Advanta V12 Research Articles

A 10mm Aortic Arch Sealing Ring Distal to the Second Chimney Seem to Prevent a Gutter Endoleak in Aortic Arch Tevar

Introduction - A common problem when using the chimney graft technique for arch pathologies is the "gutter” endoleak, a type Ia endoleak resulting in pressure of the aneurysm sac. The chimney technique used for the renal arteries, though, seems to have less of these problems. The aim of the present study was to define the possible anatomical and technical parameter that might predict the occurrence of gutter endoleak or type Ia endoleak (EL Ia) in patients treated using chimney graft technique in aortic arch. Methods - We performed a review of our institutional endovascular aortic database of patients who had undergone TEVAR with chimney graft technique (ChTEVAR) as a debranching method of the supraaortic arteries between 2010 and 2017. Results - ChTEVAR was performed in 35 patients with a chimney in the left common carotid artery (LCCA) in eight patients, in the brachiocephalic trunk (BCT) in two patients and in both LCCA & BCT in 25 patients. The Gore® cTAG® Thoracic Endoprosthesis was used as a main stent-graft in all patients, Excluder® Iliac leg was used as a chimney in the BCT and Viabahn® (n=32) or Atrium Advanta V12® (n=3) as a chimney in the LCCA (off-label use). Five patients had an EL Ia and they all had a sealing ring distal to the most distal chimney of less than 10mm (P <.036). The rate of stent-graft oversizing (median 14%, IQR: 10-15% vs. 12%, 7-18% ), the diameter of the proximal (35mm, 34-37mm vs. 37mm, 33-41mm) and distal landing zones (26mm, 23-34mm vs. 30mm, 24-34mm) as well as the aortic diameter directly proximal to the pathology (36mm, 30-39mm vs. 34mm, 28-37mm) did not differ between the patients with and without EL Ia respectively (P>0.05). Furthermore, the patients with an EL Ia had a larger preoperative aortic arch curve diameter (P.033). A proximal overlap (chimney/aorta) >52.5 mm from the LCCA towards the aortic valves was also associated with an EL Ia (P.015). Conclusion - A sealing ring distal to the most distal chimney more than 10mm prevented from ELIa. In contrast to other studies, a longer overlap between the LCCA stent graft and the aorta would predict an ELIa. The relatively few patients and the single center nature require larger studies to verify the present results.

Endovascular Repair of a Complicated Acute Type B Aortic Dissection Using a Combination of the STABILISE and CERAB Techniques

Introduction: Endovascular treatment of type B aortic dissection has focused on covering the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained acceptance. We describe a case report in which the STABILISE technique was used in addition with the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique for complete aortic remodeling. Methods: Clinical data were collected from the hospital's records. Results: A 34-year-old male, with a history of hypertension was admitted at the emergency department for acute-onset back pain, severe hypertension and right lower limb ischemia. A CT-Angiography confirmed a type B aortic dissection with true lumen compression and right common iliac artery occlusion. At first, blood pressure and pain were controlled with IV drugs, however the lower limb ischemia persisted. A plan was made to first treat the limb ischemia and delay the aortic repair for the sub-acute phase, if necessary. A common iliac artery kissing stent was performed using Atrium Advanta V12® (10mm) stents and a self-expandable uncovered stent to the external iliac on the right side. The patient recovered well, however, 5 days later, refractory chest pain and hypertension developed. A CT-Angiography showed severe true lumen compression at the visceral aorta and we decided to perform an urgent repair of the aortic dissection. After true lumen catheterization, a TEVAR was performed landing over the left subclavian artery (COOK®ZTA P-32-201) followed by deployment of a bare-metal dissection stent ending 2 cm below the renal arteries (COOK®ZDES 36-180). A control angiography showed false lumen exclusion at the proximal aorta, however the distal aortic true lumen was still severely compressed. For that reason, a STABILISE was performed using a non-compliant 28mm balloon proximally and a 23mm balloon distally. Because the true lumen was still compressed at the infra-renal aorta, we decided to proceed with a CERAB technique, using a Bentley® Aortic BeGraft (18x48mm) deployed just distal to the renal arteries. Proximal flaring of the stent was performed using the 23mm non-compliant balloon. Two 10x59mm Atrium Advanta® V12 stents were used for the iliac extensions ending inside the previous iliac kissing stents. Angiographic control was optimal, and the patient recovered well. However, the patient was still dependent on 4 oral anti-hypertensive drugs, so a new CT-Angiography was performed and showed an intimal flap inside the right renal artery. Under local anesthesia, a Cordis® Palmaz Blue (6x18mm) stent was deployed in the right renal artery through the aortic dissection stent. The patient was latter discharged with adequate hypertension control under two oral anti-hypertensive drugs and the control CT one month after treatment showed complete remodeling of the aorta and perfusion of all visceral branches. Conclusion: We report a case of a combination of the STABILISE and CERAB techniques used to treat an acute type B aortic dissection. This combination allowed for a covering of both the entry tear and the distal re-entry tears resulting in a complete flap apposition, false lumen obliteration and optimal remodeling. Disclosure: Nothing to disclose

