Experiencia multicéntrica con la endoprótesis de relay™ bolton con escotadura distal: Un avance en la cirugía endovascular de la aorta torácica / Multicenter experience with distal scallop relay™ bolton endograft: A step forward in thoracic endografting

La corrección endovascular se ha propuesto como una alternativa efectiva a la reparación abierta para el tratamiento de varias patologías de aorta. La migración craneal es una de las cuestiones críticas relativas a durabilidad a largo plazo. Las endoprótesis hechas a medida fueron propuestas para mejorar la durabilidad y la fijación distal de cruzar el diafragma. El objetivo de ese trabajoes evaluar la viabilidad técnica y experiencia con los dispositivos hechos a medida usando la plataforma de la endoprótesis torácica Relay™ Bolton como una alternativa para el cuello distal de configuración subóptima, para mejorar la fijación distal y sellado en el cuello corto distal. Métodos: Desde enero de 2006 a junio 2009, 57 pacientes (40 hombres), han sido tratados en Europa con la endoprótesis de torácica Relay™ Bolton sob medidia. Cuarenta y cinco pacientespresentaron aneurisma de aorta torácica, nueve presentaron disección Tipo B, y tres tenían pseudoaneurisma. Resultados: Hubo despliegue con éxito en todos los casos, salvo una rotación parcial en una anatomía extremadamente tortuosa. Se logró suceso técnico en 96,4%. Buen sellado y ningún caso de mortalidad, paraplejía o embolización visceral fueron observados. En un seguimiento mediode 6 meses no se registraron complicaciones. Conclusiones: La endoprótesis de Relay™ Bolton con escotadura distal representa una alternativa viable para cuellos cortos distal. Este enfoque aumenta la aplicabilidad de endoprótesis y mejora la durabilidad de las endoprótesis torácicas en el cuello corto distal.

A correção endovascular foi proposta como uma alternativa efetiva para a cirurgia de reparação aberta para o tratamento de várias patologias da aorta. A migração cranial é uma das questões críticas relativas à durabilidade a longo prazo. As endopróteses sob medida foram propostas para melhorar a durabilidade e a fixação distal de cruzar o diafragma. O objetivo desse trabalho é avaliar a viabilidade técnica e experiència com os dispositivos sob medida, usando a plataforma da endoprótese torácica Relay™ Bolton como uma alternativa para o colo distal de configuração subóptima, para melhorar a fixação distal e fechamento completo do colo curto distal. Métodos: De janeiro de 2006 a junho de 2009, 57 pacientes (40 homens), foram tratados na Europa com a endoprótese torácica de Relay™ Bolton sob medida. Quarenta e cinco pacientes apresentaram aneurisma de aorta torácica, nove apresentaram dissecção Tipo B e três, pseudoaneurisma. Resultados: Constatou-se êxito em todos os casos, exceto uma rotação parcial em uma anatomia extremamente tortuosa. Obteve-se sucesso técnico em 96,4%. Bom fechamento completo e não apresentou nenhum caso de mortalidade, paraplegia ou embolização visceral. Em um acompanhamento médio de 6 meses não foram registradas complicações. Conclusões: A endoprótese de Relay™ Bolton com entalhe distal representa uma alternativa viável para colo curto distal. Este enfoque aumenta a aplicabilidade da endoprótese e melhora a durabilidade das endopróteses torácicas no colo curto distal.

Thoracic endografting has been proposed as an effective alternative to open repair to treat several aortic pathologies. Cranial migration is one of the critical issues concerning long term durability. The scalloped thoracic endograft was proposed to improve distal sealing and fixation crossing the diaphragm. The objective of this study was to evaluate technical feasibility and experience with a custom-made scalloped thoracic endograft using the Relay platform (Bolton Medical, Sunrise, FL) in selected cases. From January 2006 to June 2009, 57 patients (40 men) were treated in Europe with a customized distal scalloped thoracic endograft. Fortyfive patients presented with thoracic aortic aneurysm, nine presented with Type B dissection, and three had a pseudoaneurysm. Successful and accurate deployment was achieved in all cases except one partial rotation in an extremely tortuous anatomy. Technical success was achieved in 96.4%. Good sealing and no mortality, paraplegia, or visceral embolization were observed. At a mean follow-up of 6 months, no complications were registered. The Relay endograft with the distal scallop represents a feasible alternative for distal short necks. This approach may increase the applicability and durability of the endograft in short distal necks.

Is femorofemoral crossover bypass an option in claudication?

