Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVE/BACKGROUND: To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG). METHODS: 184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions. RESULTS: The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event. CONCLUSIONS: The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

Single Branched Endografts for the Preservation of Left Subclavian Artery in the Treatment of Zone II Thoracic Aortic Lesions a Systematic Review and Meta-Analysis.

BACKGROUND: We investigated the safety and feasibility of single branched endografts in the treatment of zone II thoracic endovascular aortic repair (TEVAR). METHODS: We performed a systematic research on Medline, Scopus and EMBASE for articles published up to February 2023. Primary end points included technical success, 30-day mortality, stroke and spinal cord injury (SCI) as well as unassisted left subclavian artery (LSA) branch patency by the end of follow-up. Secondary end points included early 30-day and persistent endoleaks, new onset dissection and reintervention by the end of follow-up. RESULTS: Fourteen studies, three prospective case series and 11 retrospective case series comprised of 727 patients were finally included. The pooled technical success and 30-day mortality rates were 94.86 % (95% confidence interval (CI): 90.95-97.86) and 0.14% (95% CI: 0.00-0.87). The 30-day stroke and SCI rates were 0.45% (95% CI: 0.00-1.39) and 0.08% (95% CI: 0.00-0.99), respectively, while the unassisted LSA branch patency estimate was 99.12% (95% CI: 97.97-99.86). The early 30-day and persistent endoleak rates were 5.19% (95% CI: 2.45-8.65) and 2.57% (95% CI: 0.36-6.02), whereas new onset dissections and reinterventions estimates were 0.94% (95% CI: 0.17-2.11) and 2.40% (95% CI: 0.41-5.42). CONCLUSIONS: While we have displayed the safety and feasibility of single branched endografts in the treatment of zone II thoracic aortic lesions, physicians should be aware of the persistency displayed by early type I endoleaks eventually requiring reintervention. The variations in device and lesion characteristics accompanied by the short-term follow-up presented in our review do not allow for definite conclusions to be drawn, necessitating further research through high-quality randomized controlled trials.

The Incraft stent graft for the treatment of abdominal aortic aneurysms: an iliac-friendly device with an effective conventional proximal sealing mechanism.

INTRODUCTION: The Incraft aortic stent graft (Cordis, Bridgewater, NJ, USA) is a trimodular endovascular stent graft with a conventional suprarenal active fixation specifically designed to overcome the anatomic limitation of small, stenotic, and tortuous iliac vessels. AREAS COVERED: The present article provides a complete description of the Incraft stent graft, its clinical performance, its technical characteristics as well as a comparison with other competitive endografts. EXPERT OPINION: The Incraft stent graft is an EVAR ultra low-profile device initially designed for overcoming the limitation of the hostile iliac anatomy. Recently, the device is being increasingly used in real-world conditions and not only in complex iliac anatomies with good mid-term results. Whether it remains a useful EVAR toolbox or will become a workhorse endograft is yet to be determined.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR.

BACKGROUND: Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS: A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS: From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS: Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Correlation of Baseline Plasma and Inguinal Connective Tissue Metalloproteinases and Their Inhibitors With Late High-Pressure Endoleak After Endovascular Aneurysm Repair: Long-term Results.