AAA 5. Bridging Stent Grafts in Fenestrated Aortic Repair: Performance of Different Covered Stents for This Indication in an In Vitro Model

The objective of this report was to study the performance of different covered stents as bridging stent grafts in a plain fenestrated model. Four different balloon-expandable covered stent grafts (Advanta V12 [Getinge AB, Gothenburg, Sweden], BeGraft [Bentley Innomed GmbH, Hechingen, Germany], BeGraft Plus [Bentley Innomed GmbH], and VBX [Gore Medical, Flagstaff, Ariz], each in 6 mm, 10 of each) were placed in a flat fenestrated model and flared by a 10-mm balloon. After this, the polytetrafluoroethylene (PTFE) fabric was analyzed by a micro camera (Keyence, Milton Keynes, United Kingdom). The stent structure was investigated by radiography. Pullout force was measured by recording force vs displacement to analyze the strength of the connection between the bridging stent graft and the fenestration. Tangential force vs displacement was measured to assess the shear stability of the different stents and to analyze the ability of the stents to resist migration and misalignment of a fenestrated endograft (Fig 1). No damage or rupture of the PTFE fabric was observed in all types of covered stents. Moreover, no stent fractures in any of the covered stents was seen by radiography. Maximal pullout force for 6-mm stents was 16.9 ± 1.9 N for the Advanta V12, 23.0 ± 4.3 N for the VBX, 17.6 ± 1.3 N for the BeGraft, and 28.1 ± 4.2 N for the BeGraft Plus. The slope of the measured pullout force of these stents in the first part was 2.83 N/mm for the Advanta V12, 1.9 N/mm for the VBX, 1.87 N/mm for the BeGraft, and 2.12 N/mm for the BeGraft Plus. Maximal shear strength was 29.6 ± 3.2 N for the Advanta V12, 20.4 ± 3.1 N for the VBX, 18.9 ± 1.9 N for the BeGraft, and 28.8 ± 2.0 N for the BeGraft Plus. Shear force at 6-mm displacement was 7.2 ± 1.4 N for the Advanta V12, 8.7 ± 1.9 N for the VBX, 6.7 ± 0.8 N for the BeGraft, and 9.6 ± 1.5 N for the BeGraft Plus (Fig 2). The material of all tested covered stents has withstood the flaring forces without damage of the PTFE fabric or stent fracture. Pullout force was highest in the BeGraft Plus, followed by VBX, BeGraft, and Advanta V12, but the slope of the pullout force at the first part was highest in the Advanta V12 stent, followed by BeGraft Plus, VBX, and BeGraft. The ability to withstand crushing forces was highest in Advanta and BeGraft Plus, followed by VBX and BeGraft. These findings together with the special features of the tested stents should have an important implication for clinical practice. Fatigue tests for these stents in this special indication are mandatory to ave a dedicated bridging stent graft for fenestrated aortic repair in the future.Fig 2Shear strength 6-mm bridging stent graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

TRA 1. Unusual Injury of Common Iliac and Median Sacral Arteries After Airgun Shot With Distal Embolization of the Pellet: A Case Report

We describe a case with distal embolization of a pellet into the popliteal artery after an airgun shot in the abdomen. Airguns produce low-velocity and low-powered shots, which is why many people do not perceive them to be dangerous. However, modern airgun pellets are capable of inflicting serious and sometimes life- threatening injuries. We present a case of a 37-year-old man after an airgun shot to the abdomen. The patient was admitted in hemorrhagic shock to a countryside hospital. General surgeons preformed explorative laparotomy to stop the bleeding but with no success. After this, the vascular surgeon was urgently mobilized from a nearby city. The patient was extremely unstable, with massive blood loss and multiple transfusions (10 units, 400 mL each). Therefore, we decided to perform angiography first. We verified traumatic lesions in the left common iliac and median sacral arteries, so two stent grafts were implanted to stop the bleeding—Advanta V12 (Getinge, Rastatt, Germany) 9/40 for the common iliac artery and Graftmaster (Abbott Vascular, Abbott Park, Ill) 4/19 for the median sacral artery. The pellet was not visible in the abdomen on radiography. The patient was discharged after 10 days. A computed tomography scan at 1-month follow-up showed no signs of endoleak, but the pellet was found in the middle part of the left popliteal artery (Fig 1). The patient had palpable pulses on both pedal arteries without any signs of ischemia. Nevertheless, we extracted the pellet by a posterior approach to the popliteal fossa, but the artery was so damaged that it had to be replaced with a conduit from small saphenous vein (Fig 2). Successful treatment of complex airgun shot injury was accomplished with staged endovascular and open surgery approaches. Firearm injuries of main arteries are not generally common in modern societies. Furthermore, lesions of major arterial vessels by airgun pellets are even rarer. However, these injuries remain concerning because of their small size; they can easily migrate across the entire vascular system. If they are not found within the impact area, they should be meticulously sought elsewhere. Multilevel arterial trauma is challenging for every vascular specialist, but with the advances in the endovascular field, we can perform fast and safe treatment to save the patient’s life.Fig 2Posterior approach to popliteal artery and pellet inside it (A), extracted pellet (B), and interposition of vein conduit to reconstitute popliteal artery (C).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents

Endovascular treatment of complex aortoiliac disease is seeing a growing popularity despite the Trans-Atlantic Inter-Society Consensus (TASC) II recommendations for open surgery in this cases. However, the available evidence does not focus particularly on patients with complete unilateral iliac axis obstruction (CIAO) (TASC II D4 group). This study reports mid-term results of endovascular therapy with covered stents for CIAO. This is single-center retrospective review of patients with CIAO endovascular treatment from January 2015 to December 2017 (3years). Two types of covered stents were used, alone or combined: the Viabahn self-expandable stent (W. L. Gore, Flagstaff, AZ) and the Advanta V12 balloon-expandable stent (Atrium-Maquet, Hudson, NH). Thirty-day outcomes, long-term patency (assessed with Kaplan-Meier estimates), in-hospital stay, and limb salvage were analyzed. Thirty-nine patients with CIAO were treated in the period (87.2% male, mean age 64.3±9years). A majority presented with critical limb ischemia (56.4%, n=22). Recanalization could be accomplished from an ipsilateral or contralateral femoral access in 82.1% of patients (1 case needed the use of a re-entry device), and from a left brachial access in 17.9%. Technical success was 100%. About 66.7% of cases received an aortic kissing stent technique. Common femoral artery/profundoplasty with prosthetic or bovine patch was associated with 74.3% of cases. Thirty-day mortality was 2.6% (1/39). Primary, assisted, and secondary patency rates at 24months were all 96.8%. Mean in-hospital stay was 5days; no limb loss was registered during follow-up. Endovascular treatment of complete iliac axis occlusions can offer comparable midterm patency rates to open surgery aortoiliac femoral bypass, when an adequate combination of balloon and self-expandable covered stents is used and an appropriate outflow through the common femoral artery is warranted.

In Vitro Evaluation of Balloon-Expandable Chimney Grafts in the Renal Arteries Combined With the Endurant Endograft

Purpose: To compare balloon-expandable covered stents (BECS) available for use as renal chimney grafts to the Advanta V12 approved for use with the Endurant endograft. Materials and Methods: A silicone model was manufactured based on preoperative computed tomography angiography (CTA) scans of a patient with a 7-cm juxtarenal aneurysm treated with an Endurant bifurcated endograft and an Advanta V12 covered stent for the 6-mm-diameter right renal artery. The model was placed in a flow box filled with a 37°C blood-mimicking solution equipped with a pulsatile pumping system (140/60 mm Hg). The tested BECS were the Advanta V12, the VBX, and the BeGraft+. A 36-mm-diameter Endurant II endograft with a 16-mm-diameter contralateral limb and a 6×59-mm BECS chimney graft were used in 9 consecutive tests (3 for each combination). After each implantation, the model was placed in the CT scanner, and 2 radiologists blinded to the test device independently measured the gutter areas and the patent chimney graft lumen at the level of the Endurant’s suprarenal stent, at the level of the chimney’s maximum curvature, and 10 mm inside the renal artery. The intraclass correlation coefficients (ICC) were calculated to assess interreader reliability. Results: The mean gutter areas were 19.3±7, 20.2±8, and 22.3±8 mm2 for the Advanta, VBX, and BeGraft+, respectively (all p>0.05). At the level of the aortic endograft’s suprarenal stent struts, the mean diameter of the Advanta V12, VBX, and BeGraft+ were 4.46±0.3, 4.12±0.4, and 4.12±0.3 mm, respectively (all p>0.05). At the level of the maximum chimney graft angulation, the mean diameters were 3.77±0.3, 4.16±0.1, and 3.74±0.3 mm, respectively (all p>0.05). In the right renal artery, the mean diameters were 3.91±0.2, 4.05±0.9, and 4.3±0.4 mm, respectively (all p>0.05). The ICCs varied between 0.7 and 0.9, indicating good agreement between readers. Conclusion: These in vitro findings showed comparable results between the Advanta V12 and the available BECS used in conjunction with the Endurant endograft according to the instructions for use. Further clinical evaluation is needed to confirm these results.

Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): study protocol for a randomized controlled trial

BackgroundChronic mesenteric ischemia (CMI) is the result of insufficient blood supply to the gastrointestinal tract and is caused by atherosclerotic stenosis of one or more mesenteric arteries in > 90% of cases. Revascularization therapy is indicated in patients with a diagnosis of atherosclerotic CMI to relieve symptoms and to prevent acute-on-chronic mesenteric ischemia, which is associated with high morbidity and mortality. Endovascular therapy has rapidly evolved and has replaced surgery as the first choice of treatment in CMI. Bare-metal stents (BMS) are standard care currently, although retrospective studies suggested significantly higher patency rates for covered stents (CS). The Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI) trial is designed to prospectively assess the patency of CS versus BMS in patients with atherosclerotic CMI.Methods/designThe CoBaGI trial is a randomized controlled, parallel-group, patient- and investigator-blinded, superiority, multicenter trial conducted in six centers of the Dutch Mesenteric Ischemia Study group (DMIS). Eighty-four patients with a consensus diagnosis of atherosclerotic CMI are 1:1 randomized to either a balloon-expandable BMS (Palmaz Blue with rapid-exchange delivery system, Cordis Corporation, Bridgewater, NJ, USA) or a balloon-expandable CS (Advanta V12 over-the-wire, Atrium Maquet Getinge Group, Hudson, NH, USA). The primary endpoint is the primary stent-patency rate at 24 months assessed with CT angiography. Secondary endpoints are primary stent patency at 6 and 12 months and secondary patency rates, freedom from restenosis, freedom from symptom recurrence, freedom from re-intervention, quality of life according the EQ-5D-5 L and SF-36 and cost-effectiveness at 6, 12 and 24 months.DiscussionThe CoBaGI trial is designed to assess the patency rates of CS versus BMS in patients treated for CMI caused by atherosclerotic mesenteric stenosis. Furthermore, the CoBaGI trial should provide insights in the quality of life of these patients before and after stenting and its cost-effectiveness. The CoBaGI trial is the first randomized controlled trial performed in CMI caused by atherosclerotic mesenteric artery stenosis.Trial registrationClinicalTrials.gov, ID: NCT02428582. Registered on 29 April 2015.

Single Centre Experience with Anaconda Custom-made Fenestrated Stent Graft in the Endovascular Repair of the Juxtarenal Aneurysms

Aim: The fenestrated Anaconda custom-made stent graft is one of the recently widely accepted fenestrated devices for managing complex juxta- and pararenal aortic pathology. This study showed its feasibility for treatment of challenging juxtarenal anatomy of the abdominal aorta. Methods: Over the period of 12 months, 9 patients with juxtarenal aortic aneurysm underwent fenestrated stent graft implantation in our institution. The graft fenestrations were customized on the basis of computerized tomography (CT-Angiography; CTA). Selected visceral ostia were protected with covered balloon-expandable stents after partial stent graft deployment. The perioperative and short term data were collected prospectively. Results: The mean aneurysm diameter was 58.4 mm (range 46-73 mm). The mean infrarenal neck length was 3.5 mm (range 0-7 mm), no patient had a severe (&gt;60°) angulation of proximal neck. 18 fenestration for renal arteries, 1 for SMA and 3 for coeliac´s were treated with Advanta V12 covered stent. All the target vessels were cannulated successfully through fenestrations and all the stent grafts were successfully deployed in patients with no technical issue in the release mechanism. All the patients have undergone 6 month follow-up, no aneurysm related or aneurysm-unrelated deaths were reported. On the CTA scan, 3 of the patients had a weak type IIb endoleak; no type I or Type III endoleak was demonstrated. All target vessels were open without an instance of branch-stent stenosis/occlusion. No reintervention was needed. Conclusion: The usage of custom-made Anaconda fenestrated stent graft for endovascular treatment of juxtarenal aortic aneurysms is feasible with acceptable intermediate-term results.

Deployment of stent graft in an excessively higher position above the renal artery induces a flow channel to the aneurysm in chimney endovascular aortic aneurysm repair: an in vitro study.

We aimed to investigate the influences of the sealing length above the renal artery (RA) on gutter formation, non-apposed regions between the aortic wall, stent graft (SG), and chimney graft and incidence of flow channel to the aneurysm in chimney endovascular aortic aneurysm repair (Ch-EVAR) using a juxtarenal abdominal aortic aneurysm model. Neck diameter and length of the silicone model were 24 and 4mm, respectively. In double Ch-EVAR configuration using Advanta V12, 12 combinations were tested three times with two sizes [28.5 (20%-oversize) and 31 (30%-oversize) mm] of Excluder SG, three sealing lengths above the RA (10, 20, and 30mm), and two deployment positions (anatomical and cross-leg). Gutter area, non-apposed region, and flow channels to the aneurysm were analyzed using micro-computed tomography. Average gutter area and non-apposed region of 30%-oversize SG were significantly smaller than those of 20%-oversize SG (p = 0.05). Furthermore, the non-apposed region of 30%-oversize SG with a 30-mm sealing length was significantly larger than that of the other sealing lengths. For 20%-oversize SGs, flow channel to the aneurysm was observed, except for the anatomical deployment with the sealing length of 10mm. For 30%-oversize SGs, flow channel was absent, except for the SG with a 30-mm sealing length in both deployment positions. These flow channels were frequently formed through a valley space, existing in the lower unibody above the two limbs. Our data indicated that the optimal sealing length should be chosen in consideration of the device design difference due to the device diameter in Ch-EVAR.

