Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair.

OBJECTIVE: The objective of this study was to investigate the mid-term outcomes of embolization procedures for type II endoleak after endovascular abdominal aortic repair, and clarify the risk factors for aneurysm enlargement after embolization procedures. METHODS: This was a retrospective multicenter registry study enrolling patients who underwent embolization procedures for type II endoleaks after EVAR from January 2012 to December 2018 at 19 Japanese centers. The primary end point was the rate of freedom from aneurysm enlargement, more than 5 mm in the aortic maximum diameter, after an embolization procedure. Demographic, procedural, follow-up, and laboratory data were collected. Continuous variables were summarized descriptively, and Kaplan-Meier analyses and a Cox regression model were used for statistical analyses. RESULTS: A total of 315 patients (248 men and 67 women) were enrolled. The average duration from the initial embolization procedure to the last follow-up was 31.6 ± 24.6 months. The rates of freedom from aneurysm enlargement at 3 and 5 years were 55.4 ± 3.8% and 37.0 ± 5.2%, respectively. A multivariate analysis revealed that a larger aortic diameter at the initial embolization procedure and the presence of a Moyamoya endoleak, defined as heterogeneous contrast opacity with an indistinct faint border, were associated with aneurysm enlargement after embolization management. CONCLUSIONS: The embolization procedures were generally ineffective in preventing further expansion of abdominal aortic aneurysms in patients with type II endoleaks after EVAR, especially in patients with a large abdominal aortic aneurysm and/or a presence of a Moyamoya endoleak.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry.

PURPOSE: To evaluate the clinical utility of the Gore Excluder iliac branch endoprosthesis (IBE) for Japanese patients with aortoiliac aneurysms. MATERIALS AND METHODS: This was a multicenter retrospective cohort study (J-Preserve Registry). Patients undergoing endovascular aortic repair using the Gore Excluder IBE for aortoiliac aneurysms between August 2017 and June 2020 were enrolled. Data pertaining to the baseline and anatomical characteristics, technical details, and clinical outcomes were collected from each institution. The primary endpoints were technical success, IBE-related complications, and reinterventions. Secondary endpoints were mortality, aneurysm size change, and reintervention during follow-up. Technical success was defined as accurate deployment of the IBE without type Ib, Ic, or III endoleaks on the IBE sides on completion angiography. A change in aneurysm size of 5 mm or more was taken to be a significant change. RESULTS: We included 141 patients with 151 IBE implantations. Sixty-five IBE implantations (43.0%) had at least one instruction for use violation. Twenty-two patients (15.6%) required internal iliac artery (IIA) embolization for external iliac artery extension on the contralateral side. Of 151 IBE implantations, 19 exhibited IIA branch landing zones due to IIA aneurysms. Mean maximum and proximal common iliac artery (CIA) diameters were 32.9±9.9 mm and 20.5±6.9 mm, respectively. The mean CIA length was 59.1±17.1 mm. The IIA landing diameter and length were 9.0±2.3 mm and 33.8±14.6 mm. The overall technical success rate was 96.7%. There were no significant differences in IBE-related complications (2.3% vs 5.3%, p=0.86) or IBE-related reinterventions (1.5% vs 5.3%, p=0.33) between the IIA trunk and IIA branch landing groups. The mean follow-up period was 635±341 days. The all-cause mortality rate was 5.0%. There were no aneurysm-related deaths or ruptures during the follow-up. Most patients (95.7%) had sac stability or shrinkage. CONCLUSION: The Gore Excluder IBE was safe and effective for Japanese patients in the midterm. Extending the IIA device into the distal branches of the IIA was acceptable, which may permit extending indications for endovascular aortic aneurysm repair of aortoiliac aneurysms to more complex lesions. CLINICAL IMPACT: This study suggests clinical benefits of the Gore Excluder IBE for Japanese patients, despite 43% of the IBE implantations having at least one IFU violation.

Management of Renal Arteries in Conjunction with Thoracic Endovascular Aortic Repair for Complicated Stanford Type B Aortic Dissection: The Japanese Multicenter Study (J-Predictive Study).

