Mid-term Results of Chimney and Periscope Grafts in Supra-aortic Branches in High Risk Patients.

PURPOSE: Report mid-term outcomes of thoracic endovascular aneurysm repair (TEVAR) with chimney and periscope grafts (CPG) in supra-aortic branches (SAB). METHODS: Retrospective analysis, from October 2009 to May 2014, of patients with aneurysms requiring TEVAR with zone 0/1/2 proximal landing in association with at least one CPG in the SAB. All patients were considered at high risk for conventional surgery. Peri-operative mortality and morbidity, retrograde type A dissection, maximum aortic transverse diameter (TD) and its post-operative evolution, endoleak, survival, freedom from cardiovascular re-interventions, and CPG freedom from occlusion during the follow-up were analysed. RESULTS: Forty-one patients (28.05% EuroScore II) with thoraco-abdominal aortic aneurysm (17%), arch aneurysm (39%), descending aneurysm (34%), and aneurysm extending from the arch to the visceral aorta (10%) were included. Fifteen (37%) patients were treated non-electively. Fifty-nine SABs were treated with the CPG technique: one, two, three, and four CPG were employed in 71%, 19%, 5%, and 5% of patients, respectively. The proximal landing was in zone 0 in 49% of patients, zone 1 in 17%, and zone 2 in 34%. Technical success was 95%. Peri-operative complications and neurological events were registered in six (14.6%) patients and there were 5 deaths (12%). At a median follow-up of 21.2 (mean 22, SD 18; range 0-65) months, type I/III endoleaks were registered in three (7%) cases and re-intervention in six (15%) patients. A significant aneurysm sac shrinkage (p<.001) was reported at mean follow-up and no significant aneurysm sac increase (>5 mm). The estimated 2 year survival, freedom from re-intervention, freedom from endoleak, and freedom from branch occlusion were 75%, 77%, 86%, and 96%, respectively. CONCLUSION: The chimney and periscope grafts technique was shown to be safe in aortic aneurysm disease involving the supra aortic branches, even in an emergency setting using off the shelf devices. Mid-term follow-up results in this high risk population are good, but longer follow-up is mandatory before this technique is used in intermediate-risk patients.

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure.

OBJECTIVE: The aim was to report on chimney and periscope grafts (CPGs) and their mid- and longer-term outcomes when they are used to preserve reno-visceral artery (RVA) perfusion in endovascular repair of pararenal (PRAAs) or thoraco-abdominal aortic aneurysm (TAAAs). In addition, factors associated with CPG failure are presented. Limited data exist on the outcomes of CPGs, and mid- and long-term results are generally not reported. METHODS: This was a prospective study in a cohort of 100 patients with PRAA (69) or TAAA (31). A total of 224 (mean 2.24 per patient) RVAs were preserved with 136 (61%) chimney and 88 (39%) periscope grafts. CPGs were constructed mainly using self expandable stent grafts. Patients were followed by clinical examination, CTA (82%), and/or duplex (18%). Data were collected until February 2015. RESULTS: CPG immediate technical success was 99% (222/224 branches). Mean follow up was 29 months (range 0-65; SD 17); 59% patients were followed > 2 years, 30% > 3 years, and 16% > 4 years. Post-operatively, CPG occlusion was observed early (≤30 days) in three (1.3%) branches and during follow up in 10 (4.5%). At 36 and 48 months, the estimated primary patency was 93% and 93%. After corrective percutaneous (10) or surgical (3) re-interventions, the estimated secondary patency was 96% and 96%. Thirty day mortality was 2%; at 36 and 48 months the estimated patient survival was 79%. Significant shrinkage (72 [SD 23] vs. 62 [SD 24] mm; p < .001) was observed, with a substantial reduction (>5 mm) in 55 patients, and sac enlargement in four. Incomplete aneurysm sac sealing was treated successfully by a secondary intervention in 15 patients. CONCLUSIONS: Self expandable CPGs have proved to be a highly successful and durable treatment for RVA preservation up to 5 years. Incomplete CPG expansion, inadequate length, and CPG use in small and diseased target arteries were risk factors for occlusion. These mid- and longer-term results support CPG use to treat PRAAs or TAAAs in patients unfit for open surgery or fenestrated/branched stent grafts.

