Current Clinical Knowledge on GORE EXCLUDER Conformable Abdominal Aortic Aneurysm Repair Endoprosthesis: A Case Series and Literature Review.

The GORE EXCLUDER Conformable abdominal aortic aneurysm (AAA) Endoprosthesis (CEXC), is currently the newest stent-graft system for treating patients with AAA. CEXC is approved for patients with proximal aortic neck angles ≤90° with a ≥15 mm aortic neck length or proximal aortic neck angles ≤60° with ≥10 mm aortic neck length. The present study describes a clinical series of 5 males with AAA, one of whom had a ruptured infrarenal AAA and a 90° proximal aortic neck angle. All patients were treated with 100% technical success using the CEXC device. Dosimetric data were recorded regarding the total kerma-area product and total fluoroscopy time. During the 30-day follow-up, no device migration or failure was detected, whereas type Ib and II endoleaks were observed in two patients. The type Ib endoleak required re-intervention with limb extension placement, and the type II endoleak was treated with lumbar artery embolization. This clinical series showed that CEXC has no technical defects or AAA-related mortality. We also reviewed the current knowledge on CEXC's clinical outcomes, showing promising technical and clinical results in some studies, even outside the instructions for use. CEXC expands the vascular surgeons' armamentarium against hostile neck anatomy, as it is the only repositionable endovascular aneurysm repair device available. Multicenter, long-term outcome studies should confirm the promising preliminary results of our case series and the literature review.

Myasthenia Gravis and Abdominal Aortic Aneurysm: A Rare Combination.

Abdominal aortic aneurysm in a patient with myasthenia gravis (MG) is extremely rare. We present a 64-year-old male with MG and an asymptomatic abdominal aortic aneurysm treated endovascularly. After extubation, he suffered a cardiac arrest due to an acute myocardial infarction. Cardiopulmonary resuscitation and a primary coronary angioplasty led to a satisfactory outcome. Special care is needed due to higher rates of postoperative complications in these patients.

Re-Rupture 2 Years after Endovascular Aortic Aneurysm Repair Rupture.

Re-rupture 2 years after endovascular aortic aneurysm repair (EVAR) rupture is an extremely rare event and limited data exist in the literature. We present an interesting case of a patient with an abdominal aortic rupture that had undergone 2 years before an endovascular repair for rupture after EVAR due to a type IA endoleak. The patient underwent a successful embolization of the type IA endoleak. Onyx was used to seal the gutter between the aortic wall and the endograft and the 1-month post-embolization CT showed complete sealing with no contrast in the sac. Two years after the rupture, he was presented again with clinical signs of hemodynamic shock and instability. An urgent CT Angiograph showed again rupture due to a type IA endoleak. The patient underwent an emergency open laparotomy. We analyze the re-rupture after EVAR while taking data from the literature into account.

FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY.

Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.

Endovascular Repair of an Inflammatory Abdominal Aortic Aneurysm Combined with a Congenital Pelvic Kidney: Case Report and Literature Review.

The coexistence of an abdominal aortic aneurysm and a congenital pelvic kidney is extremely rare. We present a 66-year-old male with an inflammatory aneurysm and an aberrant origin of the superior mesenteric artery. The inflammatory infrarenal abdominal aortic aneurysm with a congenital left pelvic kidney was successfully treated with endovascular repair. Coverage of one out of the two renal ectopic arteries was performed, without clinical evidence of renal function impairment.

Treatment options for dialysis access steal syndrome.

Vascular access-induced limb ischemia is a known complication of arteriovenous fistulas and grafts. Many techniques have been adopted to prevent steal in high-risk patients and to treat steal in cases of moderate ischemia not controlled with conservative management. A major factor guiding treatment is access flow volume. Management is different when ischemia is combined with the excessive flow in contrast to the combination with normal flow. We describe the most popular techniques encountered in the English literature as a part of a stepwise approach to treating dialysis access steal syndrome. In absence of ischemia, when cardiac issues emerge due to extreme access flow volumes, some of these techniques are also used to decrease flow and protect the heart. Patient's history, focused clinical examination, color duplex ultrasound examination, pulse oximetry and an angiogram are essential tools to approach this entity.

