Iliac neck dilatation causes rupture of abdominal aortic aneurysm previously treated with endovascular aortic aneurysm repair.

A 78-year-old male had undergone endovascular aortic aneurysm repair (EVAR) 7 years prior to presentation. Although the sac was stable 6 months ago, the patient presented with shock at arrival, and CT showed aortic rupture with rapid expansion due to type Ib endoleak caused by iliac neck dilatation (IND). The aneurysm sac was excluded using an endovascular strategy. Bell-bottom iliac limbs can cause IND associated with type Ib endoleak. Additionally, the risk of rupture is high when re-expansion of an aneurysm occurs after sac regression after EVAR. Therefore, close follow-up is mandatory for patients with IND after EVAR.

Feasibility of Transcatheter Aortic Valve Implantation in Patients With Very Severe Aortic Stenosis.

Background: Very severe aortic stenosis (AS) has a poor prognosis even in asymptomatic patients, and asymptomatic very severe AS is a Class IIa indication for aortic valve replacement, although the safety and effectiveness of transcatheter aortic valve implantation (TAVI) for very severe AS is not well-established. Methods and Results: This study included 366 patients undergoing TAVI at a single center, with 85 and 281 patients in the very severe AS (peak velocity ≥5 m/s or mean pressure gradient (PG) ≥60 mmHg) and severe AS groups, respectively. Procedural and clinical outcomes at 1-year follow-up were compared between groups. The calcium scores were significantly higher in the very severe AS group (2,864.5 vs. 1,405.8 arbitrary units [AU] (P<0.001). Although the patient-prosthesis mismatch rate was higher in the very severe AS group (38.3% vs. 25.7%; P=0.029), there was no significant difference in the early safety and clinical efficacy between the groups (16.5% vs. 17.1% and 12.0% vs. 18.9%, respectively). Similarly, there was no significant difference in all-cause mortality at 1 year (4.8% vs. 9.8%). Conclusions: Despite a higher incidence of prosthesis-patient mismatch in those with very severe AS, the procedural and clinical outcomes were comparable to those in patients with severe AS. TAVI may be a reasonable treatment option for very severe AS.

Coil Embolization of Recurrent Internal Iliac Artery Aneurysm via the Superior Gluteal Artery.

We report a case of recurrent internal iliac artery aneurysm previously treated with a combination of stent graft placement and coil embolization in an 85 year-old male patient. The patient was scheduled for the direct puncture embolization of the superior gluteal artery. The patient was placed in a prone position under general anesthesia. An 18G-PTC needle was inserted into the superior gluteal artery under ultrasonographic guidance. A 2.2F microcatheter was inserted through an outer needle and advanced to the aneurysmal sac. Coil embolization was successfully performed without endoleaks. This approach is technically feasible when other treatment options fail or are deemed unsuitable.

Two Cases of Surgical Correction of Recurrent Mitral Regurgitation due to Failed Catheter- Delivered Mitral Clip (MitraClip).

From April 2018 to February 2021, 150 patients underwent MitraClip implantation for severe functional mitral regurgitation (MR) at our hospital. Two of our patients, an 85-year-old man and an 84-year-old woman, developed a single leaflet device attachment in the acute phase after the implantation and had severe residual MR requiring surgical correction. The recurrent MR was first pointed out on day 5 and day 4, and the duration between MitraClip implantation and surgery was 13 and 55 days, respectively. Due to strong adhesions with the clips and severe valve damage after MitraClip implantation, both cases underwent mitral valve replacement with a good postoperative course. In patients with a high-risk baseline profile, surgical mitral valve replacement after failed MitraClip implantation should be considered at an optimal timing, and a detailed echocardiographic follow-up is required.

A Case of Acute Type A Aortic Dissection after Coronary Artery Bypass Grafting.

The patient was a 69-year-old man who underwent emergency surgery for acute aortic dissection that developed 5 months after coronary artery bypass grafting. The left internal thoracic artery (LITA) graft anastomosed to the left descending artery was not affected by the aortic dissection, and during the ascending aortic replacement, the artery was not identified for clamping. Although fully sufficient cardioplegia was not achieved due to the patent LITA graft, the patient's postoperative cardiac function was good. The two anastomotic sites of the vein grafts to the ascending aorta were excised along with a remnant of the aortic wall in an island fashion and were reimplanted onto the artificial graft. Based on the site of intimal tear, we speculated that partial clamping during the previous surgery had caused the dissection.

Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation.

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

Longterm Followup of a Pediatric Patient with Congenital Abdominal Aortic Aneurysm with Coarctation.

