A novel balloon-assisted technique to secure visceral catheterization during a chimney endovascular repair of a ruptured abdominal aortic aneurysm in a centenarian patient / Uma nova técnica assistida por balão para assegurar a cateterização visceral durante o reparo endovascular, com a técnica de chaminé, de um aneurisma de aorta roto em um paciente centenário

Abstract A 100-year-old male patient was admitted with a ruptured abdominal aortic aneurysm due to type IA endoleak. Given the proximity of the ruptured site to the superior mesenteric artery (SMA) and renal arteries, a ChEVAR was indicated. Catheterization of the target visceral vessels was a challenging procedural step because of an intensely tortuous thoracic aorta. This hostile aortic anatomy also inhibited exchange for a super stiff guide-wire and selective cannulation with the diagnostic catheter was repeatedly lost when guidewire exchange was attempted. To overcome this issue, a 5 x 40 mm balloon catheter was placed 3cm into the target arteries. The balloon was then inflated below the nominal pressure limit enabling safe exchange for a super stiff guidewire and placement of three 90-cm long 7Fr guiding sheaths. The procedure was thus safely performed with deployment of an aortic extension and the bridging stents.

Resumo Um paciente de 100 anos foi diagnosticado com um aneurisma de aorta abdominal roto por um endoleak 1A. Pela proximidade do ponto de ruptura com a artéria mesentérica superior (AMS) e as artérias renais, um ChEVAR foi indicado. A cateterização das artérias-alvo foi um passo desafiador pela intensa tortuosidade da aorta torácica. Essa anatomia aórtica hostil também impediu a troca por um fio-guia extra-rígido, e a cateterização seletiva foi repetidamente perdida quando a troca de fio-guia foi tentada. Para superar essa dificuldade, um cateter balão 5mm x 40mm foi posicionado nas artérias-alvo. O balão foi, então, insuflado abaixo da pressão nominal, permitindo uma troca segura do fio-guia por um fio-guia extra-rígido e o posicionamento de três bainhas longas 7Frx 90cm. Assim, o procedimento foi executado de forma segura, com o implante de uma extensão aórtica e dos stents recobertos.

Isquemia mesentérica: manejo endovascular

La isquemia mesentérica es una condición que puede volverse muy grave y ser letal, más aún en los casos agudos. Un tratamiento precoz es muy importante. Se presentaron cuatro casos consecutivos tratados por nuestro equipo con trombosis, o disección o aneurismas de arterias mesentérica superior y tronco celíaco, se revisaron las indicaciones y se evaluaron los tratamientos llevados a cabo. Se utilizaron procedimientos endovasculares en todos, técnicamente en forma exitosa, evitando que progrese a un desenlace peligroso. Hubo diversidad de técnicas endovasculares adaptándolas a cada caso. En ningún paciente se requirió un acceso quirúrgico abierto para completar el tratamiento realizando las intervenciones prontas. El manejo endovascular de las lesiones mesentéricas es factible y replicable, y en nuestros casos podría haber prevenido una necrosis intestinal así como la necesidad de cirugías resectivas.

SUMMARY Mesenteric ischaemia is a condition that may be very severe and potentially lethal particularly in the acute presentation. Early treatment is crucial. We present four consecutive cases managed by our team with thrombosis or dissection or aneurysm of the superior mesenteric artery and the celiac trunk reviewing indications and treatment implemented. Multiple successful endovascular procedures were used in all cases avoiding progression to lethal consequences. None of the patients required an open surgical procedure. Therefore, endovascular procedures are feasible in these patients avoiding intestinal necrosis as well as the need for open surgeries.

Discussion on the technical details of the controllable fenestrated thoracic aortic endovascular repair / 国际外科学杂志

Fenestrated thoracic aortic endovascular repair (TEVAR), as the most advantageous technique for total endovascular repair of aortic arch lesions, has been widely carried out in China, but the technical level is different, the operation process lacks standardization, and the quality control is insufficient. This article discusses the technical details include how to ensure the controllability of TEVAR in physician-modified fenestration, how to choose indications, select fenestration positions, make fenestration, install preset guide wires, unwind guide wires, accurately position fenestration of the hole, delivery and release of the bridging stent combined with author′s experience.

