Preloaded fenestrated stent-grafts for the treatment of juxtarenal aortic aneurysms.

PURPOSE: To describe a novel technique for target vessel catheterization in patients with juxtarenal abdominal aortic aneurysms requiring treatment with fenestrated stent-grafts (FSG). METHODS: The standard FSG design was modified, substituting a thin-wall tube for the solid central obturator that serves as both an attachment point for the distal end of the graft as well as a top cap retriever. Through this tube, two 0.020-inch wires are run from the hub of the delivery system through the stent-graft, out through each fenestration, and up to the proximal edge of the graft, where they are attached by sutures. The sutures are connected to a trigger wire on the control hub. The preloaded wires facilitate passage of a sheath to the fenestration, providing stability while target vessel catheterization takes place and avoiding the use of a large sheath in the contralateral groin. A third wire attached to the inside of the top cap facilitates its safe retrieval via a 6-mm balloon. The preloaded FSG was used in 5 male patients (mean age 75.6 years) with either juxtarenal aneurysms (n = 2) or aneurysms previously treated with infrarenal stent-grafts that had developed type I endoleak (n = 3). In 3 cases, a double fenestrated stent-graft was required, and in 2 cases a triple fenestrated device was deployed, with scallops for the superior mesenteric or celiac arteries. RESULTS: Sixteen of 17 target vessels were preserved, and all aneurysms were successfully excluded with no endoleak at completion. In 2 patients, tortuosity encountered during device delivery caused twisting of the wires within the preloaded FSG, preventing successful advancement of a sheath over a preloaded wire. An approach from the contralateral groin was necessary to complete the procedure in 1 case, but the target vessel was lost in the other. CONCLUSION: The use of a preloaded FSG is feasible and facilitates the catheterization of fenestrations and of target arteries. This method has the potential to reduce procedure times and lower the risk of intraoperative lower limb ischemia.

Cognitive function in late versus early postmenopausal stage.

OBJECTIVES: There are relatively few studies of cognitive performance in the first few postmenopausal years and insufficient data on whether there is differential decline in different cognitive abilities. The aim of the present analysis was to determine the nature of cognitive decline across a range of functions within a period of 5 years from early to late postmenopausal stage. METHODS: In a cross-sectional study, 189 postmenopausal women, who had experienced a natural menopause, were not taking hormonal medication and had not done so in the previous 12 months, were divided according to their postmenopausal stage into early (stage +1, < or =5 years since the last menstrual period, aged 55.4+/-0.3 years, n=80), or late (stage +2, >5 years since the last menstrual period, aged 59.8+/-0.4 years, n=109) postmenopausal stages. Participants completed a comprehensive battery of tests measuring attention, episodic and semantic memory, planning and mental flexibility. Participants also completed self-ratings of mood, sleepiness and menopausal symptoms. RESULTS: There were no differences between the groups in their performance in tests of attention, verbal fluency or memory. However, in the two tests of executive function (planning and mental flexibility) the women in the late postmenopausal stage performed significantly worse than the women in the early postmenopausal stage. These differences remained significant when effects of age and IQ were taken into account by analyses of covariance. There were no differences between the groups in their ratings of mood or of habitual sleepiness, or of feeling sleepy at the start of testing. However, by the end of testing the women in the late postmenopausal stage rated themselves as feeling sleepier than did the women in the early postmenopausal stage. The group differences in executive function remained significant when these differences in sleepiness were accounted for. CONCLUSIONS: Although there were no differences in attention, verbal fluency and memory, executive function was significantly poorer in the late postmenopausal stage women, suggesting that this aspect of cognition deteriorates more rapidly than other functions. This change was independent of change in age, suggesting that hormonal changes between the early and late postmenopausal stages may be responsible.

Cognitive improvement after 6 weeks of soy supplements in postmenopausal women is limited to frontal lobe function.

