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1.
Diagn Interv Radiol ; 27(4): 570-572, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34313244

RESUMO

Type III endoleak is an uncommon but life-threatening complication of endovascular aortic repair, and such leaks at certain sites can be challenging to treat through an endovascular route. A 77-year-old man presented with severe abdominal pain and was found to have an abdominal aortic aneurysm with contained rupture due to an unfavorably cited type IIIb endoleak. He was successfully treated with an endovascular approach using bilateral iliac limb proximal extension combined with embolization of endoleak sac, endoleak site and the feeding recess, preserving flow through both the iliac limbs obviating the need for an additional femorofemoral bypass. The patient improved clinically and had a favorable long-term follow-up profile.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Endoleak/diagnóstico por imagem , Endoleak/cirurgia , Humanos , Masculino , Stents , Resultado do Tratamento
2.
Eur J Vasc Endovasc Surg ; 62(2): 193-201, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34140226

RESUMO

OBJECTIVE: Use of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol. METHODS: Agreement between CDUS and CTA was assessed for detection of significant sac abnormalities. Surveillance protocols were extrapolated from published guidelines and applied to infrarenal EVAR patients active on local surveillance at a large, single centre. Surveillance intensity was dependent on presence of endoleak and subsequent risk of treatment failure in accordance with surveillance recommendations. Estimates for each surveillance protocol were inclusive of a range of published incidences of endoleak, contrast associated acute kidney injury (AKI), and excess hospital bed days, and estimated for a hypothetical five year surveillance period. RESULTS: The kappa coefficient between CDUS and CTA for detecting sac abnormalities was 0.68. Maximum five year surveillance cost estimates for the 289 active EVAR patients were £272 359 for SVS, £230 708 for ESVS, £643 802 for NICE, and £266 777 for local protocols, or £1 270, £1 076, £3 003, and £1 244 per patient. Differences in endoleak incidence accounted for a 1.1 to 1.4 fold increase in costs. AKI incidence accounted for a 3.3 to 6.2 fold increase in costs. CONCLUSION: A combined CTA and CDUS EVAR surveillance protocol, with CTA reserved for early seal assessment and confirmatory purposes, provides an economical approach without compromising detection of sac abnormalities. AKI, as opposed to direct imaging costs, accounted for the largest differences in surveillance cost estimates.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Angiografia por Tomografia Computadorizada/economia , Endoleak/diagnóstico por imagem , Vigilância da População/métodos , Ultrassonografia Doppler em Cores/economia , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/economia , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste/efeitos adversos , Endoleak/economia , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Seguimentos , Fidelidade a Diretrizes/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Guias de Prática Clínica como Assunto , Reoperação , Estudos Retrospectivos
4.
Eur J Vasc Endovasc Surg ; 62(2): 204-213, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33994306

RESUMO

OBJECTIVE: The aim was to describe initial outcomes of physician modified stent grafts using antegrade laser fenestrations and image fusion guidance (LEVAR) and company manufactured custom made (CM) stent grafts for the treatment of complex abdominal aortic aneurysms (CAAAs), thoraco-abdominal aortic aneurysms (TAAAs) and type I endoleaks (T1ELs). METHODS: This was a retrospective single centre study. All LEVAR and Zenith (Cook) CM stent graft procedures between 1 January 2012 and 31 December 2018 were reviewed. Endpoints included intra-operative adverse events (IOAEs), in hospital mortality, re-interventions, target vessel patency, and 12 month outcomes (overall survival, freedom from re-intervention, target vessel patency). Outcomes at 12 months were estimated using the Kaplan-Meier method. RESULTS: A hundred patients were identified and included in the study. All patients were deemed unfit for open repair. The cohort included 22 LEVAR and 78 CM stent grafts. LEVAR cases included painful aneurysms (n = 5), > 65 mm aneurysms (n = 10), anatomical constrains and/or presence of previous renal stents (n = 7) or cases declined by the manufacturer planning centre (n = 2). IOAEs were recorded in 41% of cases (n = 9) in the LEVAR group vs. 10% (n = 8, p = .002) in the CM group. The in hospital mortality rate in the LEVAR group was 9% (n = 2) vs. 4% (n = 3, p = .30) in the CM group. The median follow up duration was 22 months (7 - 38) in the LEVAR group and 28 months (11 - 78) in the CM group. The estimate of overall survival at one year was 91% in both groups. The freedom from re-intervention rate at one year was 58% in the LEVAR group vs. 87% in the CM group. The target vessel patency rates at one year were 95% in both groups. CONCLUSION: In high risk patients deemed unfit for open repair, LEVAR may provide satisfactory 12 month overall survival and target vessel patency rates, though reported IOAE, mortality, and re-interventions rates were high thus requiring close and extensive follow up.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Tomografia Computadorizada de Feixe Cônico , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Fluoroscopia , Mortalidade Hospitalar , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Stents/efeitos adversos , Cirurgia Assistida por Computador , Taxa de Sobrevida , Grau de Desobstrução Vascular
5.
Medicine (Baltimore) ; 100(18): e25732, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33950956

