Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis.

BACKGROUND: We investigated the early and midterm efficacy and safety of covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac disease (AID). METHODS: A systematic search on PubMed, Scopus, and Web of Science for articles published by August 2023 was performed. The primary end points were primary patency and secondary patency. RESULTS: Eleven retrospective case series, involving 579 patients, were incorporated in the review with 88.9% of the included lesions being categorized as Trans-Atlantic Inter-Society Consensus (TASC) C or D. The pooled primary patency estimates at 12, 24 and 36 months were 94.4% (95% confidence interval [CI], 89.4-99.7), 84.4% (95% CI, 72.3-98.5) and 83.8% (95% CI, 71.4-98.3) respectively. The mean primary patency time, representing the period during which individuals remained event-free, was 51.9 months (95% CI, 43.6-55.4). The pooled 36 months primary patency for studies with a predominantly claudicant patient population (>75% of patients) was 89.4% (95% CI, 78.5-100.0), compared with 71.5% (95% CI, 45.6-100.0) for studies with a mixed population (50% of patients). The pooled 36 months primary patency for studies with a predominantly TASC D patient population (>82% of patients) was 70.4% (95% CI, 46.4-100.0) compared with 91.0% (95% CI, 79.1-100.0) for studies with a more homogenous cohort. The pooled secondary patency estimates at 12, 24, and 36 months were 98.6% (95% CI, 96.2-100.0), 97% (95% CI, 93.1-100.0), and 97% (95% CI, 93.1-100.0), respectively. The pooled technical success, 30-day mortality and 30-day systemic complications estimates were 95.9% (95% CI, 93.7- 97.4), 1.9% (95% CI, 1.0-3.5), and 6.4% (95% CI, 4.4-9.1), respectively. The pooled intraoperative and postoperative 30-day CERAB-related complications estimates were 7.3% (95% CI, 2.0-23.0) and 4.2% (95% CI, 0.7-21.0), respectively. The pooled major amputation and target lesion reinterventions by the end of follow-up were 1.9% (95% CI, 1.0-3.4) and 13.9% (95% CI, 9.9-19.2), respectively. The pooled access site complication estimate was 11.7% (95% CI, 5.9-21.7). CONCLUSIONS: Although this review has showcased the safety and feasibility of the CERAB technique in treating AID, it has also highlighted the necessity for a close and prolonged follow-up period extending beyond 1 year. Moreover, the favorable secondary patency estimates predominantly attained via endovascular reinterventions emphasize a potentially advantageous characteristic of the CERAB technique, particularly valuable when addressing late-stage AID disease or anatomically complex lesions.

Aortobifemoral bypass vs covered endovascular reconstruction of aortic bifurcation.

BACKGROUND: Covered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly used as a first line-treatment in patients with aortoiliac occlusive disease (AIOD). We sought to compare the outcomes of patients who underwent CERAB compared with the gold standard of aortobifemoral bypass (ABF). METHODS: The Vascular Quality Initiative was queried for patients who underwent ABF or CERAB from 2009 to 2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest-neighbor match. Our primary outcomes were 1-year estimates of primary patency, major adverse limb events (MALEs), MALE-free survival, reintervention-free survival, and amputation-free survival. Standard statistical methods were used. RESULTS: A total of 3944 ABF and 281 CERAB cases were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009 and 2021. Compared with ABF, patients who underwent CERAB were more likely to be older (64.7 vs 60.2; P < .001) and more often had diabetes (40.9% vs 24.1%; P < .001) and end-stage renal disease (1.1% vs 0.3%; P = .03). In the matched analysis (229 CERAB vs 929 ABF), ABF patients had improved MALE-free survival (93.2% [±0.9%] vs 83.2% [±3%]; P < .001) and lower rates of MALE (5.2% [±0.9%] vs 14.1% [±3%]; P < .001), with comparable primary patency rates (98.3% [±0.3%] vs 96.6% [±1%]; P = .6) and amputation-free survival (99.3% [±0.3%] vs 99.4% [±0.6%]; P = .9). Patients in the CERAB group had significantly lower reintervention-free survival (62.5% [±6%] vs 92.9% [±0.9%]; P < .001). Matched analysis also revealed shorter length of stay (1 vs 7 days; P < .001), as well as lower pulmonary (1.2% vs 6.6%; P = .01), renal (1.8% vs 10%; P < .001), and cardiac (1.8% vs 12.8%; P < .001) complications among CERAB patients. CONCLUSIONS: CERAB had lower perioperative morbidity compared with ABF with a similar primary patency 1-year estimates. However, patients who underwent CERAB experienced more major adverse limb events and reinterventions. Although CERAB is an effective treatment for patients with AIOD, further studies are needed to determine the long-term outcomes of CERAB compared with the established durability of ABF and further define the role of CEARB in the treatment of AIOD.

Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent.

PURPOSE: Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. METHODS: We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. RESULTS: A total of 17 patients (mean age, 48.1 years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7 cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29 months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. CONCLUSION: Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.

Covered endovascular reconstruction of the aortic bifurcation: A versatile technique with many potential applications.

We present our experience with using the bifurcated covered endovascular reconstruction technique in two unusual conditions. One patient with a traumatic "seat belt" aortic injury and a second patient with a bleeding aorto-enteric fistula were successfully treated with the CERAB technique. We discuss potential benefits of the technique outside the usual pattern of chronic atherosclerotic aortoiliac disease.

Comprehensive management of challenging recurrent aortoiliac and lower extremity occlusive disease with simultaneous modified-covered endovascular reconstruction of the aortic bifurcation, inferior mesenteric artery snorkel, and lower extremity bypass.

OBJECTIVES: Despite recent advancements in endovascular technology and proven durability of open surgeries, managing extensive aortoiliac occlusive disease (AIOD) with concurrent severe lower extremity (LE) arterial occlusion remains a formidable challenge. This paper introduces a comprehensive approach to addressing recurrent AIOD and LE occlusive diseases by employing modified-CERAB, inferior mesenteric artery (IMA) snorkel, and LE bypass in a challenging case. METHODS: A 56-year-old male patient presented with subacute bilateral lower extremity rest pain with dry gangrene in the left great toe and a complex medical history. His history included a hostile abdomen stemming from past ischemic bowel episodes and multiple bowel resections through laparotomies. Furthermore, the patient had a persistent left ventricular thrombus (LVT), stage-2 chronic kidney disease (CKD), diabetes, and was currently experiencing bilateral LE rest pain and dry gangrene in the left great toe, accompanied by severe dermatitis in both LEs. RESULTS: He successfully underwent modified-CERAB with a concurrent snorkel technique for IMA preservation, along with an LE bypass to resolve bilateral LE critical ischemia. CONCLUSION: This comprehensive management approach, combining simultaneous modified-CERAB, IMA snorkel, and LE bypass, provides an effective alternative for addressing complex AIOD and LE occlusive disease patients with hostile abdomen.

Hemodynamic Comparison of Stent-Grafts for the Treatment of Aortoiliac Occlusive Disease.

PURPOSE: To compare the flow patterns and hemodynamics of the AFX stent-graft and the covered endovascular reconstruction of aortic bifurcation (CERAB) configuration using laser particle image velocimetry (PIV) experiments. MATERIALS AND METHODS: Two anatomically realistic aortoiliac phantoms were constructed using polydimethylsiloxane polymer. An AFX stent-graft with a transparent cover made with a new method was inserted into one phantom. A CERAB configuration using Atrium's Avanta V12 with transparent covers made with a previously established method was inserted into the other phantom, both modified stent-grafts were suitable for laser PIV, enabling visualization of the flow fields and quantification of time average wall shear stress (TAWSS), oscillatory shear index (OSI), and relative residence time (RRT). RESULTS: Disturbed flow was observed at the bifurcation region of the AFX, especially at the end systolic velocity (ESV) time-point where recirculation was noticeable due to vortical flow. In contrast, predominantly unidirectional flow was observed at the CERAB bifurcation. These observations were confirmed by the quantified hemodynamic results from PIV analysis where mean TAWSS of 0.078 Pa (range: 0.009-0.242 Pa) was significantly lower in AFX as compared with 0.229 Pa (range: 0.013-0.906 Pa) for CERAB (p<0.001). Mean OSI of 0.318 (range: 0.123-0.496) in AFX was significantly higher than 0.252 (range: 0.055-0.472) in CERAB (p<0.001). Likewise, mean RRT of 180 Pa-1 (range: 9-3603 Pa-1) in AFX was also significantly higher than 88 Pa-1 (range: 2-840 Pa-1) in CERAB (p=0.0086). CONCLUSION: In this in vitro study, the flow pattern of a modified AFX stent-graft was found to be more disturbed especially at the end systolic phase, its hemodynamic outcomes less desirable than CERAB configuration. CLINICAL RELEVANCE: While the AFX stent-graft has an advantage over the CERAB configuration in eliminating radial mismatch, and maintaining the anatomical bifurcation for future endovascular intervention, this in vitro study revealed that the associated lower TAWSS, higher OSI and RRT may predispose to thrombosis and are, thus, less desirable as compared to a CERAB configuration. Further investigation is warranted to confirm whether these findings translate into the clinical setting.

