Initial Experience with the Begraft Balloon Expandable Covered Stent-Graft System for Endovascular Treatment of Penetrating Aortic Ulcer

Abstract

Introduction - Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. PAU is a rare pathology, often clinically silent, but potentially fatal when manifesting as an acute aortic syndrome (AAS). PAU can occur at any point throughout the aorta, most commonly in the middle and lower descending aorta, less frequently in the aortic arch, abdominal aorta and iliac arteries. Complicated PAU involves degeneration towards pseudoaneurysm formation, dissection or rupture. According to the guidelines uncomplicated type B PAU should be treated medically, and followed by serial imaging surveillance, whereas endovascular repair (EVAR) should be considered for symptomatic and complicated type B PAU.1 The present study reports a single center experience with treatment of patients with PAU using the second generation BeGraft balloon expandable covered stent graft system. Methods - Between 6/2017 and 12/2017 four patients with the mean age of 62 years (range 42-81 years), were treated with the endovascular procedure due to symptomatic abdominal aorta or iliac artery ulcer. The diagnosis of PAU was confirmed by computed tomography (CT) scan. PAUs were treated by implantation of the BeGraft balloon expandable covered stent graft system (Bentley InnoMed, Hechingen, Germany) using a transfemoral vascular access. The delivery of the graft to aorta was achieved through a right femoral artery cut open over an extra-stiff guide wire. The stent-graft was placed with a 14F sheath. In the first procedure aorta with PAU was covered using two 18 mm diameter and 48 mm long BeGraft stents. In the second patient two 24 mm diameter and 48 mm long stents were implanted. In case of the iliac localization the ulcer was covered with one 10.0 mm or 9.0 mm diameter and 57 mm long stent using 7F sheath. Technical success (defined as delivery and implantation of the stent-graft in the intended position with complete exclusion of the PAU), procedure-related complications and patency were evaluated. Results - In two patients the PAU of the abdominal aorta was treated, in the other two cases covered stents were implanted due to left common iliac artery ulcer. Average procedural time was 33.8 ± 8.8 min. All six stent grafts were successfully delivered and deployed. No peri-procedural complication or adverse events were noted. The average hospital stay was 4 days (range 3-5). After a mean follow-up of 225 days all stent grafts remained patent. During follow-up, no endoleak or ulcer recurrence were observed. Conclusion - Endovascular surgery remain the method of choice in treating penetrating aortic or iliac ulcer when intervention is indicated. Currently, the preferred and most commonly used endovascular approach for PAU is a standard EVAR with a bifurcated endograft. To date, none of the balloon expandable covered stents which are currently available in Europe have been specifically designed and evaluated for that purpose. This is so far the first reported endovascular therapy of PAU with BeGraft. Although this is off-label use, it can surely help the endovascular surgeon in some challenging situation when no standard stent-graft system is available. Endovascular repair of penetrating ulcer with BeGraft has excellent short-term results. Long-term follow-up is required to confirm these promising results. References1V. Riambau, D. Bockler, J. Brunkwall, et al. Management of Descending Thoracic Aorta Disease. Eur J Vasc Endovasc Surg (2017) 53, 4-52.