Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results.

BACKGROUND: Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS: The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS: Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS: LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Calcification of abdominal aorta in patients recently starting hemodialysis: A single-center experience from Egypt.

Vascular calcification (VC) is a well-known complication in patients with chronic kidney disease (CKD). Keeping in mind, the end goal to assess the genuine effect of mineral bone disease in the pathogenesis of blood vessel calcification during the pre-dialysis course of CKD, we assessed the prevalence and extent of abdominal aortic calcification (AAC) in nondiabetic CKD patients recently starting hemodialysis (HD). Eighty-one patients with end-stage renal disease beginning HD over a one-month period were selected. They underwent a detailed clinical examination and laboratory evaluation, including serum calcium, phosphorus, parathyroid hormone, fibroblast growth factor (FGF-23), and alkaline phosphatase were measured, and spiral computed tomography was performed to evaluate AAC score. AAC was present in 64 patients (79%). There was a significant correlation between the AAC score and age (r = 0.609, P <0.001) and FGF-23 (r = 0.800, P <0.001). This study suggests that the prevalence and extent of AAC are critical in incident HD patients. Serum FGF-23 level is the sole statistically significant correlate of AAC in these patients.

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation.

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

Discriminatory Value of the Ascending Aorta Diameter in Suspected Acute Type A Aortic Dissection.

OBJECTIVE: The objective was to determine if ascending aorta (AscAo) diameters measured by noncontrast computed tomography (CT) allow for meaningful discrimination between patients with and without type A aortic dissection (TAAD), ideally with 100% sensitivity. METHODS: This study was a retrospective analysis of cases of TAAD, as well as controls, undergoing evaluation for TAAD with CT aortography, presenting to 21 emergency departments within an integrated health system between 2007 and 2015. AscAo diameters were determined using axial noncontrast CT images at the level of the right main pulmonary artery by two readers. AscAo diameters were additionally normalized for age, sex, and body surface area (assessed by a Z-score, which is the number of standard deviations between the observed and expected AscAo diameters). Overall model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Comparative discrimination was assessed using both the change in AUC (∆AUC) and the continuous net reclassification index (NRI). RESULTS: A total of 230 cases of TAAD and 325 controls were included in the study. The median ages for cases and controls were 65 and 62 years, and the median AscAo diameters were 50 and 35 mm, respectively. The raw and normalized AscAo diameters demonstrated similarly excellent discrimination (AUCs of 0.96 vs. 0.97, respectively; ∆AUC = 0.01, p = 0.09) and an NRI of 0.30 (95% confidence interval [CI] = 0.13-0.47), both indicating small incremental improvements in classification with the use of the normalized AscAo measures. A raw AscAo diameter of 34 mm and a normalized Z-score of 1.84 both yielded 100% sensitivity for TAAD, with respective specificities of 35% (95% CI = 29.6%-40.2%) and 67% (95% CI = 61.7%-72.2%). CONCLUSIONS: Nearly all patients with TAAD appear to have enlarged AscAo diameters as measured by noncontrast CT, whereas most patients with suspected but absent TAAD have relatively normal AscAo diameters. Both raw and normalized AscAo measures provided relatively comparable discriminatory value. If validated, these data may be useful in adjudicating risk among patients with suspected TAAD in whom a criterion standard test is unavailable, nondiagnostic, or contraindicated.

Influence of aortic neck characteristics on successful aortic wall penetration of EndoAnchors in therapeutic use during endovascular aneurysm repair.