BACKGROUND: Since the introduction of femorofemoral crossover bypass by Freeman and Leeds in 1952 (Calif Med 1952;77:229-233), it has been used as an alternative to anatomic surgical reconstruction for unilateral iliac disease. The objective of this review was to summarize results on femorofemoral crossover bypass surgery for disabling claudication from the most recent studies. METHODS: All publications describing series or registries of patients treated for claudication by femorofemoral crossover bypass were sought through computerized searches of MEDLINE database. Main outcome measures considered for comparisons were primary and secondary patency rates; mortality; complications such as infection, amputation, or loss of function; improving walking distance or ankle-brachial index; Quality of Life (QoL) variations. RESULTS: Six studies met the inclusion criteria. In the considered series, primary interventions were performed with Dacron, polytetrafluoroethylene (PTFE) or autologous vein graft. The number of patients treated for claudication ranged from 66 to 211 in the considered series. One-year primary patency rates ranged from 71.6 to 96%. In two series, 5-year primary patency rates reported were 71.8 and 72%, and in one series secondary patency rate at 5 years was 89%. CONCLUSIONS: The femorofemoral crossover bypass in patients with disabling claudication caused by unilateral iliac artery disease is still a valuable alternative to aortofemoral grafting in those who are not suitable for endovascular repair or major abdominal surgery, or have poor general (age, coronary artery disease, chronic obstructive pulmonary disease (COPD), etc.) or local (hostile abdomen, sepsis, porcelain aorta) conditions, presenting in recent series with good long-term patency and low complication rates.

Experience with a scalloped thoracic stent graft: a good alternative to preserve flow to the celiac and superior mesenteric arteries and to improve distal fixation and sealing.

Thoracic endografting has been proposed as an effective alternative to open repair to treat several aortic pathologies. Cranial migration is one of the critical issues concerning long-term durability. The scalloped thoracic endograft was proposed to improve distal sealing and fixation crossing the diaphragm. The objective of this study was to evaluate technical feasibility and experience with a custom-made scalloped thoracic endograft using the Relay platform (Bolton Medical, Sunrise, FL) in selected cases. From January 2006 to June 2009, 57 patients (40 men) were treated in Europe with a customized distal scalloped thoracic endograft. Forty-five patients presented with thoracic aortic aneurysm, nine presented with type B dissection, and three had a pseudoaneurysm. Successful and accurate deployment was achieved in all cases except one partial rotation in an extremely tortuous anatomy. Technical success was achieved in 96.4%. Good sealing and no mortality, paraplegia, or visceral embolization were observed. At a mean follow-up of 6 months, no complications were registered. The Relay endograft with the distal scallop represents a feasible alternative for distal short necks. This approach may increase the applicability and durability of the endograft in short distal necks.

Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results.

Endovascular correction of aorta thoracic pathology in renal transplant patients is a challenge. The aim of this study is to review early and intermediate-term results of endovascular repair of thoracic aorta pathology in patients with functioning previous renal transplant. The records of 81 patients submitted to a thoracic endograft between 2003 and 2008 were reviewed. Five patients with six previous renal transplants were submitted to six thoracic endografting. Two were women. The mean age was 55.4 years (range, 43-75 years). There were two patients with type B aortic dissection, one penetrating ulcer, one aneurysm of the aortic arch and one descending thoracic aorta aneurysm. Three patients underwent hybrid procedures: two total supra-aortic transpositions and one partial transposition of visceral trunks. Three patients presented postoperative complications. There were two cases of pneumonia, one acute limb ischemia and a stroke, with an early death. The mean follow-up was 16.2 months (range, 1-40 months). In this period all patients sustained renal function without any related complication. Despite the fact that it is a small series, in our clinical experience, endovascular thoracic aortic surgery can be performed as an alternative to open correction, in high-risk patients with a previous working renal transplant.

Endovascular treatment of acute traumatic thoracic aortic injuries: a retrospective analysis of 20 cases.

OBJECTIVE: We report our 10-year experience in the endovascular treatment of acute traumatic thoracic aorta rupture at the Hospital Clinic. METHODS: We reviewed 20 patients with an acute traumatic thoracic aorta lesion treated with a thoracic endograft between August 1997 and July 2007. All patients had multi-trauma resulting from high-velocity accidents or accidents with great impact. The diagnosis of aortic injury was made on a clinical basis and conventional imaging, confirmed by computed tomographic angiography. The following parameters were studied: age, sex, type and site of the lesion, type of endovascular graft, endovascular operation time, length of stay in the intensive care unit, length of stay in the hospital, immediate and perioperative complications, and mortality. Follow-up data were recorded, consisting of clinical visits, computed tomographic angiography, and plain chest radiographs at regular intervals (3, 6, and 12 months and every subsequent year). The mean follow-up was 58 months. RESULTS: All endovascular procedures were technically successful, and the mean operating time for the endovascular procedure was 74 minutes (range, 55-130 minutes). We recorded an external iliac lesion during the procedure as an unique immediate complication, and it was corrected by an iliofemoral bypass. The only perioperative death (perioperative mortality rate of 5%) was unrelated to the aortic rupture or stent placement. There was no intervention-related mortality during the follow-up. Postoperative data showed no severe endovascular graft- or procedure-related morbidity. We recorded 2 cases of stent fracture, diagnosed by chest radiograph and computed tomographic angiography, without clinical impact or signs of endoleak. CONCLUSION: The short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are promising, especially when compared with open surgical treatment, indicating that endovascular therapy is preferable in patients with multi-trauma and traumatic ruptures of the thoracic aorta. Nevertheless, long-term follow-up data are necessary to assess the overall durability of this procedure, considering the young age of these patients. The long-term follow-up results will determine whether endovascular treatment should replace open surgery as first-line therapy in thoracic aortic injuries.

