Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair.

An aneurysm sac enlargement caused by type II endoleak (T2EL) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms may cause serious complications such as rupture. Consequently, methods that preoperatively prevent or postoperatively treat T2EL have been employed. When significant aneurysm enlargement occurs due to persistent T2EL, embolization is first performed through several access points. However, although these endovascular reinterventions have a high technical success rate and are safe, their effectiveness remains questionable. When such endovascular procedures fail to stabilize sac enlargement, open surgical conversion (OSC) becomes the last-resort treatment option. We review several strategies of OSC for the repair of T2EL following EVAR. Among the three main OSC procedures, namely, complete endograft removal, partial endograft removal, and complete endograft preservation, partial endograft removal under infrarenal clamping was considered the most appropriate owing to its less invasiveness and durability.

Early Clinical Outcomes of Initial Launch of the Zenith Alpha Abdominal Endovascular Graft in Japan.

PURPOSE: This study retrospectively evaluated the 12-month outcomes of the Zenith Alpha Abdominal Endovascular graft (Zenith Alpha AAA, Cook, Inc, Bloomington, Indiana), which was launched partially in Japan in March 2019, starting with 9 selected sites. METHODS: A retrospective analysis was performed of all endovascular aneurysm repairs (EVAR) for abdominal aortic aneurysms using the Zenith Alpha AAA. Late complications were defined as any aneurysm-related events occurring >30 days after EVAR, including an aneurysm sac enlargement of >5 mm and any reinterventions performed. Endoleaks without sac enlargement or reinterventions were excluded from late complications. RESULTS: During the study period, 79 EVARs using the Zenith Alpha AAA were performed. The mean age was 76.6±6.9 years old, 91.1% of patients were male, and the mean aneurysm diameter was 51.1±7.5 mm. Instructions for use violation was observed in 27 patients (34.2%), most frequently being a severely angulated proximal neck (>60°). There were 4 intraoperative complications, including 2 unintentional partial renal artery coverages caused by the premature anchoring of the exposed suprarenal stent barb to the aortic wall, which was a result of the design change of the top cap deletion. Since it was a partial coverage without flow impairment and since renal stenting was unsuccessful, it was left untreated and had no subsequent renal function impairment. During the mean follow-up of 444±123 days, 74 patients completed 12 months of follow-up. Freedom from late complications at 12 months was 90.8%, which included 2 limb occlusions (2.5%). Of 71 patients with a 12-month computed tomography scan, there was only 1 type 1a endoleak (1.3%), 1 sac enlargement of >5 mm (1.3%), and an aneurysm sac shrinkage of >5 mm was observed in 42.2% of patients. There was no type 3 endoleak during the follow-up. CONCLUSIONS: This study demonstrated that the new generation of low-profile Zenith Alpha AAA has satisfactory early clinical outcomes, comparable to those obtained with the conventional Zenith endovascular graft. Long-term follow-up is needed to determine whether these favorable outcomes persist.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis for Japanese Patients With Aortoiliac Aneurysms: A Study Based on J-Preserve Registry.

