Endovascular treatment for isolated acute abdominal aortic dissection.

BACKGROUND: Isolated acute abdominal aortic dissection (IAAAD) is considered an unusual clinical entity and is traditionally treated by open surgical repair. We report our single-center experience during the last 9 years, evaluating the outcomes after endovascular repair in this patient population. METHODS: All patients with a diagnosis of IAAAD treated in our institute were included in this retrospective review. Between January 2004 and December 2012, 38 patients suffering from an acute aortic dissection were referred regionally for intervention to our department: 24 (63.2%) with a thoracic aortic dissection type B and 14 patients (36.8%, all male; median age, 65 years) with an IAAAD. Demographics, perioperative, procedure-specific, and follow-up data were prospectively aggregated in an electronic database. RESULTS: Patients suffering from IAAAD presented with acute abdominal pain (n = 13) and acute lumbar pain (n = 1). Insufferable pain and enlargement of the aorta were the main indications for treatment. Mean (± standard deviation) maximal abdominal aortic diameter at presentation was 3.5 ± 0.94 cm (range, 2.6-5.1 cm). None of these patients had a concomitant thoracic aortic dissection. All patients were treated by endovascular means, with a primary technical success rate of 100%. Two patients (14%) died perioperatively from cardiac causes. Median hospital stay was 4.5 days (range, 3-16 days). During a mean follow-up period of 37.41 ± 23.56 months (range, 8-82 months; median, 32.5 months), two patients experienced primary treatment failure needing reintervention that led to a successful outcome. The cumulative free-from-reintervention rate was estimated 90.9% at 58 months (standard error, 8.7%). A full aortic remodeling without any events was noted in all other patients during the follow-up period. CONCLUSIONS: Based on our series, IAAAD may represent a not so rare clinical entity as generally thought, suggesting that it may be underdiagnosed. Endovascular treatment of IAAAD appears to be a feasible and efficient therapeutic approach and might be considered as the first-line treatment in all patients with suitable anatomy.

Stent fractures in the Hemobahn/Viabahn stent graft after endovascular popliteal aneurysm repair.

OBJECTIVE: During the last decade, endovascular repair of popliteal artery aneurysms (PAAs) has become a valid alternative to open repair. This study analyzes the incidence and origin of stent graft fractures after endovascular repair, its impact on patency, and strategies to prevent fractures. METHODS: Data of 78 atherosclerotic PAAs in 64 patients were gathered in a prospectively-held database from 1998 to 2009. All x-rays were reviewed to detect stent fractures. Only circumferential fractures were included for analysis; localized strut fractures were excluded. Clinical endpoints were circumferential stent fracture, occlusion, and clinical status of the patient. RESULTS: Mean follow-up time was 50 months (range, 1-127 months). Fifteen circumferential stent fractures occurred in 13 (16.7%) patients. The majority of stent fractures (93.3%) were associated with the use of multiple stent grafts. At univariate analysis, younger age was identified as the only significant predictor for stent fracture (P = .007). The cumulative stent fracture-free survival was estimated at 78% and 73% at 5- and 10-year follow-up, respectively. The cumulative primary patency rate, defined as time to occlusion, was not different for the fracture group compared with the nonfracture group (P = .284). CONCLUSIONS: The incidence of stent fractures after endovascular PAA repair is probably underreported in the literature. Stent graft fractures mainly occur at overlap zones and are associated with younger age of the patient. Fracture of the stent did not significantly influence patency of the stent graft.

A modified technique for Gore Excluder limb deployment in difficult iliac anatomy during endovascular abdominal aortic aneurysm repair.

Complex iliac anatomy including extreme tortuosity constitutes a relative contraindication for endovascular abdominal aortic aneurysm repair with additional risk of limb-graft occlusion. The Gore Excluder limb-graft is a flexible stent-graft, which adapts easily to iliac tortuosity. Nevertheless, the presence of the stiff guide wire does not always allow for an ideal apposition of the stent graft to the angulated common iliac artery vessel wall. We describe herein a modified technique for Gore Excluder limb-graft deployment with partial removal of the stiff wire in cases with difficult tortuous or narrow iliac arteries during endovascular abdominal aortic aneurysm repair.

Endovascular management of an arteriovenous malformation using an occluder stent graft.

A 58-year-old woman presented with gangrene of the left upper arm stump caused by an arteriovenous malformation originating from the subclavian artery. She had been treated unsuccessfully in the past with repeated attempts of coil embolization and débridement, but finally she underwent arm amputation. A 14 mm diameter occlusion self-expandable stent was placed in the left subclavian artery via ipsilateral brachial artery access, with immediate and complete interruption of arterial supply to the vascular malformation. This minimally invasive treatment provides an alternative method of management of arteriovenous malformations in the subclavian region.

Infected femoral artery pseudoaneurysm in drug addicts: the beneficial use of the internal iliac artery for arterial reconstruction.

BACKGROUND: Infected femoral artery pseudoaneurysm (IFAP) is a severe complication in parenteral drug abusers, with difficult and controversial management. Ligation alone without revascularization is frequently associated with later intermittent claudication and limb amputation. Furthermore, arterial reconstruction with a synthetic or venous conduit is limited because of a contaminated field and, often, unavailability of autologous venous grafts. In this study, we present our experience with the internal iliac artery (IIA) as a graft for arterial reconstruction after IFAP excision in these patients. METHODS: Data of 14 consecutive patients who presented with IFAP secondary to parenteral drug abuse from 2001 to 2005 were analyzed. Twelve patients (85.7%) were male. The median age was 27 years (range, 19-42 years). In 13 cases, the IFAP involved the common femoral artery, and in 1 case it involved the profunda femoris artery (PFA). In nine patients, we used the IIA for arterial reconstruction (five as a patch and four as an interposition graft), whereas in two patients the arterial deficit was repaired with a great saphenous vein patch. In two cases, an extra-anatomic bypass with a synthetic polytetrafluoroethylene graft was performed. In one patient, the pseudoaneurysm involved the PFA and was treated with excision and ligation of the PFA. RESULTS: All nine patients who underwent revascularization with the use of IIA were free of claudication symptoms. None of them experienced any perioperative complications, had signs of reinfection, or required limb amputation during the follow-up period (median, 19 months; range, 4-52 months). Regarding the remaining five patients, one died 25 days after surgery because of multiorgan failure, and one underwent reoperation because of proximal anastomotic rupture of a synthetic graft. The latter patient finally underwent a transmetatarsal amputation. CONCLUSIONS: The use of IIA for arterial reconstruction after IFAP excision in drug abusers is safe and effective. These preliminary results indicate that the implementation of this technique offers many advantages compared with traditional treatment options.

Primary aortoduodenal fistula without abdominal aortic aneurysm in association with psoas abscess.

Primary aortoenteric fistula (PAEF) is a communication between the aorta and the enteric tract without any previous vascular intervention, e.g., aortic grafting. Although rare, PAEF is a potentially lethal condition that requires a high index of suspicion and prompt surgical intervention. Most of the reported cases involve an abdominal aortic aneurysm. However, in this report, we describe a rare case of a primary aortoduodenal fistula in a nonaneurysmal aorta in association with a psoas abscess, which was treated successfully. At 2-year follow-up, the patient is alive without episodes of bleeding or fever.