OBJECTIVE: To assess the effects of 6 weeks of treatment with soy supplements on mood, menopausal symptoms, and cognition in postmenopausal women not taking other forms of hormone therapy. DESIGN: In a double-blind, placebo-matched parallel groups study, 50 postmenopausal women (aged 51-66 y) were randomly allocated to receive daily treatment with a soy supplement (Novasoy, 60 mg total isoflavone equivalents/day) or matching placebo capsules. They were tested at baseline before treatment began and after 6 weeks of treatment in tests of attention, memory, and frontal lobe function, and completed questionnaires to assess sleepiness, mood, and menopausal symptoms. RESULTS: After 6 weeks of treatment, there was a significant (P < 0.02) reduction in somatic menopausal symptoms in the group taking soy supplements, but there were no other significant effects of soy on menopausal symptoms or mood. On the test of nonverbal short-term memory, the soy group showed greater improvement than the placebo group (P < 0.03), but there were no effects of soy on long-term memory, category generation, or sustained attention. However, the soy treatment produced significantly better performance on the two tests of frontal lobe function, those of mental flexibility (simple rule reversal, P < 0.05; complex rule reversal, P < 0.03) and of planning ability (P < 0.05). CONCLUSIONS: The results suggest that the main improvement after 6 weeks of soy supplementation was in frontal lobe function. Significant improvements in the same three measures of frontal lobe function were previously found after 12 weeks of soy supplements in postmenopausal women. The effects of soy on memory seem less robust.

Differential cognitive effects of Ginkgo biloba after acute and chronic treatment in healthy young volunteers.

RATIONALE: Acute doses of Ginkgo biloba have been shown to improve attention and memory in young, healthy participants, but there has been a lack of investigation into possible effects on executive function. In addition, only one study has investigated the effects of chronic treatment in young volunteers. OBJECTIVES: This study was conducted to compare the effects of ginkgo after acute and chronic treatment on tests of attention, memory and executive function in healthy university students. METHODS: Using a placebo-controlled double-blind design, in experiment 1, 52 students were randomly allocated to receive a single dose of ginkgo (120 mg, n=26) or placebo (n=26), and were tested 4 h later. In experiment 2, 40 students were randomly allocated to receive ginkgo (120 mg/day; n=20) or placebo (n=20) for a 6-week period and were tested at baseline and after 6 weeks of treatment. In both experiments, participants underwent tests of sustained attention, episodic and working memory, mental flexibility and planning, and completed mood rating scales. RESULTS: The acute dose of ginkgo significantly improved performance on the sustained-attention task and pattern-recognition memory task; however, there were no effects on working memory, planning, mental flexibility or mood. After 6 weeks of treatment, there were no significant effects of ginkgo on mood or any of the cognitive tests. CONCLUSIONS: In line with the literature, after acute administration ginkgo improved performance in tests of attention and memory. However, there were no effects after 6 weeks, suggesting that tolerance develops to the effects in young, healthy participants.

Limited cognitive benefits in Stage +2 postmenopausal women after 6 weeks of treatment with Ginkgo biloba.

Gingko biloba has cognitive benefits both in populations suffering from dementia and after acute treatment in healthy volunteers, with some evidence indicating that those with poorer cognitive performance show greater benefit. We have previously found that 1 week of treatment with ginkgo improved attention, memory and mental flexibility in post-menopausal women, but the evidence for any beneficial effects of longer treatment is less well-established. The present study aimed to determine whether cognitive benefits, similar to those previously found after 1 week of treatment, would persist after 6 weeks of treatment, and whether those with poorer cognitive performance would benefit more. In a placebo-controlled, double-blind study, postmenopausal women (aged 51-67 years) were randomly allocated to receive a standardized extract of ginkgo (LI 1370, Lichtwer Pharma, Marlow, UK) (one capsule/day of 120 mg, n = 45) or matching placebo (n = 42) for 6 weeks. According to an established reproductive staging system, subjects were divided into those in the early (Stage +1; mean age 55 years) and late (Stage +2: mean age 61 years) stages of menopause. At baseline and after 6 weeks of treatment, subjects completed tests of mental flexibility, planning, memory and sustained attention, and ratings of mood, sleepiness, bodily and menopausal symptoms. The only significant effects of ginkgo were in the test of mental flexibility, in which there were significant menopausal stage-ginkgo interactions. This was because subjects in Stage +2 required fewer trials to complete the task and made fewer errors after ginkgo treatment, whereas those in Stage +1 showed no benefits. Subjects in Stage +2 had poorer performance at baseline compared to those in Stage +1 both in this task and the test of planning ability. The beneficial effects of ginkgo were limited to the test of mental flexibility and to those with poorer performance.

