Intravascular Iliac Artery Lithotripsy to Facilitate Aortic Endograft Delivery: Midterm Results of a Dual-Center Experience.

PURPOSE: To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries. MATERIALS AND METHODS: Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed. RESULTS: Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17-36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up. CONCLUSIONS: This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results. CLINICAL IMPACT: In this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to "paving and cracking" and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

Modified upside-down technique with Gore tapered iliac limbs for isolated iliac artery aneurysms.

PURPOSE: To describe the off-label use of tapered iliac limbs for the treatment of isolated iliac aneurysms with proximal landing zone significantly larger than distal landing zone. TECHNIQUE: Inversion of a Gore Excluder tapered leg (W. L. Gore & Associates Inc, Flagstaff, Arizona) with a modified upside-down technique is described. The endoprosthesis, with the olive at the tip of the releasing system previously cut, is inserted in a tip-to-tip fashion into a 15 Fr introducer sheath. The graft is released inside the introducer. An 18 Fr introducer sheath is advanced up to the proximal sealing zone. Following the removal of the 18 Fr dilator, the 15 Fr introducer with the pre-released graft is inserted co-axially into the 18 Fr introducer. A pre-cut 15 Fr dilator is brought up to the endograft and used as a pusher. A pull-back maneuver of the co-axial system, countertractioning with the dilator maintained in position, allows the delivery of the endograft. CONCLUSION: This technique might offer a feasible option in case of endovascular exclusion of isolated iliac artery aneurysms with significant landing zone diameter mismatch. Extracorporeal inversion is time-saving and could be safer in terms of graft damage and infection.

Disappearing multiple visceral aneurysms in Vascular Ehlers-Danlos syndrome.

OBJECTIVE: To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS). METHODS: We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms. RESULTS: Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.

Cavoatrial junction stenting in vascular hemodialysis catheter malfunction.

In patients undergoing hemodialytic treatment via intravascular catheters, stenosis or occlusion of central veins is common. Despite an extensive characterization of Superior Vena Cava Syndrome (SVCS) no data is available about CavoAtrial Junction (CAJ) stenosis. We report the case of two patients with a story of multiple catheter failures due to thrombosis or infection. Computed tomography (CT) showed radiological signs of CAJ stenosis confirmed at the following venography. In absence of other feasible options to place a vascular access, the two underwent stenting with Gore Viabahn VBX balloon expandable endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA) of the CAJ stenosis. Completion venography showed complete resolution of the stenosis in both patients. No complications occurred during the procedures. At a mean follow-up of 878 ± 559 days no signs of in-stent restenosis or recoil were found. The present cases emphasize the feasibility and safety of CAJ stenting, underlining the importance of preserving CAJ and upper veins patency in hemodialysis access.

Performance of a new generation balloon expandable stent-graft (Gore VBX) as bridging stent for B-EVAR.

BACKGROUND: The aim of this study was to report the results of a single-centre experience with a new generation balloon expandable stent-graft (Viabahn VBX; W. L. Gore & Associates, Flagstaff, AZ, USA) as bridging stent in branched endovascular aortic repair (B-EVAR). METHODS: This is a retrospective single institution analysis of a prospectively maintained database. All patients undergone implantation of at least one VBX as bridging stent in B-EVAR over the last 5 years (from July 1, 2018, to November 31, 2023) were included. Primary outcomes were technical success, primary and secondary stent patency rate, branch-related reinterventions, and branch instability. Secondary outcomes were clinical success, mortality, and rate of aortic-related reinterventions. RESULTS: This study involved 40 patients for a total of 147 VBX stent-grafts implanted in 141 target vessels as bridging stents in B-EVAR (62.5% off-the-shelf and 37.5% custom made devices; 65% with outer branches and 35% with inner branches) for the treatment of 38 (95%) degenerative and 2 (5%) postdissection aneurysms. In 28 cases (70%) a total transfemoral approach was used to deliver the bridging stents. Technical success was 100%. No target vessel was lost intraoperatively. Over a median follow-up of 26.5 months (range 0-74), primary and secondary patency, branch-related reintervention, and branch instability were 98.5% (139/141), 99.3% (140/141), 15% (6/40), and 4.9% (7/141), respectively. Four of the 7 cases of branch instability, all requiring an endovascular correction, were secondary to type Ic endoleak. Clinical success was 97.5% as effect of 1 perioperative death. During the follow-up other 6 patients died, contributing to an overall survival rate of 82.5%. The overall rate of aortic-related reinterventions was 20%. CONCLUSIONS: Despite further evaluation is mandatory to determine durability of the VBX in the long-term after B-EVAR, in our experience VBX demonstrated a high flexibility and trackability, excellent stent retention, and outstanding patency over time. A generous distal landing of the bridging stent into the target vessel should be always achieved, whereas possible, to reduce the risk of type Ic endoleak, which seems to be the main cause of branch instability.

Extravascular Ultrasound (EVUS) to Assess the Results of Peripheral Endovascular Procedures.

Contrast arteriography (CA) is considered the gold standard to evaluate any phase in peripheral arterial disease (PAD) interventions, from diagnostics to final results. Nevertheless, duplex ultrasonography (DUS) mostly used for the pre/postoperative phase and follow-up control, could be a potential intraoperative adjunctive imaging tool to assess the effects of endovascular revascularization in patients with iliac and femoropopliteal lesions. The PAD "duplex-assisted" protocol includes a preoperative DUS control followed by an intraoperative and a postoperative control. The most important parameters are pulsed doppler spectral analysis and waveform changes, which are impossible to detect with intravascular ultrasound (IVUS). By using a similar acronym, the intraoperative DUS has been previously described as extravascular ultrasound (EVUS). B-mode imaging, color flow, and peak systolic velocity (PSV) are considered. EVUS could be very useful to evaluate the effects of endovascular treatment, mainly in cases of unclear CAs, severe calcifications and/or dissections. In the context of the "leaving nothing behind" strategy, EVUS can drive the physician to evaluate the absence of flow-limiting dissections and decide which target lesion should be treated with antirestenotic therapy, further vessel preparation, or stenting. The EVUS protocol could be a safe and feasible option to improve the completion assessment of endovascular PAD treatment. A better ultrasound waveform is a sign of improved luminal gain and compliance, which is extremely important to finalize the results of new peripheral device technology, such as intravascular lithotripsy.

A Rare but Fatal Behçet Variant: The Hughes-Stovin Syndrome-Successful Case Report and New Evidence from Literature Review.

Hughes-Stovin syndrome (HSS) is a rare potentially fatal vasculitis supposedly belonging to the spectrum of Behçet disease without ocular involvement. HSS tends to play by a temporal pattern, starting with thrombosis and followed by formation of pulmonary aneurysms. Since its mortality can reach 25% of cases, early recognition and appropriate therapy represent the major clinical challenges. We describe a rare case of HSS successfully treated via multidisciplinary management by an endovascular approach and immunosuppressive therapy.