Fenestrated and Scalloped Endovascular Grafts in Zone 0 and Zone 1 for Aortic Arch Disease.

BACKGROUND: The aim of this study is to present midterm results of thoracic endovascular aortic repair (TEVAR) using scalloped or fenestrated custom-made endovascular grafts (CMEGs) in aortic arch Zones 0 and 1. METHODS: A retrospective review of prospectively collected data involving consecutive patients with aortic arch disease treated by scalloped or fenestrated Relay Plus stent grafts (Terumo Aortic, Sunrise, FL) landed in Zones 0 and 1. Patient demographics, operative details, clinical outcomes, and complications were analyzed. RESULTS: Between February 2014 and February 2020, 14 patients (9 male and 5 female) with a median age of 66 years (range 48-84) underwent scalloped or fenestrated TEVAR to preserve flow to the supra-aortic trunks (SATs). In 6 cases the landing zone was Zone 0 and in 8, Zone 1. Target vessels for the scallops were left common carotid artery in 8 cases (Zone 1) and innominate artery (IA) in 1 (Zone 0). All 5 fenestrations were designed to preserve the IA (Zone 0). Technical success was 100% with no endoleaks on completion angiography. One fatal perioperative stroke (7%) occurred in a patient with a fenestration for the IA and atherosclerotic plaques in the arch. During median follow-up of 37.5 (3-72) months, no other patient died, and all the target vessels and cervical revascularizations remained patent. There was no paraplegia, no retrograde dissection, and no other complication. Two patients (14%) with scallops in Zone 1 developed late endoleak: 1 type Ib at 6 months and 1 type Ia endoleak at 12 months. There were no endoleaks at all in the group of fenestrated endografts (Zone 0). CONCLUSIONS: When anatomy allows, endovascular treatment using scalloped or fenestrated CMEGs in Zones 0 and 1 is a feasible technique to treat patients with aortic arch disease involving the SATs.

Reduced high-density lipoprotein cholesterol: A valuable, independent prognostic marker in peripheral arterial disease.

OBJECTIVE: The prognosis of patients with peripheral arterial disease (PAD) is characterized by an exceptionally high risk for myocardial infarction, ischemic stroke, and death; however, studies in search of new prognostic biomarkers in PAD are scarce. Even though low levels of high-density lipoprotein cholesterol (HDL-C) have been associated with higher risk of cardiovascular (CV) complications and death in different atherosclerotic diseases, recent epidemiologic studies have challenged its prognostic utility. The aim of this study was to test the predictive value of HDL-C as a risk factor for ischemic events or death in symptomatic PAD patients. METHODS: Clinical and demographic parameters of 254 symptomatic PAD patients were recorded. Amputation, ischemic coronary disease, cerebrovascular disease, and all-cause mortality were recorded during a mean follow-up of 2.7 years. RESULTS: Multivariate analyses showed that disease severity (critical limb ischemia) was significantly reduced in patients with normal HDL-C levels compared with the group with low HDL-C levels (multivariate analysis odds ratio, 0.09; 95% confidence interval [CI], 0.03-0.24). A decreased risk for mortality (hazard ratio, 0.46; 95% CI, 0.21-0.99) and major adverse CV events (hazard ratio, 0.38; 95% CI, 0.16-0.86) was also found in patients with normal vs reduced levels of HDL-C in both Cox proportional hazards models and Kaplan-Meier estimates, after adjustment for confounding factors. CONCLUSIONS: Reduced HDL-C levels were significantly associated with higher risk for development of CV complications as well as with mortality in PAD patients. These findings highlight the usefulness of this simple test for early identification of PAD patients at high risk for development of major CV events.

Endovascular treatment of abdominal aortic aneurysms involving iliac bifurcation: role of iliac branch graft device in prevention of buttock claudication.

BACKGROUND: The aim of this study was to describe our early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair at our institution and to evaluate the technical feasibility, short-term patency rate, and potential clinical benefits, with special focus on prevention of buttock claudication. METHODS: From March 2009 to November 2010, 9 consecutive patients (all men), mean age 71.1 years (range 62-80 years), underwent IBG implantation at our institution. Indications were abdominal aortic aneurysm (AAA) with common iliac artery (CIA) involvement (n = 7), bilateral CIA aneurysm (n = 1), and AAA with bilateral CIA and unilateral IIA involvement (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography (CT) within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 14.7 (range 9-29) months. RESULTS: Technical success rate, as defined by successful implantation of the iliac branch graft (IBG) with no intraprocedural type I or type III endoleak, was 100%. The mean hospitalization duration was 4 days (range 3-6 days), with 0% mortality at 30 days. There were 3 cases of type II endoleak detected perioperatively, which were treated conservatively. Two endoleaks sealed spontaneously on the 1-month CT scan and 1 persists without aneurysm sac expansion. All stent-implanted aortic and iliac aneurysms remained stable in size during follow-up, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up and all patients were asymptomatic. CONCLUSIONS: Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of abdominal aortic aneurysms involving the iliac bifurcation. This technique can efficiently prevent buttock claudication.