Background Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: -16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: -13% ± 14 vs 8.5% ± 14, P = .004). Conclusion Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss. © RSNA, 2019 Online supplemental material is available for this article.

Candy-Plug Technique Using an Excluder Aortic Extender for Distal Occlusion of a Large False Lumen Aneurysm in Chronic Aortic Dissection.

PURPOSE: To describe the candy-plug technique using an Excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. TECHNIQUE: A 60-year-old female patient with a history of chronic type B aortic dissection and high-dose steroid use for Churg-Strauss syndrome developed a large 6.2 cm maximum diameter false lumen aneurysm. She underwent thoracic endovascular aortic repair from the left common carotid artery to the descending aorta to cover the proximal entry at the level of distal arch, with coil embolization of the left subclavian artery. To occlude the large false lumen from the reentry just below the level of the left renal artery ostium, a modified 32×45-mm Excluder aortic extender was deployed in the false lumen through the reentry, and a 16-mm Amplatzer Vascular Plug I was deployed in the waist of the modified Excluder aortic extender for complete occlusion. No obvious technical complication was seen. Contrast-enhanced computed tomography at 1 and 14 months revealed no endoleaks and showed complete false lumen thrombosis. CONCLUSION: The candy-plug technique using the Excluder aortic extender is feasible for occlusion of a large false lumen aneurysm in chronic aortic dissection.

[Right ventricular rupture due to blunt trauma diagnosed by MDCT; report of a case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

[Acute abdominal aortic occlusion in a patient with a giant thrombus in the left atrium and mitral stenosis; report of a case].

The patient was a 69-year-old male who had had percutaneous transvenous mitral commissurotomy (PTMC) 15 years ago, and had stopped taking warfarin after PTMC. He was transferred to our emergency room( ER) because of sudden severe pain in his both lower legs. We recognized pulselessness in his both femoral arteries, and pallor, paresthesia and poikilothermia in his lower extremities. Electorocardiogram(ECG) showed arterial fibrillation, and computed tomography( CT) showed occlusion of the abdominal aorta just below inferior mesenteric artery( IMA) and both common iliac arteries. By echocardiography, a giant thrombus was detected in the left atrium with severe mitral stenosis. Thrombectomy and angioplasty were performed at about 5 hours after the onset of occlusion, and revascularization was successful. Three days after the operation, we excised the giant thrombus in the left atrium and performed mitral valve replacement because we considered that myonephropathic metabolic syndrome (MNMS) had been prevented. The postoperative course was uneventful and he was discharged on the 27th postoperative day.

Use of the Endurant stent graft system for ruptured infrarenal aortic aneurysms: short-term experience in nine patients.

PURPOSE: To report the early results of use of the Endurant stent graft in the treatment of ruptured abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS: Nine consecutive patients (seven men and two women; mean age, 76 y; range, 65-87 y) underwent endovascular aneurysm repair (EVAR) for a ruptured AAA with the Endurant stent graft between April and December 2012. EVAR was emergent in all cases. Early technical success, clinical success, major complication, and mortality rates were analyzed. RESULTS: Intraoperative immediate technical success was achieved in all nine patients. The 30-day clinical success rate was 67% (six of nine patients). The 30-day mortality rate was 33% (three of nine patients). During a mean follow-up of 6 months (range, 3-10 mo), none of the cases required reintervention; there was one late death attributed to probable endograft infection. CONCLUSIONS: The short-term results of EVAR with the Endurant stent graft in patients with ruptured AAAs are encouraging.

Coil Embolization of Recurrent Internal Iliac Artery Aneurysm via the Superior Gluteal Artery.

We report a case of recurrent internal iliac artery aneurysm previously treated with a combination of stent graft placement and coil embolization in an 85 year-old male patient. The patient was scheduled for the direct puncture embolization of the superior gluteal artery. The patient was placed in a prone position under general anesthesia. An 18G-PTC needle was inserted into the superior gluteal artery under ultrasonographic guidance. A 2.2F microcatheter was inserted through an outer needle and advanced to the aneurysmal sac. Coil embolization was successfully performed without endoleaks. This approach is technically feasible when other treatment options fail or are deemed unsuitable.

