisted midterm patency after IBD implantation was 93.1%. Gluteal claudication occurred in seven patients (15.2%) who had undergone intentional or accidental occlusion of the IIA or the superior gluteal artery. Reintervention rates within the midterm follow-up were 13.8% (n = 4) after IBD implantation and 4.3% (n = 1) after coverage of the IIA ostium. No ruptures were observed during follow-up, and no complications occurred during reinterventions. CONCLUSIONS: Implantation of IBD devices for the treatment of hypogastric artery aneurysms shows good technical results with a high primary patency and a low rate of perioperative complications. Although successful aneurysm exclusion while preserving pelvic blood flow is associated with a higher rate of reinterventions during midterm follow-up, it should be taken into consideration, especially in complex endovascular aortoiliac aneurysm repair.

Custom-Made Iliac Fenestrated Device.

Iliac branch devices (IBDs) are undergoing rapid popularization. They allow for treatment of an iliac aneurysm while preserving blood flow to the hypogastric artery. Certain anatomic criteria are necessary for the use of an iliac side branch device to be technically feasible. Custom-made fenestrated iliac stent grafts may provide an alternative when anatomic criteria for an IBD are not met.

Endograft Infection Due to Secondary Aortoenteric Fistula Treated With Custom-Made Bovine In Situ Aortic Bifurcation Graft.

PURPOSE:: To increase awareness of the clinical presentation, diagnostic workup, and treatment options for endograft infections. CASE REPORT:: A 75-year-old male patient was admitted with suspected endograft infection 4 years after endovascular aortic aneurysm repair (EVAR). Although preoperative diagnostics showed no definitive signs of endograft infection, eventual surgical exposure of the endograft revealed signs of advanced inflammation, including the unexpected finding of an aortoduodenal fistula. CONCLUSION:: A detailed evaluation of patient history and clinical examination, performed as a part of routine follow-ups, may be beneficial in identifying possible severe complications after EVAR early on. Regarding options for aortic reconstruction in case of endograft infection, bovine pericardium deserves consideration as a promising, feasible, and easily available graft material.

Successful percutaneous access for endovascular aneurysm repair is significantly cheaper than femoral cutdown in a prospective randomized trial.

OBJECTIVE: Because of its minimally invasive nature, percutaneous femoral access for endovascular aneurysm repair (pEVAR) is currently undergoing rapid popularization. Compared with surgical cutdown for femoral access (cEVAR), it offers the advantage of faster recovery after surgery as well as a reduction in wound complications. Despite proposed advantages, the method is largely considered uneconomical because of its reliance on costly closure devices. METHODS: There were 50 patients undergoing EVAR who were enrolled in this randomized prospective single-center trial. Each patient randomly received percutaneous access in one groin and surgical access in the other. The primary end points were access duration and cost. Secondary end points were wound complications and the postoperative pain levels. RESULTS: Surgery was performed per protocol in 44 patients. Mean access times for pEVAR and cEVAR were 11.5 ± 3.4 minutes and 24.8 ± 12.1 minutes (P < .001), respectively. Total access costs were €559.65 ± €112.69 for pEVAR and €674.85 ± €289.55 for cEVAR (P = .016). Eight complications in six patients were attributed to cutdown, none to pEVAR (P = .02). The percutaneously accessed groin was significantly less painful at day 1 and day 5 after surgery (P < .001). An intention-to-treat analysis (N = 50 patients) included six cases of pEVAR conversion due to technical failure in three patients (6%) and change of the operative strategy in another three patients (eg, aortouni-iliac stent graft followed by crossover bypass). The intention-to-treat analysis showed shorter mean overall access time for pEVAR (pEVAR, 14.65 ± 10.20 minutes; cEVAR, 25.12 ± 11.77 minutes; P < .001) and no cost difference between the two methods (pEVAR, €651.29 ± €313.49; cEVAR, €625.53 ± €238.29; P = .65). CONCLUSIONS: Our data confirm proposed potential benefits attributable to the minimally invasive nature of pEVAR while demonstrating cost-effectiveness despite the additional cost of closure devices. Taking into account pEVAR failures still does not increase pEVAR costs over cEVAR. Further considering reduced postoperative pain and wound complications, the technique deserves consideration in suitable patients.