PURPOSE: To evaluate the clinical utility of the Gore Excluder iliac branch endoprosthesis (IBE) for Japanese patients with aortoiliac aneurysms. MATERIALS AND METHODS: This was a multicenter retrospective cohort study (J-Preserve Registry). Patients undergoing endovascular aortic repair using the Gore Excluder IBE for aortoiliac aneurysms between August 2017 and June 2020 were enrolled. Data pertaining to the baseline and anatomical characteristics, technical details, and clinical outcomes were collected from each institution. The primary endpoints were technical success, IBE-related complications, and reinterventions. Secondary endpoints were mortality, aneurysm size change, and reintervention during follow-up. Technical success was defined as accurate deployment of the IBE without type Ib, Ic, or III endoleaks on the IBE sides on completion angiography. A change in aneurysm size of 5 mm or more was taken to be a significant change. RESULTS: We included 141 patients with 151 IBE implantations. Sixty-five IBE implantations (43.0%) had at least one instruction for use violation. Twenty-two patients (15.6%) required internal iliac artery (IIA) embolization for external iliac artery extension on the contralateral side. Of 151 IBE implantations, 19 exhibited IIA branch landing zones due to IIA aneurysms. Mean maximum and proximal common iliac artery (CIA) diameters were 32.9±9.9 mm and 20.5±6.9 mm, respectively. The mean CIA length was 59.1±17.1 mm. The IIA landing diameter and length were 9.0±2.3 mm and 33.8±14.6 mm. The overall technical success rate was 96.7%. There were no significant differences in IBE-related complications (2.3% vs 5.3%, p=0.86) or IBE-related reinterventions (1.5% vs 5.3%, p=0.33) between the IIA trunk and IIA branch landing groups. The mean follow-up period was 635±341 days. The all-cause mortality rate was 5.0%. There were no aneurysm-related deaths or ruptures during the follow-up. Most patients (95.7%) had sac stability or shrinkage. CONCLUSION: The Gore Excluder IBE was safe and effective for Japanese patients in the midterm. Extending the IIA device into the distal branches of the IIA was acceptable, which may permit extending indications for endovascular aortic aneurysm repair of aortoiliac aneurysms to more complex lesions. CLINICAL IMPACT: This study suggests clinical benefits of the Gore Excluder IBE for Japanese patients, despite 43% of the IBE implantations having at least one IFU violation.

Two-Year Results of a Multicenter Prospective Observational Study of the Zenith Spiral-Z Limb Deployed in the External Iliac Artery During Endovascular Aneurysm Repair.

BACKGROUND: Limited data is available on the use of a polyester graft limb with a helical stent configuration deployed in the external iliac artery (EIA) during endovascular aneurysm repair (EVAR), so we prospectively analyzed the efficacy of the Zenith Spiral-Z limb deployed in the EIA.Methods and Results:Patients undergoing EVAR using a Zenith stent-graft and Spiral-Z limb deployed in the EIA were prospectively registered in 24 Japanese institutions from June 2017 to November 2017. In total, 65 patients (74 limbs) (mean age: 77.1±8.0 years, 87.7% men, mean abdominal aortic aneurysm (AAA) diameter: 51.9±7.2 mm, mean iliac artery aneurysm (IAA) diameter: 38.3±10.0 mm) were registered and followed up. The most common reason for deployment in the EIA was a common IAA (43 limbs, 58.1%), and 8 limbs (10.8%) had a bare nitinol stent placed at the Spiral-Z limb. A total of 61 patients (70 limbs) completed a 24-month follow-up. There were 2 Spiral-Z limb stenoses and 1 occlusion, leading to a primary patency of 95.5% and a secondary patency of 100%, at 24 months. Buttock claudication occurred in 24.3% of the limbs treated at 1 month but decreased to 4.3% at 24 months. CONCLUSIONS: Our multicenter prospective study showed that Spiral-Z limb deployed in the EIA was associated with satisfactory results and seems to be a durable option, even in the era of iliac branch devices.

Abdominal Aortic Aneurysm Caused by Aortic Fibromuscular Dysplasia: A Case Report.

Fibromuscular dysplasia (FMD) mainly develops in medium-sized arteries, including renal, extracranial, and extremity arteries, but it rarely causes abdominal aortic aneurysm (AAA). A 69-year-old woman with AAA diagnosed on ultrasonography by a home doctor visited our hospital. Contrast-enhanced computed tomography revealed a saccular aneurysm of terminal abdominal aorta. We performed abdominal aortic replacement and resected the section with aneurysm. Pathological examination of the wall tissue of the resected aneurysm revealed findings that are consistent with FMD. We report this case of AAA caused by aortic FMD because of its rarity.

Endovascular Stent-Graft Repair of a Persistent Sciatic Artery Aneurysm.

