Current treatment strategies for primary upper extremity deep venous thrombosis; a retrospective observational multicenter case series.

Introduction: Current treatment strategies for primary upper extremity deep venous thrombosis (pUEDVT) range from conservative treatment with anticoagulation therapy to invasive treatment with thoracic outlet decompression surgery (TOD), frequently combined with catheter directed thrombolysis, percutaneous transluminal angioplasty, or stenting. Due to a lack of large prospective series with uniform data collection or a randomized trial, the optimal treatment strategy is still under debate. We conducted a multicenter observational study to assess the efficacy and safety of both the conservative and invasive treatment strategies for patients with pUEDVT. Methods: We retrospectively collected data from patients treated in five vascular referral and teaching hospitals in the Netherlands between 2008 and 2019. Patients were divided into a conservative (Group 1), an invasive treatment group (Group 2) and a cross-over group (Group 3) of patients who received surgical treatment after initial conservative therapy. Follow-up consisted of outpatient clinic visits and an electronic survey. Primary outcome was symptom free survival defined as absence of any symptom of the affected arm reported at last follow-up regardless of severity, or extent of functional disability. Secondary outcomes were incidence of bleeding complications, recurrent venous thromboembolism, surgical complications, and reinterventions. Results: A total of 115 patients were included (group 1 (N = 45), group 2 (N = 53) or group 3 (N = 27). The symptom free survival was 35.6%, 54.7% and 48.1% after a median follow-up of 36, 26 and 22 months in groups 1, 2 and 3 respectively. Incidence of bleeding complications was 8.6%, 3.8% and 18.5% and recurrent thrombosis occurred in 15.6%, 13.2% and 14.8% in groups 1-3 respectively. Conclusion: In this multicenter retrospective observational cohort analysis the conservative and direct invasive treatments for pUEDVT were deemed safe with low percentages of bleeding complications. Symptom free survival was highest in the direct surgical treatment group but still modest in all subgroups. Perioperative complications were infrequent with no related long term morbidity. Of relevance, pUEDVT patients with confirmed VTOS and recurrent symptoms after conservative treatment may still benefit from TOD surgery. However, symptom free survival of this delayed TOD seems lower than direct surgical treatment and bleeding complications seem to occur more frequently.

Modular branched endograft system for aortic aneurysm repair: evaluation in a human cadaver circulation model.

A circulation model was created in 6 nonaneurysmal human cadavers to evaluate the deliverability, deployment, and acute performance of a modular branched endograft system for treatment of aortic aneurysms containing essential branch vessels. Two fenestrations were created in an appropriately sized aortic main endograft. Under fluoroscopic guidance, the main endograft was advanced to the target site and the fenestrations were aligned with the ostia of the renal arteries. Branch grafts were placed through the fenestrations into the renal arteries. The outcome was evaluated by post implant angiography and autopsy. Eleven branch grafts were deployed at the target site. All targeted renal arteries showed good patency. At autopsy, all main endografts were adequately deployed, and 10 of 11 branch grafts were locked in place. In this model, deliverability and deployment of the modular branch graft system is feasible in a reliable, predictable, and timely fashion.

Carotid artery dynamics after carotid angioplasty and stenting.

Carotid angioplasty and stenting (CAS) has emerged as an alternative treatment for carotid artery occlusive disease. As initial results in patients with an increased surgical risk appeared promising, the popularity of CAS has increased substantially over the last years and CAS has more often been advocated as an alternative to the gold standard, carotid endarterectomy (CEA). Several controlled trials comparing CAS with CEA are currently being conducted. However, long-term results of CAS are still sparse and several issues regarding the inherent differences between treatment modalities have not yet been elucidated. Interestingly, to date, very little attention has been directed towards the mobile features of the carotid artery and the implications of stent placement on carotid artery dynamics.

Repeated arterial thrombosis as a complication of carboplatin-based chemotherapy.

We describe a case of a 57-year-old woman with repeated acute arterial thrombosis of the femoral arteries following intravenous carboplatin-based combination chemotherapy for metastatic ovarian carcinoma. By extensive workup, no other known causes of arterial thrombosis were found. To our knowledge, this is the first case describing arterial thrombosis occurring as a complication of carboplatin therapy.

Fenestrated and branched endografts: assessment of proximal aortic neck fixation.

