Additional Stent-graft Placement Research Articles

Distal stent graft – induced new entry after frozen elephant trunk procedure for type a aortic dissection: two cases report

Objectives: We report two clinical cases that wherein stent graft-induced new entry (dSINE) after frozen elephant trunk (FET) procedure for type A aortic dissection were resolved successfully by additional stent graft placement.
 Methods: Describe rare clinical cases.
 Results: Two patients were hospitalized after FET procedure for type A aortic dissection treatment. The former had refractory abdominal pain and the latter had sudden chest pain; both their abdominal thoracic CT scanner showed dSINE. We decided to place additional stent grafts to cover the new entry. Both patients recovered well and were discharged after 5 and 12 days, respectively, without any significant complications.
 Conclusions: Supplemental stent graft placement is an effective and safe treatment choice for dSINE post-FET procedure.

Double homemade fenestrated stent graft for total endovascular aortic arch repair

ObjectiveThe aim of this retrospective analysis was to evaluate the outcomes of physician-modified double fenestrated stent grafts for total endovascular aortic arch repair: one proximal large fenestration for the brachiocephalic trunk and the left common carotid artery and one distal fenestration for the left subclavian artery (LSA). MethodsFrom January 2017 through February 2018, 17 patients (88.2% elective) underwent thoracic endovascular aortic repair (TEVAR) with double homemade fenestrated stent graft for total endovascular aortic arch repair to maintain supra-aortic trunk patency. Indications were degenerative aortic arch aneurysm (n = 7), dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n = 6), chronic complicated type B aortic dissection (n = 3), and acute complicated type B aortic dissection (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and supra-aortic trunks patency and endoleak. ResultsThe median time for stent graft modification was 19 minutes (range, 16-20 minutes). Endovascular exclusion of the aortic arch was achieved in all the cases. One LSA catheterization failed and LSA revascularization was performed by carotid axillary bypass and coverage of the LSA fenestration by additional stent graft placement. Additional planned endovascular procedures were required in three patients: closure of supra-aortic trunks re-entry tears in two cases of dissecting aortic arch aneurysms and one transcatheter aortic valve replacement for severe native aortic valve regurgitation. One stroke, with no long-term deficit, was observed. No patients died. All left supra-aortic trunks are patent. No type I endoleak was observed. We only observed one patient with a type II endoleak. During a mean follow up of 7 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection. ConclusionsDouble homemade fenestrated TEVAR is both feasible and effective for maintaining the patency of the supra-aortic trunks and allows total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Homemade fenestrated stent-graft for thoracic endovascular aortic repair of zone 2 aortic lesions

ObjectiveThe aim of this retrospective analysis was to evaluate the outcomes of homemade fenestrated stent-grafts for thoracic endovascular aortic repair of zone 2 aortic lesions. MethodsFrom November 2013 to January 2017, 24 patients underwent thoracic endovascular aortic repair with left subclavian artery revascularization using a homemade fenestrated stent-graft to preserve the patency of the left subclavian artery. Elective cases accounted for 54% (n = 13) of the sample. Indications included acute complicated type B aortic dissection (n = 9), degenerative aneurysm (n = 9), penetrating aortic ulcer (n = 5), and intramural hematoma (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess thoracic endovascular aortic repair and left subclavian artery fenestration patency and endoleak. ResultsMedian duration for stent-graft modification was 16 minutes (range, 14-17 minutes). The technical success rate was 100%. One patient had a distal type I endoleak requiring additional stent-graft placement. One patient had partial coverage of the left common carotid artery requiring left common carotid artery stenting. One patient had a stroke without permanent sequelae (4.1%). Overall mortality was 0%. All left subclavian arteries were patent. Two type III endoleaks required additional left subclavian artery covered stent placement. One type II endoleak is currently observed. During a mean follow-up of 13.2 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection. ConclusionsThe use of a homemade fenestrated stent-graft for thoracic endovascular aortic repair of zone 2 aortic lesions is both feasible and effective for left subclavian artery revascularization during thoracic endovascular aortic repair involving a spectrum of thoracic aortic pathology. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Endovascular Management of Inadvertent Subclavian Artery Catheterization during Subclavian Vein Cannulation

