The influence of narrow aortic bifurcation on limb graft patency: a two-center retrospective study.

BACKGROUND: Narrow aortic bifurcation (NAB) has been considered as a potential risk factor for graft limb thrombosis after endovascular aortic repair (EVAR). The aim of this study was to compare mid- and long-term outcome of EVAR in patients with NAB and standard aortic bifurcation (SAB). METHODS: Data from patients receiving EVAR were prospectively collected and retrospectively analyzed. In case of angiographic limb stenosis (>50%), additional stenting was performed. Patients with a NAB (≤20mm) were included in the NAB group, the remaining patients in the SAB group. Primary endpoints were limb thrombosis rate and technical success. RESULTS: A total of 902 patients were included; 18.3% (N.=165/902) in the NAB and 81.7% (N.=737/902) in the SAB group. Mean follow-up time was 43 months (range 0-198 months). Bilateral stenting of the aortic bifurcation was performed in 2.7% (N.=27/902), 8.5% (N.=14/165) in the NAB and 1.4% (N.=10/737) in the SAB group (P=0.001). Limb thrombosis was found in 2.8% (N.=25/902), 3.6% (N.=6/165) in the NAB and 2.6% (N.=19/737) in the SAB group (P=0.55). Technical success was 97.8%, 98.8% in the NAB and 97.6% in the SAB group (P=0.33). Device related reintervention rate was 16% (N.=144/902), 15.2% in the NAB and 16.1% in the SAB group (P=0.75). CONCLUSIONS: Standard EVAR could safely be performed in patients with NAB (≤20mm) when a low threshold for additional stenting was applied. This resulted in no significant higher incidence of limb thrombosis. Additional stent deployment did not increase the complication rate.

Treatment of ruptured subclavian steal flow-related vertebrobasilar junction aneurysms: Case report on surgical and endovascular considerations from two cases.

INTRODUCTION: Subclavian steal phenomenon causes retrograde flow through the vertebral artery, ipsilateral to the affected subclavian artery, which rarely leads to flow-related vertebrobasilar junction (VBJ) aneurysms. CASE DESCRIPTIONS: We describe two cases of subarachnoid hemorrhage from such ruptured aneurysms in which the retrograde flow direction in the vertebral artery complicated surgical and endovascular treatment. DISCUSSION: Reversed flow in the vertebral artery, ipsilateral to the stenotic subclavian artery leads to a lack of proximal control in surgical clipping of these VBJ aneurysms and jeopardizes stability of coil and stent placement in endovascular aneurysm treatments in this setting. CONCLUSION: From these 2 experiences over 7 years, treatment considerations emerged for future cases.

The impact of type 1a endoleak on the long-term outcome after EVAR.

OBJECTIVE: Endoleaks remains a major determinant of outcome after endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysms. The objective of this study is to evaluate the long-term impact of proximal type 1 endoleak encountered at the case end of the EVAR procedure or during follow-up. METHODS: All patients treated with EVAR between February 2001 and August 2017 in our institution were included. Data were collected retrospectively. A descriptive analysis of subgroups with type 1a endoleak at case end or with type 1a endoleak first encountered during follow-up was performed. RESULTS: In total, 468 patients were included for analysis. At the case end of the EVAR procedure, in 5.3% (25/468) of patients, a type 1a endoleak was seen. In 72% of cases (18/25) the type 1a endoleak spontaneously disappeared on the first follow-up computed tomography angiography and never recurred. At the end of the follow-up period, no patient in this subgroup died with a type 1a endoleak on follow-up. In 3.4% (16/468) of all cases, a type 1a endoleak was encountered for the first time during follow-up. In 87.5% (14/16) of these cases, reintervention was performed. Two patients died with a persisting type 1a endoleak during follow-up. CONCLUSIONS: Clinicians should differentiate between the type 1a endoleak at the case end and the type 1a endoleak first occurring during follow-up. For type 1a endoleak at the case end, expectant management can be adopted. Delayed type 1a endoleak seen during follow-up rarely seals spontaneously and needs reintervention in the majority of cases.

