Hemolytic Anemia Caused by Graft Kinking Following Ascending Aortic Replacement: Endovascular Treatment With a Palmaz XL Stent.

A 66-year-old man presented with hemolytic anemia, which required frequent blood transfusion, 6 months after surgical repair of an ascending aortic pseudoaneurysm. Hemolysis was attributed to luminal stenosis caused by graft kinking by laboratory test, CT and four-dimensional magnetic resonance imaging. First, an Excluder cuff was placed at the stenotic site under rapid pacing, but it migrated distally. Thereafter a Palmaz XL stent was placed at the stenotic site, which led to resolution of anemia. In this case, a Palmaz XL stent was successfully used to treat hemolytic anemia caused by graft kinking following ascending aortic surgery.

Usefulness of 18F-FDG PET/computed tomography in differentiating between subacute and chronic aortic dissection: initial investigation.

OBJECTIVES: In the selection of thoracic endovascular repair for aortic dissection (AD), it is important to distinguish between the subacute and chronic phases, but there is no reliable way to distinguish between them in patients with unknown onset of AD. The purpose of this study was to assess the diagnostic performance of 2-[18F] fluoro-2-deoxy-d-glucose (18F-FDG)-PET/computed tomography (PET/CT) for discriminating subacute AD from chronic AD. METHODS: Thirteen patients with AD who were medically treated and followed up for 6 months were studied. 18F-FDG PET/CT images were obtained for each patient in the subacute phase (the first scan) and at 6 months (the second scan) after the onset. Target-to-background ratio (TBR) was measured as the maximum standardized uptake value (SUV) in the dissected aortic wall divided by blood pool SUV. RESULTS: TBR was significantly higher in the first scan (mean ± SD, 1.97 ± 0.32) than in the second scan (1.69 ± 0.29, P = 0.007). The area under the receiver operating characteristic curve of TBR for discriminating subacute AD from chronic AD was 0.76. With a threshold of 1.74, the TBR showed the sensitivity, specificity, and positive and negative predictive value of 85%, 69%, 73%, and 82%, respectively, for the discrimination of subacute AD from chronic AD. CONCLUSION: Metabolic assessment of dissected aortic wall by 18F-FDG PET/CT is useful in differentiating between subacute and chronic AD and can provide important information in determining the appropriate indication for treatment for patients with AD of unknown onset.

Utility of Psoas Muscle Area in Selecting Older Patients Feasible for Thoracic Endovascular Aortic Repair.

BACKGROUND: The impact of psoas muscle area on overall survival is unknown for older patients undergoing elective thoracic endovascular aortic repair. METHODS: We retrospectively reviewed 105 patients aged 75 years or more who underwent elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height squared to derive psoas muscle mass index. The patients were stratified into two groups, sarcopenia and nonsarcopenia. sarcopenia was defined as a psoas muscle mass index less than 5.40 cm2/m2 for men and less than 3.56 cm2/m2 for women. The overall survival was compared with the age- and sex-matched general population using the one-sample log rank test. The propensity score adjusted Cox proportional hazards model was applied to determine the hazard ratio for all-cause mortality. RESULTS: Twenty-three patients died during the follow-up period (median, 3 years). Thirty-eight patients (36%) were classified as sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29% to 73%) for sarcopenia and 84% (95% confidence interval, 74% to 94%) for nonsarcopenia. The overall survival was significantly lower in the sarcopenia group than in its matched general population (P = .004), whereas no statistically significant difference in overall survival was found between the nonsarcopenia group and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio 2.64; 95% confidence interval, 1.02 to 6.82; P = .045). CONCLUSIONS: Psoas muscle mass index may be a good predictor of mortality among older patients undergoing elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm.

Comparison of Outcomes and Complications Among Patients with Different Indications of Acute/Subacute Complicated Stanford Type B Aortic Dissection Treated by TEVAR: Data from the JaPanese REtrospective multicenter stuDy of ThoracIc Endovascular Aortic Repair for Complicated Type B Aortic Dissection (J-Predictive Study).