Congenital abdominal aortic aneurysm (AAA) with coarctation has been considered an extremely rare condition. In this study, we present a 3-year-old boy, who was diagnosed by chance with congenital AAA at first operation. We replaced the AAA+coarctation with a 6-mm polytetrafluoroethylene (PTFE) graft. Histological examination of the aortic wall revealed no particular abnormalities. Collateral vessels were noted to develop over 14 years of followup. Good blood flow to both lower limbs and no intermittent claudication were observed. After growth, at the age 17, he underwent extra-anatomical bypass using a 12-mm PTFE graft. This is the first report of successful treatment of congenital AAA+coarctation with longterm followup.

Clinical Utility of the Candy-Plug Technique Using an Excluder Aortic Extender.

Objective: To describe the clinical utility and technical aspects of the candy-plug technique using an Excluder aortic extender (Ex-cuff) for false lumen (FL) occlusion in chronic aortic dissection. Materials and Methods: This is a retrospective study analyzing seven consecutive patients (mean age, 63 years; range, 44-78 years; 6 men) with aneurysmal dilatation or rupture in chronic aortic dissection. All patients had undergone thoracic endovascular aortic repair with FL occlusion using this technique. We assessed technical (deployment accuracy) and clinical (no FL backflow on the latest contrast-enhanced computed tomography) success. Results: Technical success was obtained in six patients (86%). Technical failure was caused by the malposition of the candy-plug. The mean follow-up period was 593 days (range, 222-1225 days). Clinical success was obtained in four (57%), and incomplete Amplatzer Vascular Plug (AVP) embolization was seen in two. There was no enlarged FL after the procedure, and all patients are alive during the follow-up periods. Conclusion: The candy-plug technique using an Ex-cuff may be a feasible option; however, it takes time to achieve complete AVP embolization. Therefore, using additional embolic materials should be considered when we use it for the rupture case. (This is a translation of Jpn J Endovasc Interv 2018; 19: 29-35.).

A Successful Endovascular Technique for Complete False Lumen Thrombosis in Chronic Abdominal Aortic Dissection.

A 66-year-old man presented with an enlarging abdominal aorta false lumen, after type A aortic dissection repair. Residual entries were located at the left renal artery, abdominal aorta, and left external iliac artery. The patient underwent endovascular aortic repair with left renal artery stenting to close the entries. Completion aortography showed no false lumen flow without an endoleak, and contrast-enhanced computed tomography 1 month after the procedure demonstrated complete false lumen thrombosis. A total endovascular approach is possible for abdominal aneurysmal dilation in chronic aortic dissection when all entries can be closed using a one-stage procedure with stent grafts and/or branch stenting.

New-Generation Transcatheter Aortic Valves in Patients With Small Aortic Annuli　- Comparison of Balloon- and Self-Expandable Valves in Asian Patients.

BACKGROUND: Asian patients have smaller aortic annuli. Although 20-mm balloon-expandable (BE) transcatheter heart valves (THV) are manufactured for transcatheter aortic valve implantation (TAVI) in these cases, the supra-annular design of self-expandable (SE) THV is considered more suitable; however, real-world comparative data are scarce.Methods and Results:Consecutive TAVI cases (n=330) in a single Japanese center were reviewed. Based on the cutoff for the new-generation 20-/23-mm BE-THV, a small aortic annulus was defined as <330 mm2. A considerable number of patients had small annuli: 49/302 (16%). Of these, 33 BE-THV and 13 SE-THV using new-generation valves were compared. Although the SE-THV group had smaller annulus area (median 297 (interquartile range, 280-313) vs. 309 (303-323) mm2(P=0.022)), it had more favorable post-procedural parameters; for SE-THV and BE-THV, respectively, effective orifice area (EOA), 1.5 (1.3-1.6) vs. 1.1 cm2(0.9-1.3) (P=0.002); mean pressure gradient, 7.6 (5.6-11.0) vs. 14.2 mmHg (11.2-18.8) (P=0.001); and peak velocity, 1.8 (1.6-2.4) vs. 2.7 m/s (2.3-3.1) (P=0.001). Although new left bundle branch block was higher with SE-THV (24% and 62%, P=0.02), patient-prosthesis mismatch (PPM) ≥ moderate (indexed EOA <0.85 cm2/m2) was significantly less with SE-THV than with BE-THV (8% vs. 55%; P=0.04). Hemodynamic findings were consistent up to 1 year. CONCLUSIONS: Small annuli are often seen in Asian patients, for whom SE-THV implantation results in favorable hemodynamics with less PPM.