Update on covered endovascular reconstruction of the aortic bifurcation.

OBJECTIVE: The covered endovascular reconstruction of the aortic bifurcation (CERAB) technique was introduced in 2009 in order to provide an anatomically and physiologically optimal endovascular reconstruction of the aortic bifurcation. METHOD: In the current review, all available evidence on this technique was summarized. RESULTS: In vitro studies have shown a more favorable geometry of CERAB compared to kissing stents, leading to better local flow conditions. The results of CERAB are at least as good as those achieved with kissing stents in a more complex group of treated patients. The mid-term patency rates approach those of surgical reconstruction. Initial data show that the technique can also be used in combination with chimney grafts in order to preserve side branches. CONCLUSION: CERAB has proven to be the most optimal endovascular treatment option for aorto-iliac occlusive disease with regard to geometry and flow and is related to promising clinical outcomes. Prospective and comparative trials are necessary to elucidate the most optimal treatment algorithm for patients with aorto-iliac occlusive disease.

Trans-Atlantic Inter-Society Consensus Class D Aortoiliac Lesions: A Comparison of Endovascular and Open Surgical Outcomes.

OBJECTIVE. The purpose of this study is to compare the clinical and safety outcomes between two groups of patients with Trans-Atlantic Inter-Society Consensus class D (TASC II D) aortoiliac occlusive disease (AIOD): those with higher-risk comorbidity who underwent endovascular reconstruction and those with lower-risk comorbidity who underwent surgical bypass. MATERIALS AND METHODS. Thirty-two consecutive patients with symptomatic TASC II D AOID who underwent surgical bypass or endovascular reconstruction from 2012 to 2017 were retrospectively reviewed. Lesion characteristics, technical approach, survival, limb salvage, patency, and change in clinical symptoms were analyzed. RESULTS. Nineteen patients with higher comorbidity underwent endovascular reconstruction, whereas 13 patients with lower comorbidity underwent surgical bypass. Patients undergoing endovascular reconstruction had an older median age (67.0 vs 62.0 years; p = 0.007), higher rates of hypertension (94.7% vs 61.5%; p = 0.018) and coronary artery disease (26.3% vs 0%; p = 0.044), and advanced renal impairment (mean [± SD] chronic kidney disease stage, 1.4 ± 1.5 vs 0.7 ± 1.3; p = 0.005). There were no significant differences in Rutherford classification between the groups. During long-term follow-up of 2.76 years, endovascular reconstruction and surgical bypass showed equivalent rates of survival (89.5% vs 84.6%; p = 0.683), limb salvage (100.0% vs 92.3%; p = 0.219), and primary or primary-assisted patency (85% vs 85%; p = 0.98). Groups showed similar clinical improvements in walking distance, rest pain, and tissue loss at 30 days (95% vs 85%; p = 0.158) and at long-term follow-up (74% vs 62%; p = 0.599). CONCLUSION. For properly selected patients, the clinical outcomes of endovascular reconstruction versus surgical bypass for TASC II D AOID may be equivalent at 2.5 years after the procedure. The decreased operative risk associated with endovascular reconstruction suggests that it is the technique of choice for high-risk patients.

In vivo geometry of the kissing stent and covered endovascular reconstruction of the aortic bifurcation configurations in aortoiliac occlusive disease.