Acute Mesenteric Ischaemia and Coralliform Aorta

A 77 year old man presented with acute mesenteric ischaemia and peritonitis. Computed tomography angiography revealed acute thrombosis of the proximal calcified superior mesenteric artery (SMA) arising from a coralliform aorta (A, asterisk). He underwent emergency retrograde open mesenteric stenting (ROMS) using a 7 × 59 mm Atrium Advanta V12 stent graft (Maquet, Rastatt, Germany) with great saphenous vein patch angioplasty (panel B), followed by right colectomy. Ilio-mesenteric bypass was not feasible because of previous iliac kissing stents and femoro-femoral bypass. The patient is alive at 2 months after temporary dialysis. ROMS is a useful bailout technique to treat acute SMA thrombosis despite coralliform aorta.

Preservation of the Inferior Mesenteric Artery With a Surgeon-customised Fenestration

Abdominal aortic aneurysms (AAA) are most frequently treated by endovascular aneurysm repair (EVAR). A recognised drawback of EVAR is loss of the inferior mesenteric artery (IMA), which when associated with the additional occlusion of both hypogastric arteries, puts the patient at risk of ischaemic colitis or pelvic ischaemia. A surgeon-customised fenestration technique used in a 70 year old man with an AAA, occluded hypogastric arteries, and a large IMA is described. The diameter of the IMA, distance to the lower renal artery, and clock face positions were assessed with TeraRecon software (TeraRecon Foster City, CA, USA). The main body of an Endurant stent graft (Medtronic, Dublin, Ireland) was partially unsheathed. The location and shape of the fenestration was drawn on the graft between two rows of stent. A 6 mm fenestration was created by using a 1205 °C cautery loop tip (Accu-Temp; Beaver-Visitec International, Waltham, MA, USA). To prevent the burning of the polyester, the graft was continuously irrigated with cold isotonic saline. A segment of a 25 mm Amplatz goose neck snare (Medtronic) was sutured around the fenestration with a polytetrafluoroethylene monofilament suture (CV-5 Gore-Tex; WL Gore & Associates, Flagstaff, AZ, USA) to serve as a radio-opaque marker (Fig. 1A). The graft was then re-sheathed by using a silicone rubber band tightly wrapped around the graft and loosened gradually when the sheath came over (Fig. 1B). Once the stent graft was deployed, the fenestration and the IMA were catheterised with a SIM1 catheter and a 7 × 22 mm covered stent (Advanta V12; Maquet, Sunderland, UK) (Fig. 2A and B) was subsequently deployed and flared with a 9 × 20 mm angioplasty balloon.Figure 2(A) Catheterisation of the inferior mesenteric artery by surgeon-customised fenestration. (B) Post-operative three dimensional reconstruction showing patency of the fenestration and occlusion of both hypogastric arteries.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Surgeon-customised fenestration is a straightforward technique that provides an option for maintaining IMA patency in patients at risk of ischaemic colitis and pelvic ischaemia following infrarenal EVAR.

Computed tomography image quality of aortic stents in patients with aortic coarctation: a multicentre evaluation

BackgroundStents are commonly used to treat aortic coarctation. The objective of this study was to evaluate the post-implantation computed tomography (CT) image quality of different stent types used to treat aortic coarctation.MethodsAdult and paediatric patients with stent-treated aortic coarctation who underwent contrast-enhanced CT were retrospectively included from three tertiary care centres. CT scans were subjectively scored for image quality using a 4-point scale (1 = unacceptable; 2 = poor; 3 = good; 4 = excellent). Furthermore, the amount of stent-induced blooming artefacts was measured as the percentage of the difference between outer and inner stent diameters over the outer stent diameter.ResultsA total of 35 children and 34 adults implanted with 71 stents of six different types were included. The most commonly used stent type was the Cheatham Platinum stent (52 stents, 73%). The subjective image quality of the Cheatham Platinum stents was moderate with a score of 2.0±0.8 (mean ± standard deviation) in children and 2.3±0.6 in adults. The image quality in patients with Formula stents was 2.3±1.2. The Cheatham Platinum stents induced 34–48% blooming, the Formula stents 44–55%. The image quality in patients with the less commonly used Atrium Advanta V12, IntraStent, AndraStent and Palmaz stents was scored 3 (good) to 4 (excellent) with less blooming. The electrocardiographic gating and tube voltage (kVp) did not affect image quality.ConclusionsThere is a substantial variation in CT image quality and blooming artefacts for different stent types used to treat aortic coarctation.

In Vitro Quantification of Gutter Formation and Chimney Graft Compression in Chimney EVAR Stent-Graft Configurations Using Electrocardiography-Gated Computed Tomography