The soya isoflavone content of rat diet can increase anxiety and stress hormone release in the male rat.

RATIONALE: Most commercial rodent diets are formulated with soya protein and therefore contain soya isoflavones. Isoflavones form one of the main classes of phytoestrogens and have been found to exert both oestrogenic and anti-oestrogenic effects on the central nervous system. The effects have not been limited to reproductive behaviour, but include effects on learning and anxiety and actions on the hypothalamo-pituitary axis. It is therefore possible that the soya content of diet could have significant effects on brain and behaviour and be an important source of between-laboratory variability. OBJECTIVES: To determine whether behaviour in two animal tests of anxiety, and stress hormone production, would differ between rats that were fed a diet which was free of soya isoflavones and other phytoestrogens (iso-free) and those that were fed a diet which contained 150 microg/g of the isoflavones genistein and daidzein (iso-150). This controlled diet has an isoflavone concentration similar to that in the maintenance diet routinely used in our institution. METHODS: Male rats were randomly allocated to the iso-free and iso-150 diets and their body weights and food and water consumption were recorded for 14 days. They were then maintained on the same diets, but housed singly for 4 days, before testing in the social interaction and elevated plus-maze tests of anxiety. Corticosterone concentrations in both dietary groups were determined under basal conditions and after the stress of the two tests of anxiety. Vasopressin and oxytocin concentrations were determined after brief handling stress. RESULTS: The groups did not differ in food or water intake, body weight or oxytocin concentrations. Compared with the rats fed the iso-free diet, the rats fed the iso-150 diet spent significantly less time in active social interaction and made a significantly lower percentage of entries onto the open arms of the plus-maze, indicating anxiogenic effects in both animal tests. The groups did not differ in their basal corticosterone concentrations, but the iso-150 group had significantly elevated stress-induced corticosterone concentrations. Stress-induced plasma vasopressin concentrations were also significantly elevated in the iso-150 diet group compared with the iso-free rats. CONCLUSIONS: Major changes in behavioural measures of anxiety and in stress hormones can result from the soya isoflavone content of rat diet. These changes are as striking as those seen following drug administration and could form an important source of variation between laboratories.

Soya phytoestrogens change cortical and hippocampal expression of BDNF mRNA in male rats.

Adult male hooded Lister rats were either fed a diet containing 150 microg/g soya phytoestrogens or a soya-free diet for 18 days. This concentration of phytoestrogens should have been sufficient to occupy the oestrogen-beta, but not the oestrogen-alpha, receptors. Using in situ hybridisation, significant reductions were found in brain-derived neurotrophic factor (BDNF) mRNA expression in the CA3 and CA4 region of the hippocampus and in the cerebral cortex in the rats fed the diet containing phytoestrogens, compared with those on the soya-free diet. No changes in glutamic acid decarboxylase-67 or glial fibrillary acidic protein mRNA were found. This suggests a role for oestrogen-beta receptors in regulating BDNF mRNA expression.

Binge drinking and sex: effects on mood and cognitive function in healthy young volunteers.

This study compared the mood and cognitive performance of male and female teetotal and binge drinking students. The binge drinkers had significantly lower self-ratings of trait anxiety and depression and of state alertness at the time of testing than did the teetotallers. The females had significantly higher ratings of trait and state anxiety, but there were no Sex x Bingeing interactions on mood. The binge drinkers made significantly fewer correct responses in a test of sustained attention and recalled fewer line drawings. There was a significant Sex x Binge interaction in a spatial recognition task because the male, but not the female, binge drinkers were slower to make correct responses. Males performed better than females in both the spatial and pattern recognition memory tasks. There were three tests of executive function. In a spatial working memory task, males performed better than females, but there were no effects of binge drinking. There were no effects in a test of mental flexibility. However, in a test of planning, the binge drinkers were significantly slower than the teetotallers were. Thus, compared with a group of teetotallers, the binge drinkers had lower trait anxiety and depression and poorer performance in tests of sustained attention, episodic memory and planning ability.