Endovascular treatment of wide-neck saccular renal artery aneurysm with waffle-cone technique / Tratamento endovascular de aneurisma renal sacular com colo largo com técnica do waffle-cone

Abstract In the past, treatment of visceral artery aneurysms (VAAs) was exclusively surgical. These aneurysms were rarely diagnosed in elective or emergency cases. Development of imaging techniques and endovascular procedures has changed the history of the therapeutic options for this pathology. Endovascular management of VAAs has arisen to advances in endovascular techniques and has achieved high efficacy.

Resumo No passado, o tratamento de aneurismas da artéria visceral (VAAs) era exclusivamente cirúrgico e raramente diagnosticado em casos eletivos ou de emergência. O desenvolvimento de técnicas de imagem e procedimentos endovasculares mudou a história das opções terapêuticas dessa patologia. O manejo endovascular de VAAs surgiu devido ao avanço das técnicas endovasculares, o qual apresentou uma alta eficácia.

Pseudoaneurisma roto de artéria ileocólica: relato de caso / Ruptured ileocolic artery pseudoaneurysm: case report

Resumo Os aneurismas de artérias viscerais (AAVs) e pseudoaneurismas de artérias viscerais (PAAVs) são condições raras e potencialmente letais quando rotos. Em geral, são encontrados incidentalmente na tomografia computadorizada de pacientes assintomáticos. Embora a cirurgia aberta convencional seja considerada atualmente o tratamento padrão ouro, a abordagem endovascular vem ganhando relevo por ser considerada um procedimento minimamente invasivo e com riscos cirúrgicos menores. Destaca-se, nessa abordagem, o uso de embolização por molas (coils) em AAVs e PAAVs saculares e implante de stent modulador de fluxo como alternativa de tratamento para aneurismas fusiformes. Apresentamos o caso de uma paciente de 51 anos com queixa de dor abdominal aguda, taquicardia e hipotensão, com evidência de sangramento abdominal em angiotomografia e diagnóstico de pseudoaneurisma de artéria ileocólica (AIC) roto. Ela foi submetida a tratamento endovascular precoce de embolização da AIC com sucesso, e houve melhora do quadro clínico.

Abstract Visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) are rare conditions and are potentially lethal when they rupture. They are usually found as incidental findings on computed tomography (CT) scans of asymptomatic patients. Although conventional open surgery is currently considered the gold standard treatment, the endovascular approach has gained prominence as a minimally invasive procedure with lower surgical risk. In this approach, use of coil embolization in saccular VAAs and VAPAs and implantation of flow-modulating stents constitute alternative treatments for fusiform aneurysms. We present the case of a 51-year-old female patient complaining of acute abdominal pain, tachycardia, and hypotension, with evidence of abdominal bleeding on CT angiography, who was diagnosed with a ruptured ileocolic artery (ICA) pseudoaneurysm. She underwent early endovascular treatment for ICA embolization, which was successful and achieved clinical improvement.

Efficacy and safety of endovascular treatment vs medical treatment in anterior circulation stroke beyond 6 Hours: A systematic review and metaanalysis

@#Background & Objective: Endovascular treatment is the widely accepted treatment for patients with anterior circulation stroke within 6 hours of onset of stroke. We aimed to evaluate the advantages of endovascular treatment compared to standard medical treatment in treating patients with anterior circulation stroke beyond the 6-hour therapeutic window. Methods: We reviewed the literature concerning endovascular treatment versus medical treatment beyond the 6-hour therapeutic window. Using random-effects meta-analysis, we evaluated the following outcomes: modified Rankin scale in the three-month follow-up [excellent outcome (mRS≤1), functional independence (mRS≤2), moderate outcome(mRS≤3)], recanalization rate at 24 hours, mortality at 90 days or in-hospital, symptomatic intracranial hemorrhage, parenchymal hematoma type 2 and hemorrhagic infarction 1. Results: Four studies including 642 patients were evaluated. Endovascular treatment was associated with higher odds of excellent outcome (OR 2.55; 95% CI 1.48 to 4.41,), functional independence (OR 3.64; 95% CI 2.43 to 5.45), moderate outcome (OR 2.70; 95% CI 1.95-3.74) and recanalization rate at 24 hours (OR 8.81; 95%CI 2.81 to 27.69) compared to MT. No difference in the rates of mortality, symptomatic intracranial hemorrhage, parenchymal hematoma type 2 or hemorrhagic infarction 1 was found between the 2 groups. Studies using strict perfusion imaging inclusion selection showed better moderate outcome in comparison to the studies without perfusion imaging inclusion selection (P <0.012). Conclusion: Our study highlights the superiority of endovascular treatment over standard medical treatment alone for treating patients with anterior circulation stroke beyond 6 hours since stroke onset, although more studies are required for further investigation. Standard of strict selection for eligible patients before endovascular treatment should be based on DAWN or DEFFUSE 3 inclusion criteria.