Morphological Differences in the Aorto-iliac Segment in AAA Patients of Caucasian and Asian Origin.

OBJECTIVE: The objective was to quantify aorto-iliac morphology differences between AAA patients of Caucasian and Asian origin. Additionally, the impact of patient demographic characteristics was assessed, which could influence the morphological differences. METHODS: This international multicentre study included two tertiary referral institutions from Europe and one from China. CT scans with 3D reconstruction of 296 patients with infrarenal AAA >5 cm were analysed. Eighteen measurements were recorded from each CT scan and compared between Caucasian and Asian patients. RESULTS: Caucasian patients had longer common iliac arteries (right: 65.0 vs. 33.1 mm, p < .001 left: 65.0 vs. 35.2 mm, p < .001), longer aneurysm neck (33.0 vs. 28.4 mm, p < .001), greater aneurysm to aortic axis angle (153.0° vs. 142.2°, p < .001), and longer combined aorto-iliac length (195.7 vs. 189.2 mm, p < .001). However, Asian patients had a longer infrarenal abdominal aorta (152.0 vs. 130.0 mm, p < .001), longer AAA (126.2 vs. 93.0 mm), and greater linear distance from renal artery to aorto-iliac bifurcation (143.6 vs. 116.0 mm, p < .001). Caucasian patients had a larger inner common iliac artery diameter (right: 16.0 vs. 14.9 mm, p < .001, left: 16.0 vs. 15.2 mm, p < .001), larger inner exernal iliac artery diameter (right: 9.0 vs. 7.5 mm, p < .001 left: 9.0 vs. 7.7 mm, p < .001), and larger inner common femoral artery diameter (right: 10.0 vs. 5.9 mm, p < .001 left: 10.0 vs. 6.1 mm, p < .001). No difference was observed in AAA transverse diameter (62.0 vs. 63.1 mm, p = .492). CONCLUSION: The results showed that aorto-iliac anatomy in Caucasians differs significantly from Asians, particularly in the length of the common iliac arteries and infrarenal abdominal aorta, and in the transverse diameter of the common, external iliac, and common femoral arteries. Therefore, the exact criteria for stent graft design are dependent on the racial origin of the patient.

Diagnostic performance of 18F-FDG-PET/CT in vascular graft infections.

OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy of positron emission tomography/computed tomography with (18)F-fludeoxyglucose (FDG-PET/CT) in a population with suspected graft infection and to validate a new diagnostic imaging score for FDG-PET/CT. METHODS: This was a prospective cohort study. FDG-PET/CT was performed prospectively in 34 patients with suspected graft infection, in 12 of them before the start of antimicrobial treatment. Diagnostic accuracy was assessed using a new five point visual grading score and by using a binary score. Maximum standardized uptake values (SUVmax) were calculated for quantitative measurements of metabolic activity, and cut off points were calculated using the receiver operator curve (ROC). The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. RESULTS: Using the new scale, FDG-PET/CT correctly recognized 27 patients with graft infection, one patient was diagnosed as false positive, six patients were correctly classified as true negative, and no patients were rated false negative. Hence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of FDG-PET/CT for the diagnosis of graft infections were 100%, 86%, 96%, 100%, and 97%, respectively. Using a previously established binary score, sensitivity, specificity, PPV, NPV, and accuracy were 96%, 86%, 96%, 86%, and 94% respectively. ROC analysis suggested an SUVmax cut off value of ≥3.8 to differentiate between infected and non-infected grafts (p < .001). Additionally, FDG-PET/CT provided a conclusive clinical diagnosis in six of seven patients without graft infection (i.e., other sites of infections). CONCLUSIONS: The diagnostic accuracy of FDG-PET/CT in the detection of aortic graft infection is high. A newly introduced five point visual grading score and early imaging prior to antimicrobial treatment may further improve the diagnostic accuracy.