RESUMO

INTRODUCTION: Although the clinical significance of type II endoleaks remain controversial, management strategies continue to expand. The laparoscopic approach is a minimally invasive method for persistent type II endoleak repair after endovascular aneurysm repair. PATIENT CONCERNS: A 70 - year - old male patient with a history of endovascular aneurysm repair with left internal iliac artery embolization presented with persistent type II endoleak from the lumbar arteries 2 years ago. The aneurysm sac size had increased more than 10 mm during follow up period. DIAGNOSIS: Persistent type II endoleak after endovascular aneurysm repair. INTERVENTIONS: Transarterial embolization was attempted and failed. A minimally invasive laparoscopic lumbar artery ligation was then utilized. OUTCOMES: The patient was discharged without any complications after surgery. Follow-up computed tomography angiography has shown the complete disappearance of the type II endoleaks. CONCLUSIONS: Laparoscopic lumbar artery ligation may be a safe and effective alternative treatment for type II endoleaks, especially in high resource settings.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Laparoscopia , Idoso , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico , Endoleak/etiologia , Humanos , Ligadura/métodos , Masculino , Resultado do Tratamento
6.
Vasc Endovascular Surg ; 55(6): 645-650, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33813979

RESUMO

INTRODUCTION: A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed. REPORT: In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak. DISCUSSION: Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Cateterismo Periférico , Endoleak/cirurgia , Procedimentos Endovasculares , Artéria Mesentérica Superior , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Punções , Reoperação , Resultado do Tratamento
7.
J Endovasc Ther ; 28(4): 519-523, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33899573

RESUMO

PURPOSE: Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. TECHNIQUE: The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. CONCLUSION: Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aortografia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Desenho de Prótese , Stents , Resultado do Tratamento
9.
Int Angiol ; 40(3): 240-247, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33739077

RESUMO

BACKGROUND: Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. METHODS: All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. RESULTS: Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). CONCLUSIONS: Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino
10.
Eur J Vasc Endovasc Surg ; 61(6): 938-944, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33773906

RESUMO

OBJECTIVE: Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. METHODS: Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. RESULTS: Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. CONCLUSION: Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.


Assuntos
Anastomose Cirúrgica , Aneurisma Dissecante/cirurgia , Aorta Torácica , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Prótese Vascular , Endoleak , Procedimentos Endovasculares , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Aorta Torácica/patologia , Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Virilha/irrigação sanguínea , Humanos , Japão/epidemiologia , Masculino , Mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Artéria Subclávia/patologia , Artéria Subclávia/cirurgia
11.
J Vasc Surg ; 74(3): 720-728.e1, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33600929

RESUMO

BACKGROUND: Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant. METHODS: The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation. RESULTS: Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation. CONCLUSIONS: The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Remoção de Dispositivo , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Oclusão de Enxerto Vascular/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Stents , Trombose/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Canadá , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/mortalidade , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents/efeitos adversos , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/mortalidade , Fatores de Tempo , Resultado do Tratamento
12.
Expert Rev Med Devices ; 18(3): 281-290, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33618596

RESUMO

Introduction: The Aorfix aortic stent graft is a modular device with greater compliance and flexibility. This systematic review aims to assess the evidence regarding the technical success and outcomes of the AorfixTM stent graft.Methods: Electronic bibliographic databases were searched. We conducted our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards.Results: This review of the 442 documented cases of AorfixTM EVAR demonstrates assisted technical success to be achieved in 97.7% of cases. The need for unplanned adjunct maneuvers was low at 9.8% and was most commonly required for resolving an intra-operative type I endoleak. The need for secondary intervention in the 1-year follow up period was even lower, at 1.3% in the same eight studies, while Malas et al reports a re-intervention rate of 7.8% at 1-year.Conclusion: The AorfixTM device has been used in AAA with highly angulated proximal necks with success, with acceptable short- and midterm results. But larger multi-center comparative studies, and registry data is needed to be to compare the safety of different stent grafts and for optimal graft selection. This will increase the likely number of patients considered suitable for EVAR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Stents , Idoso , Aneurisma da Aorta Abdominal/patologia , Ensaios Clínicos como Assunto , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Seguimentos , Humanos , Masculino , Desenho de Prótese , Fatores de Tempo , Resultado do Tratamento
13.
Eur J Vasc Endovasc Surg ; 61(4): 571-578, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33414067

