Covered endovascular reconstruction of the aortic bifurcation: A versatile technique with many potential applications.

We present our experience with using the bifurcated covered endovascular reconstruction technique in two unusual conditions. One patient with a traumatic "seat belt" aortic injury and a second patient with a bleeding aorto-enteric fistula were successfully treated with the CERAB technique. We discuss potential benefits of the technique outside the usual pattern of chronic atherosclerotic aortoiliac disease.

Type IIIb Endoleak: The Great "Masquerader" - Risks of Liquid Agent Dislocation During Sac Embolization Techniques.

The diagnosis of late type III endoleaks may be very challenging on non-invasive imaging studies, and it is not unusual for type IIIb endoleaks to be misdiagnosed as type I endoleaks. The present report illustrates a type III endoleak that was misdiagnosed and treated as Type Ia endoleak. Embolization of the endoleak using a liquid embolic agent (Squid) was complicated by intraluminal graft dislodgement of the liquid agent. This unusual complication was recognised and treated successfully. Type IIIb endoleaks should always be considered in patients with persistent aneurysm sac perfusion treated with embolization using liquid embolic agents.

Global experience with an inner branched arch endograft.

BACKGROUND: Branched endografts are a new option to treat arch aneurysm in high-risk patients. METHODS AND RESULTS: We performed a retrospective multicenter analysis of all patients with arch aneurysms treated with a new branched endograft designed with 2 inner branches to perfuse the supra aortic trunks. Thirty-eight patients were included. The median age was 71 years (range, 64-74 years). An American Society of Anesthesiologists score of 3 or 4 was reported in 89.5% (95% confidence interval [CI], 79.7-99.3) of patients. The 30-day mortality rate was 13.2% (95% CI, 2.2-24.2). Technical success was obtained in 32 patients (84.2% [95% CI, 72.4-95.9]). Early secondary procedures were performed in 4 patients (10.5% [95% CI, 0.7-20.3]). Early cerebrovascular complications were diagnosed in 6 patients (15.8% [95% CI, 4.0-27.6]), including 4 transient ischemic attacks, 1 stroke, and 1 subarachnoid hemorrhage. The median follow-up was 12 months (range, 6-12 months). During follow-up, no aneurysm-related death was detected. Secondary procedures during follow-up were performed in 3 patients (9.1% [95% CI, 0.0-19.1]), including 1 conversion to open surgery. We compared the first 10 patients (early experience group) with the subsequent 28 patients. Intraoperative complications and secondary procedures were significantly higher in the early experience group. Although not statistically significant, the early mortality was higher in the early experience group (30% [95% CI, 0.0-60.0]) versus the remainder (7.1% [95% CI, 0.0-16.9]; P=.066). Being part of the early experience group and ascending aortic diameter≥38 mm were found to be associated to higher rates of combined early mortality and neurologic complications. CONCLUSIONS: Our preliminary study confirms the feasibility and safety of the endovascular repair of arch aneurysms in selected patients who may not have other conventional options. CLINICAL TRIAL REGISTRATION INFORMATION: Thoracic IDE NCT00583817, FDA IDE# 000101.

Coagulopathy associated with sac reperfusion for reversing paraplegia after endovascular repair of type II thoracoabdominal aneurysm.

Sac perfusion may be helpful in preventing or reversing spinal cord injury after endovascular repair of thoracoabdominal aneurysms and it has been used as an adjunct to the standard physiologic measures of sustained hypertension and cerebrospinal fluid drainage. Coagulopathy as a result of endoleak after endovascular aneurysm repair has been reported, and very rare cases of treatment after repair of these endoleaks have been described. We report a 73-year-old man who had endovascular repair of a type II thoracoabdominal aneurysm with a branched stent graft. Sac reperfusion was initiated to manage postoperative paraplegia. The paraplegia partially resolved but severe hemorrhagic complications developed that were attributed to sac perfusion-related hyperfibrinolysis. Discontinuation of sac perfusion resolved the coagulopathy but resulted in paraplegia.

Treatment of aortic arch aneurysms with a modular transfemoral multibranched stent-graft: initial experience.

