Feasibility of the Application of Holographic Augmented Reality in Endovascular Surgery Using Microsoft HoloLens Head-Mounted Display.

OBJECTIVES: Advances in virtual, augmented (AR) and mixed reality have led to the development of wearable technologies including head mounted displays (HMD). The aim of this study was to investigate the feasibility to use HMD during endovascular surgery. METHODS: We propose an adaptation of AR-HMD using Microsoft HoloLens. Software was developed to enable visualization of the vascular system during endovascular procedures. A video was performed to present an overview of the device and show its use in real conditions. RESULTS: The device allowed a successful visualization of perioperative angiography during peripheral angioplasty, carotid angioplasty and aortic aneurysm endovascular repair. The device was operated on voice command, preserving the environment sterility. CONCLUSION: This video illustrated the feasibility of the application of holographic AR during endovascular intervention and brings perspectives to use artificial-intelligence derived tools for image-guided surgery.

Applications of Head-Mounted Displays and Smart Glasses in Vascular Surgery.

OBJECTIVES: Advances in virtual, augmented and mixed reality have led to the development of wearable technologies including head mounted displays (HMD) and smart glasses. While there is a growing interest on their potential applications in health, only a few studies have addressed so far their use in vascular surgery. The aim of this review was to summarize the fundamental notions associated with these technologies and to discuss potential applications and current limits for their use in vascular surgery. METHODS: A comprehensive literature review was performed to introduce the fundamental concepts and provide an overview of applications of HMD and smart glasses in surgery. RESULTS: HMD and smart glasses demonstrated a potential interest for the education of surgeons including anatomical teaching, surgical training, teaching and telementoring. Applications for pre-surgical planning have been developed in general and cardiac surgery and could be transposed for a use in vascular surgery. The use of wearable technologies in the operating room has also been investigated in both general and cardiovascular surgery and demonstrated its potential interest for image-guided surgery and data collection. CONCLUSION: Studies performed so far represent a proof of concept of the interest of HMD and smart glasses in vascular surgery for education of surgeons and for surgical practice. Although these technologies exhibited encouraging results for applications in vascular surgery, technical improvements and further clinical research in large series are required before hoping using them in daily clinical practice.

Endovascular aneurysm sealing as an alternative for the treatment of failed endovascular aneurysm repair.

OBJECTIVE: The Nellix EndoVascular Aneurysm Sealing (EVAS) system has offered a novel approach in the treatment of abdominal aortic aneurysm (AAA). While it is currently indicated as a primary procedure in patients with infrarenal AAA with suitable anatomy according to the indications for use, a few studies aimed to address its potential interest in failed endovascular aneurysm repair (EVAR). The aim of this systematic review was to analyze the postoperative outcomes of patients with prior EVAR who underwent EVAS. DESIGN OF THE STUDY: A literature search was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines in May 2019 and included patients with prior EVAR who underwent EVAS. The publications had to report at least one of the basic postoperative outcomes (technical success rate, all-cause complications, mortality, length of in-hospital stay, length of stay in intensive care unit, the need of re-intervention). RESULTS: Eleven studies fulfilled the inclusion criteria, for a total of 46 patients. EVAS was used to treat endoleaks in 45 cases (97.8%): 29 type Ia endoleaks (63%), 6 type IIIa endoleaks (13%), and 10 type IIIb endoleaks (21.7%). Standard EVAS procedure was performed in 21 patients (45.7%), and 25 patients (54.3%) had chimney-EVAS. The technical success was achieved in all the studies. Two patients (4.9%) died during the 30-day postoperative period, but no aneurysm-related mortality was reported. The presence of endoleaks was reported in five patients (9.8%) during the follow-up. CONCLUSION: The results suggest the safety and the efficiency of EVAS in the treatment of complications following EVAR including type Ia, type IIIa, and type IIIb endoleaks. Further studies on larger cohorts and longer follow-up periods are required to confirm the interest of EVAS in the endovascular management of failed EVAR.

A fully automated pipeline for mining abdominal aortic aneurysm using image segmentation.