Iliac neck dilatation causes rupture of abdominal aortic aneurysm previously treated with endovascular aortic aneurysm repair.

A 78-year-old male had undergone endovascular aortic aneurysm repair (EVAR) 7 years prior to presentation. Although the sac was stable 6 months ago, the patient presented with shock at arrival, and CT showed aortic rupture with rapid expansion due to type Ib endoleak caused by iliac neck dilatation (IND). The aneurysm sac was excluded using an endovascular strategy. Bell-bottom iliac limbs can cause IND associated with type Ib endoleak. Additionally, the risk of rupture is high when re-expansion of an aneurysm occurs after sac regression after EVAR. Therefore, close follow-up is mandatory for patients with IND after EVAR.

Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation.

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

Longterm Followup of a Pediatric Patient with Congenital Abdominal Aortic Aneurysm with Coarctation.

Congenital abdominal aortic aneurysm (AAA) with coarctation has been considered an extremely rare condition. In this study, we present a 3-year-old boy, who was diagnosed by chance with congenital AAA at first operation. We replaced the AAA+coarctation with a 6-mm polytetrafluoroethylene (PTFE) graft. Histological examination of the aortic wall revealed no particular abnormalities. Collateral vessels were noted to develop over 14 years of followup. Good blood flow to both lower limbs and no intermittent claudication were observed. After growth, at the age 17, he underwent extra-anatomical bypass using a 12-mm PTFE graft. This is the first report of successful treatment of congenital AAA+coarctation with longterm followup.

Comparison of Outcomes and Complications Among Patients with Different Indications of Acute/Subacute Complicated Stanford Type B Aortic Dissection Treated by TEVAR: Data from the JaPanese REtrospective multicenter stuDy of ThoracIc Endovascular Aortic Repair for Complicated Type B Aortic Dissection (J-Predictive Study).

PURPOSE: To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair. MATERIAL AND METHODS: The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test. RESULTS: Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair. CONCLUSIONS: Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia. LEVEL OF EVIDENCE: Level 4, Case series.

Clinical Utility of the Candy-Plug Technique Using an Excluder Aortic Extender.

Objective: To describe the clinical utility and technical aspects of the candy-plug technique using an Excluder aortic extender (Ex-cuff) for false lumen (FL) occlusion in chronic aortic dissection. Materials and Methods: This is a retrospective study analyzing seven consecutive patients (mean age, 63 years; range, 44-78 years; 6 men) with aneurysmal dilatation or rupture in chronic aortic dissection. All patients had undergone thoracic endovascular aortic repair with FL occlusion using this technique. We assessed technical (deployment accuracy) and clinical (no FL backflow on the latest contrast-enhanced computed tomography) success. Results: Technical success was obtained in six patients (86%). Technical failure was caused by the malposition of the candy-plug. The mean follow-up period was 593 days (range, 222-1225 days). Clinical success was obtained in four (57%), and incomplete Amplatzer Vascular Plug (AVP) embolization was seen in two. There was no enlarged FL after the procedure, and all patients are alive during the follow-up periods. Conclusion: The candy-plug technique using an Ex-cuff may be a feasible option; however, it takes time to achieve complete AVP embolization. Therefore, using additional embolic materials should be considered when we use it for the rupture case. (This is a translation of Jpn J Endovasc Interv 2018; 19: 29-35.).

A Successful Endovascular Technique for Complete False Lumen Thrombosis in Chronic Abdominal Aortic Dissection.

A 66-year-old man presented with an enlarging abdominal aorta false lumen, after type A aortic dissection repair. Residual entries were located at the left renal artery, abdominal aorta, and left external iliac artery. The patient underwent endovascular aortic repair with left renal artery stenting to close the entries. Completion aortography showed no false lumen flow without an endoleak, and contrast-enhanced computed tomography 1 month after the procedure demonstrated complete false lumen thrombosis. A total endovascular approach is possible for abdominal aneurysmal dilation in chronic aortic dissection when all entries can be closed using a one-stage procedure with stent grafts and/or branch stenting.

Clinical Utility of Coil in Plug Method (CIP) for Internal Iliac Artery Embolization during Endovascular Aortic Aneurysm Repair.

