RESUMO
OBJECTIVE: This study aimed to analyze early and midterm results of custom-made proximal scallop and fenestrated stent grafts for thoracic endovascular aortic repair (TEVAR) with a proximal landing zone (PLZ) in the aortic arch. METHODS: All consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc.) in 10 Italian centers between January 2014 and December 2022 were included. The primary end points were technical success, incidence of intraoperative major adverse events, deployment accuracy, and rate of early neurological complications, endoleaks (ELs) and retrograde aortic dissection. RESULTS: During the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The proximal landing zone was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) owing to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III EL were detected. There were no cases of in-hospital mortality, major adverse events, or retrograde dissection. Three minor strokes (6.1%) (National Institutes of Health Stroke Scale score of ≤4) were observed. At a mean follow-up time of 36.3 ± 21.3 months the rate of types I to III ELs and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) from nonaortic causes. CONCLUSIONS: Our early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.
RESUMO
OBJECTIVE: The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR). METHODS: Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up. RESULTS: One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively. CONCLUSION: The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Itália , Masculino , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Type II endoleak is the most frequent procedure-related complication during endovascular aneurysm exclusion. Actually, there is little controversy in the management of type I and III endoleak, while type II endoleak still generates conflicting reports about their timing and type of treatment. Currently, the intervention is needed only in case of sac enlargement but not in case of persistent endoleak alone. We report the case of a 77-year-old man treated with a custom-made branched/fenestrated endograft for a type III thoracoabdominal aortic aneurysm. A low-flow type II endoleak was detected at the end of the intervention, and a conservative approach was adopted. The sixth month follow-up computed tomography scan demonstrated a 6-mm aneurysm sac growth that required the type II endoleak management. The endoleak nidus, situated between the inferior mesenteric artery (IMA) and left renal artery stent graft, was embolized through the IMA punctured laparoscopically. IMA origin laparoscopic clipping completed the intervention. To our knowledge, this is a unique case in the literature. Type II endoleak management should be reserved to selected patients. The combination of different techniques may offer safe and feasible treatment options in complex aneurysms treated with advanced endovascular materials.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Embolização Terapêutica/métodos , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Laparoscopia , Stents , Idoso , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Masculino , Desenho de Prótese , Resultado do TratamentoRESUMO
We report the case of a 77-year-old man treated with a custom-made fenestrated endograft for pararenal aortic aneurysm repair. Fenestrations for the superior mesenteric and both the renal arteries and augmented anterior valley and/or scallop for the celiac trunk were performed. The procedure was complicated by the superior mesenteric artery stent-graft entrapment from the endograft delivery system release wires and total dislodgement into the endograft main body. Superior mesenteric artery restenting and displaced stent-graft removal completed the intervention. Fenestrated-endograft deployment should be performed by a team familiar with the device, deployment system, and bail out solutions.
Assuntos
Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Aneurisma Aórtico/diagnóstico , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Humanos , Masculino , Artéria Mesentérica Superior/cirurgia , Desenho de Prótese , Artéria Renal/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Endovascular treatment is now considered the first-line therapy for the aortoiliac occlusive disease (AIOD). We report our experience with the total endovascular treatment of infrarenal and pararenal aortoiliac occlusions and the 7-year approach evolution. METHODS: A total of 22 patients underwent total endovascular treatment of AIOD from January 2008 to September 2014. Bare metal stents in kissing configuration were deployed in 9 cases, covered stents in kissing configuration in 9 patients and the aortic bifurcation reconstruction with the Y-guidewire configuration technique was performed in the last 4 patients. RESULTS: Technical success was 100%. Perioperative mortality rate was 4.5%. ankle-brachial index improved from 0.49 ± 0.19 to 0.96 ± 0.05 at the right side and from 0.53 ± 0.17 0.98 ± 0.04 at the left side (P < 0.01). Mean follow-up was 39.5 months (range, 5-80 months). The primary patency rate was 95.2% at 1 year and 90.5% at 3 years, and the secondary patency rate was 95.2% at 1 year and 100% at 3 years. CONCLUSIONS: Different stent types and configurations used for the aortoiliac endovascular treatment offer all the benefits of these materials for treatment on a case-by-case basis. The Y-guidewire configuration technique for the aortic bifurcation reconstruction may render the procedure more feasible. More cases and longer follow-up are necessary before the widespread use of this technique.