Use of carbon dioxide for therapeutic decision-making in endoleaks: a case report / Uso de CO2 na tomada de decisão terapêutica de endoleak: relato de caso

Abstract Endovascular aneurysm repair is currently the most frequently treatment modality for infrarenal aortic aneurysms. Endoleaks are the most common cause of reintervention after endovascular aneurysm repair. It is often unclear which type of endoleak is the correct diagnose, making the treatment decision difficult. We report the case of a 72-year-old man with an endoleak two years after endovascular aneurysm repair. Images suggested a type III endoleak, but this was not confirmed by contrast aortography. We proceeded with the investigation using aortography with carbon dioxide and observed a type IA endoleak. This was successfully treated by implantation of a proximal cuff. A review of the literature shows that the role of carbon dioxide in endoleak management is still unclear. We present a case in which carbon dioxide was essential to both diagnosis and therapeutic decision-making in a type IA endoleak.

Resumo O tratamento endovascular dos aneurismas de aorta abdominal é atualmente a modalidade de tratamento mais comum. Os endoleaks representam a causa mais frequente de reintervenção após o tratamento endovascular. O diagnóstico do tipo de endoleak frequentemente é incerto, tornando o tratamento desafiador. Apresentamos o caso de um paciente de 72 anos, com endoleak após 2 anos de tratamento endovascular de aneurisma de aorta abdominal. Os exames de imagem pré-operatórios sugeriam um endoleak tipo III; entretanto, durante aortografia com contraste iodado, não foi possível identificá-lo. Optamos por realizar aortografia com dióxido de carbono (CO2), sendo, então, identificado um endoleak tipo IA, que foi tratado com sucesso com o uso de uma extensão (cuff) proximal. O papel do CO2 no diagnóstico de endoleaks ainda não está claro. Relatamos um caso em que o uso do CO2 foi essencial para o diagnóstico e para a decisão de tratamento do endoleak tipo IA.

Endovascular Treatment of Ruptured Vertebral Artery Dissecting Aneurysm in Fibromuscular Dysplasia

Background Fibromuscular dysplasia (FMD) affects predominantly the cervical and renal arteries and may cause the classical angiographic pattern of string-of-beads. The diagnosis is increasing with the advances of imaging techniques. Case Report A 37-year-old man presenting with subarachnoid hemorrhage due to a dissecting aneurysm of the vertebral artery was treated by angioplasty with stent, with good outcome. All of the cervical and renal arteries were diseased and showed dysplasia and/or ectasias. Conclusions There are no guidelines or protocols to treat patients with FMD.

Trends in endovascular aneurysm repair research: bibliometric analysis from 1994 to 2017

PURPOSE: Since endovascular aneurysm repair (EVAR) was first introduced in 1991, it has undergone rapid technical and quantitative developments. We analyzed the characteristics and trends of EVAR research through bibliometric analysis. METHODS: Comprehensive online searches focused on EVAR were performed from January 1994 to August 2017. The following information was collected: title, year of publication, countries' contribution, authorship, subspecialty, institution, subject category, and top 10 cited articles. RESULTS: A significant increase was demonstrated globally in the number of annual publications on EVAR. The highest number of publications was from the United States (n = 849, 35.08%), followed by England (n = 343, 14.17%), and the institutions with highest number of publications were Stanford University (n = 61, 2.52%) and Skane University Hospital Malmo (n = 45, 1.86%). The Journal of Vascular Surgery published approximately one quarter of the total publications. Vascular surgeons produced the most publications (n = 1871, 78.14%), followed by radiologists (n = 377, 15.58%) and cardiologists (n = 73, 3.02%). The most studied topics on EVAR were complications and procedures. The number of publications on complex EVAR and EVAR in juxtarenal aneurysm has increased more from 2013 to 2017 (5.1%, 9.5%) compared with from 1998 to 2002 (2.1%, 1.8%). CONCLUSION: Our bibliometric analysis showed the characteristics and trends of publications on EVAR over a period of 25 years. The results of the bibliometric analysis revealed the quantitative improvements of publications and the qualitative improvements in challenging EVAR.