To retrospectively review a 9-year experience with endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation. From June 2000 through July 2009 (109 months), 13 patients underwent endovascular management of inadvertent subclavian artery catheterization. All catheters were still in situ, including one 7-F catheter, six 8-F catheters, and six large-bore 10-11-F catheters. Treatment was performed with an Angio-Seal device (n = 6) or balloon catheters (n = 7) and by additional stent-graft placement (n = 4). Mean follow-up was 27.3 months (range, 0.4-78 months). The 30-day mortality rate was 7.7% and the late mortality rate was 46.1%. Primary technical success was achieved in nine patients (69.2%), in four with the use of a compliant balloon catheter and in the other five with an Angio-Seal device. Complications required additional stent-graft placement in four patients (30.8%), one because of stenosis after Angio-Seal device deployment and three as a result of insufficient closure of the puncture site by balloon tamponade. Stent-graft repair was successful in all four patients, for a primary assisted technical success rate of 100%. Endovascular techniques offer a less invasive alternative to surgery. The present limited experience shows that the use of the Angio-Seal device is not without risks, whereas balloon tamponade is not always reliable in closing the puncture site. Stent-graft placement may be required in patients in whom balloon tamponade fails or in whom the use of the Angio-Seal device is contraindicated.

Die endovaskuläre Behandlung von Bauchaortenaneurysmen bei älteren Patienten (≥ 80 Jahre)

The increase in life expectancy results in a higher number of patients with an advanced age over 80 years requiring abdominal aortic aneurysm therapy. The aim of this study was to review the outcome of octogenarians undergoing endovascular treatment for abdominal aortic aneurysms. Between June 2004 and March 2008 25 patients (24 males, one female), with a mean age of 83 +/- 2.6 years (range: 80-91 years) underwent elective endovascular treatment for abdominal aortic aneurysms. The average preoperative aneurysm diameter was 57 +/- 9.8 mm (range: 40-80 mm). All procedures were carried out in the angiography suite under general anesthesia. Endovascular abdominal aortic aneurysm repair was technically successful in all patients. There was one perioperative death due to an aneurysm-related complication. The perioperative (30 days) mortality rate was 4 %. Intensive care unit admission was required in five patients. The in-hospital morbidity rate was 20 %. Mean follow-up time was 18.7 +/- 14 months (range: 2 to 47 months). Two patients died from unrelated causes. There were no device- or aneurysm-related deaths. A patient with a type I A endoleak underwent correction by additional stent-graft placement four weeks after initial placement. Endovascular abdominal aortic aneurysm repair in octogenarians is a valuable alternative to open aortic repair and can be performed safely and successfully. We strongly recommend the endovascular treatment for patients over 80 years of age with an appropriate size of aortic aneurysm.

Intravascular Ultrasound–guided Direct Intrahepatic Portacaval Shunt: Midterm Follow-up

To describe the midterm patency and clinical results of the intravascular ultrasound (US)-guided direct intrahepatic portacaval shunt (DIPS) procedure for the treatment of intractable ascites and variceal bleeding. From February 23, 1999, to December 18, 2002, inferior vena cava (IVC)-to-portal vein (PV) shunts were created in 40 patients for ascites (n = 35) and bleeding (n = 5). Intravascular US was used to guide direct puncture from the IVC to the PV. The shunts were completed with the use of single (n = 15) or overlapping (n = 25) polytetrafluoroethylene (PTFE)-covered Palmaz stents. These stent-grafts were deployed primarily at diameters of 8 mm. The diameter of the shunt was increased in three cases to achieve a target portosystemic gradient (PSG) of 15 mm Hg or lower. All patients were followed clinically and with portography with manometry. All DIPSs were created successfully. Mean PSGs were reduced from 23 mm Hg before DIPS creation to 9 mm afterward. During the follow-up period of a maximum of 38 months, 22 of 40 patients died or underwent liver transplantation (mean follow-up, 9 months; median, 6 months). At the time of this report, 18 of 40 patients remain living after follow-up ranging in duration from 8 to 38 months (mean, 22 months; median, 16.5 months). During the follow-up period, there was one stent-graft occlusion and three stenoses. These four patients were successfully treated by additional stent-graft placement. In addition, two patients developed IVC stenosis cephalad to the DIPS, which required IVC stent placement. The primary patency rates by Kaplan-Meier analysis were 100% at 6 months and 75% (95% CI, 53%-97%) at 12 months. Intravascular US-guided direct IVC-to-PV shunts may be created successfully with minimal complications. Primary patency of the shunt is greater than that with conventional TIPS with a bare wire stent and appears equal to that with TIPS with a PTFE-covered stent-graft.

