Delayed Leucoencephalopathy as a Complication after Endovascular Therapy of Intracranial Aneurysms-A Case Series.

We describe the clinical presentation, radiological findings, treatment and outcomes of three patients with delayed leukoencephalopathy occurring after endovascular treatment (EVT) for cerebral aneurysms-a rare, albeit recurring, complication. The symptoms occurred 6 to 12 months following the EVT of the cerebral aneurysm. Characteristic imaging findings included high-signal changes on T2 images in the white matter without diffusion restriction predominantly at the distribution of the vascular territory of the catheterized arteries, coupled with patchy gadolinium enhancement or low susceptibility weighted imaging (SWI) signals within the white-matter lesions. Steroid pulse therapy is the treatment of choice and promptly improves clinical and imaging findings. Tapering or cessation of steroids may result in clinical and imaging relapses; close- and long-term follow-up for patients presenting this complication is warranted.

Resection of an orbital haemangiopericytoma after direct intraoperative injection of 40% N-butyl-2-cyanoacrylate and 60% Lipiodol.

Haemangiopericytoma is a highly vascular tumour, which is a rare soft tissue lesion that may arise anywhere in the body, including the orbit. During its surgical resection, it is too friable for the surgeon to handle and it can bleed severely causing many problems to the surgeon. That is why many surgical approaches have been reported till now, aiming at total excision with minimal blood loss. In this case, total resection of an orbital haemangiopericytoma in a 61-year-old Caucasian woman, using an intraoperative 23G needle injection of 40% n-butyl-2-cyanoacrylate and 60% lipiodol, is presented. The lesion was directly injected under fluoroscopic visualization, after which it became firm enough to be surgically removed without significant bleeding.

Periprocedural to 1-year safety and efficacy outcomes with the Pipeline Embolization Device with Shield technology for intracranial aneurysms: a prospective, post-market, multi-center study.

BACKGROUND: The first and second generations of the Pipeline Embolization Device (PED) have been widely adopted for the treatment of intracranial aneurysms (IAs) due to their high associated occlusion rates and low morbidity and mortality. The objective of this study was to evaluate the safety and effectiveness of the third- generation Pipeline Shield device (PED-Shield) for the treatment of IAs. METHODS: The SHIELD study was a prospective, single-arm, multicenter, post-market, observational study evaluating the PED-Shield device for the treatment of IAs. The primary efficacy endpoint was complete aneurysm occlusion without significant parent artery stenosis or retreatment at 1-year post-procedure and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurological death. RESULTS: Of 205 subjects who consented across 21 sites, 204 subjects with 204 target aneurysms were ultimately treated (mean age 54.8±12.81 years, 81.4% [166/204] female). Technical success (ie, deployment of the PED-Shield) was achieved in 98.0% (200/204) of subjects with a mean number of 1.1±0.34 devices per subject and a single device used in 86.8% (177/204) of subjects. The primary effectiveness endpoint was met in 71.7% (143/200) of subjects while the primary safety endpoint occurred in six (2.9%) subjects, two (1.0%) of which led to neurological death. CONCLUSIONS: The findings of the SHIELD study support the safety and effectiveness of the PED-Shield for IA treatment, evidenced by high occlusion rates and low rates of neurological complications in the study population. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02719522.

Vacuum for straightening the microcatheter after intra-aneurysmal looping: The "Lagman vacuum" technique.

In many cases, an intra-arterial microcatheter loop is necessary to bypass the neck of wide-necked giant aneurysms for the placement of a stent across it. The removal of this loop is usually challenging, and many techniques have been described to achieve it. We describe a simple novel technique for straightening the microcatheter across the aneurysm's neck, without the need for additional products/devices or complex exchanging techniques. The method has been successfully applied in two cases. We named this novel maneuver the "Lagman vacuum" technique.

Treatment of intracranial aneurysms using the pipeline flex embolization device with shield technology: angiographic and safety outcomes at 1-year follow-up.

PURPOSE: The Pipeline Embolization Device (PED) is a routine first-line treatment option for intracranial aneurysms (IAs). The Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is an updated version of the PED which has been modified to include a surface phosphorylcholine biocompatible polymer. Its early technical success and safety have been reported previously. Here, we assessed the long-term safety and efficacy of the Pipeline Shield for the treatment of IAs. MATERIALS AND METHODS: The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study was a prospective, single-arm, multicenter study for the treatment of unruptured IAs using the Pipeline Shield. The primary endpoint was a major stroke in the territory supplied by the treated artery or neurologic death at 1-year post-procedure. Angiographic outcomes were also assessed by an independent radiology laboratory at 6 months and 1 year. RESULTS: Fifty patients (mean age, 53 years; 82% female) with 50 unruptured IAs were treated. Mean aneurysm diameter was 8.82±6.15 mm. Of the target aneurysms, 38/50 (76%) were small (<10 mm), 11/50 (22%) were large (≥10 and<25 mm), and 1/50 (2%) was giant (≥25 mm). Forty-seven (94%) were located in the internal carotid artery and three (6%) in the vertebral artery. At 1-year post-procedure, no major strokes or neurologic deaths were reported, and complete occlusion was achieved in 27/33 (81.8%). There were no instances of aneurysm recurrence or retreatment. CONCLUSIONS: Our 1-year follow-up concerning angiographic and safety outcomes corroborate previous evidence that the Pipeline Shield is a safe and effective treatment for IAs. TRIAL REGISTRATION NUMBER: NCT02390037.