Imaging software have become critical tools in the diagnosis and the treatment of abdominal aortic aneurysms (AAA). The aim of this study was to develop a fully automated software system to enable a fast and robust detection of the vascular system and the AAA. The software was designed from a dataset of injected CT-scans images obtained from 40 patients with AAA. Pre-processing steps were performed to reduce the noise of the images using image filters. The border propagation based method was used to localize the aortic lumen. An online error detection was implemented to correct errors due to the propagation in anatomic structures with similar pixel value located close to the aorta. A morphological snake was used to segment 2D or 3D regions. The software allowed an automatic detection of the aortic lumen and the AAA characteristics including the presence of thrombus and calcifications. 2D and 3D reconstructions visualization were available to ease evaluation of both algorithm precision and AAA properties. By enabling a fast and automated detailed analysis of the anatomic characteristics of the AAA, this software could be useful in clinical practice and research and be applied in a large dataset of patients.

Endovascular Aneurysm Sealing and Chimney Endovascular Aneurysm Sealing in the Treatment of Type Ia and Type III Endoleaks After Endovascular Aneurysm Repair.

BACKGROUND: The aim of this study was to report the treatment of type Ia and type III endoleaks after endovascular aneurysm repair (EVAR) or chimney EVAR using endovascular aneurysm sealing (EVAS) and chimney EVAS. METHODS: Ten consecutive patients who underwent the EVAS procedure to treat endoleaks after EVAR were retrospectively included between July 2015 and July 2017. Technical success of EVAS was defined as a successful sealing of the Nellix endograft with visceral vessel patency on intraoperative completion angiography. RESULTS: The median time between EVAR and EVAS procedure was 41.5 months (29-81.8). Eight patients had an elective procedure, whereas 2 were treated in emergency. Chimney endografts were placed during the EVAS procedure in 4 patients, whereas classic EVAS was performed for the other 6 patients. The median procedural time was 222.5 min (138.8-418.8). The technical success was achieved for all patients. The median length of stay after EVAS was 7 days (6.8-14). No death related to abdominal aortic aneurysms or vascular complications were reported for a median follow-up duration of 13.5 months (6.3-25.5). A reintervention was required for 2 patients who developed persistent type II and type Ia endoleaks, which were successfully treated using an embolization procedure. CONCLUSIONS: EVAS and chimney EVAS in the treatment of type Ia and type III endoleaks after EVAR and chimney EVAR are technically feasible. Short-term follow-up suggests that the procedure is a safe and efficient therapeutic alternative to manage disabled EVAR.

Impact of Polar Renal Artery Coverage on Early Renal Function after Chimney Endovascular Aortic Aneurysm Repair.

PURPOSE: To evaluate impact of polar renal artery coverage on early renal function after chimney endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Consecutive patients who underwent chimney EVAR for treatment of asymptomatic juxtarenal abdominal aortic aneurysm were retrospectively included. Estimated glomerular filtration rate (eGFR) was recorded before the intervention and at 1-, 5-, 7-, and 30-day follow-up. Patients without a polar renal artery were compared with patients with an uncovered polar renal artery and patients with a polar renal artery covered by the endograft. RESULTS: Among 76 patients who underwent chimney EVAR, 15 (19.7%) had a polar renal artery. Four patients (5.3%) had an uncovered polar renal artery and 11 (14.5%) had a covered polar renal artery. The median polar renal artery diameter was 3.3 mm (interquartile range, 2.2-3.8 mm). Preoperative eGFR was similar between the 3 groups (65.5 mL/min/1.73 m2, 61.1 mL/min/1.73 m2, and 53 mL/min/1.73 m2, P = .488). For the 3 groups, postoperative eGFR tended to decrease after the intervention compared with preoperative values, and this decrease reached statistical significance at 5 days and 30 days in patients without a polar renal artery. No significant difference was observed between the 3 groups at any time point. No correlation was observed between the diameter of the covered polar renal artery and eGFR changes postoperatively. CONCLUSIONS: Polar renal artery coverage during chimney EVAR does not significantly impair early renal postoperative function, suggesting the safety of the procedure.

Diabetes mellitus is not associated with worse vascular outcome following percutaneous transfemoral transcatheter aortic valve implantation.