Endovascular Treatment of Complicated Type-B Aortic Dissection with Stent-Grafts: Midterm Results

To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts. Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo). There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery. Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.

The endoleak problem in endoluminal therapy

Endovascular treatment of aortic aneurysms with stent grafts was performed increasingly in recent years. The most frequent complication after endovascular therapy of aortic aneurysms is an endoleak. In case of a persistent endoleak, diameter of the aneurysm is increasing with a high risk of aneurysm ruptur. Diagnostic tools are spiral computed tomography and angiography. Spiral computed tomography is the most sensitive method for the diagnosis of an endoleak ad should be performed with a biphasic acquisition. In- and outflow of sidebranches can be identified correctly with selective angiography in 86%. Perigraft endoleaks should be treated in any case. Patent side branches generally are observed over a period of 6 months. After 6 months approximately half of these endoleaks are thrombosed. Is there an increasing of the diameter of the aneurysm or any changing in the morphology of the aneurysm there is an indication for embolisation of these sidebranches of the aneurysmal sac. Preinterventional embolisation of patent sidebranches is under discussion. Type I endoleaks can be managed by additional stent-graft implantation or coil embolisation. In case of type II endoleaks in- ad outflow vessels should be embolised with coils. Therapy of type III endoleak is performed mostly by additional stent-graft placement. The total incidence of secondary interventions in the Eurostar-study was nearly 10% per year.

The problem with endoleakage in endoluminal therapy

Endovascular treatment of aortic aneurysms with stent grafts was performed increasingly in recent years. The most frequent complication after endovascular therapy of aortic aneurysms is an endoleak. In case of a persistent endoleak, diameter of the aneurysm is increasing with a high risk of aneurysm rupture. Diagnostic tools are spiral computed tomography and angiography. Spiral computed tomography is the most sensitive method for the diagnosis of an endoleak ad should be performed with a biphasic acquisition. In- and outflow of sidebranches can be identified correctly with selective angiography in 86%. Perigraft endoleaks should be treated in any case. Patent side branches generally are observed over a period of 6 months. After 6 months approximately half of these endoleaks are thrombosed. Is there an increasing of the diameter of the aneurysm or any changing in the morphology of the aneurysm there is an indication for embolisation of these sidebranches of the aneurysmal sac. Preinterventional embolisation of patent sidebranches is under discussion. Type I endoleaks can be managed by additional stent-graft implantation or coil embolisation. In case of type II endoleaks in- ad outflow vessles should be embolised with coils. Therapy of type III endoleak is performed mostly by additional stent-graft placement. The total incidence of secondary interventions in the Eurostar-study was nearly 10% per year.