Treatment options for isolated iliac artery aneurysms and their impact on aortic diameter after treatment

PURPOSE: Isolated iliac artery aneurysm (IIAA) is uncommon. It is frequently treated by endovascular aneurysm repair (EVAR). This study was to evaluate treatment results of IIAA and survey aortic diameter after EVAR. METHODS: Patients treated for IIAA in Seoul St. Mary's Hospital and Bundang Seoul National University from 2005 to April 2016 were retrospectively enrolled. The inclusion criteria of IIAA was >30 mm of iliac artery aneurysm without abdominal aortic aneurysm, which was treated by open surgical repair (OSR) or EVAR. Patients' clinical characteristics, treatment results, and mortality were obtained from electronic medical records. Diameters of aorta and iliac arteries were measured periodically with scheduled interval based on CT scans. RESULTS: Forty-nine patients (40 males; mean age, 71.9 ± 11.1 years) were enrolled. Five ruptured IIAAs were treated with EVAR (n = 1) or hybrid methods (n = 4). The diameter of ruptured IIAAs was 65 ± 31.4 mm, which was not significantly different from that of elective (44.3 ± 17.0 mm). Forty-four elective IIAA underwent 9 OSR, 31 EVARs, and 3 hybrid treatments (15 bifurcated and 12 straight stent-grafts). Treatment success rate was 93.8% without hospital mortality. There were 4 type I endoleak, 1 type II endoleak, and 1 type III endoleak without aneurysm-related mortality during follow-up. However, the aortic diameter was increased over time though there was no change or decrease in common iliac artery's diameter. CONCLUSION: Treatment of IIAA included various endovascular modalities as well as open surgery. Regular surveillance is still needed due to aortic dilatation after its treatment.

Hybrid Approach for Treatment of Multiple Traumatic Injuries of the Heart, Aorta, and Abdominal Organs / 대한흉부외과학회지

A 55-year-old man was admitted to the trauma center after a car accident. Cardiac tamponade, traumatic aortic injury, and hemoperitoneum were diagnosed by ultrasonography. The trauma surgeon, cardiac surgeon, and interventional radiologist discussed the prioritization of interventions. Multi-detector computed tomography was carried out first to determine the severity and extent of the injuries, followed by exploratory sternotomy to repair a left auricle rupture. A damage control laparotomy was then performed to control mesenteric bleeding. Lastly, a descending thoracic aorta injury was treated by endovascular stenting. These procedures were performed in the hybrid-angio room. The patient was discharged on postoperative day 135, without complications.

Fracture of the Bare Spring of a Thoracic Endograft for Type A Aortic Dissection: A Case Report

Retrograde type A aortic dissection (RTAD) following thoracic endovascular aortic repair is a devastating complication associated with high mortality rates. In particular, a deployed endograft in a bird-beak formation in an acute curve of the aortic arch can induce injury to the fragile aortic wall, with the subsequent development of RTAD. Here, we describe an extremely rare case of RTAD caused by fracture of the bare spring of the thoracic endograft for type A aortic dissection.

Rescue therapy with stent retrievers for thromboembolism during endovascular treatment of intracranial aneurysms / Terapia de resgate com stent para tromboembolismo durante tratamento endovascular de aneurismas intracranianos

ABSTRACT Thromboembolism is the most frequent complication in endovascular treatment of intracranial aneurysms, causing disability and death. As stent retrievers have achieved high rates of arterial recanalization in the management of ischemic stroke, these devices were tested as rescue therapy of thromboembolism during aneurysm embolization. We retrospectively analyzed 10 consecutive patients with transprocedural arterial occlusion, treated with mechanical thrombectomy at a single center. Good angiographic recanalization was achieved in eight cases, mTICI 3, 2b and 2a in five, three and two patients, respectively, without additional complications or any deaths. Five patients showed complete recovery (mRS 0) and all patients showed improvement of disability (average mRS 1.1) over a mean follow-up period of 31 months. Eight patients had good clinical recovery, while two remained with deficits (mRS 3 and 4). The study found that the stent retriever is a valuable, rapid and effective tool for restoring blood flow, improving the safety of endovascular treatment.