Effects on cognition and mood in postmenopausal women of 1-week treatment with Ginkgo biloba.

In a double-blind, placebo-controlled study, postmenopausal women (53-65 years old) were randomly assigned to 7-day treatment with Ginkgo (120 mg/day, n=15) or matched placebo (n=16). They were given a battery of cognitive tests and measurements of mood and menopausal symptoms at baseline (before treatment began) and at the end of 7 days. The group treated with Ginkgo was significantly better than the placebo group in a matching-to-sample test of nonverbal memory, but the groups did not differ in immediate or delayed paragraph recall or in delayed recall of pictures. In a test of frontal lobe function (rule shifting) and in the Paced Auditory Serial Addition Test (PASAT) (which measures sustained attention but also involves frontal lobe function), the group treated with Ginkgo performed significantly better than the placebo group. However, the groups did not differ in a test of planning. The treatments did not differ in their effects on the volunteers' ratings of menopausal symptoms, sleepiness, bodily symptoms or aggression. The benefits of Ginkgo on memory and frontal lobe function found in this study are modest but are unlikely to be secondary to major mood changes.

Does drinking have effects on mood and cognition in male and female students?

Self-ratings of mood and bodily symptoms were made by groups of IQ and education-matched male and female students [teetotal, low (2-9 units/week for both sexes; 1 UK unit=8 g alcohol) and moderate (12-34 units/week for males; 10-24 units/week for females) drinkers], before the start and at the end of cognitive testing. Multivariate analyses of variance (MANOVAs) showed that there were significant Alcohol x Time interactions, because the teetotal group responded to the cognitive tests with greater increases in the factors of somatic anxiety and aggressive mood than did the other two groups. Thus, the teetotallers had greater ratings of anxiety, sweating, palpitations, irritability, headache, feeling angry, quarrelsome, belligerent, resentful, hostile, spiteful and rebellious. No differences were found in immediate or delayed logical memory, in verbal fluency, trails, clock-drawing or mental flexibility tests. In tests of sustained attention [rapid visual information processing (RVIP)] and planning, males performed better than females. The moderate-alcohol group performed better than the low-alcohol group in RVIP and planning (completed significantly more tasks in the minimum moves), although in the hardest parts of the latter test, they took longer in planning the initial move. In conclusion, there was no evidence that the group drinking moderate levels of alcohol had any cognitive impairment and the teetotal group responded to the cognitive tests with the greatest increases in negative mood.

Computed tomography virtual intravascular endoscopy in the evaluation of fenestrated stent graft repair of abdominal aortic aneurysms.

BACKGROUND: This study aimed to investigate the diagnostic value of computed tomography virtual intravascular endoscopy (VIE) in the follow-up of patients with abdominal aortic aneurysm (AAA) treated with fenestrated stent grafts. METHODS: A total of 19 patients (17 males and 2 females; mean age: 75 years) with AAA undergoing fenestrated stent grafts were retrospectively studied. Pre- and post-fenestration computed tomography data were reconstructed for the generation of VIE images of aortic ostia and fenestrated stents and compared with two-dimensional axial and multiplanar reformation (MPR) images. Serum creatinine was measured pre and post fenestration to evaluate the renal function. RESULTS: The mean intra-aortic length measured by VIE, two-dimensional axial and MPR were 4.7, 4.4 and 4.6 mm, respectively, for the right renal stent; 5.0, 4.9 and 5.0 mm, respectively, for the left renal stent; and 5.9, 6.0 and 6.0 mm, respectively, for the superior mesenteric artery stent. Comparisons of these measurements did not show significant difference (P > 0.05). The mean diameters of renal artery ostia measured on VIE visualization pre and post fenestration were 9.2 x 8.3 and 10 x 8.9 mm for the right renal ostium; 8.3 x 7.1 and 9.9 x 8.9 mm for the left renal ostium, with significant changes observed (P < 0.01). No renal dysfunction was observed in this group. CONCLUSION: VIE is a valuable visualization tool in the follow-up of fenestrated stent graft repair of AAA by providing intraluminal appearance of fenestrated stents and measuring the length of stent protrusion.