PURPOSE: To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair. MATERIAL AND METHODS: The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test. RESULTS: Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair. CONCLUSIONS: Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia. LEVEL OF EVIDENCE: Level 4, Case series.

Therapeutic window for obtaining favorable remodeling after thoracic endovascular aortic repair of type B aortic dissection.

OBJECTIVE: The purpose of the present study was to determine the most appropriate timing for thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD) in terms of remodeling of the aorta. METHODS: A total of 41 patients who had undergone TEVAR for the treatment of aortic dissection were included in the present study. The patients were divided into two groups: those who had undergone TEVAR in the acute or subacute phase (group A) and those who had undergone TEVAR in the chronic phase (group B). The indications for TEVAR as the treatment of TBAD were the presence of aortic rupture or malperfusion of the aortic branches, a maximum aortic diameter of ≥40 mm on the initial diagnostic computed tomography scan, and/or expansion of the aorta of ≥5 mm within 3 months for acute and subacute TBAD. The indication was a maximum aortic diameter of ≥50 mm or expansion of the aorta of ≥5 mm within 1 year for chronic TBAD. The diameters of the aorta, true lumen, and false lumen were measured at the level of the most dilated part of the descending aorta (level M) and at the diaphragm (level D) on the computed tomography scan obtained before TEVAR and at the 2-year follow-up examination. RESULTS: The median interval between TEVAR and the onset of TBAD was 0.2 month (interquartile range, 0.03-0.7 month) in group A (n = 21) and 32 months (interquartile range, 4.7-35.2 months) in group B (n = 20). Except for the aortic diameter at level D in group B, favorable remodeling was obtained at both levels in both groups. The diameter change ratio of the aorta at level D was significantly greater in group A than in group B (P = .02). Receiver operating characteristic curve analysis of the interval for a significant decrease in the aortic diameter at level D yielded 4.2 months as the optimal threshold for performing TEVAR (area under the curve, 0.859; 95% confidence interval, 0.7-1.0). CONCLUSIONS: TEVAR for TBAD will result in favorable outcomes, irrespective of the timing of the procedure. However, it might be more effective to perform TEVAR within 4.2 months of the onset of TBAD, provided that the TEVAR procedure can be performed safely.

18F-FDG uptake as a predictive factor for progressive aortic enlargement in aortic dissection.

OBJECTIVE: Progressive aortic enlargement (PAE) is a critical adverse event in patients with medically treated aortic dissection (AD). However, no reliable predictor of the PAE has been established. The purpose of this study was to evaluate the value of 18F-FDG PET/CT for the prediction of PAE in patients with medically treated AD. METHODS: Sixteen patients with AD who underwent optimal medical therapy were enrolled. 18F-FDG PET/CT examinations were performed in subacute phase (2 weeks-3 months) after the onset of AD. Target-to-background ratio (TBR) was measured as the maximum standardized uptake value (SUV) in the dissected aortic wall divided by blood pool SUV. The relation between TBR and occurrence of PAE (> 10 mm/year) was evaluated. RESULTS: PAE was observed in four patients during the median follow-up period of 24 months. The TBR measured in the 4 patients showing PAE was significantly higher than that in the remaining 12 patients without PAE (2.44 ± 0.56 vs 1.87 ± 0.33, P = 0.025). The area under the receiver operating characteristic curve of TBR for predicting PAE was 0.82. With a threshold of 2.34, the TBR showed the sensitivity, specificity, and positive and negative predictive value of 75%, 92%, 75%, and 92%, respectively, for the prediction of PAE. CONCLUSIONS: Higher 18F-FDG uptake in the dissected aortic wall as determined by TBR is associated with increased risk of PAE in patients with medically treated AD. TBR shows good specificity and negative predictive value for predicting PAE.

Relevance of Aortic Dissection Chronicity to the Development of Stent Graft-induced New Entry.