OBJECTIVE: This study sought to quantify EndoAnchor (Medtronic Vascular, Santa Rosa, Calif) penetration into the aortic wall in patients undergoing endovascular abdominal aortic aneurysm repair and to assess predictors of successful penetration and its relationship to postprocedural type IA endoleak. METHODS: A subset of patients from the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) were included if they met the following criteria: the indication for EndoAnchor use was to treat a type IA endoleak, and postprocedure contrast-enhanced computed tomography (CT) scans of sufficient quality were available for core laboratory review. Patients undergoing implantation of cuffs or stents during the EndoAnchor implantation procedure were excluded. Baseline anatomic characteristics were recorded. The cohort was divided into patients with and without persistent type IA endoleaks at the first postoperative CT scan. Penetration of each EndoAnchor measured on this CT scan was defined as good penetration when the EndoAnchor penetrated ≥2 mm into the aortic wall, borderline penetration when EndoAnchor penetration was <2 mm or a gap remained between the endograft and aortic wall, or no penetration when the EndoAnchor did not penetrate into the aortic wall. Differences between the groups were analyzed with the Mann-Whitney U test or Fisher exact test. Multivariate analyses were performed to identify independent predictors of EndoAnchor penetration, and procedural success was defined by absence of type IA endoleak. RESULTS: Eighty-six patients of the primary (n = 61 [71%]) and revision (n = 25 [29%]) arms of the ANCHOR registry were included. There were 53 (62%) without and 33 (38%) with persistent type IA endoleaks on the first postprocedural CT scan. The median number of EndoAnchors with good penetration was significantly greater in the cohort without endoleaks, 4 (interquartile range, 3-5) vs 3 (interquartile range, 1.5-4), respectively (P = .002). A multivariate model for EndoAnchor penetration identified use of a Medtronic Endurant endograft as a factor associated with good penetration (P = .001), whereas poor penetration was associated with a larger aortic neck diameter 10 mm distal to the lowest renal artery (P < .001) and greater proximal neck calcium thickness (P = .004). EndoAnchor penetration was the only variable that attained significance (P < .001) in the multivariate model for successful treatment of a type IA endoleak. CONCLUSIONS: Adequate EndoAnchor penetration into the aortic wall is less likely when the aortic neck diameter is large or when the neck contains significant mural calcium. No penetration of the EndoAnchor was the only factor predictive of postprocedural type IA endoleak. This study stresses the importance of careful selection of patients based on preoperative assessment of the infrarenal neck on CT angiography and emphasizes careful deployment of EndoAnchors into the aortic wall to improve successful treatment of type IA endoleaks.

An Institution-Wide Algorithm for Treatment of Type II Endoleak Following Endovascular Aneurysm Repair (EVAR).

OBJECTIVES: Multiple endovascular techniques have been described for the treatment of persistent type II endoleaks (pT2ELs) causing aneurysm sac growth following endovascular aneurysm repair (EVAR). In the event of a failed endovascular procedure and a pT2EL, a consensus regarding further treatment is lacking, and the literature suggests repeated endovascular attempts are rarely successful. Herein, we propose an algorithm for definitive management of pT2ELs with persistent sac growth following EVAR. METHODS: A retrospective review of 29 patients who underwent treatment of persistent sac growth in the setting of pT2ELs was performed. Intervention methods were determined at the discretion of the operating surgeon. Aneurysmal sac enlargement was defined as a diameter increase > 5 mm, and persistent endoleak was defined as lasting greater than 6 months. RESULTS: From 2000 to 2015, 917 EVAR procedures were performed at our institution. Isolated pT2ELs with sac enlargement were identified in 29 patients. Twenty-five patients underwent direct translumbar sac puncture and coiling and/or Onyx (Onyx, Plymouth, Minnesota) embolization of the culprit vessels. Thirteen (52%) of 25 patients had pT2EL after first endovascular intervention, and 10 (40%) of 25 patients failed 2 endovascular treatments. Of those 10, 7 displayed persistent aneurysmal sac growth and underwent a third embolization procedure. Type II endoleaks persisted in 6 patients; 3 patients were subsequently treated with laparotomy, ligation of lumbar vessels, sac exploration, and sac plication around the endograft. Technical success for this technique was 100%. During a mean follow-up of 38.4 months, no recurrent T2ELs, stent graft migration, and/or disjunction were observed. CONCLUSIONS: We propose a new algorithm for the management of pT2ELs. If 2 endovascular procedures fail to control of the endoleak, repeat endovascular attempts are not recommended. Endovascular failure should be followed by laparotomy with surgical ligation of culprit feeding vessels followed by sac exploration and plication of the sac, and endoaneurysmorrhaphy.

One-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease.