Periprocedural outcomes and early safety with the use of the Pipeline Flex Embolization Device with Shield Technology for unruptured intracranial aneurysms: preliminary results from a prospective clinical study.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device (PED) has become a routine first-line option for treatment of intracranial aneurysms (IAs). We assessed the early safety and technical success of a new version of PED, Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield), which has the same design and configuration but has been modified to include a surface synthetic biocompatible polymer. MATERIALS AND METHODS: The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study is a prospective, single-arm, multicenter study for the treatment of unruptured IAs using Pipeline Shield. The primary study endpoints included the occurrence of major stroke in the territory supplied by the treated artery or neurologic death at 1 year post-procedure. Secondary endpoints included the rate of Pipeline Shield-related or procedure-related serious or non-serious adverse events. Analyses were conducted to evaluate early safety findings in the 30-day post-procedure period as well as technical procedural success outcomes. RESULTS: Fifty patients with 50 unruptured target IAs were enrolled. Mean aneurysm diameter was 8.82±6.15 mm. Thirty-eight aneurysms (76%) were small (<10 mm). Device deployment was technically successful with 98% of devices. Complete wall apposition was achieved immediately post-procedure in 48 cases (96%). No major strokes or neurologic deaths were reported in the 30-day post-procedure period. CONCLUSIONS: The results of this first experience with the new Pipeline Flex corroborate the early safety of the device. Mid-term and long-term follow-up examinations will provide data on safety outcomes at the 6-month and 1-year follow-up periods. CLINICAL TRIAL REGISTRATION: NCT02390037.

Thoracic Aortic Injury: Embolization of the Tenth Intercostal Artery and Endovascular Treatment in a Young Woman after Posterior Spinal Instrumentation.

Iatrogenic aortic injuries are rare and well-recognized complications of a variety of procedures, including spinal surgery. The placement of pedicle screws is sometimes associated with devastating consequences. Aortic perforation with rapid hematoma formation and delayed aortic trauma leading to pseudoaneurysm formation have been described in the literature. A case describing a significant time interval between iatrogenic aortic injury and diagnosis in the absence of pseudoaneurysm formation is described in this paper and, according to our knowledge, is unique in the literature. The aortic injury was successfully treated, selecting the appropriate graft and, as a consequence, normal spinal cord blood flow was achieved.

Primary endoanchoring in the endovascular repair of abdominal aortic aneurysms with an unfavorable neck.

PURPOSE: To investigate the feasibility and early results of endoanchoring (endostapling) using a new commercially available device as an adjunctive procedure during endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with an unfavorable proximal neck. METHODS: Between June 2010 and May 2012, 13 consecutive patients (all men; median age 73 years, range 62-82) were prospectively enrolled in a 2-center registry to follow outcomes of adjunctive primary endoanchoring (Aptus HeliFX Aortic Securement System) of the proximal endograft to enhance proximal graft fixation and sealing during EVAR. Indications for proximal neck endoanchoring included at least one of the following: neck angulation 45° to 90°, length 8 to 15 mm, diameter 29 to 33 mm, conical neck configuration, or an irregularly shaped neck. The median AAA diameter was 56 mm (range 50-98). The Endurant stent-graft was implanted in 4 patients and the Zenith device in 9. RESULTS: A median of 4 endoanchors were implanted per patient (range 3-10) in adjunctive procedures that required a median 12 minutes (range 7-20). Intraoperatively, 2 proximal type I endoleaks were present following endoanchor implantation (85% primary technical success); a cuff was deployed in 1 case, which successfully sealed the endoleak (92% assisted primary technical success). The second proximal type I endoleak was minute and sealed spontaneously within 30 days. No further major device-related complications occurred intraoperatively. In the 30-day perioperative period, the only procedure-related complications were 2 type II endoleaks, which required no intervention. Over a median follow-up of 7 months (range 2-17), no further complications occurred apart from an asymptomatic internal iliac artery occlusion and a non-lethal myocardial infarction at 9 months. The type II endoleaks spontaneously sealed. No endograft migration was noticed nor loss of endoanchor integrity. No deaths occurred throughout follow-up. CONCLUSION: Primary endoanchoring using the HeliFX aortic securement system is feasible, and early results were promising in this series.

Percutaneous endovascular treatment of aortic aneurysms: clinical evaluation and literature results.

