Early Experience with Ovation Alto Stent-Graft.

BACKGROUND: Alto is the latest generation of the Ovation stent-graft platform for endovascular aneurysm repair (EVAR). Its ultra-low profile and its proximal sealing zone close to the lowest renal artery (≥7 mm) increase standard EVAR eligibility. We report early clinical and technical outcomes with the Alto stent-graft in our University Hospital Center after CE Mark approval in August 2020. METHODS: Seven patients (all male, mean age 76.1 ± 6.2 years) underwent EVAR with Ovation Alto stent-graft between June 2021 and February 2022. All the EVAR procedures were performed by a team of vascular surgeons experienced on EVAR with previous generation of Ovation platform. Follow-up consisted of duplex ultrasound examination at 1, 3, and 6 months and of a 1-month control computed tomography angiography (CTA). Patients treated gave consent to participate in this case series and publication. A descriptive analysis of variables was performed. SPSS (version 25) and Excel were used for statistical analysis. RESULTS: Most of the patients had a fusiform abdominal aortic aneurysm (n = 5; 71.4%). The median maximal transversal aortic diameter was 5.06 cm (range, 3.98-6.99). Because of hostile aortic neck anatomy, on-label EVAR was considered feasible only with Ovation Alto stent-graft. Narrow iliac arteries (<6 mm) were also present in 2 cases. All procedures were performed according to the instruction for the use of the device. Technical success was achieved in all cases. No type IA/IB/III endoleak occurred at completion angiography. No distal migration (>10 mm) but 2 distal displacements (≥2 mm) were observed at control CTA. During follow-up, duplex ultrasound and CTA showed no type I/III endoleak, no stent-graft migration (>10 mm), and no proximal aortic neck variations (P = not statistically significant). Three patients (42.8%) are under strict surveillance because of low-flow type II endoleak not associated with sac variations. CONCLUSIONS: Our early experience shows promising technical and clinical success with Alto stent-graft. The proximal relocation of the proximal sealing rings and the ultra-low profile delivery system allow on-label EVAR in a wider range of aortic anatomies. Notwithstanding, further studies, meta-analysis, and prospective registries are mandatory to evaluate mid- and long-term efficacy and safety of this latest Ovation platform.

Laparoscopic Resection of a Middle Colic Artery Aneurysm.

We report herein the successful laparoscopic resection of an asymptomatic 3-cm middle colic artery aneurysm in a young woman. Endovascular treatment represents nowadays the first-line option facing visceral artery aneurysm, but in this case, embolization was excluded because of hostile anatomy. Advantages of laparoscopic approach were the safe resection of the aneurysm with immediate evaluation of the bowel tolerance and the possibility of a histological examination of the arterial wall, without the disadvantages of laparotomy.

Six-year multicenter experience of standard endovascular treatment of critical limb ischemia in the era of drug-eluting devices.

BACKGROUND: There has been increasing evidence to support the endovascular-first approach in the treatment of below-the-knee (BTK) lesions. Plain old balloon angioplasty (POBA), with bailout bare-metal stent scaffolding in case of flow limiting dissection or recoil, have been considered the standard treatment of choice but industries are continually developing innovative equipment and dedicated technologies, such as drug-eluting platforms whose use is increasingly extended, despite significant costs and lack of high-quality evidence to support a well-established strategy. This study's objective was to analyze the 6-year results of "standard" endovascular treatment of BTK lesions in the era of drug-eluting devices. METHODS: From August 2008 to February 2010, 21 French speaking European centers consecutively enrolled critical limb ischemia (CLI) patients with BTK lesions treated endovascularly into the Angioplastie Jambière (ANJE) registry. Primary endpoint was 1-year limb salvage, a subgroup analysis was performed to compare POBA, bare nitinol stents and balloon-expandable stents (BESs). RESULTS: Of the 282 patients included (61.7%, men, mean age 75.8±10.0 years), 53.5% were diabetic and 29.4% presented with chronic kidney disease. At 1 year, complete wound healing was described in 187 patients (82.7%), the overall limb salvage rate was 94.0% with a survival rates of 89.2%. The primary and secondary patency rates were 84.5% and 91.7% respectively with significantly lower primary patency rates after stenting (80.6% vs. 87.6% after POBA; P=0.043). The rate of freedom from target lesion revascularization (TLR) was 86.3% with significantly lower rates after stenting (81.8% vs. 89.9% after POBA; P=0.01). The subgroup analysis showed no significant difference between nitinol stents, BESs and POBA in terms of limb salvage and survival rates, however, primary and secondary patency rates were significantly lower after BESs (primary and secondary patency rates of 84.0% after nitinol stents vs. 77.4% after BES vs. 87.6% after POBA; P=0.012 and 93.0% vs. 77.4% vs. 87.6%; P=0.003, respectively), as well as freedom from TLR rates (82.3% vs. 81.2% vs. 89.9%; P=0.04). CONCLUSIONS: In the drug eluting era, the endovascular first approach of BTK lesions based on POBA with bailout spot stenting is feasible, affordable but most importantly remains effective and should be the first line strategy until the place of drug eluting stents is precisely defined.