Predictive Factors of Operative Need in Medically Managed Type B Aortic Dissections.

BACKGROUND: Aneurysmal degeneration of medically managed type B aortic dissection (TBAD) can be a life-threatening condition. Preventive thoracic endovascular aorta repair (TEVAR) in patients at risk could potentially be beneficial. The aim of this study was to examine the predictors for late aneurysmal dilatation after TBAD. METHODS: A retrospective study was conducted on 82 patients with medically managed acute TBAD for a minimum of 14 days. Relevant demographic, biochemical, and radiographic variables at presentation were studied. The aortic dissection risk calculator tool developed by Sailer et al., predicting the risk of adverse events after aortic dissection based on demographic and radiographic variables at presentation, was tested retrospectively. RESULTS: With a median follow-up of 36 months (range 13-68), 25 (30.5%) patients underwent surgery (92% TEVAR). A larger initial aortic and false lumen diameter as well as a greater distal extension of the dissection was associated with higher need for surgery (respectively, P = 0.003, P = 0.004, and P = 0.001). We observed higher growth rates of maximum aortic diameter in patients with a greater distal extension of the dissection, larger false lumen diameters and false lumen outflow, and entry tears located at the inner aortic arch (respectively, P = 0.001, P = 0.005, P = 0.001 and P = 0.014). No significant correlations could be found for the risks provided by the calculator tool. CONCLUSIONS: The initial maximum aortic diameter of TBAD is a key predictor for aortic growth. Furthermore, the distal extension of the dissection also seems to play an important role in late aneurysmal degeneration. However, we were not able to confirm the added value of the risk calculator tool in our study group.

Late hematogenous seeding and infection of a femoropopliteal Omniflow II bypass.

INTRODUCTION: Omniflow II is promoted as an infection-resistant vascular graft. It is used to treat vascular graft infection; nevertheless, early graft infection has been reported.Report: A 71-year-old patient was treated with an Omniflow II bypass for a non-healing diabetic foot ulcer. Seven months postoperatively, late infection occurred secondary to hematogenous spread from a persistent foot infection. CONCLUSION: We report on the first case of late infection of an Omniflow II vascular graft caused by hematogenous spread. Despite promising results of the Omniflow II graft in the treatment of vascular graft infection, late infection may not be avoided.

Mid- to Long-Term Outcome Results of the Ovation Stent Graft.

BACKGROUND: To report mid-term to long-term outcome data for endovascular aortic repair using the Ovation stent-graft system (Endologix, Santa Rosa, CA) in a single university center. METHODS: All patients treated with the Ovation stent graft between February 2012 and January 2019 were included. Patient demographics, anatomical and operative details, as well as follow-up data including complications, need for further interventions, and mortality were analyzed. RESULTS: A total of 74 patients (93% males; mean age, 74.5 years) were treated with the Ovation stent graft. The median maximal aortic diameter was 60 mm (range, 36-100). Sixty-two of 74 patients (83.8%) were considered to have a hostile neck. About 33% had a (reversed) conical neck, 59% had circumferential neck calcification (>50%), and 39% had significant neck thrombus (>50%). Technical success rate was 91.89%. Despite additional measures, 4 patients had a persistent type Ia endoleak on completion angiography, of which 3 disappeared on the first postoperative computed tomography angiography. Mean follow-up duration was 31.62 months ± 21.3 (range, 0-72.74 months). Twenty-four patients had a follow-up time of at least 36 months. Freedom from reintervention at 1, 2, 3, and 5 years was 92.7%, 90.8%, 80.1%, and 80.1%, respectively. Estimated freedom from mortality at 1, 2, 3, and 5 years was 96.8%, 95.0%, 87.3%, and 68.5%, respectively. No late type Ia or type III endoleak was detected during follow-up. No aneurysm-related mortality was seen. CONCLUSIONS: Our mid- to long-term experience with the Ovation stent-graft system demonstrates safe and durable results without late type Ia or type III endoleak.