Purpose: To investigate whether plasma and connective tissue matrix metalloproteinases (MMP) and their inhibitors (TIMP) may predict late high-pressure endoleak after endovascular aneurysm repair (EVAR). Materials and Methods: Samples of inguinal fascia and blood were collected in 72 consecutive patients (mean age 73.1 years; 68 men) undergoing primary EVAR with the Endurant stent-graft. Baseline plasma levels of MMP-2, MMP-9, TIMP-1, and TIMP-2 and baseline MMP-2 and MMP-9 activity estimated using gelatin zymography (GZ) were compared between patients who developed late endoleak in follow-up and those who did not. Subgroup analyses were performed between patients with (n=18) and without inguinal hernias and between patients with moderate-diameter (50-59 mm; n=45) or large-diameter (≥60 mm; n=27) abdominal aortic aneurysms (AAA) at primary EVAR. Results: The mean follow-up period was 63.1 months (range 7.5-91.5), during which time 13 (18.1%) patients developed type I (6 Ia and 5 Ib) or 2 type III endoleaks. Only GZ-analyzed proMMP-9 concentrations were higher in the endoleak group than in patients without endoleak (mean difference 8.44, 95% CI -19.653 to -1.087, p=0.03). The patients with primary inguinal hernia at presentation had significantly higher tissue TIMP-2 values (0.8±0.7 vs 0.5±0.4, p=0.018) but lower plasma total (pro- + active) MMP-9 values (11.9±7.8 vs 16.2±7.4, p=0.042) than patients without hernias at the time of EVAR. Patients with AAAs ≥60 mm had significantly higher mean tissue homogenate levels of total (pro- + active) MMP-9 (p=0.025) and total (pro- + active) MMP-2 (p=0.049) as well as higher proMMP-9 (p=0.018) and total (pro- + active) MMP-9 (p=0.021) levels based on GZ compared to patients with moderate-diameter AAAs. Regression analysis revealed a significant association between total (pro- + active) MMP-9 plasma samples and the presence of hernia (OR 0.899, 95% CI 0.817 to 0.989, p=0.029) and between GZ-analyzed proMMP-9 and late endoleak (OR 1.055, 95% CI 1.007 to 1.106, p=0.025). GZ-analyzed proMMP-9 and active MMP-9 were strong predictors of late endoleak in patients with hernia (p=0.012 and p=0.044, respectively) and in patients with AAAs ≥60 mm (p=0.018 and p=0.041 respectively). Conclusion: Inguinal fascial tissue proMMP-9 significantly predicted late endoleak. ProMMP-9 and active MMP-9 biomarkers are significantly associated with late endoleak in hernia patients and in patients with AAAs ≥60 mm. Considering the clinical association between hernia and AAA and the fact that the AAA wall connective tissue environment remains exposed to systemic circulation after EVAR, inguinal fascia extracellular matrix dysregulation and altered MMP activity may reflect similar changes in AAA biology, leading to complications such as endoleak.

Use of a temporary shunt to preserve the patency of a hemodialysis graft while performing ipsilateral axillo-femoral bypass.

Increased blood flow in the subclavian artery feeding a vascular access for hemodialysis can rarely induce steal phenomena in the vertebral and internal mammary artery leading to potentially life-threatening conditions. On the contrary, transient interruption of blood flow in the subclavian artery feeding a dialysis arteriovenous fistula can theoretically induce access thrombosis. Here, we describe a technical maneuver preserving continuous ipsilateral upper arm access flow when constructing a unilateral axillo-femoral polytetrafluoroethylene bypass operation for critical limb ischemia in a hemodialysis patient.

Positional Changes of an Endurant Endograft Leading to Simultaneous Ipsilateral Iliac Limb Obstruction and Contralateral Type IIIa Endoleak.

We report the case of a 79-year-old man who was admitted to our department with acute limb ischemia due to the occlusion of the left iliac limb of an Endurant endograft. The admission computed tomography angiography revealed also a type IIIa endoleak due to modular disconnection of the iliac extensions from the right iliac limb of the endograft main body. Interestingly, during the 4-year post-endovascular aneurysm repair period, an increased kinking of the right limb has been observed leading to an almost cross-limb configuration of the limbs at the time of complications. To our knowledge, this is the first case in the literature of the simultaneous presence of limb thrombosis and late type IIIa endoleak with this particular device. The ischemia was treated with a femoro-femoral cross-over bypass, and the endoleak was corrected with the position of 2 Endurant iliac limb extensions bridging the dislocated endograft pieces.

Early Results of the Bolton Treovance Endograft in the Treatment of Abdominal Aortic Aneurysms.

PURPOSE: To present early results with the Treovance aortic stent-graft in the treatment of abdominal aortic aneurysms (AAAs). METHODS: Between October 2013 and January 2016, 35 consecutive AAA patients (mean age 74±7.7 years; 32 men) were treated with Treovance. The maximum diameter of the treated AAA was 60±9 cm. Nine (25%) patients presented with concomitant iliac aneurysms. Seven (20%) AAAs had infrarenal neck angulation >60°. The infrarenal neck length and diameter were 21.6±12.6 mm and 25.7±4.6 mm, respectively. Sixteen (45%) AAAs had a reversed tapered neck contour. Six (17%) and 9 (25%) patients showed severe or moderate iliac tortuosity, respectively. Primary endpoints were endoleak, reintervention, and aneurysm-related death. RESULTS: Primary technical success was 94% due to 2 intraoperative type Ia endoleaks, which were successfully treated with a proximal aortic extension (100% assisted primary technical success). Local dissection was encountered in 5 (7%) of 70 femoral artery access sites in 4 patients. During a mean 12-month follow-up (range 6-24), clinical success was 97%. No type I or III endoleak, death, AAA rupture, open conversion, or device-related serious adverse events were documented. Four type II endoleaks were detected; one resolved spontaneously at 12 months and 2 remained stable, while one associated with AAA sac enlargement was treated successfully with embolization of the lumbar arteries (3% reintervention rate). CONCLUSION: Treovance shows accurate deployment even through angulated and tortuous iliac vessels and presents satisfactory conformability in highly angulated necks with acceptable clinical results. Future development to lower the profile and increase the flexibility of its delivery system will enhance its applicability in cases of narrow access vessels.