Sense and nonsense of bare metal stents below the knee.

INTRODUCTION: Critical limb ischemia (CLI) is increasingly present in daily practice, and diabetes is responsible for a preferential below the knee (BTK) localization of the disease. The objective was to determine if there is still a sense to BTK implantation of bare metal stents (BMSs) in CLI patients in the era of drug eluting strategies. EVIDENCE ACQUISITION: An extensive review of the literature was carried out over the last 15 years on the use of BMSs in BTK revascularization based on a PubMed (Medline), EMBASE and PubMed Central search. EVIDENCE SYNTHESIS: The Chromis Deep® (Invatec, Roncadelle, Italy) was the first dedicated stent in BTK lesions, followed by passive coated BMSs developed in an attempt to inhibit platelets deposition. Comparative results showed no advantage of primary BMS implantation over peripheral transluminal angioplasty (PTA) in improving primary patency rates, Rutherford classification or wound healing and the place of BMSs was restricted to bailout spot stenting. The fear of patency loss in connection with possible stent fractures led to an interest towards nitinol stents, but results were disappointing, especially in patients with severely calcified lesions. Drug-eluting stents (DESs) were then developed and showed better long-term primary patency, restenosis and freedom from target lesion revascularization (TLR) rates, even in long calcified lesions against BMS or drug eluting balloons (DEB). However, limb salvage and wound healing rates were not significantly improved. CONCLUSIONS: Primary BMS implantation showed no advantage over PTA and as of today DES trials have not shown enough clinical or economic benefit. Thus, BMSs are recommended over DESs, and only as a bailout strategy in case of flow limiting dissection or recoil. Quality trials assessing long-term clinically relevant outcomes, evolution in stents designs and vessel preparation could lead to a change in those recommendations.

Early cannulation of the Flixene™ arteriovenous graft.

PURPOSE: The aim of this review was to search for evidence of the efficiency of early cannulation of the Flixene™ (Maquet-Atrium Medical, Hudson, NH, USA) arteriovenous graft (AVG) in the current literature and to assess its patency and complication rates. METHODS: Searches in Pubmed, Medline, Embase and the Cochrane Library were performed using the following specific search terms: early cannulation AVG and/or Flixene™ graft. The primary outcomes were mean time to first cannulation and patency rates at 12 months. Secondary outcomes were complications. RESULTS: Six studies reporting outcomes in a total of 260 procedures were included in this review. The median delay from intervention to first cannulation was documented in four studies and was less than 3 days. Primary assisted patency at 12 months ranged from 45% to 53% in the four documented series. In five studies, documented secondary patency at 12 months ranged from 63% to 92%. Two studies compared outcomes between traditional and Flixene™ grafts: one study reported significantly (p<0.01) improved one-year patency using the Flixene™ graft, the two studies did not report significant differences in complication rates between both groups. The rate of infection and pseudo-aneurysm formation ranged from 0 to 11% and 0 to 6%, respectively. CONCLUSIONS: This review shows that early cannulation of the Flixene™ graft within 3 days following its implantation is feasible with one-year patency and complication rates equivalent to those of conventional grafts which can be cannulated only after 2 weeks.

Hemodynamic Conditions may Influence the Oversizing of Stent Grafts and the Postoperative Surveillance of Patients with Ruptured Abdominal Aortic Aneurysm Treated by EVAR.

BACKGROUND: To report the causes of second rupture in patients treated with a stent graft for ruptured abdominal aortic aneurysm (rAAA). CASE REPORT: A 69-year-old man was admitted for abdominal pain and hypovolemic shock 22 months after endovascular exclusion of an rAAA with an aortomonoiliac stent graft and a crossover bypass despite normal duplex ultrasound and sac shrinkage at 1 year. During emergent laparotomy, a type IA endoleak was discovered and the aortomonoiliac stent graft was explanted. A Dacron bypass was interposed between the infrarenal aorta and the iliac extension stent graft. CONCLUSIONS: Considering the literature, this report has 3 implications for the endovascular treatment of rAAA. First, 30% oversizing is preferable to 15% when treating an rAAA assessed by computed tomography angiography (CTA) performed during permissive hypotension. Second, the surveillance program should rely on CTA and not on a duplex examination to detect any endoleaks or migration. Finally, partial stent graft explantation is a valid option for decreasing aortic clamping time.

The Antegrade Approach Using Transbrachial Access Improves Technical Success Rate of Endovascular Recanalization of TASC C-D Aortoiliac Occlusion in Case of Failed Femoral Access.