How to diagnose and treat abdominal compartment syndrome after endovascular and open repair of ruptured abdominal aortic aneurysms.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are frequently encountered in patients treated for ruptured abdominal aortic aneurysms (rAAA) and carry a high morbidity and mortality risk. Despite these facts, IAH/ACS are still overlooked by many physicians, timely diagnosis is missed and treatment often inadequate. All staff involved in the treatment of rAAA should be aware of the risk factors predicting IAH/ACS, the profound implications and derangements on all organ systems, the clinical presentation, the appropriate measurement of intra-abdominal pressure to detect IAH/ACS and the current treatment options for these detrimental syndromes. This comprehensive review provides contemporary knowledge that should help to improve patient survival and long-term outcome.

Team training in ruptured EVAR.

Ruptured abdominal aortic aneurysms are almost always a fatal condition. The incidence of ruptured aortic aneurysms (rAAA) is declining, the number of teams is increasing and there is an increased focus on patient safety resulting in limited real life training opportunities to maintain or improve the technical and human factor skills required to manage this acute aortic pathology. The availability and experience of the multidisciplinary team together with accessibility of appropriate resuscitation and efficient logistics all influence the modality of rAAA repair. A standardised patient's pathway for rAAA management and reliable multidisciplinary team are the keys to improve patient outcomes. Whole rEVAR team training using high fidelity simulation may be the one answer to allow clinicians to learn, practice, rehearse, improve and maintain team-based knowledge, technical and human factor skills and team attitudes to manage this challenging pathology.

Patient-specific rehearsal prior to EVAR: a pilot study.

OBJECTIVES: This study aims to evaluate feasibility, face validity, influence on technical factors and subjective sense of utility of patient-specific rehearsal (PsR) prior to endovascular aortic aneurysm repair (EVAR). DESIGN: A prospective, multicentre pilot study. METHODS: Patients suitable for EVAR were enrolled and a three-dimensional (3D) model of the patient's anatomy was generated. Less than 24 h prior to the real case, rehearsals were conducted in the laboratory or clinical angiosuite. Technical metrics were recorded during both procedures. A subjective questionnaire was used to evaluate realism, technical and human factor aspects (scale 1-5). RESULTS: Ten patients were enrolled. In one case, the treatment plan was altered based on PsR. In 7/9 patients, the rehearsal significantly altered the optimal C-arm position for the proximal landing zone and an identical fluoroscopy angle was chosen in the real procedure. All team members found the rehearsal useful for selecting the optimal fluoroscopy angle (median 4). The realism of the EVAR procedure simulation was rated highly (median 4). All team members found the PsR useful to prepare the individual team members and the entire team (median 4). CONCLUSIONS: PsR for EVAR permits creation of realistic case studies. Subjective evaluation indicates that it may influence optimal C-arm angles and be valuable to prepare the entire team. A randomised controlled trial (RCT) is planned to evaluate how this technology may influence technical and team performance, ultimately leading to improved patient safety.

Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection.

OBJECTIVE: We report our experience with the treatment of femoral artery aneurysms (FAAs) under local anaesthesia with limited dissection, using endografts to facilitate the proximal anastomosis and some distal anastomoses. METHOD: Between January 2006 and December 2010, six males, mean age 72 years (range, 65-80 years) with FAAs were treated at the University Hospital of Zurich. All operations were performed under local anaesthesia with analgosedation, except for one performed under spinal anaesthesia. After limited dissection and puncture of the anterior wall of the FAA, a sheath and a self-expanding endograft were introduced over a guide wire and with fluoroscopy they were guided intraluminally into the proximal normal neck of the FAA and deployed. Proximal arterial control was achieved with a balloon catheter introduced through the endograft. Then the FAAs were opened and distal arterial control is obtained with balloon catheters. The distal end of the stent graft was then sutured to the normal-sized distal arteries or to stent grafts placed within them. RESULTS: Of the six FAAs, four were true and two were false anastomotic aneurysms. Mean FAA diameter was 5.0 cm (range, 3.0-6.5 cm). Four patients also had aneurysmal involvement of the external iliac artery, one patient also had deep femoral aneurysms, but deep femoral circulation was always preserved. In three of the patients, the distal anastomosis was created to the femoral artery bifurcation, in two patients to the deep femoral artery when the superficial femoral artery (SFA) was chronically occluded and in one patient to the SFA. Immediate technical success was achieved in all six patients, and graft patency was observed from 9 to 48 months (mean 29 months). There were no amputations, complications or deaths. CONCLUSION: This technique for repair of FAAs can be performed under local anaesthesia, minimises dissection and complications and simplifies exclusion of these lesions. It is of particular value in high-risk patients with large FAAs.

Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience.

OBJECTIVE: To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months. BACKGROUND: Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair. METHODS: We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an "EVAR-whenever-possible" approach until April 2009 (EVAR/OPEN period) and thereafter according to a "100% EVAR" approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2. RESULTS: Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4-7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9-16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3-3.7). CONCLUSIONS: The "EVAR-ONLY" approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.

The use of Endurant stent-graft for abdominal aortic aneurysm: the story about extension of instruction for use with persistent good results of stent-graft latest generation.

The Endurant stent-graft (Medtronic, Inc., Minneapolis, MN, USA) is a latest generation device for the treatment of abdominal aortic aneurysm. The idea behind designing such a graft came from the intention to broad the instruction for use (IFU) and to enable it to treat more challenging anatomy including the 10mm neck lengths, and more severe suprarenal and infrarenal angulations. Endurant stent-graft has active fixation through suprarenal stent with anchoring pins to provide migration resistance, optimized heights of stents and spacing between them for improved flexibility and conformability, low-profile delivery system with hydrophilic coating and controlled simple deployment mechanism. Short term results are excellent. Technical and clinical success is confirmed in Regulatory trials (EU and USA), as well as in ENGAGE and the Canadian registry. Many current publications record the use of Endurant stent-graft outside the Instruction for use. The results in a group of patients outside the instruction for use are comparable to those within instruction for use; with the exception of perioperative proximal endoleak type I. Mid-term results are consistent with short-term results. The long-term results are lacking.

Simultaneous appearance of leukemoid reaction and phlegmasia cerulea dolens.

A leukemoid reaction is an extreme form of reactive leukocytosis defined as granulocytic leukocytosis above 50 × 10(9)/L produced by normal bone marrow, mostly in response to systemic infection or cancer. The mechanism as to how the haematopoetic system is altered to elevate production of myeloid cells is not known. A 69-year-old man presented with phlegmasia cerulea dolens caused by massive iliofemoral thrombosis. His workout at admission revealed absolute white blood cell count of 73.4 × 10(9)/L, with neutrophil granulocyte of 68.5 × 10(9)/L. The new increase in white blood cell count happened at day 5 after admission, when the haematoma of the anteromedial thigh was evacuated in general anaesthesia. There was a gradual decrease in counts until they reached the normal range. Deteriorated general condition with signs of systemic inflammatory response syndrome improved with supportive therapy, and the patient was discharged from hospital after 30 days. During hospitalization we did not identify any infectious focus, or any malignancy. We could not exclude other occult chronic conditions (malignancy) but the patient did not develop any other condition during 4.5 years of follow-up.

Malignant biliary stenosis treated with two percutaneous stents--case report.

INTRODUCTION: During last three decades interventional radiology became most powerfull tool in palliative treatment of patients with malignant biliary stenosis. CASE REPORT: We report a case of 62-year-old patient with malignant biliary obstruction caused by recidivant tumor of common bile duct remnant with infiltration of previously created hepaticojejunostomia. Biliary decompression was achieved by placement of two self-expanding metallic stents. DISCUSSION: In presented patient, due to previous surgery percutaneous approach was mandatory. Also, considering the unresectability of recidivant lesion and poor prognosis, definitive, preferable internal biliary drainage was to be achieved. Therefore the placement of metallic self-expanding stent was the therapeutic method of choice. CONCLUSION: The aim of percutaneous minimally invasive radiological interventions is to achieve effective biliary decompression with internal bile drainage if possible.