RESUMO

OBJECTIVE: Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR). METHODS: A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared. RESULTS: Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65-100) and 70 mm (60-80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%). CONCLUSION: Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Remoção de Dispositivo , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Ann Vasc Surg ; 71: 535.e1-535.e5, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32947001

RESUMO

Type Ia endoleaks are a complication of endovascular aneurysm repair that require intervention due to the increased risk of aneurysmal rupture. Many techniques have been studied in order to minimize the occurrence of these complications, as well as to aid in their repair. We introduce the utilization of intravascular ultrasound in conjunction with the endovascular EndoAnchor systems for the repair of a complex type Ia endoleak in an infrarenal aortic stent graft. This technique allowed us to have real-time feedback of EndoAnchor placement and aortic wall to stent graft apposition with a reduction in radiation exposure and contrast dye load.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Ultrassonografia de Intervenção , Idoso de 80 Anos ou mais , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Valor Preditivo dos Testes , Reoperação , Resultado do Tratamento
16.
Ann Vasc Surg ; 71: 48-55, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32927033

RESUMO

BACKGROUND: Retrograde type A dissection (RTAD) after zone 0 hybrid aortic arch repair is highly lethal and not infrequent complication. The aim of this study was to assess the safety and effectiveness of rapid cardiac pacing as an adjunctive tool to prevent RTAD during or after hybrid procedures for zone 0 disease. METHODS: We performed a retrospective review of 42 consecutive patients with zone 0 hybrid aortic arch repair between November 2004 and January 2018. Right ventricular pacing was carried out through unipolar electrodes attached to the epicardium of the right ventricle through the sternotomy (the indifferent electrode was in the subcutaneous tissue). Pacing was utilised during the clamping of the ascending aorta, release of the aortic clamp, and stent-graft deployment. RESULTS: Operative indications were aortic arch aneurysm 45% (n = 19), aortic arch dissection 45% (n = 19), traumatic rupture of isthmus 7% (n = 3), and type IA endoleak 2% (n = 1). Urgent procedures 48% (n = 20). The mean proximal aortic diameter was 34.14 ± 2.9 mm. Mean stent-graft oversizing was 12.97 ± 3.4%. The 30-day mortality rate was 14% (n = 6). RTAD was observed in 7% (n = 3). The actuarial survival rate was 74% over a mean follow-up of 50 ± 30.2 months. Since January 2013, rapid right ventricular pacing (overdrive pacing at a rate of 200 beats/min) was systematically used (n = 24). No RTAD was observed in this group of patients. Rapid right ventricular pacing reduced significatively the risk of RTAD (P = 0.038). CONCLUSIONS: Rapid right ventricular pacing is an effective method of inducing hypotension and appears to decrease the risk of retrograde type A dissection after zone 0 hybrid aortic arch repair.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Estimulação Cardíaca Artificial , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Estimulação Cardíaca Artificial/efeitos adversos , Estimulação Cardíaca Artificial/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/mortalidade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento
17.
Ann Vasc Surg ; 70: 434-443, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32599108