BACKGROUND: The relevance of aortic dissection chronicity to the development of stent graft-induced new entry (SINE) is unknown. METHODS: This study enrolled 69 patients who underwent thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection from January 2006 to December 2017 and were followed up for ≥6 months. Their medical records were reviewed retrospectively. Patients were stratified according to TEVAR timing into an early group (≤6 months from the onset of aortic dissection) and a late group (>6 months after the onset). The incidence of SINE as well as the interval between TEVAR and the development of SINE was compared between these groups. RESULTS: During the follow-up period, SINE occurred in 12% (3/26) and 35% (15/43) of patients in the early and late groups, respectively (P = .029). The interval between TEVAR and SINE development was significantly longer in the late group than the early group (median, 92 days vs 1144 days, respectively; P = .002). According to the multivariate analysis results, the late group (hazard ratio, 3.667; 95% confidence interval, 1.037-12.968; P = .044) and the distal oversizing ratio (hazard ratio, 1.492; 95% confidence interval, 1.071-2.080; P = .018) were the independent predictors for SINE development. CONCLUSIONS: TEVAR should be performed in the early period of the chronic phase to prevent SINE. Close and lifelong follow-up is mandatory for patients who undergo TEVAR >6 months after onset because SINE can develop several years after TEVAR in those patients.

Parallel Placement of Excluder Legs for the Treatment of a Type IIIb Endoleak Using AFX2.

Endoleak is a major complication of endovascular aneurysm repair (EVAR). Type IIIb endoleaks, which are caused by endograft fabric disruption, are relatively rare. Although relining of the previously placed endograft with another main endograft is considered an ideal approach, it is sometimes difficult. The efficacy of parallel placement of Excluder legs has been reported in various settings. Here, we report the successful treatment of a type IIIb endoleak with parallel placement of Excluder legs during EVAR by using an AFX2 device.

Parallel Placement of Excluder Legs to Treat Abdominal Aortic Aneurysms with Aortoiliac Occlusive Lesion.

The effectiveness of endovascular aneurysm repair (EVAR) has been proven, but anatomical limitations, including narrow access route, may obstruct procedure of EVAR and cause serious complications. Parallel placement of Excluder legs (W. L. Gore & Associates, Inc., Newark, DE, USA) was established to treat patients with type IIIb endoleak or those with a narrow aorta, who could not be treated using a standard main body. In this report, we applied this technique in two patients with aortoiliac aneurysms with occlusive lesion.

Management of Renal Arteries in Conjunction with Thoracic Endovascular Aortic Repair for Complicated Stanford Type B Aortic Dissection: The Japanese Multicenter Study (J-Predictive Study).

Background Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: -16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: -13% ± 14 vs 8.5% ± 14, P = .004). Conclusion Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss. © RSNA, 2019 Online supplemental material is available for this article.

Thoracic endovascular aortic repair for the treatment of ruptured acute type B aortic dissection.

PURPOSE: To evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) for ruptured acute type B aortic dissection (r-ATBAD). MATERIALS AND METHODS: The study included 18 patients (15 men and 3 women) who underwent TEVAR for r-ATBAD in two institutions between 1997 and 2017. The mean patient age was 74 ± 10 years. The false lumen was patent in 13 patients (72%) and was mostly thrombosed in 5 patients (28%). Three patients had malperfusion of aortic branches. Eight patients (44%) were in circulatory shock. RESULTS: Eleven patients (61%) died during or following TEVAR during admission. The causes of death were aortic rupture (n = 6), sepsis (n = 2), cerebral hypoxia (n = 1), pneumonia (n = 1), and renal failure (n = 1). Statistical analysis showed that dissection extending to the infrarenal level was significantly related to death from aortic rupture (P = 0.013). Early adverse events were observed in 12 patients (67%). One patient died from a non-aorta-related cause (sepsis) after discharge. The overall survival rate at 1 year was 39%. After discharge, an aorta-related adverse event (intimal injury) was observed in one patient. The adverse event-free survival rate at 1 year was 17%. CONCLUSIONS: Our results indicate that TEVAR for r-ATBAD is associated with high mortality and morbidity. More advanced strategies may be required to improve the outcome.