OBJECTIVE: To present an initial experience with a new modular transfemoral multibranched stent-graft for treating aortic arch aneurysms. METHODS: Six patients, considered high risk for open surgery, were treated with a custom-made branched stent-graft. Two patients had aortic arch aneurysms, three had descending thoracic aortic aneurysms involving the distal arch, and one had a saccular aneurysm of the arch adjacent to the origin of the innominate artery. All patients had undergone a staged left carotid subclavian bypass before the endovascular procedure. Each branched graft had a 12-mm side branch for the innominate artery and an 8-mm side branch for the left common carotid artery. The branches were extended into their respective target arteries with covered self-expanding stents. RESULTS: Aneurysm exclusion without endoleak was successful in 5 of the 6 patients, and 11 of the 12 target vessels were successfully cannulated and preserved. Patient 1 developed a type I endoleak that was managed successfully with coiling and gluing of the aneurysm sac. Patients 2, 3, 5, and 6 had uneventful placement of the prostheses, with successful exclusion of the aneurysm sac. In patient 4, cannulation of the innominate branch was unsuccessful, and an extra-anatomic bypass was necessary to perfuse the right carotid and vertebral arteries. CONCLUSIONS: We have demonstrated the technical feasibility of a modular transfemoral branched stent-graft for treatment of aortic arch aneurysms. Our initial experience has shown that the method is relatively safe. Long-term follow-up is necessary to evaluate the efficacy and safety of this new device.

Midterm results following endovascular repair of blunt thoracic aortic injuries.

OBJECTIVE: Previous studies have focused on early outcomes of thoracic endovascular repair (TEVAR) of blunt thoracic aortic injuries (BTAIs). Late results remain ill-defined. The purpose of this study is to review the midterm results of our experience with endovascular repair of BTAIs. METHODS: A retrospective analysis was performed reviewing all endovascular repairs of BTAIs from 2002 to present. Preoperative, operative, and postoperative variables were recorded. Clinical end points included aortic-related mortality, stroke and paraplegia, hospital length of stay, procedure-related complications, endoleaks, and reinterventions. Computed tomography data sets were postprocessed for assessing integrity of stent grafts and late complications. RESULTS: A total of 24 cases of BTAIs treated with TEVAR were identified. Thoracic endovascular repair was successful in treating BTAIs in all patients and there were no instances of procedure-related death, stroke, or paraplegia. One access complication occurred, requiring an iliofemoral bypass. Actuarial survival estimates and freedom from reintervention at 5 years were 88.7% and 95.8%, respectively. No late endoleaks, stent fractures, or device migration were identified. One patient required a secondary intervention 1 year following the initial repair to treat a pseudocoarctation syndrome caused by a diaphragm at the distal half of the stented aorta. This was treated successfully with repeated endografting. CONCLUSIONS: Thoracic endovascular repair for BTAIs can be performed safely with low periprocedural mortality and morbidity. Midterm follow-up data presented in this report further support the therapeutic role of endoluminal approach for treating BTAIs in anatomically suitable patients.

Macrophage infiltration and smooth muscle cells content associated with haptoglobin genotype in human atherosclerotic carotid plaques.

We assessed the association between the haptoglobin (Hp) genotype and 2 common indicators of atherosclerotic plaque instability: macrophage infiltration and the smooth muscle cell (SMC) content. A total of 70 consecutive patients who underwent carotid endarterectomy were included in the study. For immunohistochemical study the anti-CD68 and anti-a-actin antibodies were used on adjacent serial sections; 36 plaques from patients with the Hp 1-1 or 2-1 genotype and 34 plaques from patients with the Hp 2-2 genotype were analyzed. The macrophage content (CD68+) was significantly higher in the Hp 2-2 group compared with that in the Hp 1-1 or 2-1 group (P < .001). In plaques from patients with diabetes, the SMC content was significantly lower in the Hp 2-2 group (P = .034). Carotid plaques from diabetic patients with Hp 2-2 genotype had higher macrophage infiltration and lower SMC content. Both parameters are indicators of atherosclerotic plaque instability.

Endovascular treatment of an iatrogenic vertebrojugular fistula with a balloon-expandable covered stent: case report and review of the literature.

We report a case of a fistula between the vertebral artery and the internal jugular vein that occurred after the erroneous placement of a central venous catheter. The patient was presented with tinnitus. Endovascular treatment with a balloon expandable covered stent placed into the vertebral artery was performed. One year follow-up showed satisfactory exclusion of the fistula, patency of the stented vertebral artery, and resolution of the symptoms. Only few other similar cases are reported in the literature with the use of different types of stents.

Results and challenges for the endovascular repair of aortic arch aneurysms.