RESUMO

BACKGROUND: The aim of the study is to report the early and midterm outcomes of late open conversion (LOC) after endovascular aortic repair (EVAR) using the "new aortic carrefour technique" (NACT) for preservation of the stent-graft iliac limbs. Late conversions were defined as explants >6 months after previous EVAR. METHODS: Patients treated for elective or urgent LOC after EVAR with the NACT at a single center (2009-2019), and with ≥6 months of follow-up, were included. Briefly, after completing the proximal aortic anastomosis, the endograft iliac limbs were truncated and sutured together to create a "new aortic carrefour" (Veraldi's technique). A Dacron-knitted straight graft was therefore sutured to the newly created aortic bifurcation. Outcomes of interest were as follows: immediate technical success, intraoperative characteristics, and reinterventions. Results are reported as the number (and percentages) or median (and interquartile range [IQR]). RESULTS: During the study period, 433 patients underwent standard EVAR for abdominal aortic aneurysm and 20 underwent LOC. Of these, 9 consecutive patients were deemed suitable and treated with NACT. The indication for conversion was endoleak in 6 (type IA n = 1, type II n = 4, type III n = 1), complete graft thrombosis (n = 2), and one case of sac enlargement without any clear signs of endoleak at computed tomography angiography. Of these cases, six were treated electively, while three were treated in urgent setting including one case of rupture. The median procedure, aortic cross-clamping, and distal anastomosis times were 280 minutes (IQR: 225-290), 24 minutes (IQR: 22-29), and 15 minutes (IQR: 14-18), respectively. The median blood loss was 1,600 mL (IQR: 700-1,900), and the median hospital stay was 8 days (IQR 7-12). None of the patients died and neither required unplanned reintervention within 30 days. At a median imaging follow-up of 13 months (IQR 8-43), there were no reinterventions due to residual leaks or technical defects. One patient died during follow-up, and the recorded cause of death was heart failure. CONCLUSIONS: The use of the NACT with preservation of the original endograft iliac limbs for LOC after EVAR is a safe and feasible technique, which results in a low perioperative morbidity and mortality rate in selected patients. The technique is effective during midterm follow-up and might represent a valuable tool to expand the armamentarium of vascular surgeons for surgical regrafting after EVAR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Conversão para Cirurgia Aberta , Endoleak/cirurgia , Procedimentos Endovasculares , Oclusão de Enxerto Vascular/cirurgia , Trombose/cirurgia , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Conversão para Cirurgia Aberta/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Reoperação , Estudos Retrospectivos , Fatores de Risco , Stents , Trombose/diagnóstico por imagem , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento
18.
Ann Vasc Surg ; 70: 197-201, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32335254

RESUMO

We describe a novel endovascular technique in which three 0.014″ guidewires are placed in parallel through a 0.035″ lumen catheter, in order to create a stiff platform to allow for delivery of 0.035″ profile devices through challenging anatomy. Three illustrative cases are presented: a difficult aortic bifurcation during lower extremity intervention, a tortuous internal iliac artery during placement of an iliac branch device, and salvage of a renal artery after inadvertent coverage during proximal cuff deployment for type 1a endoleak. We also quantify the relative stiffness of the triple 0.014″ wire configuration, using several well-known 0.035″ wires for comparison. The "triple wire technique" is an effective method for tracking endovascular devices through difficult tortuous anatomy, and can be used in a variety of clinical settings. The technique is especially useful when a traditional, stiff 0.035″ wire will not track without "kicking out." Each 0.014″ wire is reasonably soft and traverses the tortuous vessel easily, but when the 3 wires are used together as a rail it provides a stiff enough platform for delivery.


Assuntos
Implante de Prótese Vascular/instrumentação , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Artéria Femoral/cirurgia , Aneurisma Ilíaco/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Dispositivos de Acesso Vascular , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular , Endoleak/tratamento farmacológico , Desenho de Equipamento , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Maleabilidade , Stents
19.
J Endovasc Ther ; 28(2): 295-299, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33070677

RESUMO

PURPOSE: To describe steps related to intraoperative C-arm orientations that can be taken during preoperative planning of thoracic stent-graft repair to facilitate the deployment of EndoAnchors in the distal aortic arch. TECHNIQUE: Previous experience from transcatheter aortic valve implantation (TAVI) may be helpful in addressing issues with C-arm orientation. In TAVI, preoperative computed tomography (CT) images are routinely obtained to generate a patient-specific curve that represents a virtually complete rotation of the C-arm perpendicular to the annulus. The curve clearly demonstrates that each adjustment in cranial or caudal view needs parallax correction in the left or right anterior oblique direction to remain perpendicular, and vice versa. This experience can be translated to the preoperative planning of EndoAnchor use in the aortic arch. By placing markers along the circumference of the proximal landing zone of the preoperative CT scan, the required C-arm orientations can be determined for each marker. CONCLUSION: Determining the optimal C-arm orientation during preoperative planning will facilitate successful EndoAnchor deployment and may contribute to improved durability of endovascular repair in hostile necks in the aortic arch.


Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Desenho de Prótese , Stents , Resultado do Tratamento
20.
Vasc Endovascular Surg ; 55(3): 282-285, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33047669

RESUMO

An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Duodenopatias/cirurgia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Fístula Intestinal/cirurgia , Fístula Vascular/cirurgia , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Duodenopatias/diagnóstico por imagem , Duodenopatias/etiologia , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Humanos , Fístula Intestinal/diagnóstico por imagem , Fístula Intestinal/etiologia , Masculino , Reoperação , Resultado do Tratamento , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/etiologia
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