Abdominal compartment syndrome.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are frequently encountered in critically ill patients and carry a high morbidity and mortality risk. Despite these facts, IAH/ACS are still overlooked by many physicians and therefore timely diagnosis is not made and treatment is often inadequate. All clinicians should be aware of the risk factors predicting IAH/ACS, the profound implications and derangements on all organ systems, the clinical presentation, the appropriate measurement of intra-abdominal pressure to detect IAH/ACS and the current treatment options for these detrimental syndromes. This comprehensive review provides knowledge about known facts, unresolved issues and future directions for research to improve patient survival and long-term outcome.

Choice of treatment for the patient with urgent AAA: practical tips.

Since the first successful attempts of emergency endovascular aneurysm repair (eEVAR) for patients with ruptured AAAs in the mid 1990s, surgeons have had to decide whether to treat patients by conventional open surgery or by minimally invasive but technically more demanding eEVAR. To date, selection of patients for eEVAR is still heavily debated and factors like hemodynamic instability, fear of treatment delay for patient transfer or imaging procedures and logistic issues often lead to the exclusion of anatomically suitable patients from eEVAR. However, these adverse factors may be overcome by adherence to an appropriate (intention-to-treat) protocol employing the use of a hypotensive hemostatic approach, transfemoral aortic balloon occlusion technique (when needed), different types of devices and an appropriate plan to resolve logistic issues, leaving anatomic suitability as the single most important determinant of suitability for EVAR.

Pull-down technique to allow complete endovascular relining of failed AAA Vanguard endografts with Excluder bifurcated endografts.

INTRODUCTION: Endovascular replacement of failed Vanguard endoprosthesis with a newly inserted bifurcated Excluder endograft in 6 selected patients over a 10-year period is reported. REPORT: Six male patients were treated by secondary EVAR procedures for endograft failure (type I and/or III endoleaks caused by endograft disintegration and/or migration). All failed endografts (1 tube, 5 bifurcated) were Vanguard prostheses. Technically, a new bifurcated Excluder endograft was placed within the old failing Vanguard endograft. All reinterventions were performed under local anesthesia supplemented by systemic analgesia/sedation. In 3 patients, insertion of the new Excluder endograft was possible without any additional technical measure as the failing Vanguard endograft trunk had migrated distally. In another 3 patients, the failed Vanguard endograft trunk was still in place. In these patients, the Vanguard main body was pulled caudally with a transfemoral cross-over guide wire in order to gain sufficient length to allow the short limb of the Excluder endograft to open within the trunk of the failed Vanguard endoprosthesis. This guide wire was introduced through a second femoral 5F in the main access and exeteriorized with a snare through the contralateral 12 Fr sheath. The main body and short limb of the Excluder was then deployed whilst pulling on the cross-over wire. RESULTS: Six patients initially treated by a Vanguard endograft underwent complete relining with a newly inserted Excluder bifurcated stentgraft. The mean interval from the first EVAR procedure to the described replacement procedure was 75+/-20.2 months (range: 53-109). The new bifurcated Excluder endografts were successfully deployed in all patients (technical success: 100%). Primary sealing (defined as absence of endoleaks type I, III or IV in the postoperative contrast enhanced CT scan) was achieved in 6 of the 6 patients. There was no operative mortality. No further endovascular or open treatment was needed in the other 5 patients. During the mean follow-up period of 26+/-20.1 months (range 2.5-50 months), 2 patients died from unrelated causes. CONCLUSION: Secondary endovascular replacement of failed Vanguard endografts with a bifurcated Excluder endograft proved to be feasible and safe with no 30-day mortality. Technical detail requires traction on a cross-over wire to pull the old graft caudally and create enough space for the new bifurcated graft to be deployed.