PURPOSE: To investigate proximal fixation characteristics of different aortic endograft designs: a suprarenally placed fenestrated endograft, a modular branched endograft, an infrarenal endograft with suprarenal bare stent fixation, and the gold standard, a conventional hand-sewn anastomosis. METHODS: Ten human cadaveric aortas were obtained at autopsy and transected 20 mm below the renal arteries to mimic an infrarenal aneurysm neck. In random order, the infrarenal, fenestrated, and branched endografts were deployed into the aorta. Using a hydraulic material testing machine, longitudinal load was applied to the distal end of each endograft until migration occurred, thus defining the displacement force (DF). Subsequently, a hand-sewn infrarenal anastomosis was tested in a similar manner. RESULTS: The median DF was 4.67 N (3.82-6.37) for the infrarenal endograft, 9.17 N (8.03- 10.81) for the fenestrated endograft, and 16.95 N (14.78-19.67) for the branched endograft. The differences in DF between the infrarenal and fenestrated endografts and between the fenestrated and branched designs were statistically significant (both p=0.005). The median force to dislodge the graft from the conventional anastomosis was 89.16 N (71.24-105.23). CONCLUSIONS: Suprarenally placed endografts, especially with additional branch grafts, provide improved proximal fixation compared to an infrarenal endograft with suprarenal bare stent fixation. However, none of the tested endografts approached the optimal, time-proven fixation, the hand-sewn anastomosis.

Impact of head movements on morphology and flow in the internal carotid artery after carotid angioplasty and stenting versus endarterectomy.

OBJECTIVE: Because stents can cause vessel angulation during movement, we hypothesized that internal carotid artery (ICA) stents might lead to alterations of cerebropetal blood flow. This study assessed three-dimensional anatomy and volumetric flow rate (VFR) in the ICA in various head positions by comparing patients treated with carotid angioplasty and stenting (CAS) with patients treated with carotid endarterectomy (CEA). METHODS: Three-dimensional time-of-flight magnetic resonance angiography and magnetic resonance flow quantification were performed on six subjects after CAS (median age, 70 years) and on six subjects after CEA (median age, 67 years). All investigations were performed in five head positions: neutral, bent forward, bent backward, and turned to the treated, ipsilateral side and to the contralateral side. Maximum-intensity projection reconstructions were obtained to measure maximal angulation of the ICA in the forward, backward, ipsilateral, and contralateral positions compared with neutral. Subsequently, the plane perpendicular to the ICA, 1 cm distal to the stent or 4 cm distal to the carotid bifurcation (CEA patients), was established. The VFR through this plane was measured for each position, and the forward, backward, ipsilateral, and contralateral positions were compared with neutral. RESULTS: In CAS patients, there was a median change in ICA angulation of +10.2 degrees (interquartile range, +7.3 degrees to +17.9 degrees ) in the forward position, compared with +0.2 degrees (-1.0 degrees to +2.4 degrees ) in CEA patients ( P = .016). In all other head positions, there was no statistically significant difference in angulation change. There was no statistically significant difference in VFR change between groups in any of the head positions tested. CONCLUSIONS: There was a significant increase in ICA angulation in CAS patients if the head was bent forward; this was not observed in CEA patients. This angulation change did not lead to significant acute changes in cerebropetal blood flow, but it might have chronic effects not yet tested.

A temporary hemostatic valve in the short limb of a bifurcated stent-graft to facilitate endovascular repair of ruptured aortic aneurysm: experimental findings.

PURPOSE: To evaluate a homemade tricuspid valve placed in the short limb of a bifurcated aortic stent-graft to facilitate endovascular treatment of ruptured abdominal aortic aneurysms (AAA). METHODS: A valve consisting of 3 polytetrafluoroethylene cusps was constructed in the short limb of a bifurcated stent-graft. The endoprosthesis was placed into an in vitro circulation model with pulsatile flow. Angiography was performed before and after insertion of the second graft limb. RESULTS: Angiographically, there was complete occlusion of the short limb before and normal patency after deployment of the second graft limb. Cannulation of the short limb with a guidewire was performed without technical difficulty. CONCLUSIONS: Addition of a temporary hemostatic valve in the short limb of a bifurcated stent-graft can potentially reduce blood loss during endovascular treatment of ruptured AAAs.

Endovascular grafting of complex aortic aneurysms with a modular side branch stent-graft system in a porcine model.