Purpose: To assess the dynamic behavior of chimney grafts during the cardiac cycle. Methods: Three chimney endovascular aneurysm repair (EVAR) stent-graft configurations (Endurant and Advanta V12, Endurant and Viabahn, and Endurant and BeGraft) were placed in silicone aneurysm models and subjected to physiologic flow. Electrocardiography (ECG)-gated contrast-enhanced computed tomography was used to visualize geometric changes during the cardiac cycle. Endograft and chimney graft surface, gutter volume, chimney graft angulation over the center lumen line, and the D-ratio (the ratio between the lengths of the major and minor axes) were independently assessed by 2 observers at 10 time points in the cardiac cycle. Results: Both gutter volumes and chimney graft geometry changed significantly during the cardiac cycle in all 3 configurations (p<0.001). Gutters and endoleaks were observed in all configurations. The largest gutter volume (232.8 mm3) and change in volume (20.7 mm3) between systole and diastole were observed in the Endurant-Advanta configuration. These values were 2.7- and 3.0-fold higher, respectively, compared to the Endurant-Viabahn configuration and 1.7- and 1.6-fold higher as observed in the Endurant-BeGraft configuration. The Endurant-Viabahn configuration had the highest D-ratio (right, 1.26–1.35; left, 1.33–1.48), while the Endurant-BeGraft configuration had the lowest (right, 1.11–1.17; left, 1.08–1.15). Assessment of the interobserver variability showed a high correlation (intraclass correlation >0.935) between measurements. Conclusion: Gutter volumes and stent compression are dynamic phenomena that reshape during the cardiac cycle. Compelling differences were observed during the cardiac cycle in all configurations, with the self-expanding (Endurant–Viabahn) chimney EVAR configurations having smaller gutters and less variation in gutter volume during the cardiac cycle yet more stent compression without affecting the chimney graft surface.

Parallel-Stenting Technique in a Sandwich Configuration for Hypogastric Artery Preservation during Endovascular Aneurysm Repair: An In Vitro Study

The aim of the study was to identify the best conditions in iliac sandwich procedure for hypogastric artery preservation during endovascular aneurysm repair, testing different devices, different oversizing (OS) degrees as well as different methods to measure it. Four external iliac devices (16-mm Endurant and 12-mm Aorfix limb extensions; 11- and 13-mm Viabahn endografts) were tested with 2 distinct internal iliac stent grafts (8-mm Advanta V12 and 8-mm Viabahn) inside different proximal silicon iliac limb models (10, 12, 14, 16, and 18mm), simulating an iliac sandwich procedure for hypogastric preservation. After remodeling all devices in a saline bath at 37°C, the combinations were computed tomography scanned. Gutter size, parallel-stent compression, and inadequate parallel-stent deployment or infolding were recorded. Oversizing between both parallel stents and the iliac limb models were examined in terms of added diameter, perimeter, and area being additionally compared. All three sizing methods (diameter, perimeter, and area) were highly correlated (diameter OS to perimeter and area OS correlation coefficient 0.998 and 0.997, respectively, P<0.001 for both); thus, diameter OS was used for further comparisons. Increasing diameter OS (< 30%, 30-55%, 55-75%, and > 75%) showed a significant tendency toward smaller gutters (38.9, 12.2, 5.4, and 2.6 mm2, respectively, P<0.001) but also increasing parallel-stent compression (13.5%, 28.9%, 43.9%, and 55.1%, P<0.001) and infolding (0%, 0%, 38%, and 60%, P<0.001). There were no significant differences between the analyzed devices. In iliac sandwich procedures, better apposition is usually achieved when using 30-55% diameter OS; higher OS is related to smaller gutters but higher rates of malpositioning and parallel-stent compression. No clear recommendations in material selection can be performed. All sizing methods are highly correlated and predictable.

Atrium Advanta V12 Large Diameter Stent-Graft Applications for Infrarenal Abdominal Aortic Pseudoaneurysms (due to Behcet Disease): Safety and Efficacy

The aim of the study was to determine the safety and effectiveness of Atrium Advanta V12 large diameter stent-graft applications for infrarenal abdominal aortic pseudoaneurysms (due to Behcet disease [BD]). Data of Advanta V12™ (Atrium Europe B.V, Mijdrecht, the Netherlands) applied 12 female patients (mean age 30.5±6.3, range 26-44) with infrarenal abdominal aortic pseudoaneurysms were analyzed retrospectively. All Advanta V12 large diameter stent grafts were implemented from right or left sided 12F femoral sheaths. Stent grafts with 12-16mm in size and 29-61mm in length were utilized. Technical success rate, procedure-related mortality and morbidity, and primary patency rate at 4 years were evaluated. Technical success rate was 100%. Neither procedure-related mortality nor morbidity was determined. The mean aortic diameter was 14.0±0.8mm for pseudoaneurysmatic abdominal aortas. The mean follow-up period was 46.5±40.3months (range 18-75). During follow-ups, only one recurrent aneurysm has evolved at the stenting site due to patients' withdrawal of immunosuppressive treatment. The advent of a new aneurysm proximal or distal to the stent-graft region or at the femoral access localization was not observed. There were no stent occlusions. Primary patency rate at 4 years was 100%. Complete aneurysm exclusion was achieved 100% at 48months. The use of Advanta V12 large diameter stent grafts for infrarenal abdominal aortic pseudoaneurysms (due to BD), especially in female patients with small aortic diameter, is safe and efficient. Primary patency rate of the stent grafts at 4 years is excellent.