In this study we aimed to evaluate the efficiency of percutaneous endovascular aortic aneurysm repair (p-EVAR). Anatomically selected patients treated with a single 10Fr Perclose Prostar XL vascular closure device (VCD) were examined. Primary success rate and common femoral artery (CFA) open conversion (OC) requirement per sheath size used were recorded. A literature review on p-EVAR results was also performed. One-hundred patients were enrolled. Successful p-EVAR was achieved in 183 of the 196 CFA access sites (93.4%), and was specifically 85.9% and 98.3% for sheaths ≥20Fr and ≤18Fr respectively. There were 13 periprocedural complications (bleeding = 10, arterial dissection and thrombosis = 1, pseudoaneurysm = 2) all leading to OC. Use of ≥20Fr sheaths had significantly higher OC rate (P < .05). Reconstruction was achieved with primary repair (N = 11) and patch angioplasty (N = 2). Mean hospital stay was 1.8 days. The literature review (vascular closure of 2921 CFA access sites) revealed an overall technical success rate of 92.3%. Device related- were more common than patient related-OCs (P < .05). p-EVAR procedures are safe and feasible. Sheath size is a significant predictor of OC rate and more OCs might be expected with very large (≥20Fr) sheath sizes.

The Aorfix stent-graft to treat infrarenal abdominal aortic aneurysms with angulated necks and/or tortuous iliac arteries: midterm results.

PURPOSE: To present performance data on the use of the Aorfix stent-graft in patients with hostile infrarenal abdominal aortic aneurysm (AAA) anatomy. METHODS: A study protocol was designed to examine the safety and efficacy of the Aorfix endovascular stent-graft in AAA patients who had a proximal neck diameter between 18 and 30 mm, neck angulation between 60 degrees and 90 degrees , and/or severe iliac artery angulation/tortuosity. Between September 2005 and April 2009, 20 men (mean age 72.4+/-7.7 years, range 55-89) were enrolled in the study. The mean AAA diameter was 61.8+/-14.9 mm (range 45.5-102). The mean angulation of the proximal neck was 61.9 degrees +/-16.5 degrees (range 30 degrees -90 degrees ); in the iliac arteries, the angulation was 59.9 degrees +/-16.3 degrees (range 30 degrees -85 degrees ) for the left and 60.9 degrees +/-17.6 degrees (range 28 degrees -90 degrees ) on the right. Fourteen (70%) patients had >60 degrees proximal neck angulation. Outcome measures were analyzed using life-table analysis. RESULTS: The graft was successfully implanted in all but 1 patient (technical success 95%); failure to cannulate the contralateral iliac limb resulted in conversion to aortomonoiliac stent-graft placement. In 1 patient, bilateral renal artery stent rescue was performed due to severe procedure-related stenosis. Occlusion of an internal iliac artery was noted in 2 patients. Mean follow-up was 26.9 months (range 4.5-43.5). No aneurysm-related rupture or death occurred. Two endoleaks were observed: 1 type I without migration at 3 years and 1 type II at 13 months. Freedom from any type of endoleak was 91.6% at 1 year and 75.9% at 2 years. Freedom from any early or late intervention was 88.8% at 1 year and 76.0% at 2 years. Aneurysm sac shrinkage (>5 mm) was evident in 79% (11/14) of the cases reaching 12-month follow-up. CONCLUSION: The Aorfix device seems to be safe and reliable in purely complex infrarenal AAA anatomy, demonstrating good short and midterm clinical outcomes. Further larger or multicenter studies are needed to confirm the suitability of the Aorfix stent-graft in hostile infrarenal AAA anatomy.

Improving endograft stability by accommodation onto the aortic bifurcation.

PURPOSE: To report the technique for deploying a 3-part endovascular graft onto the native aortic bifurcation for greater stent-graft stability. TECHNIQUE: The Zenith Composite Endovascular Graft is a 3-part system consisting of a proximal tubular body with an uncovered Gianturco Z stent, a distal bifurcated body, and a contralateral leg. Proximally, 8-mm flexible interstent gaps facilitate precise infrarenal aortic placement, even in angulated necks. Technically, the bifurcated part is deployed first and pulled down to the aortic bifurcation, while the tubular main body and contralateral leg deployment follow. Using this technique to accommodate the graft onto the natural aortic bifurcation, distal stability can be enhanced and graft migration minimized. CONCLUSION: The Composite configuration can be an alternative to ensure a higher security index in difficult anatomies. It may be beneficial in patients with short (10-15 mm), angulated (>60 degrees ), or conical necks and deserves investigation in these patient populations.

Sizeable carotid body tumor excision by ultrasonic surgical aspirator: a new technical approach.

Carotid body tumors (CBTs) are rare neoplasms. Excision is the preferred treatment and is associated with low mortality and morbidity, although rates of cranial nerve dysfunction postoperatively and blood loss are still high. We herein present a case of a huge CBT, Shamblin group 3, managed successfully by the use of the Cavitral Ultrasonic Surgical Aspirator after preoperative superselective embolization. Our goal was to minimize the possibility of cranial nerve injury, blood loss, and vascular reconstruction. Careful preoperative evaluation, management, and intraoperative precision are essential for successful outcomes. Ultrasonic dissection of a CBT allows a precise and energy-controlled approach, minimizing intraoperative complications in such a demanding and delicate operation.

Surviving common carotid rupture caused by a cervical abscess.

CASE REPORT: This article describes the events preceding and following the rupture of the right common carotid artery caused by a cervical abcess. Stent grafting resulted in a good outcome.