Assuntos
Doenças da Aorta/cirurgia , Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Ilíaca , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/diagnóstico , Doenças da Aorta/mortalidade , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
We report the case of a 76-year-old man presented with three saccular aneurysms at the aortic arch and descending thoracic aorta. A two-staged hybrid approach was performed. A left common carotid-to-left subclavian artery bypass and a custom-made fenestrated endograft were used for the two proximal aneurysms. The endograft deployment was complicated by the unadverted coverage of the left common carotid artery ostium, promptly corrected with the chimney technique. The endovascular treatment was completed with the third endovascular aneurysm exclusion 5 months after the first procedure to reduce the risk of spinal cord ischemia. Yearly follow-up computed tomography scan confirmed aortic arch and descending thoracic aorta aneurysms exclusion with supra-aortic vessels, bypass, and stent patency. Endovascular repair of the aortic arch aneurysm with a fenestrated endograft is safe and feasible in selected patients. Complications may be solved with total endovascular approach. Long term follow-up remains mandatory.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Desenho de Prótese , Stents , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
The use of extra-anatomic bypasses for the hybrid repair of thoracic aortic pathologies should consider the risk of vascular graft infection. Graft infections at cervical level are extremely rare and are associated with high mortality and morbidity rates. We report 2 cases of infected extra-anatomic bypasses for supra-aortic vessels debranching treated with a hybrid approach: re-extra-anatomical bypass with the Viabahn Open Revascularization Technique (VORTEC) in the first patient and the EndoVAC approach in the second case. Endovascular techniques may offer bail-out solutions in a hybrid fashion to treat vascular graft infection in patients considered unfeasible for the conventional surgical repair, associated with appropriate antibiotic therapy.
Assuntos
Antibacterianos/uso terapêutico , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares , Infecções Relacionadas à Prótese/terapia , Infecções Estafilocócicas/terapia , Adulto , Idoso , Implante de Prótese Vascular , Humanos , Masculino , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/etiologia , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/etiologiaRESUMO
Total chronic occlusion of the common carotid artery with patent internal and external carotid arteries can induce cerebral embolism and hypoperfusion. We report a hybrid approach that was used to treat 2 patients presented with symptomatic chronic occlusion of the common carotid artery and ipsilateral internal carotid stenosis. Antegrade recanalization and retrograde stenting of the common carotid artery was performed in both patients associated to carotid bulb endarterectomy. Fresh thrombus observed in the distal common carotid stump was responsible for the embolic cerebral lesions and patients' previous symptoms. Patients remain asymptomatic at the 23rd- and 18th-month follow-up, respectively.
Assuntos
Estenose das Carótidas/cirurgia , Idoso , Anticoagulantes/uso terapêutico , Prótese Vascular , Implante de Prótese Vascular/métodos , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Doença Crônica , Diagnóstico por Imagem , Endarterectomia das Carótidas , Feminino , Humanos , Embolia Intracraniana/etiologia , StentsRESUMO
An 81-year-old man presented with rapid enlargement of a 2-year known abdominal aortic and common iliac aneurysms. A hybrid approach to preserve both hypogastric arteries (HAs) was planned: a bifurcated endograft for the right aortoiliac axis, right femoral-to-left femoral artery bypass, and left external-to-internal iliac artery stent graft placement. Urethral stenosis requiring an epicystostomy rendered this approach not feasible. After left HA embolization, a bifurcated endograft was deployed for the abdominal aortic aneurysm exclusion. The endograft right limb was extended using a second bifurcated endograft for the ipsilateral aortoiliac axis. Surgical femoral accesses were used for the 2 bifurcated endografts and left HA embolization. Through the left brachial access, 2 stent grafts were used to preserve the right hypogastric artery revascularization. The 5-year follow-up computed tomography scan demonstrated complete aneurysm exclusion and HA patency.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Diagnóstico por Imagem , Aneurisma Ilíaco/cirurgia , Estômago/irrigação sanguínea , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico , Prótese Vascular , Meios de Contraste , Humanos , Aneurisma Ilíaco/diagnóstico , Masculino , Desenho de Prótese , StentsRESUMO
BACKGROUND: Bypass surgery in severe aorto-iliac calcifications is a complex procedure. Aortic clamping can be highly risky and endovascular approach can be unsuccessful. We report our experience describing three cases of chronic mesenteric ischemia. In all three cases the preoperative computed tomography angiography revealed an ostial occlusion of the celiac trunk and of the superior mesenteric artery (SMA), a coral reef abdominal aorta, and severe calcification of the iliac arteries. An antegrade aorto-mesenteric bypass using a hybrid clampless anastomosis on the supraceliac aorta was performed. RESULTS: The procedures were performed via laparotomy. We carried out the exposure of the anterior supraceliac aorta limited to the zone without major calcifications; then we performed a side-to-end media-adventitial anastomosis between the supraceliac aorta and a Dacron graft 7 mm without any arteriotomy or clamping. The proximal graft and the aortic anastomosis site were punctured using a 18 G needle. An introducer was then positioned over a wire through the prosthetic graft and pushed into the aorta. Balloon expandable covered stenting to open and stabilize the anastomosis site was performed. Finally, the graft was tunneled to the SMA, and an end-to-side anastomosis was performed. The postoperative courses were uneventful, and the patients were promptly discharged. The follow-up, which in the first case is 4 years, showed the complete patency of the graft in each of the cases treated. CONCLUSIONS: The hybrid clampless anastomosis appears to be safe and useful in cases of severe aortic calcification.