Benchtop quantification of gutter formation and compression of chimney stent grafts in relation to renal flow in chimney endovascular aneurysm repair and endovascular aneurysm sealing configurations

BackgroundThe chimney technique has been successfully used to treat juxtarenal aortic aneurysms. The two main issues with this technique are gutter formation and chimney graft (CG) compression, which induce a risk for type Ia endoleaks and stent thrombosis, respectively. In this benchtop study, the geometry and renal artery flow of chimney endovascular aneurysm repair configurations were compared with chimney configurations with endovascular aneurysm sealing (ch-EVAS). MethodsSeven flow phantoms were constructed, including one control and six chimney endovascular aneurysm repairs (Endurant [Medtronic Inc, Minneapolis, Minn] and AFX [Endologix Inc, Irvine, Calif]) or ch-EVAS (Nellix, Endologix) configurations, combined with either balloon-expandable or self-expanding CGs with an intended higher positioning of the right CG in comparison to the left CG. Geometric analysis was based on measurements at three-dimensional computed tomography angiography and included gutter volume and CG compression, quantified by the ratio between maximal and minimal diameter (D-ratio). In addition, renal artery flow was studied in a physiologic flow model and compared with the control. ResultsThe average gutter volume was 343.5 ± 142.0 mm3, with the lowest gutter volume in the EVAS-Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) combination (102.6 mm3) and the largest in the AFX-Advanta V12 (Atrium Medical Corporation, Hudson, NH) configuration (559.6 mm3). The maximum D-ratio was larger in self-expanding CGs than in balloon-expandable CGs in all configurations (2.02 ± 0.34 vs 1.39 ± 0.13). The CG compression had minimal influence on renal volumetric flow (right, 390.7 ± 29.4 mL/min vs 455.1 mL/min; left, 423.9 ± 28.3 mL/min vs 410.0 mL/min in the control). ConclusionsThis study showed that gutter volume was lowest in ch-EVAS in combination with a Viabahn CG. CG compression was lower in configurations with the Advanta V12 than with Viabahn. Renal flow is unrestricted by CG compression.

MP32-11 PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR TREATMENT OF TRANSPLANT RENAL ARTERY STENOSIS

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II1 Apr 2016MP32-11 PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR TREATMENT OF TRANSPLANT RENAL ARTERY STENOSIS Alexander Massmann, C. Marchal, Christina Niklas, Sarah Seiler-Mußler, Urban Sester, Gunnar Heine, G.K. Schneider, Arno Bücker, Michael Stöckle, and Martin Janssen Alexander MassmannAlexander Massmann More articles by this author , C. MarchalC. Marchal More articles by this author , Christina NiklasChristina Niklas More articles by this author , Sarah Seiler-MußlerSarah Seiler-Mußler More articles by this author , Urban SesterUrban Sester More articles by this author , Gunnar HeineGunnar Heine More articles by this author , G.K. SchneiderG.K. Schneider More articles by this author , Arno BückerArno Bücker More articles by this author , Michael StöckleMichael Stöckle More articles by this author , and Martin JanssenMartin Janssen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES After kidney transplantation transplant renal artery stenosis (TxRAS) can cause significant morbidity and loss of renal function. To evaluate the percutaneous transluminal angioplasty, a single-center database was studied retrospectively. Perinterventional and functional outcome was recorded to evaluate safety and feasibility. METHODS From Jan 2000 to November 2015, 383 patients recieved a renal transplant, 67/383 after living donation. 66 patients underwent catheter-angiography (n=41 male; mean age and standard deviation 54,8 ±15,1 years). Peri-interventional data, complications and functional data e.g. ultrasound, bloodpressure and GFR were studied. RESULTS TxRAS was detected in 63 patients after a mean of 219 (range 1-891) days after transplantation, and treated by interventional means. The inital technical success (residual stenosis <25%) after stent-placement was 100%. A balloon-mounted CoCr-Stent (Cordis Palmaz Blue) was used in 62 cases, in one patient a ePTFE-coated balloon-mounted stent (Atrium Advanta V12) was placed to protect potential rupture in a patient with a filiforme anastomosis. No peri-interventional complication was recoreded, During a mean follow-up of 35 (21-62) months all functional parameters improved: reduction of arterial systolic and diastolic blood-pressure (given mean, std. dev. and t-test result comparing pre- and post-intervention) pre-interventional systolic RR: 138±12 to post 1-year: 137±5 mmHg (p=0,0233), diastolic RR from pre: 87±12 mmHg, to post 1-year: 77±9 mmHg (p=0.052). The total number of different antihypertensive medication and daily dosing were reduced. A reduction of the accelerated renal arterial flow was recorded: pre 3.1±1.2 m/s to 1.3±0.4 m/s (p=0.0089). The resistence-index improved: pre 0.64 ±0.09 to post 1-year: 0.73 ±0.09 (p=0.0195). Renal function improved after one week: S-creatinine pre: 2.68±1.04 (1.8-5.5) to post 1.99±0.32 (1.6-2.5) mg/dl (p=0.0625), and GFR pre: 31.5±5.1 (23.2-39.1) to post 38.4 ±7.2 (25.8-50.4) (p=0.0309). The primary 1-year patency and graft-survival was 100%. CONCLUSIONS Interventional stent placement is a safe and efficient method for TxRAS treatment improving arterial hypertension, haemodynamics and graft-function. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e432 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alexander Massmann More articles by this author C. Marchal More articles by this author Christina Niklas More articles by this author Sarah Seiler-Mußler More articles by this author Urban Sester More articles by this author Gunnar Heine More articles by this author G.K. Schneider More articles by this author Arno Bücker More articles by this author Michael Stöckle More articles by this author Martin Janssen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Atretic aortic coarctation in a 32-year-old woman diagnosed after her third pregnancy, treated percutaneously using a covered stent