A case report of surgical repair of a post-catheterization radial pseudoaneurysm.

We report an 83-year-old patient with a huge post-catheterization right radial pseudoaneurysm, presented 17 months after a coronary angiography. Cases of radial post-catheterization pseudoaneurysms with a similar size are scarce in the literature. Delay in presentation led to painful skin ischemia due to tension, a sign of imminent rupture, which is also rare in the literature. Symptomatology included severe wrist pain and clinical signs consisted of a pulsatile painful mass in the right distal forearm. Management consisted of surgical excision and ligation of the radial artery in an urgent base. This case emphasizes the need for early diagnosis and management of post-catheterization pseudoaneurysms as delay may lead to severe enlargement with skin necrosis and imminent rupture. Ligation of the radial artery is an acceptable option when reconstruction of the artery is troublesome, provided that the palmar arch remains patent.

Endovascular Juxtarenal Aortic Aneurysm Repair Using the ALTO Abdominal Stent Graft System: The First Case Series.

The ALTO abdominal stent graft system (Endologix Inc., Irvine, CA, USA) is a latest-generation polymer-based device used to treat patients with abdominal aortic aneurysms. The present study describes the first case series of patients with abdominal aortic aneurysms, including two patients with juxtarenal aneurysms, treated using the ALTO stent graft system. Six males were treated using the ALTO device at a single public center. All procedures were uneventful, and the dosimetric results recorded in terms of kerma-area product and fluoroscopy time were similar to those reported in previous studies. At the 1-month follow-up, computed tomography angiography showed no evidence of endoleak, device migration, thrombosis, or structural graft failure. This clinical series demonstrates that the use of the ALTO stent graft system is associated with promising patient outcomes. Lifelong postoperative imaging surveillance may highlight possible late failures and suggest potential graft improvements.

Patient Transfer with Kocher Forceps on the Axillary Artery: A Rare Case of Ongoing Iatrogenic Vascular Injury.

Iatrogenic trauma of the axillary artery by non-vascular surgeons can occur during various general surgical procedures such as resection of soft tissue tumors or axillary lymph node clearance. Prompt recognition, appropriate initial management, and rapid transfer to a tertiary vascular surgery service, if needed, are key steps to ensuring patient safety. Here we present a case of iatrogenic axillary artery injury during the resection of a recurrent soft tissue tumor in a local hospital. The desperate application of a Kocher clamp on the bleeding axillary artery by the operating general surgeons controlled the bleeding but led to further arterial damage. The patient was transferred to our tertiary hospital, where the arterial injury was repaired using a vein interposition graft. Apart from the encountered intraoperative technical challenges, this case highlights the need for broader training of nonvascular specialist surgeons on the core principles of basic vascular surgical techniques and oncovascular surgery.

Treatment of Dialysis Access Steal Syndrome with Concomitant Vascular Access Aneurysms.

Limb ischemia is a known complication of vascular access that may appear early postoperatively or after years. Over the last few decades, various techniques based on different physiological mechanisms have been used for treatment. A standardized treatment does not exist, and must be individualized based on the flow volume, and the type and location of the access. True and false vascular access aneurysms are another common complication of arteriovenous fistulas, which develop because of venous hypertension or repeated needling. Evidence in the literature regarding treatment of patients with steal syndrome and concomitant true arteriovenous aneurysms is scarce. A female with a brachiocephalic fistula complicated by steal syndrome and vascular access aneurysms was treated successfully with tapered graft placement and aneurysm exclusion.

Complete agenesis of the infra-renal aorta.

Complete agenesis of the infra-renal aorta is an extremely rare anatomical variant, and its presence can complicate the accurate interpretation of the aortic sonographic assessment.

Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy.

A 75-year-old male presented with an immediately threatened grade IIb acute ischemia of the left leg due to thrombosis of a femoro-infrapopliteal prosthetic bypass graft. After an urgent Computed Tomography Angiography, an urgent graft thrombectomy was performed using a 5 Fr Fogarty catheter, which had a troublesome distal passage, causing a tibial A-V fistula.