BACKGROUND: Technical success rates of endovascular recanalizations for Trans-Atlantic Inter-Society Consensus (TASC) C-D chronic occlusions are highly variable and depend on the characteristics and sites of the lesions as well as on the operator experience. We hypothesized that an antegrade approach via transbrachial access could improve the technical success rate of endovascular treatment of TASC C-D occlusions in case of failed femoral access. METHODS: From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac occlusion were treated with an endovascular-first approach. Recanalization was first attempted using a femoral access. In case of failure, an antegrade approach using a transbrachial access was performed. Patient characteristics, anatomic details, procedural data, and immediate outcomes were prospectively recorded. RESULTS: During the study period, 73 patients (99 arteries) were included. Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery occlusions and 16 external iliac artery (EIA) occlusions involving the common femoral or the internal iliac arteries. Forty-six (63%) patients had TASC D occlusions including 10 aortoiliac occlusions, 31 unilateral occlusions of both common and EIAs, and 5 bilateral EIA occlusions. Technical success with femoral access has been obtained in 53 arteries. An antegrade approach via transbrachial access allowed technical success in the other arteries, except in 7 arteries. Overall technical success rate was 93%, and 2 complications were related to the brachial accesses including 1 thrombosis and 1 pseudoaneurysm both requiring a reintervention. CONCLUSIONS: Brachial access for TASC C-D aortoiliac chronic occlusion improves the technical success rate without the need for reentry devices.

Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis.

BACKGROUND: The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients. METHODS: All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups. RESULTS: During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups. CONCLUSION: During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.

Use of the Flixene vascular access graft as an early cannulation solution.

OBJECTIVE: The primary end points of this study were safety and efficacy of early cannulation of the Flixene graft (Maquet-Atrium Medical, Hudson, NH). Secondary end points were complications and patency. METHODS: This is a prospective single-center nonrandomized study. Study data included patient characteristics; history of vascular access; operative technique; interval between implantation and initial cannulation; complications; and patency at 1 month, 3 months, and every 6 months. Patency rates were estimated by the Kaplan-Meier method. RESULTS: Between January 2011 and September 2013, a total of 46 Flixene grafts were implanted in 44 patients (27 men) with a mean age of 63 years. The implantation site was the upper arm in 67% of cases, the forearm in 11%, and the thigh in 22%. Seven grafts were never cannulated during the study period. Of the remaining 39 grafts, 32 (82%) were successfully cannulated within the first week after implantation, including 16 (41%) on the first day. The median interval from implantation to initial cannulation was 2 days (interquartile range, 1-3 days). The median follow-up was 223.5 days (interquartile range, 97-600 days). Five hematomas occurred, but only one required surgical revision. Primary assisted and secondary patency rates were 65% and 86%, respectively, at 6 months and 56% and 86%, respectively, at 1 year. CONCLUSIONS: This study suggests that cannulation of the Flixene graft within 1 week after implantation is safe and effective. Early cannulation avoids or shortens the need for a temporary catheter. One-year patency rates appeared to be comparable to those achieved with conventional grafts, but long-term follow-up and randomized controlled studies will be needed to confirm this finding.

Don't trust a vein graft to treat carotid aneurysm in patients with Behçet disease.

Extracranial carotid aneurysm is a rare vascular manifestation of Behçet disease. To our knowledge, only 32 cases have been reported. This article presents a complex case of a 28-year-old man who was first treated by vein graft reconstruction. At 12 months of follow-up, a nonanastomotic false aneurysm of the vein graft occurred and was treated by interposition of prosthetic graft. Two months later, an anastomotic pseudoaneurysm between the two grafts was excluded by two stent grafts. Based on our experience and a review of the literature, we compared the outcomes of prosthetic and autologous vein reconstructions and discussed the role of carotid ligation and immunosuppressive treatment.

A retrospective multicenter study of endovascular treatment of popliteal artery aneurysm.

PURPOSE: To evaluate the feasibility of endovascular exclusion of popliteal artery aneurysm (PAA) using stent grafts. METHODS: The clinical data of all patients who underwent endovascular exclusion of PAA at three French vascular departments between December 1999 and December 2007 were retrospectively analyzed. Outcome measures included graft patency and endoleak. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. RESULTS: A total of 57 PAA in 50 patients (48 men; mean age, 72 +/- 11 years; range, 57-96 years) were treated. The type of stent graft used was Hemobahn/Viabahn in 42 (73.7%) cases, Wallgraft in 14 (24.5%) and Passager in one. The mean duration of hospitalization was 5 +/- 1.8 days (range, 3-11 days). No patients were lost from follow up (mean, 36 +/- 19.4 months; range, 6-96 months). Nine (16%) occlusions and six (10.5%) endoleaks occurred. The global limb salvage rate was 96.5% (55 of 57 PAA). Kaplan-Meier estimates for primary and secondary patency were 85.8% and 87.5% at one year and 82.3% and 87.5% at three years. CONCLUSIONS: Endovascular treatment of PAA is feasible in selected patients. The main determinants of success are suitable aneurysm anatomy and dual antiplatelet postoperative therapy. Further studies are warranted to determine long-term outcomes of endovascular repair for PAA.