Atretic aortic coarctation is a severe form of coarctation of aorta, where there is loss of luminal communication at the site of aortic isthmus. We present a case of a 32-year-old woman who had long-standing, treatment-resistant hypertension. She had three pregnancies. The third pregnancy ended in premature labor of a newborn female infant who was found to have severe coarctation of aorta. This diagnosis in the newborn child prompted proper evaluation of the mother, who was found to have atretic coarctation. The woman was treated successfully using a covered Advanta V12 stent (Atrium, Hudson, NH, USA), after percutaneous needle puncture of the atretic isthmus. Anatomical orientation of the aorta at the site of coarctation and its relationship to the safety of needle puncture approach are discussed. This case brings an old lesson to the table, where proper evaluation of severe, treatment-resistant hypertension in adults should include screening for secondary causes.<Learning objective: Evaluation of severe and resistant systemic hypertension in adults should include screening for aortic coarctation. Pregnancy in women with coarctation of aorta carries significant risk to both the woman and the fetus. Atretic coarctation is a severe form of coarctation where there is complete obstruction of aortic isthmus. This can be treated successfully by percutaneous approach using covered stents.>

Outcomes of covered expandable stents for the treatment of TASC D aorto-iliac occlusive lesions.

Aortoiliac arterial occlusive disease is frequently encountered in the management of lower limb vascular insufficiency. We report our experience with covered balloon-expandable stents for treatment of TASC D lesions of the abdominal aorta and common iliac arteries. A retrospective study of 30 patients who underwent aortoiliac stenting with the Atrium Advanta V12 from March 2010 to September 2012 was conducted. Patient demographic data, clinical signs and symptoms and procedural details were recorded. Outcomes assessed were primary patency, secondary patency, technical success, complications, limb salvage and survival. Median age was 67 years (range 48-84) and 40% of patients underwent treatment for critical limb ischaemia. Median follow-up was 13 months (range 3-38 months). Stent configuration comprised of long iliac stents in 20 patients, a large diameter aortic stent with iliac stenting in six patients, and aortic stent alone in four patients. Radiological success was achieved in 100% and the complication rate was 6%. Primary patency at 6, 12 and 24 months was 97%, 90% and 79%, respectively. Four cases of in-stent stenosis were reported, with three of these undergoing re-interventions resulting in a secondary patency rate of 97% at the end of follow-up. One patient death occurred within the follow-up period. This case series demonstrates that treatment of complex aortoiliac occlusive disease with covered balloon-expandable stents can have acceptable results with good patency and good clinical outcome. Secondary patency rates are comparable to open surgical revascularisation, with lower morbidity.

Radiofrequency In Situ Fenestration for Aortic Arch Vessels During Thoracic Endovascular Repair

Purpose: To report the first clinical application of a novel technique using radiofrequency puncture to create retrograde in situ fenestrations during thoracic endovascular aortic repair (TEVAR). Methods: Between June 2011 and December 2013, 40 TEVAR procedures were performed in our facility, including 10 cases in which in situ fenestration was planned. Two thoracic stent-graft models were deployed: the Valiant (n=5) and the Zenith TX2 (n=5). A 0.035-inch PowerWire radiofrequency guidewire delivered from a brachial approach was used to fenestrate the grafts covering a left subclavian artery (LSA) in 9 cases and a left common carotid artery in one. The fenestrations were serially dilated to 6 mm, and self-expanding Advanta V12 covered stents were positioned in the target arteries. Results: Technical success was achieved in 6 of the 10 planned cases. Of the remaining 4 cases, stent-grafts were deployed in zone 3 in 2 cases (one received a chimney to the LSA). Another stent-graft was deployed in zone 2 without endoleak after fenestration was abandoned (the LSA had good filling via the vertebral artery). In the last case, the fenestration was unsuccessful in double-layered (proximal extension overlap) stent-grafts; a carotid-axillary bypass was required. There were no fenestration-related complications, but overall surgical complications included a case of paraparesis that resolved following spinal drainage and a death from a preexisting aortoesophageal fistula. There were no postoperative strokes. All fenestrations remained patent, and there were no endoleaks at a mean 12-month follow-up (range 1–33). Conclusion: Radiofrequency puncture is a viable alternative to needle or laser punctures for in situ fenestration during TEVAR. Early clinical results suggest technical feasibility and acceptable early outcomes.