The Effect of Revascularization on the Hemodynamic Profile of Patients with Infrarenal Aortic Occlusion.

BACKGROUND: Patients undergoing revascularization for infrarenal aortic occlusion (IAO) have been reported to present improved survival rates compared to those treated conservatively. Aim of this study was to investigate the hemodynamic changes induced after revascularization for IAO, as expressed with pulse wave velocity (PWV), augmentation index (Aix), augmentation pressure (AP), and pulse wave reflection coefficient (RC). MATERIALS AND METHODS: Twelve patients underwent revascularization (9 aortobifemoral/aortobiiliac bypasses, 2 primary iliac stenting, and 1 hybrid procedure of unilateral aortoiliac stenting and crossover bypass). Calculation of hemodynamic parameters was performed in all patients preoperatively, at 1 month, and 1 year postoperatively. Pulse wave analysis was performed noninvasively with a novel validated brachial cuff-based automatic oscillometric device (Mobil-O-Graph; IEM, Stolberg, Germany). The estimated hemodynamic parameters were AIx, AP, RC, and PWV. Data were analyzed with the Friedman analysis of variance test. RESULTS: Aix decreased significantly at 1 month and further at 1 year postoperatively compared to preoperative values (24 ± 11 and 17 ± 13 vs. 34 ± 13.5, respectively, P = 0.0006). AP decreased at 1 month and 1 year postoperatively compared to preoperative values (6.5 ± 4 mm Hg and 8 ± 6.5 mm Hg vs. 13 ± 12 mm Hg, respectively, P = 0.045). RC decreased also at 1-month and 1-year postoperatively compared to preoperative values (62 ± 5.5, 64 ± 4.3 vs. 73 ± 5.1, respectively, P = 0.002). However, changes in PWV were less prominent in this short-term postoperative period. CONCLUSIONS: Improved hemodynamic profile may theoretically contribute to the enhanced survival rates of these patients.

Abdominal Pain in the Presence of Small Abdominal Aortic Aneurysms: If in Doubt, Cut It Out!

Although small (<5 cm) abdominal aortic aneurysms (AAA) have been associated with symptoms and indication for intervention scarcely, the clinicians should never exclude such potential association especially in the absence of other overt pathological findings. In such cases, a surgical exploration with consequent intervention, if feasible, should be justified to prevent a detrimental evolution in a dubious scenario. In this article, we present 2 cases of patients with small AAA presenting with severe abdominal pain. In the absence of other solid clinical and radiological pathological findings, both patients underwent laparotomy where an inflammatory small AAA was identified and subjected either to resection and restoration with a tube graft or secondary endovascular repair because the periaortic fibrosis precluded the open repair. The characteristics and rationale of treatment modalities are exemplified and discussed.

A critical appraisal of endovascular stent-grafts in the management of abdominal aortic aneurysms.

Endovascular repair of abdominal aortic aneurysms has widely replaced the open surgical repair due to its minimal invasive nature and the accompanying lower perioperative mortality and morbidity. During the past two decades, certain improvements and developments have provided a wide variety of endograft structural designs and geometric patterns, enabling the physician to approach a more patient-specific treatment of AAA. This review presents the currently available aortic endografts and describes the clinical, technical and mechanical characteristics of them.

Endovascular treatment of complex abdominal and thoracoabdominal type IV aortic aneurysms with fenestrated technology.