Conservative treatment of non-aneurysmal infectious aortitis: a case report and review of the literature.

BACKGROUND:  Non-aneurysmal infectious aortitis is a rare clinical entity with most often lethal complications when surgical intervention is delayed. OBJECTIVES:  This report describes the case of a non-aneurysmal infectious aortitis complicated with a penetrating aortic ulcer in an elderly woman, caused by a methicillin-sensitive Staphylococcus aureus. Surgery was deemed contra-indicated and treatment was limited to the administration of intravenous vancomycin (2 grams daily), followed by flucloxacillin (6 times 2 grams daily). She remains well after one year. METHODS: The Internet databases Medline and Embase were searched. Articles were selected based on relevanceof abstract, article type and impact of the journal. RESULTS:  A literature review addresses current insights in the pathogenesis, diagnosis, and treatment of non-aneurysmal infectious aortitis.

Endovascular Treatment of Isolated Degenerative Superficial Femoral Artery Aneurysm.

Isolated degenerative superficial femoral artery (SFA) aneurysms are rare. One hundred forty-two cases are described in literature. Threshold for operative management varies in literature. In literature, only 10 cases are treated in an endovascular way. We present a case of a 77-year-old patient who presented with nonhealing wounds on the right foot. Duplex ultrasound revealed an isolated aneurysm of the SFA on the right side as a source of emboli. The patient was treated in an endovascular way with a covered stent graft. The procedure was complicated by embolization in the peroneal artery as a single outflow vessel. An overview of endovascular treatment of SFA aneurysms in literature is discussed.

A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges.

BACKGROUNDS: Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity. CASE REPORT: A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding. CONCLUSIONS: Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.

A ruptured omental aneurysm, a rare cause of intraabdominal bleeding.

Of all splanchnic artery aneurysms, the omental artery aneurysm is the most uncommon. In the published literature, there is no report of an incidental diagnosis, and all were discovered only after rupture. Until now, this is only the sixth case of a ruptured omental aneurysm published, and the first case with a concomitant nonruptured omental aneurysm.

Thoracic endovascular aortic repair for treatment of late complications after aortic coarctation repair.

BACKGROUND: To report our experience with thoracic endovascular aortic repair (TEVAR) for treatment of postcoarctation repair aortic aneurysms. METHODS: Between November 2000 and December 2008, 13 patients were treated with TEVAR and rerouting of the supra-aortic vessels for aortic aneurysm (n = 10) and pseudoaneurysm (n = 3). RESULTS: One patient (7.7%) died due to peroperative perforation of the aorta. For the other patients, the median hospital stay was 9 days. One patient needed an additional stent because of a type I endoleak. Two patients (15.4%) developed a small type II endoleak for which no additional intervention was needed. One patient developed hemothorax, four patients (30.8%) had a Horner syndrome, one patient had a phrenic nerve paresis, and another patient developed hemiplegia. The mean follow-up of the survivors was 35 months (range, 2-72) with a median of 30 months. Most patients (84.6%) showed a decrease or stabilization of the size of the aneurysm sac. One patient had recurrent pneumonia with increase of the size aneurysm after 3 years. CONCLUSIONS: TEVAR is appealing for patients with late complications after aortic coarctation repair, but necessitates long-term follow-up.

Long-term results after endovascular abdominal aortic aneurysm repair using the Cook Zenith endograft.

OBJECTIVE: This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). METHODS: Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. RESULTS: Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. CONCLUSION: Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

Transcatheter embolization of a type II endoleak after hybrid repair for thoracoabdominal aortic aneurysm.