Thoracic endovascular aortic repair for retrograde type A aortic dissection.

OBJECTIVE: The efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A aortic dissection (r-TAAD) with the entry tear in the descending aorta has not been clarified. METHODS: The medical records of 31 patients who underwent TEVAR for r-TAAD at three institutions between May 1997 and January 2016 were retrospectively reviewed. RESULTS: The mean age of the patients (30 men and 1 woman) was 64 ± 11 years. The entry tear was located in the descending thoracic aorta in all patients. Seven patients (23%) had dissection-related complications. The false lumen of the ascending aorta was patent in 13 patients (42%) and thrombosed in 18 (58%). The maximum diameter of the ascending aorta was 45 ± 4 mm. TEVAR was performed in the acute phase in 24 patients (77%) and in the subacute phase in 7 (23%). Only one patient (3%) died of aortic rupture within 30 days after TEVAR. Early aorta-related adverse events were observed in eight patients (26%), of whom five underwent additional interventions. The mean follow-up period was 99 ± 69 months. There were no late aorta-related deaths, although five patients died of other causes during follow-up. Overall survival rates at 1 year, 5 years, and 10 years were 97%, 93%, and 80%, respectively. Late aorta-related adverse events were observed in seven patients (23%), of whom five underwent additional interventions. Aorta-related event-free survival rates at 1 year, 5 years, and 10 years were 58%, 58%, and 51%, respectively. CONCLUSIONS: TEVAR for r-TAAD seems promising in terms of survival. However, the incidence of postoperative aorta-related adverse events is not negligible, so careful selection of patients is important. In addition, close follow-up is mandatory after TEVAR to avoid catastrophic consequences.

Splenic Artery Aneurysm Treated With Endovascular Stent Grafting: A Case Report and Review of Literature.

INTRODUCTION:: Although endovascular therapy is becoming an alternative to open surgical repair of splenic artery aneurysms (SAAs), reports on the use of stent grafts for SAA repair are limited. We present our experience of endovascular therapy using a stent graft for the treatment of an SAA that had ruptured into the gastric lumen. We also reviewed 18 cases of stent graft repair for SAAs, including the present case. CASE REPORT:: A 43-year-old man was admitted due to hematemesis. Endoscopic examination and contrast-enhanced computed tomography (CT) revealed a dissecting SAA that had ruptured into the stomach. Two 10 × 100 mm Viabahn (W.L. Gore, Flagstaff, Arizona) stent grafts were used to exclude the aneurysm. No complications occurred during the procedure. Although postoperative CT showed complete exclusion of the aneurysm, endoscopic examination showed a discharge of purulent matter from the aneurysm. Therefore, surgical debridement and omental implantation were added to avoid stent graft infection. Follow-up CT obtained 1 year later showed the residual aneurysm almost disappeared without any evidence of infection. LITERATURE REVIEW:: A literature search in the PubMed database returned 17 cases with sufficient data. Review of these cases, together with the present case, revealed a 100% technical success rate, 11% splenic infarction rate, 94% graft patency rate, and 0% reintervention rate. CONCLUSION:: Endovascular repair of SAAs using stent grafts appears to be safe and effective. In terms of preserving the blood flow and avoiding splenic infarction, it may be superior to coil embolization. Even in a case with aneurysm infection, stent graft repair may be an acceptable method to minimize invasion of concomitant surgical intervention.

Treatment of Infected Aneurysm with Combined Endovascular Aneurysm Repair and Abscess Drainage.