Geometry of Tricuspid Valve Apparatus in Patients with Mitral Regurgitation due to Fibroelastic Deficiency versus Barlow Disease: A Real-Time Three-dimensional Transesophageal Echocardiography Study.

BACKGROUND: Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography. METHODS: Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n = 42) and FED (n = 64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1 month. RESULTS: TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8 ± 2.9 vs 9.2 ± 2.4 cm2, 4.6 ± 1.6 vs 2.3 ± 1.1 mm, and 1.3 ± 0.8 vs 0.3 ± 0.3 mL; all P < .01). In contrast, TV tenting height and tenting volume were smaller in BD than in FED (2.6 ± 1.5 vs 4.4 ± 2.4 mm and 0.3 ± 0.4 vs 0.9 ± 1.0 mL; both P < .01). These morphologic differences in TV were similar to those in MV. There was a strong correlation between MV billowing volume and TV billowing volumes (R = 0.83, P < .01). The prevalence of significant residual TR after TAP was greater in BD than in FED (35% vs 0%, P < .01). Moderate correlations between TV billowing height and volume and residual TR after TAP were observed (R = 0.47 and 0.49, respectively, both P < .01). CONCLUSIONS: Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

Stent-Graft Relining by Combined Aortic Cuff with Double-D Technique for Type IIIb or V Endoleak after Endovascular Aneurysm Repair: A Case Report.

We report the case of a 83-year-old man with aneurysmal sac enlargement after endovascular aneurysm repair for an abdominal aortic aneurysm, despite no overt endoleak (EL) detected on imaging. Occult type II EL was suspected, and treatment was performed. However, the aneurysm continued to enlarge. Thus, we diagnose with type V EL as exclusion diagnosis. We combined an aortic cuff and stent-graft leg to cover the initially inserted stent graft, as a diagnostic treatment for unrefined type IIIb EL. Subsequently, the aneurysm diameter decreased. This technique and concept may be effective for type V EL, which may include another type occult EL.

Clinical Utility of Coil in Plug Method (CIP) for Internal Iliac Artery Embolization during Endovascular Aortic Aneurysm Repair.

Objective: To evaluate the clinical utility of the coil in plug (CIP) method in internal iliac artery (IIA) embolization during endovascular aortic aneurysm repair (EVAR) compared to conventional coil embolization (CCE). Material and Methods: From July to December 2018, 10 patients who underwent IIA embolization during EVAR were divided into CIP (n=5) and CCE (n=5) groups. In the CIP technique, the AVP-1 with a size more than 30%-50% of that of the embolized IIA diameter was used. The AVP-1 was deployed in the IIA. Before detachment of the AVP-1, a 2.2-F micro catheter was inserted through the 6-F delivery guiding sheath, and entered the plug. The AVP-1 was then packed with hydrogel micro coils. We compared number of coils used, embolization length, embolization time, volume embolization ratio, and embolic material cost between the groups. Results: The CIP method achieved shorter embolization length with fewer coils used compared to CCE. The CIP method decreased the cost of total embolic materials. Conclusion: The CIP method can achieve shorter embolization length with fewer coils used compared to CCE.

Emergent Transcatheter Arterial Embolization via a Transpopliteal Approach for Internal Iliac Artery Injury during Lumbar Disk Surgery in the Prone Position.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

A Novel Technique for the Treatment of Type 2 Endoleak After Endovascular Aortic Repair: Sac Embolization with Balloon Occlusion of the Aorta (SEBOA).

PURPOSE: We presented a new method of sac embolization using n-butyl-cyanoacrylate (NBCA) with balloon occlusion of the aorta (SEBOA) that can facilitate decreasing flow rate of the involved branches with the goal of type 2 endoleak resolution after endovascular aortic repair (EVAR). TECHNIQUE: This technique is demonstrated in six patients who required type 2 endoleak treatment including previous technical failure. A transarterial approach was performed in four patients and transabdominal direct puncture in two. Technical success was defined as complete embolization of both involved branches and sac on postoperative CT. Sacography under balloon occlusion of the aorta demonstrated decreased flow rate of the all involved branches in all patients. SEBOA was performed using 25 or 33% of NBCA diluted with lipiodol. Technical success was obtained in 3 of 6 patients, and one major complication was observed with adhesion of NBCA to the microcatheter resulting in foreign body retention. CONCLUSION: SEBOA may help solve the difficulty of type 2 endoleak treatment after EVAR as decreased flow rate of the involved branches under balloon occlusion of the aorta was achieved in all patients. However, protocols regarding concentration of NBCA or using other embolic materials are needed to improve the success rate.