OBJECTIVE: The objective of this study was to report the methodology and 1-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease (TAAD). METHODS: Complex TAADs without a feasible conventional surgical repair were prospectively evaluated by vascular surgeons of the same public health service (National Health System) located in a huge area of 22,994 km2 with 3.7 million inhabitants and 11 tertiary hospitals. Surgeons evaluated computed tomography scans and clinical details that were placed on a web platform (Google Drive; Google, Mountain View, Calif) and shared by all surgeons. Patients gave informed consent for the teleconsultation. The surgeon who submits a case discusses in detail his or her case and proposes a possible therapeutic strategy. The other surgeons suggest other solutions and options in terms of grafts, techniques, or access to be used. Computed tomography angiography, angiography, and clinical outcomes of cases are then presented at the following telemeetings, and a final agreement of the operative strategy is evaluated. Teleconsultation is performed using a web conference service (WebConference.com; Avaya Inc, Basking Ridge, NJ) every month. An inter-rater agreement statistic was calculated, and the κ value was interpreted according to Altman's criteria for computed tomography angiography measurements. RESULTS: The rate of participation was constant (mean number of surgeons, 11; range, 9-15). Twenty-four complex TAAD cases were discussed for planning and operation during the study period. The interobserver reliability recorded was moderate (κ = 0.41-0.60) to good (κ = 0.61-0.80) for measurements of proximal and distal sealing and very good (κ = 0.81-1) for detection of any target vessel angulation >60 degrees, significant calcification (circumferential), and thrombus presence (>50%). The concordance for planning and therapeutic strategy among all participants was complete in 16 cases. In one case, the consultation was decisive for creating an innovative therapeutic strategy; in the remaining seven cases, the strategy proposed by the patient's surgeon was changed completely after the discussion. Technical success was the same (100%) if concordance in planning was present initially or not. Overall 6-month mortality was 4%, 0% for those patients with initial concordance in planning vs 12% for those without initial concordance (P = .33). Surgery was always performed in a tertiary hospital by local surgeons, and in two cases (8%) external surgeons joined the local surgical team. CONCLUSIONS: Such a regional service of teleconsultation may be of value in standardizing the treatment and derived costs of complex TAADs in a huge region under the same health provider. The shared decision-making strategy may be of medical-legal value as well.

Emergent Endovascular Treatment of Thoracoabdominal Aortic Rupture in Behcet's Disease.

BACKGROUND: Aortic rupture in Behcet's disease is associated with high mortality rates. Endovascular approach with parallel graft technique can be a valid solution in emergency setting for the treatment of thoraco-abdominal aorta involvement in Behcet's disease. METHODS: We describe the clinical case of a 41-year-old man, urgently hospitalized for a rupture of thoraco-abdominal aorta with occlusion of the celiac trunk and involvement of superior mesenteric artery. The patient also presented a massive right hemothorax and a massive left pulmonary thromboembolism. An aortic endoprosthesis was deployed from the third bottom of the thoracic aorta to the origin of the renal arteries. Parallel stent-graft technique was used to preserve the patency of the superior mesenteric artery. The procedure was performed with local anaesthesia due to the critical conditions of the patient. The patient was discharged in good clinical conditions. RESULTS: The angio-computed tomography performed 6 months after surgery showed good deployment of the endoprosthesis and patency of the superior mesenteric artery. CONCLUSION: In high risk for surgery patients, endovascular treatment with parallel stent graft of thoraco-abdominal aorta rupture is safe and feasible.

Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia.

BACKGROUND: Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony. CASE PRESENTATION: We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit. DISCUSSION: This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Parallel placement of Excluder legs for treatment of type IIIb endoleaks caused by fabric tear after endovascular aneurysm repair.

A total of 576 patients underwent endovascular aneurysm repair using main body devices for treatment of abdominal aortic aneurysms or iliac artery aneurysms. During follow-up, type IIIb endoleaks caused by fabric tear occurred in six patients (1.0% [6/576]). The device used was Zenith (Cook Medical, Bloomington, Ind) in five cases and Talent (Medtronic, Santa Rosa, Calif) in one case. All endoleaks were close to the flow divider of the main body devices. The distance between the lower renal artery and the top end of the contralateral leg was 53 ± 14 mm. Bell-bottom-shaped Excluder (W. L. Gore & Associates, Flagstaff, Ariz) legs were placed parallel from the top of the main body device through both legs to treat these endoleaks. In two patients, coil embolization was required to treat gutter endoleaks. Postoperative computed tomography showed the obliteration of type IIIb endoleaks in all patients. Our technique may be an acceptable method for treatment of type IIIb endoleaks, especially when they occur near the flow divider.

Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair.

BACKGROUND: Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO2) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO2 among patients with no contraindication to ICM. METHODS: From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO2 or ICM group. RESULTS: We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO2-related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO2 group than in the ICM group. Among CO2 group procedures, 62.5% of the patients needed ICM complementary use. CONCLUSIONS: The use of CO2 as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO2, there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

Open Conversion after Aortic Endograft Infection Caused by Colistin-Resistant, Carbapenemase-Producing Klebsiella pneumoniae.

A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae.

Prophylactic Intraoperative Embolization of Abdominal Aortic Aneurysm Sacs Using N-Butyl Cyanoacrylate/Lipiodol/Ethanol Mixture with Proximal Neck Aortic Balloon Occlusion during Endovascular Abdominal Aortic Repair.

PURPOSE: To determine the feasibility of prophylactic intraoperative abdominal aortic aneurysm (AAA) sac embolization using a mixture of N-butyl cyanoacrylate/Lipiodol/ethanol (NLE) with proximal neck aortic balloon occlusion during endovascular aneurysm repair (EVAR) to prevent the occurrence of endoleak and aneurysm sac expansion. MATERIALS AND METHODS: Prophylactic intraoperative AAA sac embolization was performed in 24 patients with an infrarenal neck angulation > 60° (n = 16) or AAA sac diameter > 60 mm (n = 17). AAA sac pressure was continuously measured with a 3-F catheter inserted into the AAA sac. The systolic sac pressure index (SPI) was calculated as the ratio of systolic AAA sac pressure to the simultaneously measured systolic aortic pressure, and was measured with and without proximal neck aortic balloon occlusion. The aneurysm sac was embolized with NLE during proximal neck aortic balloon occlusion immediately after EVAR. Endoleak and AAA sac diameter were evaluated by enhanced computed tomography and subtraction magnetic resonance imaging at 6 months and yearly after EVAR. RESULTS: Mean SPIs after EVAR with and without proximal neck aortic balloon occlusion were 0.36 and 0.57, respectively. There were no adverse events related to intraoperative sac embolization. Follow-up imaging (mean, 12.1 mo) revealed three minor endoleaks (12.5%) and no aneurysm sac expansion. CONCLUSIONS: Prophylactic intraoperative sac embolization with NLE during proximal neck aortic balloon occlusion was safe and feasible and may reduce endoleaks and prevent sac expansion after EVAR in patients with unfavorable anatomic factors.

Utility of a preloaded fenestrated graft in thoracoabdominal aneurysm repair.

An 84-year-old man with a thoracoabdominal aortic aneurysm was treated using a fenestrated stent graft with a preloaded guidewire system under local anesthesia. He suffered from severe chronic obstructive pulmonary disease. We successfully placed 4 bridging stent grafts for perfusion of the celiac artery, superior mesenteric artery, and bilateral renal arteries via the 4 fenestrations. A preloaded wire system was used to insert a catheter into the celiac artery from the left brachial artery. Our findings indicate that a fenestrated stent graft with a preloaded wire system may expand the indication for treating thoracoabdominal aortic aneurysms in high-risk patients.

Standard endovascular treatment of abdominal aortic aneurysms in patients with very short proximal necks using the Endurant stent graft.

