Percutaneous Embolization of Delayed External Carotid Artery Pseudoaneurysm Eight Years after Partial Parathyroidectomy.

External carotid artery pseudoaneurysm (ECAP) is very rare. The usual mechanism is trauma or iatrogenic. We report a case of a patient with an asymptomatic, chronic ECAP secondary to partial parathyroidectomy. Percutaneous injection of the 2-component Fibrin Sealant (Tisseel; Baxter int, Deerfield, IL) with the 2 active ingredients (Sealer Protein Solution and Thrombin Solution) was carried out with successful occlusion of the pseudoaneurysmal sac. The 6-month follow-up computed tomographic scan confirmed the ECAP thrombosis. The ECAP endovascular approach is less invasive and reduces the complications of the open surgical intervention, especially in high-risk patients or presenting with hostile neck.

Extra-Anatomic Revascularization of Extensive Coral Reef Aorta.

BACKGROUND: Coral reef aorta (CRA) is a rare, potential lethal disease of the visceral aorta as it can cause visceral and renal infarction. Various surgical approaches have been proposed for the CRA treatment. The purpose of this article is to report different extensive extra-anatomic CRA treatment modalities tailored on the patients' clinical and anatomic presentation. METHODS: From April 2006 to October 2012, 4 symptomatic patients with extensive CRA were treated at our department. Extra-anatomic aortic revascularization with selective visceral vessels clamping was performed in all cases. RESULTS: Technical success was 100%. No perioperative death was registered. All patients remained asymptomatic during the follow-up period (62, 49, 25, and 94 months, respectively), with bypasses and target vessels patency. CONCLUSIONS: The extra-anatomic bypass with selective visceral vessels clamping reduces the aortic occlusion time and the risk of organ ischemia. All approaches available should be considered on a case-by-case basis and in high-volume centers.

Proximal Embolic Protection Devices in Complicated Carotid Artery Stenting.

The most frequent complication during carotid artery stenting (CAS) is intraoperative distal embolization. Three categories of embolic protection devices (EPDs) are routinely used through a transfemoral or transcervical approach: distal occlusion devices, distal EPDs with flow preservation using filters, and the proximal occlusive protective systems. We report the case of the internal carotid artery (ICA) plaque rupture during CAS using a proximal EPD (the Mo.Ma system; INVATEC), treated with immediate surgery. The proximal occlusive protective system permitted the common carotid artery and ICA endoclamping for the time necessary to prepare the patient for the carotid endarterectomy. The EPDs should always be chosen considering the patient's and lesion's characteristics. This knowledge allows their use even as "bridge" endovascular devices.

Laparoscopic Transarterial Embolization of Type II Endoleak after Branched/Fenestrated Thoracoabdominal Aortic Aneurysm Endovascular Repair.

Type II endoleak is the most frequent procedure-related complication during endovascular aneurysm exclusion. Actually, there is little controversy in the management of type I and III endoleak, while type II endoleak still generates conflicting reports about their timing and type of treatment. Currently, the intervention is needed only in case of sac enlargement but not in case of persistent endoleak alone. We report the case of a 77-year-old man treated with a custom-made branched/fenestrated endograft for a type III thoracoabdominal aortic aneurysm. A low-flow type II endoleak was detected at the end of the intervention, and a conservative approach was adopted. The sixth month follow-up computed tomography scan demonstrated a 6-mm aneurysm sac growth that required the type II endoleak management. The endoleak nidus, situated between the inferior mesenteric artery (IMA) and left renal artery stent graft, was embolized through the IMA punctured laparoscopically. IMA origin laparoscopic clipping completed the intervention. To our knowledge, this is a unique case in the literature. Type II endoleak management should be reserved to selected patients. The combination of different techniques may offer safe and feasible treatment options in complex aneurysms treated with advanced endovascular materials.

Complicated Fenestrated Endovascular Repair of a Pararenal Aortic Aneurysm.

We report the case of a 77-year-old man treated with a custom-made fenestrated endograft for pararenal aortic aneurysm repair. Fenestrations for the superior mesenteric and both the renal arteries and augmented anterior valley and/or scallop for the celiac trunk were performed. The procedure was complicated by the superior mesenteric artery stent-graft entrapment from the endograft delivery system release wires and total dislodgement into the endograft main body. Superior mesenteric artery restenting and displaced stent-graft removal completed the intervention. Fenestrated-endograft deployment should be performed by a team familiar with the device, deployment system, and bail out solutions.

Seven-Year Approach Evolution of the Aortoiliac Occlusive Disease Endovascular Treatment.