OBJECTIVES: To evaluate and refine a stent-graft system with side branches for treatment of aneurysms with essential branch arteries. METHODS: In a porcine model (n=4) supra- and juxta-renal aortic aneurysms were created by suturing an artificial patch onto an anterior aortotomy. Angiography was performed to determine the exact location of the renal arteries. Accordingly, fenestrations were created in an appropriately sized aortic stent-graft. Initial deployment of the aortic graft is partial, whereby the top stent is secured in a cap and distal stents are being restrained, thus ensuring longitudinal and rotational manoeuvrability during alignment of the branch arteries. Separate branch grafts with silicone flanges for connection with the main stent-graft are subsequently placed in the renal arteries followed by full deployment of the main stent-graft. Outcome was evaluated by postoperative angiography and autopsy results and by measuring operating time, blood loss and use of contrast agent. RESULTS: Branched grafts were placed successfully in all trials. The median endovascular procedure time was 126 min (90-160), with 575 ml (400-800) blood loss and 65 ml (50-80) contrast agent use. Angiographically, all aneurysms were excluded without signs of endoleak and all renal arteries were patent. At autopsy, the main stent-graft and all side branches were adequately placed with intact connections between main stent-graft and branch grafts. CONCLUSIONS: In this model, endovascular repair of complex aneurysms using a modular branch graft system is feasible in a reliable, predictable and timely fashion.

False lumen thrombectomy of the superior mesenteric artery followed by iliomesenteric bypass after Stanford type B aortic dissection.

A 55-year-old man with an acute Stanford type B aortic dissection presented with clinical signs of mesenteric ischemia. Computed tomography (CT) revealed a thrombosed false lumen in the superior mesenteric artery. At laparotomy, the dissection was found to be extending into the jejunal branches and medial colic artery. Thrombus was removed from the false lumen, and perfusion was restored with an iliomesenteric bypass, with the dissected layers tacked together in the suture line. A postoperative CT scan showed a stable diameter of the thoracoabdominal aorta and a patent iliomesenteric bypass.

Carotid stent mobility with regard to head movements: in vitro analysis.

Given that considerable motion of the carotid artery is present during head movements, we hypothesized that a flexible stent with low torsion might be favorable to avoid stress imparted to the stent and carotid artery. Therefore, we evaluated the flexibility of different expanded carotid stents before and after deployment in a carotid artery in vitro. Subsequently, we evaluated torsion of the bare expanded stents. Five stents (Wallstent [Boston Scientific Corp., Natick, MA], Acculink [Guidant Corp., Indianapolis, IN], Precise [Cordis Corp., Johnson & Johnson Company, Warren, NJ], Carotid SE [Medtronic AVE, Santa Rosa, CA], and Protégé [EV3, Plymouth, MN]) were tested. Flexibility was determined using a three-point bend test recording the bending load (BL) in grams required to flex the stent 25 degrees. Increased BL implies decreased flexibility. Torsion was measured by recording the rotation load (RL) in grams required to rotate the stents 30 degrees along its axis. Increased RL implies increased torsion. In the bare expanded state, the median BL was 6 g (range 1-22 g). The BL increased to 38 g (range 20-41 g) after deployment in a carotid artery, with the Carotid SE (21 g) and Wallstent (36 g) showing significantly lower BL (p < .0001 and p = .0016, respectively). Overall, the RL was 11 g (range 1-76 g). Significantly higher RL was required to rotate the Wallstent (73 g) and Precise (20 g) stents (p < .0001). The flexibility of the currently used stents decreases after deployment in a carotid artery irrespective of its flexibility in the bare state. Two stents showed increased torsion compared with the other stents. Limitations in both flexibility and torsion might influence the long-term performance of carotid angioplasty stenting.

Cine MRI assessment of aortic aneurysm dynamics before and after endovascular repair.

PURPOSE: To evaluate stent-graft and aneurysm wall motions during the cardiac cycle using cine magnetic resonance imaging (MRI) to identify mechanisms of long-term failure of endovascular aneurysm repair (EVAR). METHODS: Prior to and after EVAR in 7 patients with abdominal aortic aneurysms (AAA), 12 MRI images per cardiac cycle were acquired in transverse, sagittal, and coronal planes of the aneurysm. Two independent observers blinded to the aim of the study manually traced stent-graft and aneurysm wall contours. Translation was defined as the maximal displacement of the contours in the peak-systolic image compared to the end-diastolic image. Aneurysm wall motions before and after repair were compared. Stent-graft and aneurysm configuration changes during the cardiac cycle were evaluated. The relation between translation and the degree of angulation of the stent-graft was calculated. RESULTS: The anteroposterior translation of the aneurysm decreased from a median 1.05 mm (range <0.5-1.29) before EVAR to within pixel size (<0.5 mm) after EVAR (p=0.04). The cranial-caudal translation of the aneurysm increased from a median 1.01 mm (range <0.5-1.51) before to 1.69 mm (range 1.1-1.99) after EVAR (p=0.02). In 4 stent-grafts, bending during cardiac systole was observed at the site of maximal angulation of the device. In transverse sections, 2-dimensional pulsatile wall motion of the aneurysm was 0.25 cm(2) (range 0.07-0.29) before and 0.17 cm(2) (range 0.07-0.42) after EVAR (p=0.79). No pulsatility of the stent-graft itself was observed. The correlation coefficient between angulation of the stent-graft and the increase in cranial-caudal translation after EVAR was 0.67 (p>0.05). CONCLUSIONS: After EVAR, increased longitudinal translation of both the aneurysm and stent-graft was observed, indicating downward pulling forces at the proximal fixation site. Secondly, increased bending was seen at the site of maximal angulation, which implies a risk of metal fatigue and fabric damage at sites of stent-graft angulation.