Objectives Various configurations of kissing stent (KS) configurations exist and patency rates vary. In response the covered endovascular reconstruction of the aortic bifurcation configuration was designed to minimize mismatch and improve outcome. The aim of the current study is to compare geometrical mismatch of kissing stent with the covered endovascular reconstruction of the aortic bifurcation configuration in vivo. Methods Post-operative computed tomographic data and patient demographics from 11 covered endovascular reconstruction of the aortic bifurcation and 11 matched kissing stent patients were included. A free hand region of interest and ellipse fitting method were applied to determine mismatch areas and volumes. Conformation of the stents to the vessel wall was expressed using the D-ratio. Results Patients were mostly treated for Rutherford category 2 and 3 (64%) with a lesion classification of TASC C and D in 82%. Radial mismatch area and volume for the covered endovascular reconstruction of the aortic bifurcation group was significantly lower compared to the kissing stent configuration ( P < 0.05). The D-ratio did not significantly differ between groups. Measurements were performed with good intra-class correlation. There were no significant differences in the post-procedural aortoiliac anatomy. Conclusions The present study shows that radial mismatch exists in vivo and that large differences in mismatch exist, in favour of the covered endovascular reconstruction of the aortic bifurcation configuration. Future research should determine if the decreased radial mismatch results in improved local flow profiles and subsequent clinical outcome.

Hybrid endovascular treatment for complicated aortic dissection concomitant with true lumen obliteration: a case report.

Background: Thoracic endovascular aortic repair (TEVAR) has been widely introduced. However, unestablished transfemoral approach due to true lumen obliteration disables endovascular option. Case summary: A 74-year-old male with a history of 15-year-ago type B aortic dissection presented with chronic bilateral lower extremity claudication. CT angiography revealed that a large entry tear was located at distal to the left subclavian artery. The thoracic aneurysmal degeneration progressed and eventually required repair. True lumen of infrarenal aorta to bilateral common iliac arteries was totally collapsed by false lumen, and the re-entry tear was open at external iliac artery. Initially, we performed recanalization to the collapsed true lumen. Bidirectional approach was taken from right brachial and bifemoral arteries. The covered endovascular reconstruction of aortic bifurcation (CERAB) technique and double D-shape moulding technique (DDMT) was performed to create covered stent configuration. As secondary treatment, 1-debranching TEVAR with axillary artery bypass was successfully performed by utilizing femoral approach. Discussion: This case demonstrated feasibility of two-stage endovascular therapy for thoracic aneurysmal degeneration concomitant with true lumen obliteration. This combined technique of CERAB and DDMT was absolutely effective to minimize type Ⅲ endoleak in infrarenal segment. Hybrid endovascular treatment offered minimally invasive therapy to the patient.

Endovascular Aorto-Iliac Reconstruction vs. Aortobifemoral Bypass as First Choice for a Durable Revascularization for Aorto-Iliac Occlusive Disease.

INTRODUCTION: Aortoiliac occlusive disease (AIOD) is defined as atherosclerotic obstruction of the distal abdominal aorta and iliac arteries. Multiple options exist for management of AIOD including endovascular aortoiliac reconstruction and aortobifemoral bypass. As new technologies are developed, the best approach to manage this condition is evolving. METHODS: We performed a literature review to assess the current state of endovascular aortoiliac reconstruction and aortobifemoral bypass as options for revascularization of aortoiliac occlusive disease. CONCLUSION: Endovascular aortoiliac reconstruction and aortobifemoral bypass are both feasible and clinically effective options for management of aortoiliac occlusive disease. No randomized controlled trial has been performed to show one option to be more effective than the other. Recent literature demonstrates comparable long-term patency, limb salvage and survival among endovascular approaches to the treatment of AIOD with quicker recovery, lower costs and improved quality of life when compared to open aortobifemoral bypass (ABF) surgery. Selection of procedure should be tailored to the individual patient in order to develop an effective long-term successful strategy for management of aortoiliac occlusive disease. Further study is warranted to define durability of these endovascular approaches as well as patient specific characteristics that influence outcomes.

Endovascular reconstruction of aortoiliac occlusive disease in a case with claudication and an ectopic pelvic kidney.