RESUMO Tromboembolismo é a complicação mais frequente no tratamento endovascular de aneurismas cerebrais, podendo causar morte ou sequelas. Como os stent retrievers alcançaram altas taxas de recanalização arterial no tratamento do acidente vascular encefálico isquêmico, testamos esses dispositivos para tratar eventos tromboembólicos ocorridos durante a embolização de aneurismas. Foram analisados retrospectivamente 10 pacientes apresentando oclusão arterial transoperatória, tratados com trombectomia mecânica em um único centro. Obtivemos recanalização angiográfica em oito casos, mTICI 3, 2b e 2a em cinco, três e dois pacientes, respectivamente, sem complicações adicionais ou óbito. Cinco casos apresentaram recuperação completa (mRS 0) e todos os pacientes apresentaram melhora dos déficits (mRS médio 1.1) durante acompanhamento médio de 31 meses. Oito pacientes apresentaram boa recuperação clínica, enquanto dois permaneceram com déficits (mRS 3 e 4). O estudo concluiu que stents são uma ferramenta valiosa, rápida e eficaz para restaurar o fluxo sanguíneo, aumentando a segurança do tratamento endovascular.

Hybrid Approach of Ruptured Type B Aortic Dissection with an Aberrant Subclavian Artery in a Single Patient with Turner Syndrome: A Case Report

Turner syndrome, also described as 45, X, may present with most serious cardiovascular anomalies including risk of aortic dissection and rupture. In emergency situation, management for aortic dissection with complicated anatomy accompanying vascular anomaly is challenging. Here, we report a rare case of ruptured type B aortic dissection with aberrant subclavian artery and partial anomalous pulmonary venous connection in a Turner syndrome. Through right carotid-subclavian artery bypass and thoracic endovascular aortic repair, successful hybrid endovascular management correlated with a favorable result in this emergency situation.

In Vitro Evaluation of Fusiform-Shaped Stents for Wide-Neck Intracranial Aneurysm Treatment / 신경중재치료의학

PURPOSE: Wide-neck aneurysms (WNAs) associated with a dilated parent artery (PA) are not uncommon morphological abnormalities and usually cause inappropriate wall apposition and incomplete neck coverage of a tubular stent in stent-assisted coiling of aneurysms. We aimed to introduce a fusiform-shaped stent (FSS) and test its effectiveness in treating intracranial WNAs associated with a dilated PA using a three-dimensional (3D) model. MATERIALS AND METHODS: Two FSS types were designed with the middle one-third segment dilated by 10% (FSS10) and 20% (FSS20) and were compared with the tubular-shaped stent (TSS). A patient-specific 3D WNA model was prototyped and produced, and in vitro stent placement was performed. Angiographic images of the three stent types were analyzed and compared using predetermined parameters. RESULTS: The stent lumens were significantly larger in FSS10 and FSS20 than in TSS in the middle segments (P=0.046), particularly FSS20 (P=0.018). The non-covered area at the ostium tended to be smaller in FSS10 and FSS20 than in TSS, but the difference was not significant (P>0.05). The stent length was significantly longer in FSS10 and FSS20 than in TSS. The stent cell size was significantly larger in FSS than in TSS. CONCLUSION: Better vessel wall apposition and aneurysmal neck coverage was observed for FSS than for TSS. No significant difference was observed between FSS10 and FSS20.

Endovascular Treatment of a Giant Dissecting Aneurysm in an Infant

Introduction The incidence of intracranial aneurysms in the pediatric population is low, and endovascular treatment is becoming a safe and minimally invasive treatment option. In the present study, the occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described. Case Report A 3-month-old female infant presented with progressive proptosis and divergent strabismus at the right eye, in addition to inconsolable crying. Cerebral resonance, angiotomography and angiography exams demonstrated angiodysplasia in the right internal carotid artery with two large paraclinoid dissecting aneurysms with wide neck. The right internal carotid artery was occluded with coils by endovascular approach, without detriment to the perfusion of the ipsilateral hemisphere and without neurological deficits. The patient achieved good recovery, and a late control angiotomography confirmed the exclusion of the aneurysms. Conclusion Parent artery sacrifice via endovascular approach is an effective therapeutic option, but a long-termfollow-up is necessary to avoid recurrence and bleeding.

