Anesthetic, Sedation, and Analgesic Technique for Successful Local Anesthetic EndoSuture Aneurysm Repair.

Purpose: We aimed to describe our technique for and experience with elective endovascular aneurysm repair using EndoAnchors under local anesthesia. Materials and Methods: We included seven patients with abdominal aortic aneurysms who underwent endovascular aneurysm repair using EndoAnchors with a standard regimen consisting of local anesthesia, intravenous sedation, and analgesia. The procedural and follow-up details were retrospectively reviewed. Results: Six out of seven infrarenal abdominal aortic aneurysms were successfully treated with endovascular aneurysm repair using primary EndoAnchors under local anesthesia. One patient was converted to general anesthesia due to acute aneurysm thrombosis independent of EndoAnchor deployment during the procedure. Remifentanyl infusions of up to 3.2 mg/min, morphine doses up to 6 mg (median, 0.5 mg), and midazolam doses of up to 4 mg (mean, 1.4 mg) were used. The mean theater time was 83 minutes (range, 60-130 minutes). Two patients were discharged on day 0, and the mean hospital stay was one day. All patients were alive between 484 and 1,128 days post-procedure, with no aneurysm-specific reintervention. Conclusion: The combination of local anesthesia, intravenous sedation, and analgesia is a viable strategy for timely and effective endovascular aneurysm repair using EndoAnchors. This technique may allow endovascular repair of more ruptured aneurysms using EndoAnchors with potential survival benefits.

Fate of Asymptomatic Limb after Kissing Stents in Aortoiliac Occlusive Disease.

Purpose: Kissing stent angioplasty is an established endovascular treatment strategy for stenosis at the aortic bifurcation but not without its detractors. This study aimed to analyze the outcomes of kissing stents with regard to stent occlusion and complications in which an asymptomatic limb was treated. Materials and Methods: A total of 106 patients undergoing aortic bifurcation intervention from January 2015 to November 2020 were retrospectively reviewed. Only patients with at least one common iliac artery (CIA) ostium and undergoing bilateral CIA intervention were included in the study. Results: Patients were followed up for a median period of 26 months (interquartile range, 21-51 months). The TransAtlantic InterSociety Consensus (TASC)-II classification of lesions was as follows: A, 49%; B, 41%; C, 6%; and D, 5%. The treatment indication was limited to one side in 53% of patients. Technical and procedural success rates were 99% and 90%, respectively. Ischemic events in an asymptomatic limb occurred in 6% of cases, 3% due to late stent thrombosis >30 days, and 3% due to progression of downstream infrainguinal disease. Primary and secondary patency rates at 1, 3, and 5 years were 98%, 87%, and 85%, and 99%, 94%, and 94%, respectively. Periprocedural mortality developed in two patients with no amputation. Conclusion: Kissing stent deployment is a safe and effective strategy for the treatment of aortoiliac bifurcation disease. Unfavorable outcomes due to stenting in the asymptomatic iliac artery are very rare. Long-term surveillance is necessary due to the risk of late thrombosis or downstream disease progression.

Endovascular salvage of an aortic anastomotic pseudoaneurysm following deep vein reconstruction.

Aortoiliac reconstruction using autologous deep femoral vein (neoaortic iliac system bypass [NAIS]) is a therapeutic option for management of prosthetic aortic graft infection. Complications after NAIS are complex and reported management strategies few. Endovascular procedures offer a minimally invasive alternative to high-risk, complex open surgery. We report a case of early aortic anastomotic failure after NAIS associated with a pseudoaneurysm and significant retroperitoneal hemorrhage, which was successfully treated by endovascular stent grafting.

Thrombolysis for acute graft occlusion during elective endovascular aortic aneurysm repair.

A 65-year-old man developed acute arterial thrombosis with stent graft occlusion, during elective endovascular aneurysm repair, with bilateral acute lower limb ischaemia. We describe successful endovascular and pharmacological management using a combination of mechanical disruption of the thrombus (using the access sheaths) followed by intra-arterial thrombolysis (Actilyse) infusion. Within 4-h the endograft had completely re-canalized. The patient made an uncomplicated recovery and was discharged on the second post-operative day.

Ferumoxytol magnetic resonance angiography: a dose-finding study in patients with chronic kidney disease.

OBJECTIVES: Ferumoxytol is an alternative to gadolinium-based compounds as a vascular contrast agent for magnetic resonance angiography (MRA), particularly for patients with chronic kidney disease (CKD). However, dose-related efficacy data are lacking. We aimed to determine the optimal (minimum effective) dose of ferumoxytol for MRA in patients with CKD. METHODS: Ferumoxytol-enhanced MRA (FeMRA) was performed at 3.0 T in patients with CKD after dose increments up to a total of 4 mg/kg. Image quality was assessed by contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) in the abdominal aorta and inferior vena cava. Quadratic regression analyses were performed to estimate the effects of dose increments on CNR and SNR. RESULTS: Twenty-three patients underwent FeMRA (mean age 60 [SD 13] years, 87% men, 48% had diabetic nephropathy) with cumulative doses of 0, 1, 2, 3 and 4 mg/kg of ferumoxytol. On regression analyses, a parabolic relationship was observed between ferumoxytol dose and signal with progressive signal loss using doses exceeding 4 mg/kg. A dose of 3 mg/kg achieved ≥ 75% of predicted peak CNR and SNR and images were deemed of excellent diagnostic quality. CONCLUSIONS: In patients with CKD undergoing FeMRA, a dose of 3 mg/kg provides excellent arterial and venous enhancement. The benefits of increasing the dose to a theoretically optimal value of 4 mg/kg appear to be negligible and likely of minimal, if any, diagnostic value. KEY POINTS: • Ferumoxytol is used off-label as an MRI contrast agent but dose-related data are lacking. • In patients with CKD requiring MR angiography, a dose of 3 mg/kg provides excellent vascular enhancement.

Ferumoxytol-enhanced magnetic resonance angiography for the assessment of potential kidney transplant recipients.

OBJECTIVES: Traditional contrast-enhanced methods for scanning blood vessels using magnetic resonance imaging (MRI) or CT carry potential risks for patients with advanced kidney disease. Ferumoxytol is a superparamagnetic iron oxide nanoparticle preparation that has potential as an MRI contrast agent in assessing the vasculature. METHODS: Twenty patients with advanced kidney disease requiring aorto-iliac vascular imaging as part of pre-operative kidney transplant candidacy assessment underwent ferumoxytol-enhanced magnetic resonance angiography (FeMRA) between December 2015 and August 2016. All scans were performed for clinical indications where standard imaging techniques were deemed potentially harmful or inconclusive. Image quality was evaluated for both arterial and venous compartments. RESULTS: First-pass and steady-state FeMRA using incremental doses of up to 4 mg/kg body weight of ferumoxytol as intravenous contrast agent for vascular enhancement was performed. Good arterial and venous enhancements were achieved, and FeMRA was not limited by calcification in assessing the arterial lumen. The scans were diagnostic and all patients completed their studies without adverse events. CONCLUSIONS: Our preliminary experience supports the feasibility and utility of FeMRA for vascular imaging in patients with advanced kidney disease due for transplant listing, which has the advantages of obtaining both arteriography and venography using a single test without nephrotoxicity. KEY POINTS: • Evaluation of vascular disease is important in planning kidney transplantation. • Standard vascular imaging methods are often problematic in kidney disease patients. • FeMRA has the advantage of arteriography and venography in a single test. • FeMRA is safe and non-nephrotoxic. • FeMRA is not limited by arterial calcification.