The establishment use of fenestrated and branched devices to treat complex aortic aneurysms as a first-line management option has been previously reported. This article reviews the current literature of the use of fenestrated devices to treat complex abdominal and thoracoabdominal type IV aortic aneurysms as a first-line management option. A literature search was performed. This review particularly focuses on all the aspects of the use and results of fenestrated stent-grafts (SGs) in patients with complex abdominal and type IV thoracoabdominal aortic aneurysms and summarizes the available evidence. The use of fenestrated SGs for complex aortic aneurysm disease has grown enormously the last years. SGs with fenestrations, scallops and occasionally branches have to be customized to each patient's anatomy and precisely deployed in vivo. Bridging covered stents between the main graft and the target vessels eventually exclude the aneurysm preserving blood flow to vital organs. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. High technical success rates and satisfactory perioperative outcomes are described as well as mid- and long-term success and durability including target vessel and branch stent perfusion, data emerging mainly from high volume specialized centers. Percentage of target vessel successfully perfused was reported between 90.5 and 100%. 30-day mortality is reported between 0% and 4.1% while the lowest type 1 or type 3 endoleak rates were 2.5% and 1.3% respectively. Migration rates are kept below 3%. Renal failure was the most frequent complication reported. Advances in SG technology have reduced but not eliminated secondary interventions. Outcomes depend mostly on proximal extension of the disease which increases also the complexity of the repair. High level of expertise and organizational facilities are required for better mid- and long-term outcomes. Fenestrated EVAR (fEVAR) has been shown to be safe and effective in the short and mid-term follow-up. Remaining issues including secondary interventions and the need for follow-up are still within the range of those reported for EVAR. These, continue to plague fEVAR for complex abdominal or type IV thoracoabdominal aortic aneurysms.

Custom-Made Conical Endograft in the Treatment of Saccular Abdominal Aortic Aneurysms with Tight and Calcified Distal Neck: Thinking Out of the Box.

BACKGROUND: To describe the use of the combination of a conical custom-made TREO® (TREO CM) stent graft in the treatment of a saccular abdominal aortic endograft (AAA) with long but tight and calcified distal neck. MATERIALS AND METHODS: A 65-year-female patient was treated for a saccular 5.2 cm AAA with a 3-cm long but calcified and tight (16 mm) distal neck, precluding the safe use of a bifurcated endograft. Because the patient refused an open surgery, a conical TREO CM endograft was manufactured with 20% proximal oversizing, whereas the 3-cm caudal sealing segment demonstrated a conical configuration comprising a 2-cm and 1-cm nitinol-supported zones of 20% and 10% oversizing, respectively, to avoid excessive strain and incomplete expand at the most distal calcified area, leading ultimately to an insidious infolding and consequent type Ib endoleak. A 24 × 40 mm Treovance aortic cuff was centrally deployed resulting in a 30 mm overlap with the main endograft. RESULTS: After 6 months, there was complete sealing, and the AAA sac has been shrunk to 45 mm. CONCLUSIONS: The use of a conical TREO CM endograft with a proximal cuff provides a firm fixation centrally and a sufficient distal sealing design in AAAs with calcified and tight distal aorta, constituting a reliable alternative to bifurcated endografts or aortouniliac configurations followed by crossover adjuncts.

Preliminary Single-Center Experience with the Bolton Treovance Endograft in the Treatment of Abdominal Aortic Aneurysms.

BACKGROUND: Our aim was to present our preliminary experience with the recently introduced Treovance aortic stent-graft device (Bolton Medical, Barcelona, Spain) in the treatment of abdominal aortic aneurysm (AAA). METHODS: Eight patients underwent treatment of an infrarenal AAA (mean maximum diameter, 56.4 ± 6.8 mm) with the Treovance device. Iliac tortuosity was considered mild, moderate, or severe when ≥1 angulation of 45-90°, 1 angulation ≥90°, or ≥2 angulations ≥90°, respectively, were present. RESULTS: Mild angulation of the infrarenal neck (10-45°) was present in 7 patients, whereas the remaining patient had severe infrarenal neck angulation (65°). Three patients had severe iliac tortuosity. Primary technical success was achieved in all but 1 patient in whom a type Ia endoleak was identified on completion angiogram. The endoleak was successfully treated with a proximal aortic cuff. A femoral access complication occurred in 1 patient. Mean follow-up was 6.8 months (range, 1-12). No device-related serious adverse events or rupture occurred during the given follow-up period. The only type II endoleak identified resolved spontaneously within 12 months. CONCLUSIONS: The Treovance abdominal stent-graft system seems to guarantee an accurate, safe, and effective deployment in AAA even through angulated and tortuous iliac vessels. Although our preliminary results are promising, follow-up data are needed to establish the durability of this new-generation endovascular device in standard or challenging anatomies.