Endovascular aortic arch reconstruction provides an attractive alternative to treat aortic arch disease in high-risk patients who would otherwise be unsuitable for open repair. Success with multibranched stent grafts in the thoracoabdominal aorta along with recent advances in design such as the precurved inner nitinol cannula have simplified the endovascular reconstruction of aortic arch aneurysms with multibranched stent grafts. These devices allow for greater flexibility in conforming to difficult anatomy and preserving important side branches. During the first surgical stage, a left carotid -subclavian bypass or left subclavian artery transposition is performed. The second stage is the endovascular procedure. The device is inserted through a transfemoral approach, and crossing of the aortic valve with the device is necessary. The stent graft is deployed during brief periods of rapid pacing. Bridging from the branches to the innominate and left common carotid arteries requires a suitable covered stent. In the case of a large-diameter innominate artery, a custom-made bridging limb has to be used to ensure that adequate length and size are available. Direct flow to the innominate and left common carotid arteries do not cease for any significant time during the procedure. Initial experience with mean follow up more than 6 months is encouraging. The method is not suitable for patients with extensive atheromatous involvement of the aortic arch. Careful preoperative planning (preoperative imaging, device construction, and access issues), high endovascular skills, and appropriate imaging equipment are imperative for a successful result. Long-term follow-up is necessary to evaluate the efficacy and safety of these new devices.

Association of haptoglobin genotype and common cardiovascular risk factors with the amount of iron in atherosclerotic carotid plaques.

INTRODUCTION: The aim of this study was to evaluate the iron burden of carotid atherosclerotic plaques removed from patients treated for carotid disease and find any relation with haptoglobin genotype and other common cardiovascular risk factors. METHODS: Consecutive patients undergoing carotid endarterectomy were included in the study. All patients had high-grade carotid stenosis (>70%). The clinical characteristics and serum parameters of the study population were recorded and the haptoglobin genotype was determined. The presence of hemosiderin deposits in the plaques was identified using Perl's stain on adjacent serial sections. RESULTS: 70 specimens were processed for histologic examination: 27 plaques from diabetic patients (16 with the Hp 1-1 or 2-1 genotype and 11 with the Hp 2-2 genotype) and 43 plaques from non diabetic patients (20 with the Hp 1-1 or 2-1 genotype and 23 with the Hp 2-2 genotype). In plaques from diabetic patients the density of Perl's iron stain was significantly higher in the Hp 2-2 group compared with that in the Hp 1-1 or 2-1 group (p = 0.008). The correlation and regression analysis of all possible clinical and laboratory predictors of intraplaque iron deposition showed that four factors were independently associated with intraplaque iron deposition: male gender, serum homocysteine, Hp 2-2 genotype and diabetes mellitus treatment. CONCLUSIONS: Male diabetic patients with increased plasma levels of homocysteine and the Hp 2-2 genotype had higher carotid plaque iron deposition. Current evidence and pathophysiological considerations suggest that the increased intraplaque iron deposition may be associated with increased oxidative stress, affecting the stability of the carotid plaque.

Paraplegia prevention branches: a new adjunct for preventing or treating spinal cord injury after endovascular repair of thoracoabdominal aneurysms.

In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This technique involves using a specially designed endograft with side branches (paraplegia prevention branches [PPBs]), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.

Comparison among transposed brachiobasilic, brachiobrachial arteriovenous fistulas and Flixene™ vascular graft.

OBJECTIVE: To compare the outcomes of 3 upper arm access types: transposed brachiobasilic arteriovenous fistula (BBAVF), autogenous brachial vein-brachial artery access (ABBA), and a new type of ePTFE graft (Flixene™ graft) (AVG), in a consecutive series of patients treated in a tertiary centre. METHODS: A prospective, computerized access database was analysed retrospectively to identify all patients undergoing BBAVF, ABBA, or AVG between January 1, 2008, and December 31, 2009. RESULTS: A total of 108 patients were identified; of whom 45 had BBAVF, 15 ABBA, and 48 ePTFE brachioaxillary AVG. Early failure was similar in all 3 groups. The 18-month functional patency rates for the ABBAs, BBAVFs, and grafts were 27%, 51%, and 55%, respectively. The median time to first use for AVGs was significantly shorter (p<0.0001). Complications were not more frequent in AVGs than ABBAs and BBAVFs (p=0.127). The total number of access interventions was similar between the AVG and ABBA groups (p=0.58), but it was significantly higher in the AVG group compared with the BBAVF group (p<0.0001). CONCLUSIONS: This study supports the current recommendations of the NKF Kidney Disease Outcomes Quality Initiative for using BBAVFs as third choice after radiocephalic and brachiocephalic arteriovenous fistulas. We also showed good results with a new type of prosthetic graft (Flixene™ graft) that allows cannulation within days of implantation. We now favour the use of this graft instead of basilic vein transposition in elderly patients with short life expectancy and urgent need of renal access.