The Role of Pharmacomechanical Endovascular Intervention for Iliofemoral Vein Thrombosis Compared to Conventional Anticoagulation Therapy

Although anticoagulation therapy is the primary treatment for deep vein thrombosis (DVT), it has not been associated with the rapid recanalization of the venous occlusion. Moreover, it is associated with long-term disability due to post-thrombotic syndrome (PTS). In contrast, pharmacomechanical endovascular intervention (PMI) results in more rapid clinical improvement in DVT patients, but there are few reports on its long-term outcomes. This retrospective study evaluated the clinical effectiveness of PMI compared to conventional anticoagulation therapy (ACA) for acute and subacute iliofemoral DVT. We reviewed the medical records of 102 patients with iliofemoral DVT. A total of 46 patients for ACA and 56 patients for PMI were enrolled. We analyzed the clinical differences between the PMI and ACA groups by comparing the clinical signs, residual DVT free-rate, and PTS-free rate. There were no statistically significant differences in the demographic characteristics and risk factors except age between the groups (age: ACA, 52.0 ± 18.0 years; PMI, 59.0 ± 17.0 years; P = 0.035). The 1-, 3-, and 5-year residual DVT-free rate (ACA = 84.7%, 71.6%, and 46.0%; PMI = 82.1%, 76.8%, and 76.8%, respectively; P = 0.235) was not significantly different. However, the 1-, 3-, and 5-year PTS-free rate was significantly different (ACA = 93.5%, 74.0%, and 55.7%; PMI = 92.9%, 90.0%, and 90.0%, respectively; P = 0.019). There was no significant difference in the rate of other complications. PMI showed a lower incidence of PTS during the follow-up period. Therefore, PMI should be considered as an effective therapeutic modality for patients with iliofemoral DVT.

Locked-in Syndrome Performed Endovascular Treatment for Vertebral Artery Dissection and Basilar Artery Occlusion Caused by a Golf Swing

No abstract available.

Spontaneous dissections of multiple visceral arteries: an extremely rare case

Spontaneous dissections of visceral arteries without aortic involvement are very rare. The etiologies of these entities are unclear and their clinical managements remain controversial. We report a case of spontaneous multiple dissections affecting 4 visceral arteries including the superior mesenteric artery, the celiac artery and the bilateral renal arteries. The patient was managed conservatively and endovascularly. The clinical manifestation markedly improved and laboratory tests returned to normal limits within 1 week. The regular follow-up suggested a good clinical and radiological outcome until 84 months.

Computed Tomography-Based Thrombus Imaging for the Prediction of Recanalization after Reperfusion Therapy in Stroke / 대한뇌졸중학회지

The prediction of successful recanalization following thrombolytic or endovascular treatment may be helpful to determine the strategy of recanalization treatment in acute stroke. Thrombus can be detected using noncontrast computed tomography (CT) as a hyperdense artery sign or blooming artifact on a T2*-weighted gradient-recalled image. The detection of thrombus using CT depends on slice thickness. Thrombus burden can be determined in terms of the length, volume, and clot burden score. The thrombus size can be quantitatively measured on thin-section CT or CT angiography/magnetic resonance angiography. The determination of thrombus size may be predictive of successful recanalization/non-recanalization after intravenous thrombolysis and endovascular treatment. However, cut-offs of thrombus size for predicting recanalization/non-recanalization are different among studies, due to different methods of measurements. Thus, a standardized method to measure the thrombus is necessary for thrombus imaging to be useful and reliable in clinical practice. Software-based measurements may provide a reliable and accurate assessment. The measurement should be easy and rapid to be more widely used in practice, which could be achieved by improvement of the user interface. In addition to prediction of recanalization, sequential measurements of thrombus volume before and after the treatment may also be useful to determine the efficacy of new thrombolytic drugs. This manuscript reviews the diagnosis of thrombus, prediction of recanalization using thrombus imaging, and practical considerations for the measurement of thrombus burden and density on CT.