Hemostatic Biomarkers and Volumetry Help to Identify High-Risk Abdominal Aortic Aneurysms.

Predicting the progression of small aneurysms is a main challenge in abdominal aortic aneurysm (AAA) management. The combination of circulating biomarkers and image techniques might provide an alternative for risk stratification. We evaluated the association of plasma TAT complexes (TAT) and D-dimer with AAA severity in 3 groups of patients: group 1, without AAA (n = 52), group 2, AAA 40−50 mm (n = 51) and group 3, AAA > 50 mm (n = 50). TAT (p < 0.001) and D-dimer (p < 0.001) were increased in patients with AAA (groups 2 and 3) vs. group 1. To assess the association between baseline TAT and D-dimer concentrations, and AAA growth, aortic diameter and volume (volumetry) were measured by computed tomography angiography (CTA) in group 2 at recruitment (baseline) and 1-year after inclusion. Baseline D-dimer and TAT levels were associated with AAA diameter and volume variations at 1-year independently of confounding factors (p ≤ 0.044). Additionally, surgery incidence, recorded during a 4-year follow-up in group 2, was associated with larger aneurysms, assessed by aortic diameter and volumetry (p ≤ 0.036), and with elevated TAT levels (sub-hazard ratio 1.3, p ≤ 0.029), while no association was found for D-dimer. The combination of hemostatic parameters and image techniques might provide valuable tools to evaluate AAA growth and worse evolution.

Technique for planning and implantation of a branched endograft as a proximal extension of a previous fenestrated endovascular aneurysm repair.

Our patient had undergone a previous three-fenestration Anaconda (Terumo Medical Corp, Tokyo, Japan) fenestrated endovascular aneurysm repair (EVAR) to treat a juxtarenal aortic aneurysm. At 10 years postoperatively, distal migration of the prosthesis, a proximal type I endoleak, and aortic sac enlargement of 10 mm in 6 months was observed. Because of the short length of the Anaconda's bifurcated body, we chose to use a Zenith custom-made endograft with four branches and a bifurcated body with an inverted contralateral limb. We have also described the issues that can arise during branched EVAR after fenestrated EVAR and some of the bailout techniques we performed to successfully perform the treatment.

Endovascular repair of ascending aortic diseases with custom-made endografts.

OBJECTIVES: The aim of this article is to report the mid-term results of ascending thoracic endovascular aortic repair using a custom-made device (CMD). METHODS: This was a retrospective study performed at tertiary centres. Nine patients considered unfit for open surgery received elective total endovascular repair of the ascending aorta with a Relay® (Terumo Aortic, Sunrise; FL, USA) CMD: pseudoaneurysn (n = 5), localized dissection (n =3) and contained rupture (n = 1). RESULTS: Primary clinical success was achieved in all patients with no major complications and no early conversion to open surgery. All patients were discharged home and independent: median length of stay was 7 days (interquartile range, 6-18). No patient was lost to follow-up at a median 26 months (interquartile range, 12-36). Three patients died 2, 6 and 24 months after intervention; 1 was aorta related (late aorto-atrial fistula due to infection that required open surgery). At the last follow-up available, no endoleaks, migrations, fractures or ruptures were observed in the remaining 6 patients. CONCLUSIONS: Ascending thoracic endovascular aortic repair with Terumo Aortic CMDs was technically feasible, effective and safe in very selected lesions. CMDs showed good ascending aorta conformability with different configurations and diameters, and satisfactory mid-term durability as shown by both structural integrity and aortic lesion exclusion.

Trimethylamine-N-Oxide (TMAO) Predicts Cardiovascular Mortality in Peripheral Artery Disease.