PURPOSE: To evaluate the clinical utility of combination therapy with endovascular aneurysm repair (EVAR) and abscess drainage for the treatment of infected aneurysms. MATERIALS AND METHODS: Between July 2009 and May 2015, 8 patients underwent combination therapy with EVAR and abscess drainage. There were 5 men and 3 women, with a mean age of 75 years ± 7. Aneurysms were of the thoracic aorta in 5 patients, the abdominal aorta in 2, and the internal iliac artery in 1. Four patients had concurrent infection, including pyelonephritis in 2, pelvic abscess in 1, and suppurative knee arthritis in 1. Three patients had ruptured aneurysms. Abscess drainage was performed percutaneously under computed tomographic guidance in 5 patients, thoracoscopic guidance in 2, and both in 1. RESULTS: Six patients (75%) were discharged without additional intervention except for antibiotic therapy, and the other 2 patients (25%) underwent open repair to control infection and to repair endoleak, respectively. There were no in-hospital deaths. During the mean follow-up period of 48 months ± 22, all patients were alive except for 1 patient who died of recurrence of rectal cancer at 51 months. There were no aorta- or artery-related adverse events. Overall survival rates at 1 and 5 years were 100% and 80%, respectively. Aneurysm-related event-free rates at 1 and 5 years were 75%. CONCLUSIONS: Combination therapy with EVAR and abscess drainage for the treatment of infected aneurysms seems to be a promising strategy as an alternative or "bridge" to open surgery.

Parallel placement of Excluder legs for treatment of type IIIb endoleaks caused by fabric tear after endovascular aneurysm repair.

A total of 576 patients underwent endovascular aneurysm repair using main body devices for treatment of abdominal aortic aneurysms or iliac artery aneurysms. During follow-up, type IIIb endoleaks caused by fabric tear occurred in six patients (1.0% [6/576]). The device used was Zenith (Cook Medical, Bloomington, Ind) in five cases and Talent (Medtronic, Santa Rosa, Calif) in one case. All endoleaks were close to the flow divider of the main body devices. The distance between the lower renal artery and the top end of the contralateral leg was 53 ± 14 mm. Bell-bottom-shaped Excluder (W. L. Gore & Associates, Flagstaff, Ariz) legs were placed parallel from the top of the main body device through both legs to treat these endoleaks. In two patients, coil embolization was required to treat gutter endoleaks. Postoperative computed tomography showed the obliteration of type IIIb endoleaks in all patients. Our technique may be an acceptable method for treatment of type IIIb endoleaks, especially when they occur near the flow divider.

Treatment of Infected Aneurysms of the Abdominal Aorta and Iliac Artery with Endovascular Aneurysm Repair and Percutaneous Drainage.

Infected aneurysm remains one of the most challenging diseases for vascular surgeons. We describe the successful treatment of 2 cases of infected aneurysms with endovascular aneurysm repair and percutaneous computed tomography-guided drainage. This strategy may be an effective alternative to open surgical repair in selected patients.

Type A Aortic Dissection After Thoracic Endovascular Aortic Repair.

BACKGROUND: Type A aortic dissection (TAAD) is a rare complication associated with thoracic endovascular aortic repair (TEVAR). Although TAAD can result in catastrophic outcomes, the pathology of the condition has not been thoroughly clarified yet. METHODS: We retrospectively reviewed details from the medical records of 546 patients with diseases of the thoracic aorta (thoracic aortic aneurysm, n = 362; aortic dissection, n = 178; and fistula between the descending thoracic aorta and esophagus, n = 6) who underwent TEVAR in five hospitals from May 1997 through February 2015 to identify patients in whom TAAD developed during or after TEVAR. RESULTS: TEVAR-associated TAAD developed in 12 patients (2.2%). Pathologies originally treated with TEVAR were aortic dissection in 10 patients (83%) and true thoracic aortic aneurysm in 2 (17%). Type A aortic dissection developed during hospitalization in 4 patients (33%), within 1 year in 5 (42%), and more than 1 year later in 3 (25%). The entry tear was located in the ascending aorta or the aortic arch away from the edges of stent grafts in 8 patients (67%), whereas it was found just at the proximal edges of stent grafts in 4 patients (33%). Nine patients underwent ascending aortic replacement with or without concomitant aortic arch replacement, and 3 patients underwent medical management. Overall, 2 patients (17%) died during hospitalization. CONCLUSIONS: Type A aortic dissection can develop during TEVAR or even years after TEVAR. Careful operative procedures and follow-up should be mandatory for patients with aortic dissection as TAAD seems to occur more frequently among these patients.