INTRODUCTION AND IMPORTANCE: Ectopic kidney is a rare anomaly with an incidence of about 1 in 2500 birth in the population. Concurrency of pelvic kidney and iliac occlusion is rare, and the treatment is challenging because the pelvic kidney is associated with an atypical blood supply. CASE PRESENTATION: We reported a 68-year-old man with aortoiliac stenosis, right pelvic kidney, and high-risk cardiovascular comorbidities. He presented with the right lower extremity claudication that has been present for four years. Computed tomography angiograms showed total occlusion of right common and external iliac arteries. CLINICAL DISCUSSION: The old method for treating iliac artery stenosis is open surgery, which needs cross-clamping of the aorta. During this procedure, the chance of renal thrombosis and ischemia is high. Thus, the patient underwent an endovascular angioplasty that was done successfully for the patient without any disturbances in kidney function. CONCLUSION: Traditional treatment of iliac artery stenosis, especially in patients with high-risk cardiovascular comorbidities, may be associated with complications. Endovascular intervention is a safe and effective approach for treating aortoiliac occlusion in patients with ectopic pelvic kidneys. More research and case series are needed to review the results and compare the success rate of this method versus open surgery.

Midterm outcomes of the covered endovascular reconstruction of the aortic bifurcation for aortoiliac occlusive disease in a latinoamerican population.

INTRODUCTION: Surgical approach of aortoiliac occlusive disease (AOD) with aorto-bi-femoral graft or endarterectomy, has been the first line treatment with patency rates up to 90%. Nevertheless, this procedure has an early mortality rate of 4%. Vascular complications of aorto-bi-femoral graft have an average incidence of 5-10% and development of incisional hernia in 10% of the cases. The Covered Endovascular Reconstruction of Aortic Bifurcation or CERAB technique, as a new approach is shaping up to be a promising approach. However, there are few studies in Latin America and the Caribbean. MATERIALS AND METHODS: Retrospective multicenter study. All patients treated with the CERAB technique between February 2015 and June 2021 in three hospitals. RESULTS: A total of 9 patients (5 male and 4 female) were treated with the CERAB technique. Only one patient died. Of the total number of patients, 41.2% had a TASC II - C classification, and 58.8% had a TASC II - D classification. Complications included dissection in only 2 patients, massive bleeding in 1 patient and hematoma in 3 patients. The average number of days in critical care was 1.2 days and 2.6 in hospitalization. Two patients required endovascular reintervention. Primary patency was present in 66.7% of the patients. DISCUSSION: The CERAB technique presents a low morbidity and mortality with an 88.9% of technical success rate. None of our patients needed Chimney CERAB procedure. Our results are similar to those reported in the literature, where they report primary patency rates between 82% and 97%.

Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage-A Retrospective Study From Four Neurovascular Centers.

Objective: Dissecting aneurysms (DAs) of the vertebrobasilar territory manifesting with subarachnoid hemorrhage (SAH) are associated with significant morbi-mortality, especially in the case of re-hemorrhage. Sufficient reconstruction of the affected vessel is paramount, in particular, if a dominant vertebral artery (VA) is impacted. Reconstructive options include stent-assisted coiling and flow diversion (FD). The latter is technically less challenging and does not require catheterization of the fragile aneurysm. Our study aims to report a multicentric experience with FD for reconstruction of DA in acute SAH. Materials and Methods: This retrospective study investigated 31 patients (age: 30-78 years, mean 55.5 years) who had suffered from SAH due to a DA of the dominant VA. The patients were treated between 2010 and 2020 in one of the following German neurovascular centers: University Hospital Leipzig, Katharinenhospital Stuttgart, BG Hospital Bergmannstrost Halle/Saale, and Heinrich-Braun-Klinikum Zwickau. Clinical history, imaging, implanted devices, and outcomes were reviewed for the study. Results: Reconstruction with flow-diverting stents was performed in all cases. The p64 was implanted in 14 patients; one of them required an additional balloon-expandable stent to reconstruct severe stenosis in the target segment. One case demanded additional liquid embolization after procedural rupture, and in one case, p64 was combined with a PED. Further 13 patients were treated exclusively with the PED. The p48MW-HPC was used in two patients, one in combination with two additional Silk Vista Baby (SVB). Moreover, one patient was treated with a single SVB, one with a SILK+. Six patients died [Glasgow Outcome Scale (GOS) 1]. Causes of death were periprocedural re-hemorrhage, thrombotic occlusion of the main pulmonary artery, and delayed parenchymal hemorrhage. The remaining three patients died in the acute-subacute phase related to the severity of the initial hemorrhage and associated comorbidities. One patient became apallic (GOS 2), whereas two patients had severe disability (GOS 3) and four had moderate disability (GOS 4). Eighteen patients showed a complete recovery (GOS 5). Conclusion: Reconstruction of VA-DA in acute SAH with flow-diverting stents is a promising approach. However, the severity of the condition is reflected by high overall morbi-mortality, even despite technically successful endovascular treatment.

