Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation.

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent Graft.

OBJECTIVE: The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft. METHODS: A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter. RESULTS: A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted. CONCLUSIONS: This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms.

Ascending Aorta Endovascular Repair of a Symptomatic Penetrating Atherosclerotic Ulcer with a Custom-Made Endograft.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become lately the procedure of choice in the treatment of most pathologies of descending thoracic aorta. Aortic arch aneurysms also came to be treated by TEVAR with various hybrid techniques or custom-made scalloped/fenestrated stent grafts. Zone 0; ascending TEVAR is more challenging than TEVAR of the descending thoracic aorta or aortic arch because of the more complex pathology, hemodynamics, and anatomy. Ascending TEVAR can be a lifesaving treatment in selected high surgical risk patients. CASE REPORT: A 71-year-old male with known history of respiratory insufficiency, coronary artery disease, and low left ventricle ejection fraction, presented to emergency department with acute thoracic pain. As the initial laboratory tests and the electrocardiogram were negative for acute coronary syndrome, a computed tomography (CT) scan was performed that showed a 20 mm large and 17 mm depth penetrating atherosclerotic ulcer (PAU) in the middle portion of ascending thoracic aorta. After medical therapy administration, the thoracic pain was controlled, and due to the high surgical risk of the patient, high incidence of aortic rupture due to PAU, and favorable anatomic conditions was scheduled the implantation of a custom-made (due to short ascending aorta) stent graft (Bolton, Relay Plus). A pacemaker was implanted 1 week before the operation to induce rapid ventricular pacing during the stent-graft deployment. During the operation, the patient was under general anesthesia as it was our first case treated in this way. The delivery of the graft was achieved through a right femoral artery cut open by an extra-stiff guide wire (Lunderquist Cook) that was placed through an angio-catheter into the left ventricle of the heart. The final positioning and deployment of the graft was achieved under rapid ventricular pacing, and the final angiogram after the withdraw of the graft delivery system showed exclusion from circulation of PAU, patency of coronary arteries, and brachiocephalic trunk with competent aortic valve. CONCLUSIONS: TEVAR of the ascending aorta is a safe and feasible technique indicated mainly unfit for open surgery patients.

Contrast-enhanced ultrasound performed under urgent conditions. Indications, review of the technique, clinical examples and limitations.

Contrast-enhanced ultrasound (CEUS) is an imaging technique with various indications, most of which refer to scheduled examinations. However, CEUS can also be performed under urgent conditions for the investigation of many different clinical questions. This article reviews basic physics of ultrasound contrast agents and examines the commonest urgent clinical applications of CEUS. These include, among others, abdominal solid organ trauma and infarcts, scrotal and penile pathology and blood vessel imaging. Patients can be examined with a very short time delay at their bedside, without exposure to ionising radiation or risk of anaphylactic reaction and renal failure, while contraindications are minimal. CEUS technique is described for various urgent indications and imaging examples from our department's experience are presented. Safety matters and limitations of CEUS are also mentioned. Teaching Points • Contrast-enhanced ultrasound (CEUS) can be performed urgently for various clinical applications. • Abdominal indications include solid organ trauma and infarcts. • CEUS in abdominal organ trauma correlates well with CT and can replace it for patient follow-up. • CEUS images testicular torsion, infection and infarction, as well as testicular and penile trauma. • Blood vessels can be assessed with CEUS for obstruction, aneurysm, thrombosis and dissection.