Persistent sciatic artery (PSA) is a rare anomaly that may cause various symptoms, such as aneurysm, rupture, thromboembolism, and sciatica. Direct surgery can be performed to treat PSA aneurysm (PSAA), but is associated with complications; e.g., anatomical problems such as sciatic nerve injury. Herein we report a case of a 74-year-old woman with acute limb ischemia that developed from a distal embolism caused by a thrombus in the left PSAA; favorable results were obtained for her by treatment with a stent-graft after rapid anticoagulation therapy for limb salvage.

Emergent interventional approach for aortogastric tube fistula with massive gastrointestinal bleeding.

This report describes the successful endovascular treatment of a rare case of aortogastric tube fistula with massive gastrointestinal haemorrhage. The patient's history included oesophageal reconstruction for oesophageal carcinoma using a gastric tube. Emergent angiography revealed extravasation from the thoracic aorta into the thinner aortogastric tube fistula. A microcatheter was inserted into the aortogastric tube with the aortic approach for embolisation with a mixture of n-butyl cyanoacrylate and iodised oil to enable fluoroscopic visualisation. Aortography confirmed the complete absence of extravasation after embolisation, after which a stent graft was placed. This procedure demonstrated that transcatheter embolisation of the aortogastric tube fistula was possible, and that the technique can be used as an emergency option. CT imaging was performed 21 days after the procedure, and revealed no trace of extravasation or inflammation. There were no complications during the 14 months following the endovascular treatment; the patient remains in stable condition.

Thoracic endovascular aortic repair with homemade stent grafts: early and mid-term outcomes.

PURPOSE: We reviewed our experience with homemade stent grafts in the repair of a variety of thoracic aortic lesions. The objective of this study was to assess the early and mid-term outcomes of this therapy. METHODS: From 1999 to 2007, homemade stent grafts were inserted in 88 patients with an atherosclerotic aneurysm, dissection, pseudoaneurysm, trauma, or rupture in the thoracic aorta. The endoprostheses were stainless steel Z-stents covered by a polyester graft, and were custom-designed for each patient. RESULTS: Placement of stent grafts was technically successful in 81 of the 88 patients (92%). Within 30 days after treatment, 3 patients died, 3 had a cerebral infarction, and 3 had onset of paraplegia or paraparesis. Primary endoleaks were observed in 8 patients (9%). During the mean follow-up period of 32 ± 26 months, 7 patients had persistent endoleaks and 7 had stent-graft migration. The aneurysm-related mortality rate was 7%. The rate of freedom from open-surgery conversion at 32 months was 89.0%. CONCLUSIONS: Our early experience with elective and emergency thoracic endovascular aortic repair using homemade stent grafts provided therapeutic benefits to high-risk patients. Endoleaks and stent-graft migrations were the factors most commonly responsible for secondary intervention in the mid-term period. Careful follow-up of patients treated with this approach is needed to avoid major complications in the long term.

[Long-term outcomes of thoracic endovascular aortic repair with homemade stent-grafts].

We reviewed our experience with homemade stent-grafts in the repair of thoracic aortic lesions. The objective of this study was to assess the long-term outcomes of this therapy. From 1999 to 2008, homemade stent-grafts were inserted in 94 patients with various thoracic diseases. The endoprostheses were stainless steel Z-stents covered with polyester graft and were custom designed for each patient. Placement of the stent-grafts was technically successful in 85 of the 94 patients (90%). Within 30 days after the treatment, 4 patients died, 3 had cerebral infarction, and 3 had the onset of paraplegia or paraparesis. Primary endoleaks were observed in 10 patients (11%). During the mean follow-up period of 43 +/- 29 months, 10 patients had endoleaks and 8 had stent-graft migration. The aneurysm-related mortality rate was 12%. Our early outcomes of elective and emergency thoracic endovascular aortic repair with homemade stent-grafts demonstrated their therapeutic effectiveness in high-risk patients with various thoracic diseases. Endoleaks and migration were, however, the factors most responsible for secondary intervention in the mid-term period. Careful follow-up of the treated patients is needed to avoid the major complication in the long-term period.