A laparoscopic endovascular aortobifemoral conduit that can be retained as a long-term bypass: a solution for patients with inadequate iliac access.

PURPOSE: To present a laparoscopic technique for placing a partially stented aortobifemoral (ABF) conduit that can be used for more proximal endovascular manipulations and then be retained as a permanent bypass of occlusive iliac disease. TECHNIQUE: Ethical approval was obtained to use a fresh frozen cadaver. The left common iliac artery, distal aorta, and proximal right common iliac artery were dissected laparoscopically. A curved hollow needle was inserted into the distal aorta, and wire access was obtained. A partially stented bifurcated Dacron bypass graft was deployed under fluoroscopic guidance into the distal aorta. The limbs of the bypass were then used as conduits for endovascular access before being tunneled behind the ureters and anastomosed to the femoral arteries in the usual way, retaining the stented graft as an ABF bypass. CONCLUSION: This novel technique combines laparoscopic access with endovascular manipulation to place an ABF conduit, which can be retained as a permanent bypass without the need for an abdominal incision. This technique could provide a minimally invasive solution for pelvic occlusive disease that hinders endovascular repairs, as well as a minimally invasive means of securing endoluminal access in patients with iliac arteries of inadequate caliber.

Multislice CT angiography of fenestrated endovascular stent grafting for treating abdominal aortic aneurysms: a pictorial review of the 2D/3D visualizations.

Fenestrated endovascular repair of an abdominal aortic aneurysm has been developed to treat patients with a short or complicated aneurysm neck. Fenestration involves creating an opening in the graft fabric to accommodate the orifice of the vessel that is targeted for preservation. Fixation of the fenestration to the renal arteries and the other visceral arteries can be done by implanting bare or covered stents across the graft-artery ostia interfaces so that a portion of the stent protrudes into the aortic lumen. Accurate alignment of the targeted vessels in a longitudinal aspect is hard to achieve during stent deployment because rotation of the stent graft may take place during delivery from the sheath. Understanding the 3D relationship of the aortic branches and the fenestrated vessel stents following fenestration will aid endovascular specialists to evaluate how the stent graft is situated within the aorta after placement of fenestrations. The aim of this article is to provide the 2D and 3D imaging appearances of the fenestrated endovascular grafts that were implanted in a group of patients with abdominal aortic aneurysms, based on the multislice CT angiography. The potential applications of each visualization technique were explored and compared with the 2D axial images.

CT virtual intravascular endoscopy in the visualization of fenestrated stent-grafts.

PURPOSE: To report the diagnostic value of computed tomographic (CT) virtual intravascular endoscopy (VIE) in the assessment of patients with abdominal aortic aneurysm (AAA) treated with fenestrated endovascular grafts. METHODS: Eight patients (7 men; mean age 76 years, range 70-82) with AAAs unsuitable for open surgery or conventional endovascular repair had fenestrated endovascular grafts implanted. Both pre- and post-fenestration multislice CT data were used to generate VIE images of the visceral artery ostia and the side branch fenestrated stents. CT VIE images were compared with conventional 2-dimensional (2D) axial CT and multiplanar reformatted (MPR) images for the ability to visualize the intraluminal appearance of stents, as well as to measure the length of stents that protruded into the aortic lumen. RESULTS: Various fenestrations were deployed in 27 aortic branches. Scalloped and large fenestrations were implanted in 6 side branch ostia, respectively, and small fenestrations in 15 renal artery ostia. Fewer than half of the stents (37%) were found to be circular on VIE images, while the remaining stents were flared to varying extents at the inferior portion. The majority (96%) of stents protruded into the lumen up to 7.0 mm. Although the configuration of the side branch ostia changed to a variable extent, no significant difference was apparent between the diameters of branch ostia before and after fenestration (p>0.05). CONCLUSION: Our preliminary study shows that VIE proved superior to conventional 2D or MPR images in visualizing the final configuration of the fenestrated vessels and was comparable to the other techniques in measuring stent protrusion into the aortic lumen. VIE could be a valuable technique to identify any suspected abnormalities associated with fenestrated endovascular grafts by demonstrating the final intraluminal configuration of the stents in the fenestrated vessels.