High brachial artery bifurcation is associated with failure of brachio-cephalic autologous arteriovenous fistulae.

OBJECTIVE: Although European Best Practice Guidelines on vascular access recommend universal pre-operative duplex scan in patients receiving brachio-cephalic (BC) arteriovenous fistulae (AVF), this is not widespread practice. Furthermore, cadaveric and angiographic studies suggest that variation in upper limb arterial anatomy is common. Our aim was to investigate the prevalence of high brachial artery bifurcation (HB) and its impact on BC AVF patency. METHODS: A retrospective analysis of consecutive autologous BC AVF created over an 18-month period (January 2008 to June 2009). Patients with high bifurcations identified at duplex scan were compared with a control group who had normal bifurcations. All patients were followed up at 1, 6 and 12 weeks post-operatively. The study endpoint was AVF patency. RESULTS: One hundred and five autologous BC AVF procedures were performed in our institution, of which 29 (27.6%) were identified as having a high brachial bifurcation on pre-operative duplex scan. The bifurcation was axillary in six patients and located at the proximal, middle and distal third of the humerus in nine, seven and seven patients, respectively. The actuarial functional patency rate was 53.2% (standard error = 9.6%) in the HB group and 76.2% (standard error = 4.9%) in the control group (log-rank test, p=0.027). CONCLUSIONS: These data show that aberrant brachial artery anatomy is both common (12%) and a predictor of autologous BC AVF failure. These data support the universal use of pre-AVF duplex scanning.

A report of spinal cord ischemia following endovascular aneurysm repair of an aneurysm with a large thrombus burden and complex iliac anatomy.

We report a case of paraplegia occurring after an elective endovascular aneurysm repair (EVAR) that was reversed by cerebrospinal fluid (CSF) drainage. This case report highlights the reality that the endovascular management of abdominal aortic aneurysms (AAAs) with large volumes of mural thrombus and complex iliac anatomy can be complicated by spinal cord ischemia (SCI). The presumed mechanism of SCI is dissemination of atherosclerotic material during protracted catheter and wire manipulations. Embolization of internal iliac arteries (IIAs), profunda femoral arteries, and possibly other arterial networks may explain the delayed presentation. The complex iliac anatomy necessitating covering of one and reconstruction of the other hypogastric artery and the prolonged operative time may be 2 other contributing factors. The prompt CSF drainage may reverse the neurologic deficit.

Two-year outcome after Xpert stent implantation for treating below the knee lesions in critical limb ischemia.

We investigated the efficacy of Xpert (Abbott Vascular, Abbott Park, IL) nitinol stents for the treatment of infrapopliteal lesions in patients with Critical Limb Ischemia (CLI). Between May 2005 and November 2007, 94 CLI patients (70 male, mean age 73.5 years) received 134 Xpert stents in 102 limbs. Seventy-nine patients (71.2%) were scored as Rutherford Category 4, 31 patients (27.9%) as Category 5 and 1 patient (0.9%) as Category 6. Primary endpoint of this study was defined as 2-year duplex derived primary patency. Secondary endpoints were 2-year limb salvage rate and the absence of reintervention after the index procedure. Kaplan Meier analysis reported 2-year primary patency and limb salvage rates of 54.4% and 90.8%, respectively. Stratification by lesion location did not reveal any significant differences in 2-year primary patency rates in proximal and distal below the knee lesions. Our results suggest that treatment with nitinol Xpert stents can be considered effective for treating CLI patients, with satisfying patency outcome.

The effect of negative pressure therapy on the femoral vein blood flow and wall structure.