OBJECTIVE: This study evaluated and compared the midterm results of endovascular aortic aneurysm repair with the Endurant (Medtronic Inc, Santa Rosa, Calif) stent graft system in off-label use in patients with short (<10 mm) proximal aortic necks and in patients treated according to device-specific instructions for use. METHODS: This was a case-control (2:1) single-center retrospective analysis of prospectively collected data performed between September 2008 and December 2012. Analysis identified 19 elective patients with short (<10 mm) proximal necks and mild angulations (≤45°) treated with the Endurant stent graft and 38 patients matched for age, sex, and aneurysm diameter with proximal aortic necks ≥10 mm in length who met the instructions for use. End points included technical and clinical success and freedom from any secondary intervention, any type of endoleak, and aneurysm-related death. RESULTS: The short-neck group was a mean ± standard deviation age of 71.7 ± 8.9 years, 84% were men, and their mean infrarenal aortic neck length was 6.1 ± 1.2 mm. Mean suprarenal and infrarenal angles were 110° ± 10.4° and 170° ± 15.4°, respectively. Aortic neck diameters were similar between the groups (26.6 ± 3.8 vs 25.7 ± 3.7 mm; P = .36). Primary technical success was achieved in all cases. Off-label patients were more likely to require additional proximal cuff deployment to successfully obtain a seal (21% vs 3%; P = .04). The two patient groups were similar in rates of perioperative mortality, morbidity, and complications. Mean follow-up of 24 ± 12 months revealed no differences in clinical success, freedom from reintervention, and aneurysm-related death. No type I endoleaks were observed in either group during the follow-up period. CONCLUSIONS: The Endurant stent graft system applied off-label in patients with very short aneurysm necks (<10 mm) with mild angulation showed acceptable treatment results. These midterm results might suggest its use in carefully selected patients with very short neck anatomy. Long-term data are needed to verify the observed durability of the Endurant stent graft.

Integration of endovascular therapy of ruptured abdominal and iliac aneurysms in the treatment algorithm: a single-center experience in a medium-volume vascular center.

PURPOSE: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. MATERIALS AND METHODS: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. RESULTS: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. CONCLUSION: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

Transcatheter aortic valve implantation through a transcarotid approach under local anesthesia.

AIMS: We report the first experience of transcatheter aortic valve implantation through a transcarotid approach under local anesthesia. METHODS AND RESULTS: An 81-year-old gentleman with severe symptomatic aortic stenosis was referred for TAVI. He was not suitable for transfemoral, transapical, subclavian, or direct aortic approach. He had severe lung disease and was considered unsuitable for general anesthesia. We, therefore, performed the procedure under local anesthesia though the right common carotid artery (CCA) approach. Superficial cervical block was achieved with Levobupivacaine, and in addition, he also had a target controlled infusion of Remifentanil. Cerebral oximetry was monitored throughout the procedure. The CCA was accessed through surgical cut-down. Aortic valvuloplasty was performed through a 12-F sheath, and the CoreValve was deployed successfully through an 18-F sheath. CONCLUSION: TAVI is commonly performed through femoral access under local anesthesia. The right carotid artery approach under local anesthesia requires careful monitoring of cerebral oxygen levels but allowed us to perform successful TAVI in this high risk patient when all conventional approaches were contra-indicated. Compared with a right subclavian or left carotid access, the right carotid offers more direct angle of approach allowing precise valve placement with minimal readjustment during deployment.

Rare cause of dyspnea: yin-yang thoracic aortic aneurysm.

Aortic aneurysmal diseases, mostly found incidentally, have high mortality and morbidity. Complications mostly are associated with and accelerated in the presence of systemic hypertension, aortic valve disease, or aortic atherosclerosis. Presenting signs and symptoms can be nonspecific and need immediate and accurate recognition. We present a case of incidental finding of a large descending aortic aneurysm with "yin-yang" sign and discuss the importance of differentiating pseudoaneurysm versus intramural thrombus.

Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions.

OBJECTIVE: Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. METHODS: Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. RESULTS: Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45-87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. CONCLUSIONS: Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.

Aortic graft infection and mycotic aneurysm with Streptococcus equi zooepidemicus: two cases with favorable outcome of antibiotic treatment.

Infections with Streptococcus equi zooepidemicus are rare and are associated with contact with animals or animal products. There are very few reports about infected vascular grafts or aneurysms with this etiology. We present two patients. The first is a 77-year-old man with an infected bifurcated graft four years after an open operation for an abdominal aortic aneurysm (AAA). The second is a 72-year-old man with a symptomatic mycotic AAA, treated with endovascular aneurysm repair. Both received prolonged treatment with bactericidal antibiotics and responded well. Follow-up time at present is 5.5 years for the first, and 4.5 years for the second, patient.