Multislice CT angiography in the follow-up of fenestrated endovascular grafts: effect of slice thickness on 2D and 3D visualization of the fenestration stents.

PURPOSE: To investigate the effect of multislice computed tomography (CT) protocols on the visualization of target vessel stents in patients with abdominal aortic aneurysm (AAA) treated with fenestrated endovascular grafts. METHODS: Twenty-one patients (19 men; mean age 75 years, range 63-86) undergoing fenestrated endovascular repair of AAA were retrospectively studied. Multislice CT angiography was performed with several protocols, and the section thicknesses used in each were compared to identify any relationship between slice thickness and target vessel stents visualized on 2-dimensional (2D) axial, multiplanar reformatted (MPR), and 3-dimensional (3D) virtual intravascular endoscopy (VIE) images. Image quality was assessed based on the degree of artifacts and their effect on the ability to visualize the configuration, intra-aortic location, and intraluminal appearance of the target vessel stents and measure their protrusion into the aortic lumen. RESULTS: There were 7 different multislice CT scanning protocols employed in the 21 patients (25 datasets, with 2 sets of follow-up images in 4 patients). The slice thicknesses and numbers (n) of studies included were 0.5 (n=3), 0.625 (n=6), 1.0 (n=1), 1.25 (n=9), 2.5 (n=3), 3.0 (n=1), and 5.0 mm (n=2). Of these CT protocols, images (especially 2D/3D reconstructions) acquired at 2.5, 3.0, and 5.0 mm were significantly compromised by interference from artifacts. Images acquired with a slice thickness of 1.0 or 1.25 mm were scored equal to or lower than those acquired with a submillimeter section thickness (0.5 or 0.625 mm), with minor degrees of artifacts resulting in acceptable image quality. CONCLUSION: Visualization of the target vessel stents depends on the appropriate selection of multislice CT scanning protocols. Our results showed that studies performed with a slice thickness of 1.0 or 1.25 mm produced similar image quality to those with a thickness of 0.5 or 0.625 mm. Submillimeter slices are not recommended in imaging patients treated with fenestrated stent-grafts, as they did not add additional information to the visualization.

Repair of recurrent visceral aortic patch aneurysm after thoracoabdominal aortic aneurysm repair with a branched endovascular stent graft.

Aneurysmal degeneration of the visceral aortic patch is an uncommon late complication of surgical replacement of the thoracoabdominal aorta. We report on a 70-year-old woman who had undergone previous open thoracoabdominal aortic aneurysm repair and subsequent revision surgery for a visceral aortic patch aneurysm. The patient presented with a recurrent asymptomatic 60-mm-diameter visceral aortic patch aneurysm involving the celiac axis and superior mesenteric artery. The lesion was successfully treated with a custom-designed Zenith branched endovascular stent graft. The patient remains well at 12 months.

Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts.

Three patients with type I proximal endoleak after previous endovascular abdominal aortic aneurysm (AAA) repair were treated with fenestrated endovascular stent grafts. Six renal arteries, three superior mesenteric arteries, and one coeliac axis were targeted for incorporation by graft fenestration. The fenestration-renal ostium interface was secured with balloon-expandable stents and completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. All patients made an uncomplicated recovery. Fenestrated endovascular stent grafts can be used to salvage failed prior endovascular AAA repair in patients who are considered unsuitable for other endovascular or open surgical interventions.

A laparoscopic access technique for endovascular procedures: surgeon training in an animal model.