Peripheral artery disease (PAD) is a major cause of acute and chronic illness, with extremely poor prognosis that remains underdiagnosed and undertreated. Trimethylamine-N-Oxide (TMAO), a gut derived metabolite, has been associated with atherosclerotic burden. We determined plasma levels of TMAO by mass spectrometry and evaluated their association with PAD severity and prognosis. 262 symptomatic PAD patients (mean age 70 years, 87% men) categorized in intermittent claudication (IC, n = 147) and critical limb ischemia (CLI, n = 115) were followed-up for a mean average of 4 years (min 1-max 102 months). TMAO levels were increased in CLI compared to IC (P < 0.001). Receiver operating characteristic (ROC) curves for severity (CLI) rendered a cutoff of 2.26 µmol/L for TMAO (62% sensitivity, 76% specificity). Patients with TMAO > 2.26 µmol/L exhibited higher risk of cardiovascular death (sub-hazard ratios ≥2, P < 0.05) that remained significant after adjustment for confounding factors. TMAO levels were associated to disease severity and CV-mortality in our cohort, suggesting an improvement of PAD prognosis with the measurement of TMAO. Overall, our results indicate that the intestinal bacterial function, together with the activity of key hepatic enzymes for TMA oxidation (FMO3) and renal function, should be considered when designing therapeutic strategies to control gut-derived metabolites in vascular patients.

Endovascular Treatment of Aortic Arch Lesions Using Scalloped Endografts.

OBJECTIVE: To present our early and midterm results using thoracic endovascular aortic repair (TEVAR) with a custom-made proximal scalloped stent graft to accommodate left common carotid artery (LCCA) and innominate artery (IA) in treating aortic lesions involving the arch. MATERIALS AND METHODS: Between February 2014 and April 2017, select patients presenting with aortic arch lesions and short proximal landing zone were treated by proximal scalloped Relay Plus stent grafts. Patient demographics, operative details, clinical outcomes, and complications were analyzed. RESULTS: Six patients (50% male) with a median age of 71 years (range, 60-82) underwent scalloped TEVAR using thoracic custom-made Relay Plus stent graft to preserve flow in the proximal supra-aortic trunks. Target vessels for the scallop were LCCA in 5 cases and IA in 1 case. The technical success rate was 100%, and proximal seal was achieved in all cases with no type I endoleaks on completion angiography. The median follow-up period was 20 (7-32) months. No conversion to open surgical repair and no aortic rupture occurred. One patient had a distal type I endoleak on the 6-month computed tomography (CT) scan, and 1 patient had a proximal type I endoleak on the 12-month CT scan. There was no stroke, paraplegia, retrograde type A dissection, or other aortic-related complication. We routinely used temporary rapid right ventricular pacing to obtain a near-zero blood pressure level during the graft deployment. No complications were observed related to the use of rapid pacing. CONCLUSION: When anatomy allows, proximal scalloped stent graft to accommodate LCCA and IA is a viable therapeutic option in treating aortic lesions involving the arch with short proximal landing zones. In addition, these findings represent a strong argument for the use of temporary rapid pacing during graft deployment.

Iliac Artery Reconstruction With the Superficial Femoral Vein After Major Oncologic Resection.

The large size of some retroperitoneal tumors and the complex anatomy of the retroperitoneal structures often require en bloc resection of contiguous organs and, sometimes, resection of critical vascular structures. Vascular reconstructive techniques allow reconstruction of major vascular structures, and autologous vein grafting is the preferred option. Although great saphenous vein can be used in select cases, other options must be explored in cases of caliber mismatch between saphenous vein and native vessel. In addition, the use of synthetic grafts should be avoided in potentially infected vascular beds. The use of the superficial femoral vein in such settings is well documented especially in relation to treatment of infected aortic grafts and has the added advantage of appropriate size match for reconstruction of the major abdominal and pelvic vascular structures. Here, we present a case of a 56-year-old woman with a local recurrence of urothelial cancer in the pelvis after radical cystectomy and radiotherapy. Computed tomography (CT) angiography showed the right iliac artery directly involved by the tumor, and vessel resection was necessary to achieve oncologic surgical margins. The tumor was excised en bloc, and vascular reconstruction using the reversed contralateral superficial femoral vein in an end-to-end fashion was performed. The postoperative course was uneventful. Patient was maintained on low-molecular-weight heparin for 1 month and then on low-dose (100 mg acetylsalicylic acid) antiplatelet therapy and compression stockings. Six months later, the patient is asymptomatic, without leg swelling, and the CT scan shows patency of the vascular repair and no tumor recurrence.