Endovascular Therapy for Central Venous Thrombosis.

Central vein thrombosis is defined as thrombosis of the major vessels draining either the upper or lower extremities. It presents most commonly in the upper limb, where it affects the subclavian veins and the superior vena cava; in the lower limb, it affects the common iliac veins and the inferior vena cava. These different anatomical segments pose unique challenges in both acute and chronic settings, and this article will summarize the current best practice treatment options.

Endovascular Reconstruction of Extrahepatic Portal Vein in Noncirrhotic and Nonmalignant Chronic Portal Vein Thrombosis Secondary to an Iatrogenic Stenotic Lesion.

Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm × 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.

Percutaneous endovascular reconstruction with bare stent implantation for isolated superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated superior mesenteric artery dissection (ISMAD) is exceedingly rare. The therapeutic options range from observation to medical treatment to surgery or endovascular repair. We present our experience of the clinical management of ISMADs. METHODS: Sixteen patients with ISMAD from January 2008 to July 2012 were retrospectively analyzed. The decision to intervene was based on anatomic suitability, patient comorbidities, and symptoms. Percutaneous endovascular reconstruction with bare stents was carried out in 7 patients in this study, for patients with persistent abdominal pain despite conservative treatment or signs of bowel ischemia. The patients were kept on antiplatelet therapy from 6 to 10 months postoperatively. RESULTS: All attempted bare stent placements were successfully accomplished without any treatment-related complication. Of the 7 patients with ISMADs, 4 were treated by single stents, 2 by double overlapping stents, and 1 by triple overlapping stents. The abdominal pain alleviated after procedure and disappeared gradually within 3 days. None of the patients had ISMAD symptoms during follow-up (median, 21.7 months; range, 11-32 months). Follow-up computed tomography (CT) and CT angiography revealed patent stent and patent superior mesenteric artery (SMA) branches with complete obliteration of the dissection. CONCLUSION: Isolated SMA dissection may be managed successfully in a variety of ways based on the clinical symptoms. In this small series, percutaneous endovascular reconstruction with bare stent implantation is a feasible treatment choice with a high success rate and good clinical outcome.

Management of isolated superior mesenteric artery dissection.

AIM: To evaluate our experience of the clinical management of spontaneous isolated superior mesenteric artery dissection (ISMAD). METHODS: From January 2008 to July 2013, 18 patients with ISMAD were retrospectively analyzed, including 7 patients who received conservative therapy, 9 patients who received reconstruction with bare stents, and 2 patients who underwent surgical treatment. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms. RESULTS: Intestinal ischemia-related symptoms completely resolved in 7 patients who received conservative therapy. Stent placement was successful in 9 patients. Of the 9 patients who received endovascular stenting, abdominal pain was alleviated after the procedure and gradually disappeared within 3 d. Follow-up computed tomography and computed tomography angiography were available in all patients during the first month and the first year after the procedure, which revealed patent stent and patent involved superior mesenteric artery branches with complete obliteration of the dissection lesion. In the 2 patients who underwent surgical treatment, good clinical efficacy was also observed. CONCLUSION: ISMAD may be managed successfully in a variety of ways based on the clinical symptoms. ISMAD should be treated by conservative management as the first-line option, however, in those with bowel necrosis or imminent arterial rupture during conservative therapy, endovascular or surgical therapy is indicated.