BACKGROUND: Endovascular treatment is now considered the first-line therapy for the aortoiliac occlusive disease (AIOD). We report our experience with the total endovascular treatment of infrarenal and pararenal aortoiliac occlusions and the 7-year approach evolution. METHODS: A total of 22 patients underwent total endovascular treatment of AIOD from January 2008 to September 2014. Bare metal stents in kissing configuration were deployed in 9 cases, covered stents in kissing configuration in 9 patients and the aortic bifurcation reconstruction with the Y-guidewire configuration technique was performed in the last 4 patients. RESULTS: Technical success was 100%. Perioperative mortality rate was 4.5%. ankle-brachial index improved from 0.49 ± 0.19 to 0.96 ± 0.05 at the right side and from 0.53 ± 0.17 0.98 ± 0.04 at the left side (P < 0.01). Mean follow-up was 39.5 months (range, 5-80 months). The primary patency rate was 95.2% at 1 year and 90.5% at 3 years, and the secondary patency rate was 95.2% at 1 year and 100% at 3 years. CONCLUSIONS: Different stent types and configurations used for the aortoiliac endovascular treatment offer all the benefits of these materials for treatment on a case-by-case basis. The Y-guidewire configuration technique for the aortic bifurcation reconstruction may render the procedure more feasible. More cases and longer follow-up are necessary before the widespread use of this technique.

Endovascular treatment options for complex abdominal aortic aneurysms.

PURPOSE: To report short-term and midterm outcomes of endovascular aneurysm repair (EVAR) of complex aneurysms requiring revascularization of visceral arteries. MATERIALS AND METHODS: Prospective data were collected from patients deemed unsuitable for conventional EVAR and conventional surgery who were treated with different endovascular approaches according to the clinical presentation of the aneurysm. Custom-made fenestrated endovascular aneurysm repair (CM f-EVAR) was used in the elective setting, homemade fenestrated endovascular aneurysm repair (HM f-EVAR) or HM f-EVAR combined with chimney endovascular aneurysm repair (ch-EVAR) was used in the emergent setting in patients with hemodynamic stability, and ch-EVAR was used in unstable cases. The study included 34 consecutive patients. Primary outcomes measured were perioperative mortality and morbidity, renal function impairment (RFI), target vessel patency, and survival at mean follow-up. RESULTS: In the CM f-EVAR group (7 of 34 patients; 20.6%), an intraoperative type III endoleak (1 of 7 patients; 14%) sealed spontaneously. At 8.9 months of follow-up, 1 (1 of 7 patients; 14%) death and 1 (1 of 7 patients; 14%) episode of transient RFI were documented. Visceral vessel patency rate was 95.2%. In the HM f-EVAR group (4 of 34 patients; 11.7%) and the combination of HM f-EVAR and ch-EVAR group (3 of 34 patients; 8.8%), no complications were observed at 17.3 months of follow-up. In the ch-EVAR group (20 of 34 patients; 58.8%), visceral patency was 95% at 30.9 months of follow-up. Two cases of transient RFI and 2 cases of permanent RFI were registered (2 of 20 patients; 10%). One asymptomatic renal artery branch occlusion was observed at 11 months of follow-up. No endoleaks were documented. CONCLUSIONS: Endovascular aneurysm repair techniques including CM f-EVAR, HM f-EVAR or HM f-EVAR in combination with ch-EVAR, and ch-EVAR are valid tools to maintain blood flow in visceral arteries during treatment of complex aortic aneurysms. The proposed interventional protocol based on clinical presentation was feasible in all cases.

Aortic arch and descending thoracic aortic saccular aneurysms treatment with fenestrated endograft and chimney technique for aortic branch rescue.

We report the case of a 76-year-old man presented with three saccular aneurysms at the aortic arch and descending thoracic aorta. A two-staged hybrid approach was performed. A left common carotid-to-left subclavian artery bypass and a custom-made fenestrated endograft were used for the two proximal aneurysms. The endograft deployment was complicated by the unadverted coverage of the left common carotid artery ostium, promptly corrected with the chimney technique. The endovascular treatment was completed with the third endovascular aneurysm exclusion 5 months after the first procedure to reduce the risk of spinal cord ischemia. Yearly follow-up computed tomography scan confirmed aortic arch and descending thoracic aorta aneurysms exclusion with supra-aortic vessels, bypass, and stent patency. Endovascular repair of the aortic arch aneurysm with a fenestrated endograft is safe and feasible in selected patients. Complications may be solved with total endovascular approach. Long term follow-up remains mandatory.

Hybrid Endovascular Solutions for Supra-Aortic Vessels Extra-Anatomic Bypass Infection.

The use of extra-anatomic bypasses for the hybrid repair of thoracic aortic pathologies should consider the risk of vascular graft infection. Graft infections at cervical level are extremely rare and are associated with high mortality and morbidity rates. We report 2 cases of infected extra-anatomic bypasses for supra-aortic vessels debranching treated with a hybrid approach: re-extra-anatomical bypass with the Viabahn Open Revascularization Technique (VORTEC) in the first patient and the EndoVAC approach in the second case. Endovascular techniques may offer bail-out solutions in a hybrid fashion to treat vascular graft infection in patients considered unfeasible for the conventional surgical repair, associated with appropriate antibiotic therapy.