Carotid artery dynamics during head movements: a reason for concern with regard to carotid stenting?

PURPOSE: To evaluate carotid artery mobility patterns during head movements following carotid angioplasty/stenting (CAS). METHODS: In 7 patients (all men; mean age 69 years, range 65-76) who had undergone unilateral CAS, 3D time-of-flight magnetic resonance angiography was performed, visualizing both carotid arteries in 5 different head positions (neutral, turned left and right, and bent forward and backward). Maximum intensity projection reconstructions were obtained to measure angulation at the proximal and distal stent junction. Configuration changes of the stented section of the carotid artery and the unstented contralateral artery were judged. Secondly, transverse sections at the level of the carotid bifurcation and at the skull base were used to calculate torsion shear in the common and internal carotid arteries (CCA, ICA) during left and right head position. Results were expressed as median (range). RESULTS: In neutral head position, maximal angulation at the distal stent junction was 34.3 degrees (32.3 degrees-55.6 degrees). With the head bent forward, this angulation changed to 47.6 degrees (42.6 degrees-85.2 degrees, p=0.028) and when bent backward to 26.5 degrees (25.0 degrees-48.7 degrees, p=0.027). In all patients, configuration changes of the stented sections were absent. The contralateral unstented side showed diffuse configuration changes without specific angulation at one location. With the head turned left and right, the CCA on the stented side was subjected to 28.6 degrees (13.6 degrees-53.7 degrees) and 24.9 degrees (2.0 degrees-50.6 degrees) of torsion shear, respectively. Torsion of the ICA was subsequently 18.1 degrees (12.7 degrees-40.5 degrees) and 15.2 degrees (2.9 degrees-69.4 degrees). CONCLUSIONS: Following carotid stenting, sharp ICA angulation that are aggravated by forward bending of the head occur at the distal stent junction. The stented section of the carotid artery shows complete lack of flexibility despite highly flexible features of hte stents ex vivo. Both the CCA and ICA are subjected to considerable torsion shear with the head turned left and right. This shear is not accommodated by the current stent designs.

Endovascular repair of a type B aortic dissection with transposition of a coexistent aberrant subclavian (lusorian) artery.

PURPOSE: To report the endovascular treatment of a relatively uncommon entity: an aortic type B dissection combined with an aberrant subclavian artery (SA). CASE REPORT: A 59-year-old patient was admitted with chest pain and interscapular back pain. A transesophageal ultrasound and magnetic resonance angiography revealed a type B aortic dissection originating at the level of an aberrant SA orifice. After failure of medical therapy, the dissection was treated by transluminal implantation of an Excluder stent-graft covering the entry site of the dissection at the aberrant SA orifice. Prior to the endovascular procedure, a transposition of the aberrant SA to the right carotid artery was performed through a supraclavicular approach. The patient remains asymptomatic at 19 months after the endovascular repair. CONCLUSIONS: Endovascular repair of a type B aortic dissection in the presence of a lusorian artery appears to be a feasible, safe, and less invasive alternative to conventional surgery. The need for concurrent transposition of the SA remains to be determined.

Aortic aneurysm pulsatile wall motion imaged by cine MRI: a tool to evaluate efficacy of endovascular aneurysm repair?

OBJECTIVES: to evaluate cine MRI as a means of determining the two-dimensional pulsatile wall motion (2D-PWM) of abdominal aortic aneurysm (AAA). DESIGN: prospective study of 21 patients with AAA. 2D-PWM was defined as change in cross-sectional area. RESULTS: the median diastolic area was 28 cm(2) (intraquartile range, IQR, 22-31 cm(2)) and the median (IQR) 2D-PWM was 0.25 (0.10-0.40) cm(2). Assuming that the AAA is circular in cross-section this represents a median (IQR) diameter increase of 0.3 (0.1-0.4) mm. However, local wall displacements up to 2 mm were present in varying directions, without significant change in surface area. CONCLUSION: AAA PWM is negligible and may not therefore be a potential tool to assess efficacy of endovascular aneurysm exclusion.