Objective: To evaluate the clinical utility of the coil in plug (CIP) method in internal iliac artery (IIA) embolization during endovascular aortic aneurysm repair (EVAR) compared to conventional coil embolization (CCE). Material and Methods: From July to December 2018, 10 patients who underwent IIA embolization during EVAR were divided into CIP (n=5) and CCE (n=5) groups. In the CIP technique, the AVP-1 with a size more than 30%-50% of that of the embolized IIA diameter was used. The AVP-1 was deployed in the IIA. Before detachment of the AVP-1, a 2.2-F micro catheter was inserted through the 6-F delivery guiding sheath, and entered the plug. The AVP-1 was then packed with hydrogel micro coils. We compared number of coils used, embolization length, embolization time, volume embolization ratio, and embolic material cost between the groups. Results: The CIP method achieved shorter embolization length with fewer coils used compared to CCE. The CIP method decreased the cost of total embolic materials. Conclusion: The CIP method can achieve shorter embolization length with fewer coils used compared to CCE.

Stent-Graft Relining by Combined Aortic Cuff with Double-D Technique for Type IIIb or V Endoleak after Endovascular Aneurysm Repair: A Case Report.

We report the case of a 83-year-old man with aneurysmal sac enlargement after endovascular aneurysm repair for an abdominal aortic aneurysm, despite no overt endoleak (EL) detected on imaging. Occult type II EL was suspected, and treatment was performed. However, the aneurysm continued to enlarge. Thus, we diagnose with type V EL as exclusion diagnosis. We combined an aortic cuff and stent-graft leg to cover the initially inserted stent graft, as a diagnostic treatment for unrefined type IIIb EL. Subsequently, the aneurysm diameter decreased. This technique and concept may be effective for type V EL, which may include another type occult EL.

Emergent Transcatheter Arterial Embolization via a Transpopliteal Approach for Internal Iliac Artery Injury during Lumbar Disk Surgery in the Prone Position.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis.

PURPOSE: To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors. METHODS: We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings. RESULTS: Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients' median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis. CONCLUSIONS: Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than "pumping" and avoids the use of vasopressors.

Sepsis caused by peripelvic soft tissue infections in critically injured patients with multiple injuries and unstable pelvic fracture.

BACKGROUND: In critically injured patients with multiple injuries and unstable pelvic fracture, late mortality almost invariably results from sepsis. METHODS: We analyzed the clinical features of 11 patients with sepsis caused by soft tissue infections surrounding the fractured pelvis, of 830 patients with pelvic fracture after blunt trauma treated at our level I trauma center over the past 25 years. Soft tissue infection was defined as abscess formation in subcutaneous tissue or muscle diagnosed by computed tomography or an operation. RESULTS: Mean injury severity score was 48, and mean systolic blood pressure on arrival was 66 mm Hg. All patients had multiple concomitant injuries and prolonged hemorrhagic shock. Open pelvic fracture was present in five patients. Mean blood transfusion volume within 24 hours was 12,611 mL. Intra-aortic balloon occlusion was performed in three patients and transcatheter angiographic embolization in nine patients. Embolic sites of transcatheter angiographic embolization were bilateral internal iliac arteries (n = 9), lumbar artery (n = 5), median sacral artery (n = 2), and circumflex femoral artery (n = 2). Infection sites included the gluteal (n = 11), femoral (n = 6), sacral (n = 4), lumbar (n = 4), anterior iliac (n = 2), inguinal (n = 1), and perineal (n = 1) regions. Necrotic changes of infected soft tissue were found in all patients. They underwent open drainage and daily debridement with pulsatile irrigation followed by intravenous antibiotics. All patients developed severe sepsis, five of whom subsequently died of multiple organ failure. CONCLUSIONS: In critically injured patients with multiple injuries and unstable pelvic fracture, peripelvic soft tissue infections occasionally cause sepsis. Peripelvic infections are often accompanied by necrotic changes and easily develop into severe sepsis or multiple organ failure. Identifying high-risk patients and early diagnosis with prompt surgical treatment are indispensable for the patients' survival.