Chimney technique for aortic arch pathologies: an 11-year single-center experience.

PURPOSE: To report our single-center experience with the chimney technique for aortic arch pathologies and the mid- to long-term results in these patients. METHODS: From June 2002 to May 2013, 26 patients (18 men; mean age 71.2 years, 53-86) underwent thoracic endovascular aortic repair (TEVAR) combined with chimney technique. Indications for treatment were: a proximal landing zone <15 mm long distal to the left subclavian artery (LSA), thoracic aortic aneurysm (n=13), complicated type B aortic dissection (n=10), type I endoleak after previous TEVAR (n=2), and penetrating aortic ulcer (n=1). Treatment was performed in the emergency setting in 7 cases. The 28 chimney stent-grafts (double chimneys in 2 patients) were deployed in the innominate artery (n=7), left common carotid artery (n=10), and LSA (n=11). All patients underwent computed tomography before discharge, at 1, 6, and 12 months, and yearly thereafter. RESULTS: Technical success was 100%. One (3.8%) perioperative death was due to a cerebral hemorrhage. No major stroke was registered, but 3 (11.5%) minor strokes occurred (all resolved). Paraparesis developed in 2 (7.7%) patients. Median follow-up was 36.8 months (range 1-131), during which an additional 4 (15.4%) patients died, but only 1 death was aneurysm-related. Chimney graft patency was 89.3% (25/28); an asymptomatic fracture was found in a patent chimney stent-graft at the 18-month follow-up. The type I endoleak rate was 23% (n=6); 3 endoleaks associated with aneurysm sac enlargement were treated. CONCLUSION: The chimney technique for aortic arch pathologies is safe and feasible and may be an option in patients considered at high risk for surgery or who are ineligible for conventional TEVAR, especially in the emergency setting. Concern persists regarding type I endoleak, and long-term follow-up remains mandatory.

Hybrid treatment of symptomatic chronic isolated carotid bifurcation.

Total chronic occlusion of the common carotid artery with patent internal and external carotid arteries can induce cerebral embolism and hypoperfusion. We report a hybrid approach that was used to treat 2 patients presented with symptomatic chronic occlusion of the common carotid artery and ipsilateral internal carotid stenosis. Antegrade recanalization and retrograde stenting of the common carotid artery was performed in both patients associated to carotid bulb endarterectomy. Fresh thrombus observed in the distal common carotid stump was responsible for the embolic cerebral lesions and patients' previous symptoms. Patients remain asymptomatic at the 23rd- and 18th-month follow-up, respectively.

From aortouniiliac bifurcated to aortobisiliac trifurcated endograft for hypogastric artery preservation during EVAR.

An 81-year-old man presented with rapid enlargement of a 2-year known abdominal aortic and common iliac aneurysms. A hybrid approach to preserve both hypogastric arteries (HAs) was planned: a bifurcated endograft for the right aortoiliac axis, right femoral-to-left femoral artery bypass, and left external-to-internal iliac artery stent graft placement. Urethral stenosis requiring an epicystostomy rendered this approach not feasible. After left HA embolization, a bifurcated endograft was deployed for the abdominal aortic aneurysm exclusion. The endograft right limb was extended using a second bifurcated endograft for the ipsilateral aortoiliac axis. Surgical femoral accesses were used for the 2 bifurcated endografts and left HA embolization. Through the left brachial access, 2 stent grafts were used to preserve the right hypogastric artery revascularization. The 5-year follow-up computed tomography scan demonstrated complete aneurysm exclusion and HA patency.

Aortic aneurysm endovascular treatment with the parallel graft technique from the aortic arch to the iliac axis.