The shear stess profile of the pivotal fenestrated endograft at the level of the renal branches: A computational study for complex aortic aneurysms.

PURPOSE: This study investigated the impact of the variant angulations on the values and distribution of wall shear stress on the renal branches and the mating vessels of a pivotal fenestrated design. METHODS: An idealized endograft model of two renal branches was computationally reconstructed with variable angulations of the left renal branch. These ranged from the 1:30' to 3:30' o'clock position, corresponding from 45° to 105° with increments of 15°. A fluid-structure-interaction analysis was performed to estimate the wall shear stress. RESULTS: The proximal part of the renal branch preserved quite constant wall shear stress. The transition zone between its distal end and the renal artery showed the highest values compared to the proximal and middle segments, ranging from 8.9 to 12.4 Pa. The lowest stress values presented at 90° whereas the highest at 45°. The post-mating arterial segment showed constantly low stress values regardless of the pivotal branch angle (6.3 to 6.6 Pa). The 45° configuration showed a distribution of the highest stress posteriorly whereas the 105°-angulation anteriorly. CONCLUSIONS: The variant horizontal branch orientation influences the wall shear stress distribution across its length and affects its values only at its transition with the mating vessel. These findings and their potential association with adverse effects deserve further clinical validation.

Preemptive open surgical vs. endovascular repair for juxta-anastomotic stenoses of autogenous AV fistulae: a meta-analysis.

PURPOSE: There is controversy about the best mode of preemptive repair of juxta-anastomotic stenoses in radial-cephalic arteriovenous fistula (AVFs). The aim of the present review was to compare the outcome of surgical vs. endovascular repair of those AVF stenoses. METHODS: A systematic review and meta-analysis was performed for studies comparing the outcome of open surgical vs. endovascular preemptive repair of AVF stenoses located in the juxta-anastomotic region. A search was carried out in April 2015. The analyzed outcome measures were the primary patency at 12 and 18 months and the assisted primary patency at 24 months. In addition, assessment of the methodological quality of the included studies was carried out. RESULTS: Four non-randomized cohort studies (297 patients) were analyzed. A random effects model was used to pool the data. The pooled odds ratio (OR and 95% confidence intervals) for the primary patency at 12 and at 18 months was 0.42 (0.25-0.72) and 0.33 (0.2-0.56), respectively, showing statistically significant higher patency of the surgically repaired group. The pooled OR for the assisted primary patency at 24 months was 0.53 (0.28-0.98) also in favor of the surgically repaired group (p<0.04). CONCLUSIONS: The available evidence, based on non-randomized cohort studies, suggests that surgery is the best way to treat 'juxta-anastomotic' stenotic lesions in distal radial-cephalic AVFs, although angioplasty remains a valuable but less durable option in this location of the stenosis.

Emergent conversion of the Ovation Stent Graft System to aortouniiliac modification via occlusion of a unilateral internal iliac artery with a stentgraft as a bailout solution.

PURPOSE: To present a case of inadvertent collapse of the contralateral limb gate caused by misorientation during the deployment of the Ovation Abdominal Stent Graft System in a narrow aortic lumen and the bailout conversion to aortouniiliac modification, using a covered stent to exclude the orifice of the internal iliac artery (IIA). TECHNIQUE DESCRIPTION: Despite the repeated efforts from the femoral and brachial site, the collapsed/occluded contralateral limb gate could not be catheterized. In order to exclude successfully the orifice of the IIA, an oversized stentgraft was placed immediately at the common-to-external iliac artery (CIA-EIA) transition followed by peripheral ligation of the latter. The procedure was completed with crossover femorofemoral bypass. CONCLUSION: Occlusion the IIA orifice with an oversized stentgraft in the CIA-EIA transition can be considered as a safe, simple, fast, and efficient bailout maneuver, followed by EIA ligation and crossover bypass.

Studying the interaction of stent-grafts and treated abdominal aortic aneurysms: time to move caudally!

Since the advent of endovascular repair of aortic aneurysms (EVAR), clinical focus has been on preventing loss of sealing at the level of the infrarenal neck, which leads to type I endoleak and repressurization of the aneurysm sac. Enhanced mechanisms for central fixation and seal have consequently lowered the incidence of migration and endoleaks. However, endograft limb thrombosis and its causal mechanisms have not been addressed adequately in the literature. This article reviews the pathophysiological mechanisms associated with limb thrombosis in order to facilitate better clinical judgment to prevent iliac adverse effects.