Negative pressure therapy has been recently used for managing lymphatic or infective groin complications. The aim of this study was to investigate any possible association between application of negative pressure therapy in the groin area and deep-vein thrombosis. Acute surgical wounds were created at the inguinal areas in 7 pigs. Different negative pressures ranging from -50 to -200 mmHg were applied directly over the femoral vessels, and blood flow alterations were studied using a Doppler ultrasound. Femoral vein specimens were also removed for histological examination after 12 hours of therapy. It has been demonstrated that negative pressure therapy does not significantly alter the baseline lower limb venous return. Histology demonstrated several changes, which are associated with vein thrombogenesis. The hemodynamic and pathological findings still leave a potential for thrombogenic effects of negative pressure therapy and warrant care to protect the femoral veins, with the use of thrombosis prophylaxis measures.

Endovascular treatment of a ruptured para-anastomotic aneurysm of the abdominal aorta.

We report a case of a ruptured para-anastomotic aortic aneurysm treated with implantation of a bifurcated stent-graft. A 72-year-old patient, who had undergone aortobifemoral bypass for aortoiliac occlusive disease 16 years ago, presented with a ruptured para-anastomotic aortic aneurysm. A bifurcated stent-graft was successfully deployed into the old bifurcated graft. This is the first report of a bifurcated stent-graft being placed through an "end-to-side" anastomosed old aortobifemoral graft. Endovascular treatment of ruptured para-anastomotic aortic aneurysms can be accomplished successfully, avoiding open surgery which is associated with increased mortality and morbidity.

Stent-graft treatment of late stenosis of the left common carotid artery following thoracic graft placement.

We report the case of a patient with subtotal occlusion of the origin of the left common carotid artery (CCA) following thoracic graft placement. Retrograde endovascular placement of a stent-graft by minimal cervical access was undertaken to repair the occlusive lesion of the left CCA and prevent future complications of endoluminal thoracic reconstruction. The retrograde endovascular repair of CCA lesions, as other authors have already suggested, may be the treatment of choice in "high-surgical-risk" patients. In these cases where the ostium of supra-aortic trunks is compromised following thoracic aorta stent-graft migration, endoluminal placement of a stent-graft in the CCA can guarantee both maintenance of carotid flow and thoracic stent-graft fixation.

Statin treatment, carotid atherosclerotic plaque macrophage infiltration and circulating inflammatory markers.

BACKGROUND: Statin treatment is considered as first line therapy in patients with atherosclerotic disease. We evaluated the effect of pre-treatment with statins on carotid plaque infiltration by macrophages and on the circulating levels of proinflammatory cytokines in patients who underwent carotid endarterectomy. PATIENTS AND METHODS: One hundred fourteen patients were enrolled; 89 men and 25 women (mean age 67+/-8 years; range 42-83 years). Fifty three patients (46%) were on statin treatment at least 3 months before endarterectomy and 61 (54%) had never received statin treatment. The serum levels of high sensitivity C reactive protein (hsCRP), serum amyloid A (SAA), tumor necrosis factor alpha (TNFalpha), interleukin (IL)-1beta and IL-6 were evaluated preoperatively. The intensity of macrophage infiltration was evaluated by immunochemistry, using the monoclonal antibody CD 68. The area of the plaque covered by macrophages was measured as a proportion of the whole plaque area, using a custom designed image tool analysis. RESULTS: Patients on statins had lower serum total cholesterol levels (172+/-50 vs 194+/-35 mg/dl, p= 0.014), lower low density cholesterol levels (103+/-44 vs 123+/-31 mg/dl, p= 0.010) and lower serum hsCRP levels (1.8 [1.1-3.4] vs 3.4 [1.3-4.9] mg/l, p= 0.03), while SAA, TNFalpha, IL-6 and IL-1beta levels did not differ between the 2 groups. The infiltration of atherosclerotic plaque by macrophages was similar in statin treated patients and in controls (0.55+/-0.15% vs 0.49+/-0.19%, p= 0.21). CONCLUSION: Patients on statins have similar macrophage accumulation in their carotid atherosclerotic plaques compared with patients not on statins. Inflammatory markers were also similar in both groups except for hsCRP which was significantly lower in those taking statins.

Thoracic aneurysm repair: managing severe tortuosity with brachiofemoral traction.

Challenging anatomy of the thoracic aorta is often encountered, and aortic tortuosity may be a major impediment to the propulsion of the stent-graft. Traction on both ends of a guidewire, with one end exiting the right upper extremity and the other end exiting the lower extremity, is an excellent option to manage thoracic aorta tortuosity. Careful application of simple guidelines may lessen associated risks and improve safety.