Background: Transcatheter aortic valve implantation (TAVI) is an alternative to open surgical aortic valve replacement and the impact of diabetes on vascular outcomes is worth of investigation. The aim of our study was to determine if diabetic patients had distinct pre-operative characteristics compared to non-diabetics and to evaluate the impact of the disease on vascular outcomes.Methods: Four hundred consecutive patients who underwent TAVI with percutaneous transfemoral access were retrospectively included. Vascular outcomes were classified according to the Valve Academic Research Consortium 2 classification.Results: Seventy-eight (19.5%) patients were diabetics. Compared to non-diabetics, diabetic patients were younger and had significantly higher body mass index (29.7+/- 0.7 kg/m2 vs 26.8+/- 0.3, p < .0001), higher proportion of associated dyslipidemia (34.6% vs 11.5%, p < .0001) and arterial hypertension (60% vs 38.2%, p = .0009). Anatomical characteristics of the vascular access and procedural characteristics did not differ among the groups. No significant difference was observed in the incidence of major and minor vascular complications and 30-day post-operative mortality between diabetic and non-diabetic patients (2.6% vs 1.9%, p = .6916).Conclusion: Diabetes is not associated with worse vascular outcome following TAVI suggesting that the vascular access can be managed safely in these patients.

Endovascular Aneurysm Sealing of a Collapsed and Thrombosed Aortic Stent-Graft With Renovisceral Chimney Stent-Grafts.

PURPOSE: To report the use of the Nellix endovascular aneurysm sealing (EVAS) system in the management of proximal stent-graft collapse associated with thrombosis following endovascular aneurysm repair (EVAR). CASE REPORT: A 76-year-old man was admitted for proximal collapse of an aortic extension following bifurcated AFX stent-graft implantation associated with chimney grafts in both renal arteries and the superior mesenteric artery 1 month prior. Imaging identified thrombosis of the aortic stent-graft and the iliac limbs. A Nellix EVAS was placed into the AFX stent-graft to recanalize the aneurysm lumen and address the aortic thrombosis. There was no endoleak, and the renovisceral chimney stent-grafts remained patent over a follow-up of 25 months. CONCLUSION: While further studies are required to generalize its use, EVAS appears to be feasible in the management of aortic stent-graft collapse.

Surgical Management of Percutaneous Transfemoral Access to Minimize Vascular Complications Related to Transcatheter Aortic Valve' Implantation.

Transcatheter aortic valve implantation (TAVI) is associated with substantial rates of vascular complications. The aim of our study is to describe the surgical management of percutaneous transfemoral access by a vascular surgeon and to report the 30-day postoperative vascular complications and mortality. Perioperative procedures to manage the femoral access site were recorded retrospectively from 220 consecutive patients who underwent TAVI. Postoperative vascular complications related to the main access were categorized according to the Valve Academic Research Consortium 2 classification. Perioperative procedures related to vascular access were performed for 56 (25.4%) patients: 6 patients required open surgical repair, 48 patients underwent endovascular stenting, and 2 patients had both procedures. The all-cause mortality was 3.6%, but no death related to a vascular complication was reported during the 30-day postoperative follow-up period. Ten (4.5%) patients developed postoperative hematomas; 2 (0.9%) of them were retroperitoneal and led to major bleeding requiring an unplanned surgical intervention. Our study underlines the utility of a multidisciplinary approach to manage the percutaneous access in TAVI for managing postoperative vascular complications.

A 7-Year Single-Center Experience of Transfemoral TAVI: Evolution of Surgical Activity and Impact on Vascular Outcome.

Transcatheter aortic valve implantation (TAVI) has become a well-established alternative to open surgery to treat aortic stenosis. We describe our 7-year TAVI experience using transfemoral access and identity changes in surgical activity and evaluate its impact on postoperative vascular outcomes. Consecutive patients (N = 340) who underwent TAVI with percutaneous transfemoral access were retrospectively included and divided into 4 quartiles according to the date of intervention. Vascular outcomes were classified according to the Valve Academic Research Consortium 2 classification. The number of patients who underwent transfemoral TAVI increased over time and their clinical characteristics evolved, with a lower Society of Thoracic Surgeons score and less comorbidities. The material used evolved and TAVI could be performed despite higher iliac calcification and tortuosity scores. With experience, the procedural time, the postoperative length of stay at hospital, and the 30-day postoperative mortality significantly decreased. No significant change was observed for vascular outcome, except for minor hematoma. We witnessed an increase in transfemoral TAVI procedure, with changes in clinical and procedural characteristics associated with an improvement in postoperative outcomes.

Results of the French Multicentric Study of ANACONDA™ Fenestrated Endografts in the Treatment of Complex Aortic Pathologies (EFEFA Registry).