PURPOSE: To present a laparoscopic technique for placing a transperitoneal conduit in the common iliac artery (CIA) or distal aorta to circumvent stenosed or occluded iliac systems and to assess the success of this laparoscopic access in a live animal model. TECHNIQUE: A porcine model was used owing to similarities in anatomy and size of the pig aorta to the human common iliac artery (CIA). Ethical approval was obtained, and the technique was developed in 8 animals under general anesthesia. A curved hollow needle, a partially stented Dacron conduit, an airtight laparoscopic port and a sealing sheath and valve were developed specifically for percutaneous access through the abdominal wall. A transperitoneal approach was used to the distal aorta. Cannulation by the curved hollow needle via the new port was under direct vision. The conduit was inserted over a guidewire after needle removal and deployed under fluoroscopy. The distal end of the conduit was secured by the sealing sheath and valve, enabling wire and catheter exchange thereafter. A 2-day educational workshop was held for 12 vascular surgeons with a range of laparoscopic experience. After learning the technique on a simulator model, they worked in pairs, alternating surgeon/assistant roles to insert conduits into 12 animals under general anesthesia. Laparoscopic cannulation in all 12 animals was successful. There was no bleeding around the conduit at the aortic arteriotomy. All animals were euthanized after confirmation of conduit patency by back-bleeding. CONCLUSION: This novel technique bridges the gap between laparoscopic and endovascular techniques in striving for minimally invasive solutions to the treatment of vascular disease. Adaptation to human beings is currently underway and will mean increasing the applicability of endovascular solutions to those patients in whom it would otherwise be denied. The technique would appear not to require specialist laparoscopic skills.

Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997-2004).

PURPOSE: To describe a 7-year experience with abdominal aortic aneurysm (AAA) repair using fenestrated Zenith endovascular endografts. METHODS: Six endovascular surgeons from 7 medical centers in Perth, Western Australia, contributed data to this retrospective study of 58 AAA patients (51 men; mean age 75.5+/-8.5 years, range 60-94) treated with fenestrated endografts. Fenestrations were applied to 116 target vessels; more than half of patients had >/=2 target vessels. The results were based on satisfactory deployment of the stent-graft and fenestrations (technical success), technical success and no complications (procedural success), and aneurysm exclusion with no endoleak, rupture, unresolved complications, or dialysis (treatment success). RESULTS: Technical success was 82.8% for patients (90.5% for target vessels), procedural success was 74.1%, and treatment success was 94.8%. There were no cases of conversion or rupture. The 30-day mortality rate was 3.4% (n=2). Over a mean follow-up of 1.4+/-1.2 years, 10 (17.2%) patients experienced loss of a target vessel (9.5% of target vessels). Factors associated with target vessel loss were no stent, >60 degrees neck angulation, multiple renal vessels, and vessel diameter

Comparison of the endothelialization of small intestinal submucosa, dacron, and expanded polytetrafluoroethylene suspended in the thoracoabdominal aorta in sheep.

PURPOSE: This study was undertaken to evaluate and compare endothelialization of small intestinal submucosa (SIS), Dacron, and expanded polytetrafluoroethylene (ePTFE) in high-pressure flow without aortic wall contact and to evaluate the suitability of SIS as a vascular graft material. MATERIALS AND METHODS: In 12 adult sheep, three types of membrane leaflets of similar thickness (approximately 200 mum) were suspended within large square stents without contact with the thoracoabdominal aortic wall: SIS (n = 12), Dacron (n = 12), and ePTFE (n = 12). Each animal received one leaflet of each material. Aortograms were obtained before and after percutaneous implantation and when the animal was killed at 8 weeks (n = 6) or 18 weeks (n = 6). Cell coverage and remodeling of SIS, Dacron, and ePTFE membranes were assessed by gross and histologic microscopic examinations. RESULTS: Thirty-five successfully implanted leaflets were evaluated. SIS showed progressive remodeling. Thirty-three leaflets exhibited thickening as a result of neointimal formation and endothelialization, most likely from circulating endothelial cells. Dacron exhibited the greatest and most progressing degree of neointimal formation and endothelialization, followed by SIS and then ePTFE. With SIS and ePTFE, neointimal formation decreased with time, but endothelialization was stable. Uneven neointimal formation and endothelialization on the outer surfaces and distal leaflet positions were seen. CONCLUSIONS: SIS showed progressive remodeling with moderate and regressive neointimal formation and moderate stable endothelialization. Further study of its durability and incorporation into the aortic wall needs to be performed to evaluate its suitability as a cover for aortic endografts.