Assuntos
Implante de Prótese Vascular , Artéria Mesentérica Superior , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Resultado do Tratamento , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Anastomose CirúrgicaRESUMO
Arteriovenous fistula (AVF) is considered the gold standard for vascular access in hemodialysis, even in elderly patients. Malfunction of AVF is the first cause of hospitalization in the HD population, with a correlated increase in costs. For the monitoring and surveillance of fistulas, the 2006 K/DOQI workgroup recommends physical examination, direct flow measurement, Doppler ultrasonography and recirculation (by a non-urea-based dilutional method). We report the case of a 67-year-old woman affected by AVF stenosis. Combined AVF surveillance with recirculation and Doppler ultrasonography permitted early diagnosis and treatment with percutaneous angioplasty.
Assuntos
Angioplastia , Derivação Arteriovenosa Cirúrgica , Complicações Pós-Operatórias/terapia , Idoso , Constrição Patológica/terapia , Feminino , HumanosRESUMO
BACKGROUND: The chimney technique has been developed for the treatment of complex aortic aneurysms. We analyzed the midterm to long-term outcomes of this approach from a single-center experience. METHODS: From October 2008 to July 2016, 58 patients underwent endovascular aortic aneurysm repair using the chimney technique. Indications for treatment were thoracic aortic aneurysm (TAA) (N.=11), thoracoabdominal aortic aneurysm (TAAA) (N.=2), pararenal aortic aneurysm (PAAA) (N.=15), aortoiliac/isolated hypogastric artery aneurysm (N.=25), type I endoleak after previous TEVAR/EVAR (N.=4), proximal pseudoaneurysm after AAA open repair (N.=1). Elective (82.8%) and emergent (17.2%) procedures were included. RESULTS: The immediate technical success was 100%. Single, double and triple chimneys were performed in 46, 10, and two patients, respectively. Overall, 61 target vessels (three left common carotid arteries, eight left subclavian arteries, three celiac trunks, three superior mesenteric arteries, 19 renal arteries and 25 hypogastric arteries) were involved. Postoperative mortality was 0. No neurologic complications were registered. Primary patency rate of the chimney stent/stent graft was 98.3%. Low-flow type I endoleak was observed in four patients (6.9%). Postoperative chimney graft re-intervention rate was 1.7%. The median follow-up was 32±20 months (range 3-96 months). Overall estimated survival at 12, 50, and 80 months was 100%, 89% and 44%, respectively. Estimated freedom from endoleak at 1, 12, 24, and 36 months was 96.5%, 95%, 95%, and 93%, respectively. One hypogastric artery stent-graft occluded at the 3rd month of follow-up. No reintervention was performed. CONCLUSIONS: Our experience with the chimney technique for aortic aneurysms from the aortic arch to the iliac axis shows promising and durable mid- and long-term results. Endograft oversizing, associated with the chimney graft diameter and length choice remain fundamental to reduce the risk of the most frequent procedure complications: type I endoleak and CG occlusion. The wider use of this technique should be justified in patients considered at high risk for open repair and/or not suitable for the custom-made branched/fenestrated endografts.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Intervalo Livre de Progressão , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Stents , Fatores de TempoRESUMO
We report the treatment of a proximal ilio-iliac arterio-venous fistula and distal omolateral hypogastric artery pseudoaneurysm 23 years after incurring a gunshot wound in a 43-year old man presenting with lower back pain. No cardiac, pulmonary or omolateral lower limb alteration was observed. Endovascular exclusion of the arterio-venous fistula and pseudoaneurysm was performed, which included pseudoaneurysm embolization. Three procedure-related complications were registered. The follow-up at 12 months revealed stent grafts patency, pseudoaneurysm and fistula exclusion.
Assuntos
Falso Aneurisma/cirurgia , Fístula Arteriovenosa/cirurgia , Procedimentos Endovasculares/métodos , Ferimentos por Arma de Fogo/complicações , Adulto , Falso Aneurisma/etiologia , Fístula Arteriovenosa/etiologia , Implante de Prótese Vascular , Embolização Terapêutica , Humanos , Masculino , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
A 76-year-old woman presented with symptomatic contained-ruptured thoracoabdominal aneurysm at the level of the superior mesenteric artery (SMA) and the hepatic artery origin from the SMA. The chimney technique for celiac trunk, SMA, and right renal artery (periscope configuration) was performed. An endovascular leak from the distal landing zone of the SMA stent graft was treated using a second modified stent graft with the SMA branches preservation. The 18-month follow-up computed tomography angiography demonstrated the aneurysm exclusion, no endovascular leak, and visceral and renal arteries patency.