BACKGROUND: Most of the experience on fenestrated endovascular aneurysm repair involves the custom-made Zenith® endograft (Cook). The fenestrated Anaconda® endograft (Vascutek) was introduced with the potential advantages of complete repositioning and lack of stent material on the main aortic body for more versatility. However, few data are available. Our objective was to assess its mid-term results in the treatment of complex aortic aneurysms. METHODS: Consecutive patients treated with the custom-made fenestrated Anaconda endograft in France and the Principality of Monaco, from December 2010 to October 2015, were included. RESULTS: Eighty-six patients were included over 16 centers (82 men, mean age 73.4 ± 8.1 years, 16 (18.6%) symptomatic aneurysms). The repositioning system was used in 68 cases (79.1%). Two hundred ninety-two visceral/renal vessels were targeted, with a mean number of 3.4 ± 0.6 target vessels/patient and a successful reconstruction in 99.3% of the cases (290/292 vessels). Perioperative technical success was achieved in 86.0% (74/86 patients). In-hospital and 30-day mortality rates were 3.5% (3 patients) and 7.0% (6 patients), respectively. At 12 and 24 months, estimated overall survival rate was 88.3% and 85.2%, target vessel's patency rate was 97.2% and 96.3%, and freedom from aneurysm-related reintervention rate was 96.3% and 88.0%, respectively. At 24 months, there were 7 type II endoleaks (12.7%) and a significant reduction in aneurysm maximum transverse diameter in 70.4%. Five limb occlusions occurred at 1-year and 1 at 2-year follow-up (7.0%). CONCLUSIONS: The fenestrated Anaconda stent-graft system offers acceptable technical success rates, mid-term efficacy, and durability with respect to aneurysm sac regression, target vessel patency, overall mortality, and reintervention rates. Long-term results are still awaited, until then, the rate of graft limb occlusion is of concern and should be further investigated, especially in case of particularly complex aortic anatomies.

Angiographic Analysis of Vascular Integrity After Percutaneous Closure Using Prostar XL Device During Transcatheter Aortic Valve Implantation.

INTRODUCTION: Percutaneous closure devices are commonly used to achieve hemostasis during endovascular procedures including transcatheter aortic valve implantation (TAVI). The aim of our study was to investigate the quality of the percutaneous femoral arterial closure by Prostar XL device using a systematic peroperative angiographic control at the end of TAVI procedure. MATERIALS AND METHODS: Two hundred seventeen consecutive patients (mean age: 84 [6.5]; 112 women and 105 men) undergoing TAVI with percutaneous transfemoral access were prospectively registered in our center. Preoperative computed tomography scan was performed, and mean femoral vessel diameter was 7.9 (0.9) mm. At the end of TAVI intervention, the hemostasis was systematically achieved using the percutaneous closure device Prostar XL, without selection of patients based on anatomical criteria. An angiography with front and oblique views was performed to evaluate the quality and the safety of the closure device. Success of the percutaneous closure was defined as the absence of hemorrhage and the restitution of the arterial anatomy. Complications related to the percutaneous closure were classified as stenosis, dissection at the puncture site, suture failure, misplacement, or persistent bleeding. RESULTS: Twenty-three (10.6%) patients had complications related to arterial percutaneous closure-14 (60.8%) stenosis, 6 (26.1%) persistent bleeding, and 1 (4.3%) dissection. These lesions were accessible to endovascular treatment via a crossover procedure. One (4.3%) suture failure and 1 (4.3%) misplacement of the device, with a puncture site created above the femoral arch, were reported. The patient developed a retroperitoneal hematoma postoperatively and required transfusion of 2 units of red blood cells associated with a cutdown to remove hematoma and to repair the common femoral artery. CONCLUSION: Angiography after arterial percutaneous closure using Prostar XL device during TAVI allows detection and endovascular treatment of vascular complications and is associated with low rate of conversion to open surgery.

Complex Iatrogenic Dissection Complicating Thoracic Endovascular Aneurysm Repair.

BACKGROUND: To report one the most feared complication of thoracic endovascular aneurysm repair (TEVAR); a retrograde aortic dissection who can involve the aortic arch or ascending aorta, which require commonly coextensive open surgical repair. CASE REPORTS: We report 2 cases of combined retrograde and antegrade dissection after endovascular treatment of an aneurysm of the descending aorta. In both cases, a dissection was identified at short-term follow-up; which required open surgical repair in one case and an additional endovascular treatment for the second case. CONCLUSIONS: The incidence of extensive iatrogenic dissection after TEVAR is relatively low, open repair should be considered as a primary option in some cases with limited aortic dilatation to avoid such life-threatening complications.