Spontaneous dissection of the iliac artery in a patient with fibromuscular dysplasia.

A 49-year-old man was referred to our hospital at 10 days after the onset of sudden intermittent claudication of the right lower limb and with right lower abdominal pain. Diagnosis by computed tomography scan and pelvic angiography was dissection from the common iliac artery to peripheral external iliac artery with thrombosed false lumen. Replacement of the common and external iliac artery was performed using a 10-mm Dacron prosthesis. A pathological examination of the right common iliac artery revealed an arterial disorder caused by fibromuscular dysplasia.

Azelnidipine decreases plasma matrix metalloproteinase-9 levels after endovascular abdominal aortic aneurysm repair.

We investigated the changes of matrix metalloproteinase (MMP) -9 in the peripheral blood samples of patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs), and the effect of azelnidipine on plasma MMP-9 levels in those patients. Levels of MMP-9 were measured in 22 patients who underwent EVAR for AAAs, and results were compared between a group receiving 16 mg azelnidipine daily (n=12) and a control group without azelnidipine (n=10). Measurements were taken preoperatively, and at 1 month and 3 months, postoperatively. Patients without endoleaks after EVAR showed a significant decrease in mean plasma MMP-9 levels (preoperative value: 39.5+/-14.3 ng/mL, after 1 month: 25.0+/-12.6, after 3 months: 28.2+/-10.2 ng/mL; P=0.004). In contrast, no significant decreases in mean plasma MMP-9 levels were observed in the patients with endoleaks after EVAR (preoperative value: 37.5+/-9.0 ng/mL, after 1 month: 26.8+/-8.4, after 3 months: 38.5+/-15.7 ng/mL; P=0.219). Moreover, among patients without endoleaks, those receiving azelnidipine showed a significantly greater decrease in the mean plasma MMP-9 levels for 3 months postoperatively (preoperative value: 47.7+/-13.2 ng/mL, after 1 month: 26.6+/-12.8, after 3 months: 26.1+/-11.4 ng/mL; P0.001) compared with the control group without endoleaks (preoperative value: 31.3+/-10.5 ng/mL, after 1 month: 33.4+/-12.1, after 3 months: 30.3+/-9.1 ng/mL; P=0.792). These results showed that azelnidipine treatment in patients without endoleak after EVAR was associated with a significant decrease in mean plasma MMP-9 levels for 3 months postoperatively.

Initial and midterm results for repair of aortic diseases with handmade stent grafts.

BACKGROUND: The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs). METHODS AND RESULTS: Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41). CONCLUSION: The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.

Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections.

BACKGROUND: The purpose of this study was to examine the long-term outcome and the prognostic predictors related to the development of complications associated with acute type B aortic dissection. METHODS: Seventy-six medically treated patients with acute type B aortic dissection were examined between 1990 and 2001. The events associated with aortic dissection included dissection-related death, rupture, visceral ischemia, lower limb ischemia, an increase in the maximum aortic diameter greater than 50 mm, and a mean enlargement rate of greater than 5 mm per year. RESULTS: Among the 76 patients 10 (13%) underwent chronic phase surgery and 25 (33%) presented with an event. A statistically significant difference was observed between patients with and without events with regard to atherosclerotic factors, blood flow status in the false lumen, maximum aortic diameter upon admission, mean aortic enlargement rate, and blood pressure control during follow-up. Of these factors a patent false-lumen and a maximum aortic diameter greater than 40 mm upon admission were the most strongly associated factors with regard to the development of events. Patients with a patent false-lumen and a maximum aortic diameter greater than 40 mm upon admission were determined to exhibit significantly higher event rates than other patients. CONCLUSIONS: In determining the appropriate therapeutic approach for acute type B aortic dissection, it is important to pay careful attention to the predictors of a patent false-lumen and a maximum aortic diameter greater than 40 mm at onset to improve the long-term outcome.