Hybrid stent-graft procedures with visceral revascularization have been reported as an alternative treatment option for thoracoabdominal aortic aneurysms (TAAAs), although the potential advantages of reduced morbidity and mortality compared with open surgical repair have not been definitively demonstrated. Endovascular aneurysm repair is associated with endoleaks in as many as 20% of cases in some series, often requiring repeat intervention. In the present case, during follow-up after a hybrid TAAA repair, a patient developed a type II endoleak originating from a celiac artery that was not ligated at its origin. The endoleak was successfully treated by transcatheter coil embolization.

Esophageal necrosis after endoprosthesis for ruptured thoracoabdominal aneurysm type I: can long-segment stent grafting of the thoracoabdominal aorta induce transmural necrosis?

BACKGROUND: To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. METHOD: A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patient's family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. CONCLUSION: Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Paraparesis after thoracic stent-graft relining for an unrecognized type III endoleak.

BACKGROUND: We examined the reasons for missing a type III endoleak on conventional imaging and the pathophysiology of paraparesis after relining this stent graft. METHODS AND RESULTS: A 46-year-old man was treated with a thoracic stent graft for thoracic rupture of a chronic type B thoracoabdominal dissection with aneurysm formation. In a second intervention, retrograde revascularization of the visceral and renal arteries was performed in combination with insertion of an abdominal stent graft. After initial shrinkage of the aneurysmal sac, the thoracic aortic diameter started increasing again. Consecutive three-phase helical computed tomographic scans did not reveal any endoleak. Because of unbearable back pain, an open surgical exploration was performed. This showed a type III endoleak. Relining of the thoracic stent graft was performed, but paraparesis developed. CONCLUSION: In patients with unexplained increase of the aneurysmal sac contrast-enhanced magnetic resonance imaging could help to illuminate the underlying endoleak. The collateral network concept can explain spinal cord injury by even minor hemodynamic changes.

Endovascular treatment of an iliocaval arteriovenous fistula presenting with multiple organ failure.

Iliocaval arteriovenous fistula is an uncommon, but challenging condition. The most common cause is spontaneous rupture of the iliac artery into the venous system due to aneurismal dilatation. We report a case of iliocaval fistula after previous aortic surgery presenting as acute liver failure as most prominent part of multiple organ failure and successful endovascular repair.

Nitinol stent implantation in long superficial femoral artery lesions: 12-month results of the DURABILITY I study.

PURPOSE: To evaluate the long-term efficacy and integrity of the PROTEGE EverFlex stent in superficial femoral artery (SFA) lesions in symptomatic patients with peripheral artery disease (PAD). METHODS: A prospective, multicenter, nonrandomized study enrolled 151 subjects (111 men; mean age 67.8 years, range 42-93) undergoing percutaneous treatment of de novo, restenotic, or reoccluded SFA lesions between August 11, 2006, and June 26, 2007. Subjects were scheduled to receive a single stent and be evaluated through 12 months following the implant procedure. Occlusions were present in 40% of the patients. Mean lesion length was 96.4 mm (range 10-150). RESULTS: A total of 161 stents (158 EverFlex) were implanted in the 151 patients: single stents in 93.4% (141/151) and a second stent in 6.6% (10/151). One-year follow-up information was available for 88.7% (134/151) of the study participants; of the remaining 17 subjects, 6 subjects withdrew from the study, 2 were lost to follow-up, and 9 died. Freedom from restenosis data were available for 99.3% (133/134) of the subjects who completed a 12-month follow-up visit. The mean Rutherford classification fell from 2.8+/-0.8 (range 1-5) at baseline to 0.6+/-1.1 (range 0-5) at 12 months. The mean ankle-brachial index rose from 0.6+/-0.2 (range 0-1.4) at baseline to 0.9+/-0.2 (range 0-1.2) at 12 months. The rates for freedom from >50% restenosis at 6 and 12 months were 91.3% (95% CI 84.9% to 95.2%) and 72.2% (95% CI 63.8% to 79.6%), respectively. The freedom from target lesion revascularization rate at 12 months was 79.1% (95% CI 71.2% to 85.6%). The 1-year stent fracture rate was 8.1% (95% CI 4.0% to 14.4%). CONCLUSION: The high freedom from >50% restenosis and low fracture rate at 12 months suggests that the PROTEGE EverFlex stent offers a safe and acceptably efficacious means of treating SFA lesions in symptomatic subjects with PAD.