Endovascular Neck Stabilization Before EVAR for Infrarenal Aortic Aneurysm in Chronic Aortic Dissection.

BACKGROUND: Endovascular treatment of infrarenal abdominal aortic aneurysm (AAA) with proximal chronic aortic dissection is challenging as a false and true lumen at the level of the infra-renal neck does not allow a sufficient landing zone. We describe staged endovascular neck stabilization prior to standard endovascular aortic repair (EVAR) for AAA with chronic aortic dissection. TECHNIQUE: To create a stable proximal neck (PN) by closing entry tears, thereby resulting in total false lumen thrombosis (FLT) prior to standard EVAR. Case 1 false lumen fenestrations were present at the descending aorta, the right renal artery orifice and PN. After closing the entry tear by thoracic EVAR, an aortic cuff was placed in the true lumen of the PN and renal stenting for the right renal artery was performed. After 2 months, total FLT was achieved, and EVAR was performed. Case 2 false lumen fenestrations were present at the descending, super celiac aorta and PN. After closing the entry by TEVAR, aortic cuffs were placed at infrarenal aorta to close residual entries. After 1 month of achieving total FLT, EVAR was performed. Both cases had no type 1 endoleak during follow-up. CONCLUSION: The endovascular neck stabilization is a useful treatment option that facilitates standard EVAR for AAA in chronic aortic dissection.

Early and Mid-Term Results of Endovascular Aortic Repair Using a Crossed-Limb Technique for Patients with Severely Splayed Iliac Angulation.

Objective: We evaluated early and mid-term results of endovascular aortic repair (EVAR) using crossed-limb and non-crossed-limb techniques. Material and Methods: From December 2011 to October 2013, 37 patients (31 men; mean age 75.4 years) were treated with EVAR (crossed-limb, 21 and non-crossed-limb, 16). We compared technical success, maximum short-axis diameter of abdominal aortic aneurysm, iliac angulation, time for catheterization of the short contralateral limb gate of the main body (SCT), and complications between the groups. Results: The mean follow-up period was 810±230 days. The technical success rate was 100%. There was no significant difference between the groups in terms of mean short-axis diameter. Iliac angulation was significantly wider in the crossed-limb group (53.3±14.6 vs. 39.4±13.0, p=0.0049). There was no significant difference between the groups in terms of SCT. Limb occlusion occurred in two cases (one crossed-limb and one non-crossed-limb). There were no aneurysm-related deaths. Conclusion: There were no differences between the crossed-limb and non-crossed-limb techniques in terms of early and mid-term results of EVAR. A crossed-limb technique can be performed safely without prolonged SCT even in severely splayed iliac angulation cases.

Influence of Timing After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection.

BACKGROUND: This study aimed to analyze the influence of the timing of intervention from presentation of symptoms to thoracic endovascular aortic repair (TEVAR) and its relation to major complications. Data were collected from the Japan Adult Cardiovascular Surgery Database. METHODS: We retrospectively analyzed the data of 680 patients who underwent TEVAR for acute and subacute type B dissection between January 2008 and January 2013. RESULTS: Thoracic endovascular aortic repair for type B dissection was performed in 680 patients: 295 repairs were performed within 24 hours of presentation of symptoms (hyperacute); 97 between 24 hours and 14 days (acute); and 288 between 14 days and 6 weeks (subacute). Hyperacute patients more frequently had immediate life-threatening complications from type B dissection such as rupture or malperfusion than did acute or subacute patients (41.0% [121 of 295] versus 7.2% [7 of 97] versus 4.2% [12 of 288]; p < 0.001; and 17.3% [51 of 295] versus 8.3% [8 of 97] versus 5.6% [16 of 288]; p < 0.001, respectively). Operative mortality and severe complications including aortic dissection were more common among hyperacute patients (11.9% [35 of 295] versus 0% [0 of 97] versus 1.7% [5 of 288]; p < 0.001; and 32.5% [96 of 295] versus 10.3% [10 of 97] versus 8.3% [24 of 288]; p < 0.001, respectively) and did not differ significantly between acute and subacute patients (p = 0.191 and p = 0.553, respectively). CONCLUSIONS: Although TEVAR performed for aortic dissection within 24 hours of presentation of symptoms was associated with worse outcomes, TEVAR performed between 24 hours and 14 days, as compared with TEVAR between 14 days and 6 weeks, does not appear to increase the risk of perioperative complications.