BACKGROUND: The chimney technique has been developed for the treatment of complex aortic aneurysms. We analyzed the midterm to long-term outcomes of this approach from a single-center experience. METHODS: From October 2008 to July 2016, 58 patients underwent endovascular aortic aneurysm repair using the chimney technique. Indications for treatment were thoracic aortic aneurysm (TAA) (N.=11), thoracoabdominal aortic aneurysm (TAAA) (N.=2), pararenal aortic aneurysm (PAAA) (N.=15), aortoiliac/isolated hypogastric artery aneurysm (N.=25), type I endoleak after previous TEVAR/EVAR (N.=4), proximal pseudoaneurysm after AAA open repair (N.=1). Elective (82.8%) and emergent (17.2%) procedures were included. RESULTS: The immediate technical success was 100%. Single, double and triple chimneys were performed in 46, 10, and two patients, respectively. Overall, 61 target vessels (three left common carotid arteries, eight left subclavian arteries, three celiac trunks, three superior mesenteric arteries, 19 renal arteries and 25 hypogastric arteries) were involved. Postoperative mortality was 0. No neurologic complications were registered. Primary patency rate of the chimney stent/stent graft was 98.3%. Low-flow type I endoleak was observed in four patients (6.9%). Postoperative chimney graft re-intervention rate was 1.7%. The median follow-up was 32±20 months (range 3-96 months). Overall estimated survival at 12, 50, and 80 months was 100%, 89% and 44%, respectively. Estimated freedom from endoleak at 1, 12, 24, and 36 months was 96.5%, 95%, 95%, and 93%, respectively. One hypogastric artery stent-graft occluded at the 3rd month of follow-up. No reintervention was performed. CONCLUSIONS: Our experience with the chimney technique for aortic aneurysms from the aortic arch to the iliac axis shows promising and durable mid- and long-term results. Endograft oversizing, associated with the chimney graft diameter and length choice remain fundamental to reduce the risk of the most frequent procedure complications: type I endoleak and CG occlusion. The wider use of this technique should be justified in patients considered at high risk for open repair and/or not suitable for the custom-made branched/fenestrated endografts.

Endovascular management of total juxtarenal aortic occlusive disease in high-risk patients: technical considerations and clinical outcome.

BACKGROUND: To report our single-center experience in the endovascular treatment of juxtarenal aorto-iliac occlusions. METHODS: Between December 2008 and December 2012, 13 patients with total juxtarenal aorto-iliac occlusion, considered at high risk for open revascularization, were treated by endovascular means at our Department. Inclusion criteria were severe intermittent claudication, rest pain and distal tissue loss. Antegrade recanalization from percutaneous brachial access and retrograde angioplasty and stenting from percutaneous or surgical femoral accesses were performed. The renal arteries (RAs) were protected using filters or balloons. Aorto-iliac bare-metal stents were deployed in all patients. RESULTS: No death was registered. Technical success was 100%. In 11 patients (84.6%) the Ankle-Brachial Index increased to 0.9-1. Renal arteries were involved in 7 cases (53.8%): 3 chimney stent grafts deployment, 2 aorto-iliac stent fenestrations and 2 aorto-iliac stents placement above the renal arteries without renal function impairment. Complication rate was 38.5%: 2 cases of thrombus dislodgement into the RAs, 1 distal artery embolization, 1 common iliac artery rupture and 1 pseudo-aneurysm. All complications were treated percutaneously, except for the distal embolization treated surgically. The patient with iliac artery rupture underwent acute renal insufficiency requiring temporary dialysis after hemorrhagic shock because of retroperitoneal hematoma. Mean follow-up was 18 months (range 6-30 months). The primary and secondary patency was respectively 92.3% and 100%. CONCLUSION: Endovascular recanalization of juxtarenal aorto-iliac occlusion in selected patients is feasible and safe, with good early and mid-term results and should be considered in high risk patients.

Endovascular repair of a proximal ilio-iliac arterio-venous fistula and distal pseudoaneurysm of the hypogastric artery 23 years after penetrating trauma.

We report the treatment of a proximal ilio-iliac arterio-venous fistula and distal omolateral hypogastric artery pseudoaneurysm 23 years after incurring a gunshot wound in a 43-year old man presenting with lower back pain. No cardiac, pulmonary or omolateral lower limb alteration was observed. Endovascular exclusion of the arterio-venous fistula and pseudoaneurysm was performed, which included pseudoaneurysm embolization. Three procedure-related complications were registered. The follow-up at 12 months revealed stent grafts patency, pseudoaneurysm and fistula exclusion.

Ruptured thoracoabdominal aneurysm treatment with modified chimney stent graft.

A 76-year-old woman presented with symptomatic contained-ruptured thoracoabdominal aneurysm at the level of the superior mesenteric artery (SMA) and the hepatic artery origin from the SMA. The chimney technique for celiac trunk, SMA, and right renal artery (periscope configuration) was performed. An endovascular leak from the distal landing zone of the SMA stent graft was treated using a second modified stent graft with the SMA branches preservation. The 18-month follow-up computed tomography angiography demonstrated the aneurysm exclusion, no endovascular leak, and visceral and renal arteries patency.

Re-TEVAR for complications after blunt aortic traumatic injury stenting.

We report an endovascular approach that was used to treat two patients with previous thoracic aortic repair or endovascular repair (TEVAR) for blunt thoracic aortic injury. The first patient was a 38-year-old man who presented with distal intragraft thrombosis 24 months after TEVAR. The second patient, a 32-year-old man, developed a symptomatic distal device collapse at 39th month follow-up, associated with buttock claudication. Both patients were offered an endograft relining, complicated in the first case by distal embolization.