Hybrid procedures for complex aortic pathology: initial experience at a single center.

INTRODUCTION AND OBJECTIVES: To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta. METHODS: The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in two groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid-carotid bypasses, 12 carotid-subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3+/-1.3 (range, 62-73) years and in group B, 71.5+/-5.0 (range, 68-74) years. RESULTS: The mean hospital stay was 18+/-7.1 days (range, 5-35) and 12+/-8.2 days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the two groups, respectively. CONCLUSIONS: The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area.

Procedimientos híbridos para patología aórtica compleja. Experiencia inicial de un centro / Hybrid procedures for complex aortic pathology: initial experience at a single center

Introducción y objetivos. Revisar la experiencia de nuestro centro con técnicas híbridas para tratamiento de aneurismas complejos de la aorta torácica. Métodos. Se revisaron retrospectivamente los registros prospectivos de 41 pacientes (40 varones) con aneurismas torácicos que comprometían ramas supraaórticas o viscerales sometidos a procedimientos híbridos, en el periodo 1998-2007. Todos los pacientes fueron clasificados como ASA IV. Éstos fueron divididos en dos grupos: grupo A, 32 pacientes con aneurismas que involucraban el arco aórtico y sus ramas (2 sustituciones de aorta ascendente, 1 reparación de arco, 13 derivaciones carótido-carotídeas, 12 derivaciones carótido-subclavias y 4 transposiciones totales de troncos supraaórticos); grupo B, 9 pacientes con aneurismas toracoabdominales (4 transposiciones parciales y 5 totales de troncos viscerales). En el grupo A la media de edad fue 69,3 ± 1,3 (intervalo, 62-73) años, y en el grupo B fue 71,5 ± 5,0 (intervalo, 68-74) años. Resultados. La media de estancia hospitalaria fue 18 ± 7,1 días (intervalo, 5-35) y 12 ± 8,2 días (intervalo, 2-15) para los grupos A y B, respectivamente. La mortalidad global fue del 12,2% (el 3,4 y el 44,4% para los grupos A y B, respectivamente), con morbilidad neurológica del 3,4 y el 11,1%, respectivamente. Conclusiones. Los resultados de nuestros tratamientos híbridos en la zona del arco aórtico son comparables con los de la cirugía convencional. Las reparaciones toracoabdominales con revascularización completa de las ramas viscerales se asocian a mortalidad elevada. Así, la cirugía híbrida es una alternativa válida para pacientes de alto riesgo que no precisen la revascularización completa del área visceral (AU)

Introduction and objectives. To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta. Methods. The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in 2 groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid–carotid bypasses, 12 carotid–subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3 (1.3) (range, 62–73) years and in group B, 71.5 (5.0) (range, 68-74) years. Results. The mean hospital stay was 18 (7.1) days (range, 5-35) and 12 (8.2) days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the 2 groups, respectively. Conclusions. The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area (AU)

Endovascular occlusion of a common iliac artery aneurysm after open repair of an abdominal aortic aneurysm.

Endovascular therapy is a safe alternative to treat the late complications of open aortic surgery. Here we report the endoluminal treatment of a recurrent common iliac aneurysm. A 68-year-old man, who submitted five years previously to an aorto bifemoral in order to exclude a juxta renal aortic aneurysm, developed a recurrent aneurysm of the left common iliac artery. He underwent an occlusion of the external iliac artery with a self-expandable nitinol mesh occlusion device and the aneurysm was embolized with detachable coils, with a good outcome. Endoluminal therapy does not expose patients to elevated risks, and may be indicated in selected cases to treat the complications of open surgery.

Endovascular correction of a distal re-entry in an abdominal aorta dissection.

The re-entries are still a problem for the endovascular treatment of aortic dissections. A 60-year-old man was treated for an abdominal aortic dissection using aortic monoiliac endograft until the left iliac external artery and a femoro-femoral bypass with occlusion of the right common iliac artery and the left hypogastric artery. In his third year of follow-up, a re-entry tear in the right hypogastric ostium was diagnosed with pressurization of the aortic and common iliac aneurysmatic sac, that required correction. A self-expandable covered stent in a 'U' configuration was implanted, connecting the right external and internal iliac arteries, with preservation of the pelvic circulation, and exclusion of the aneurysmatic sac. In conclusion, the use of a flexible stent graft is a safe alternative, and simplifies some procedures in complex circumstances.