Heparin-bonded ePTFE grafts compared with vein grafts in femoropopliteal and femorocrural bypasses: 1- and 2-year results.

OBJECTIVE: Many patients with peripheral arterial occlusive disease who require a lower-limb bypass have no available autologous saphenous vein (ASV) for the procedure and thus require a prosthetic graft. Expanded polytetrafluoroethylene (ePTFE) grafts are commonly used, but results with these prostheses have varied, especially when the distal anastomosis is below the knee. However, there is increasing evidence that ePTFE grafts to which heparin has been bound with use of covalent endpoint linkage provide better results. This nonrandomized study compared the performance of these grafts with that of ASV conduits in the largest clinical series of heparin-bonded ePTFE graft implantations reported so far. METHODS: The records of 350 patients who underwent a lower-limb bypass procedure that used either a heparin-bonded ePTFE graft (n = 240) or an ASV graft (n = 110) were reviewed, and preoperative, operative, and follow-up data were recorded. Kaplan-Meier analyses were used to calculate primary patency and limb salvage rates in the two graft groups; results were compared by using log-rank testing. RESULTS: The primary patency rates at 1 year for the heparin-bonded ePTFE grafts were 92% for above-knee femoropopliteal (AK FP) bypasses, 92% for below-knee femoropopliteal (BK FP) bypasses, and 79% for femorocrural (FC) applications. The corresponding 2-year rates were 83%, 83%, and 69%, respectively. In the ASV group, the 1-year primary patency rates for AK FP, BK FP, and FC bypasses were 91%, 72%, and 69%, respectively; the 2-year rates were 80%, 72%, and 64%, respectively. There were no significant differences in patency when AK FP, BK FP, or FC procedures were considered separately. Two-year limb salvage rates in the heparin-bonded ePTFE graft group were 92%, 98%, and 87%, respectively, for AK FP, BK FP, and FC bypasses; in the ASV group, the rates were 100%, 91%, and 96%, respectively. Two infections occurred in patients given a heparin-bonded ePTFE graft. CONCLUSION: In this large retrospective study, heparin-bonded ePTFE grafts had 1- and 2-year primary patency results that were not significantly different from those for ASV grafts. Results in BK FP and FC applications were especially promising. Randomized studies comparing the use of heparin-bonded ePTFE and ASV grafts in the treatment of peripheral arterial disease are needed to substantiate our results.

The role of thrombolysis in acute infrainguinal bypass occlusion: a prospective nonrandomized controlled study.

Current treatment of acute infrainguinal bypass occlusion consists of either surgical revascularization or catheter-guided intra-arterial thrombolysis with adjunctive correction of the underlying flow-limiting lesion. In maintaining long-term patency, improving the number of outflow vessels could be of utmost importance. To compare the efficiency of both thrombolysis and primary surgical revascularization and to study the effect of thrombolysis on the number of patent outflow vessels, a prospective nonrandomized study was performed. Between February 2002 and August 2003, 54 patients with 56 occluded bypasses were included. Thirty bypasses were treated with thrombolysis, 26 primarily with surgery. Thrombolysis was successful in 80% of cases, with restoration of patency of the bypass but also with doubling of the amount of patent outflow vessels; surgery was successful in 85.71% of cases. However, in only 60% of the successfully lysed bypasses no adjunctive major surgery was needed. Amputation-free survival was 87.5% 1 year after surgery and 82.6% 1 year after thrombolysis. One year after thrombolysis without adjunctive major surgery, the amputation-free survival was only 39.7%. Therefore, a strategy could be to start with thrombolysis to improve outflow followed by a new bypass, whatever the underlying causative lesions are.