Treatment of Refractory Benign Biliary Stenoses in Liver Transplant Patients by Placement and Retrieval of a Temporary Stent-Graft: Work in Progress

To evaluate patency of refractory benign biliary strictures in liver transplant patients treated with retrievable stent-grafts. Eight male liver transplant patients who ranged in age from 42 to 52 years developed nine symptomatic biliary strictures (intrahepatic left duct, 1; hilar, 2; anastomotic, 6). These strictures had recurred despite multiple previous attempts of treatment (n = 33), including angioplasty (n = 27), surgery (n = 1), atherectomy (n = 1), metallic stent (n = 1), and prolonged catheter drainage (n = 3). As an alternative method of treatment for these refractory biliary strictures, transhepatic placement of expanded polytetrafluoroethylene stent-grafts across the strictures was performed through 10-F sheaths. In total, 14 stent-grafts were placed to treat the nine lesions, and nine of these stent-grafts were subsequently retrieved through 12-16-F sheaths. Stent-grafts were deployed successfully. Delayed migrations in two patients required additional stent-graft placement. One patient died of pneumonia 1 month after stent-graft placement; the remaining seven patients had stent-grafts successfully removed at 3-10 months (mean, 5.6 months). Nine intended stent-graft retrievals were performed successfully, with two requiring use of elongated forceps. Immediately after treatment, all strictures were widely patent. Five to 6 months after stent-graft removal in these seven patients, significant strictures recurred in four of eight lesions (50%). One patient underwent surgical revision. At 6-29 months (mean, 12 months) after stent-graft removal, the remaining six patients were without clinical or laboratory evidence of biliary obstruction, despite three patients with significant recurrent strictures. Temporary stent-graft placement for treatment of benign biliary strictures in liver transplant patients is technically feasible. Longer follow-up with larger patient series is necessary to assess effectiveness and possible broader applications.

Endovascular repair of abdominal aortic aneurysm: Getting out of trouble

The standard techniques of endovascular aneurysm repair sometimes fail to produce atraumatic stent-graft delivery of hemostatic implantation, and additional maneuvers are required to avoid conversion to open repair. Between June 1996 and May 1997 elective endovascular aneurysm repair was performed in 33 high risk patients, using a Z-stent-based prosthesis. Challenging anatomic features included: short neck (<15 mm) in four cases, angulated neck (>60°) in seven, iliac aneurysm in six, and iliac tortuosity (>80°) in 24. There were no deaths, no renal failure, no pulmonary failure, no graft thrombosis, no migration, and no conversions to open surgery. Deviations from standard technique were required to treat iliac artery dissection, iliac artery stenosis, and leaks resulting from proximal stent malalignment, proximal stent malposition, and distal stent malposition. The necessary adjunctive maneuvers included: additional stent placement, additional stent-graft placement, and balloon dilatation. Mean operating time was 191 ± 72 min, mean contrast volume was 148 ±76 ml, and mean blood loss was 314 ± 427 ml. Mean time from operation to discharge from the hospital was 3.5 ± 1.67 days. These short-term results demonstrate that endovascular aneurysm repair is safe and effective in high risk patients, only if adjunctive maneuvers are available to supplement standard technique.

Endovascular Repair of Abdominal Aortic Aneurysm: Getting Out of Trouble

The standard techniques of endovascular aneurysm repair sometimes fail to produce atraumatic stent-graft delivery of hemostatic implantation, and additional maneuvers are required to avoid conversion to open repair. Between June 1996 and May 1997 elective endovascular aneurysm repair was performed in 33 high risk patients, using a Z-stent-based prosthesis. Challenging anatomic features included: short neck (&lt; 15 mm) in four cases, angulated neck (&gt; 60°) in seven, iliac aneurysm in six, and iliac tortuosity (&gt; 80°) in 24. There were no deaths, no renal failure, no pulmonary failure, no graft thrombosis, no migration, and no conversions to open surgery. Deviations from standard technique were required to treat iliac artery dissection, iliac artery stenosis, and leaks resulting from proximal stent malalignment, proximal stent malposition, and distal stent malposition. The necessary adjunctive maneuvers included: additional stent placement, additional stent-graft placement, and balloon dilatation. Mean operating time was 191 ± 72 min, mean contrast volume was 148 ± 76 ml, and mean blood loss was 314 ± 427 ml. Mean time from operation to discharge from the hospital was 3.5 ± 1.67 days. These short-term results demonstrate that endovascular aneurysm repair is safe and effective in high risk patients, only if adjunctive maneuvers are available to supplement standard technique.