Aortic Bifurcation Research Articles

Long-Term Outcome for Covered Endovascular Reconstruction of Aortic Bifurcation for Aortoiliac Disease: A Single-Center Experience

Purpose The gold standard for the treatment of complex (TASC II C and D) atherosclerotic aortoiliac lesions is still open surgical repair. Endovascular techniques have a lower mortality and morbidity rate but this comes at the cost of worse patency rates when compared with open repair. Improved short- and mid-term results have been reported using the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. The aim of this study was to report our initial experience with the CERAB technique and report long-term patency rates. Materials and Methods All patients treated with the CERAB technique between 2012 and 2018 were prospectively registered in an institutional database and included in this study. Patient demographics, characteristics, symptoms, procedural, and follow-up details were collected and analyzed retrospectively. Perioperative complications and reinterventions were also identified. The Kaplan-Meier survival method was used to assess cumulative rates of patency. Results A total of 44 patients were treated with the CERAB technique and included in this study. The majority of the treated aortoiliac occlusions were classified as complex: TASC II C (n=7; 15.9%) or TASC II D (n=25; 56.8%). Primary patency rate at 60 months was 83.3%, assisted primary patency was 90.9% and secondary patency 95%. No significant differences were found in patency rates comparing noncomplex (TASC II A and B) and complex (TASC II C and D) aortoiliac lesions. Seven patients (15.9%) required at least one additional procedure to maintain either assisted primary patency or secondary patency during follow-up. The 30-day complication rate in this series was 20.5% (n=9), of which 55.6% (n=5) were minor complications. All major 30-day complications (n=4) occurred during or directly after the CERAB procedure. Thirty-day mortality was 0%. No limb occlusions occurred within 30 days of the procedure. Conclusion Good long-term patency rates can be achieved with the CERAB technique to treat aortoiliac stenosis or occlusions while maintaining advantages associated with endovascular interventions. This remains true even when a CERAB is used to treat complex aortoiliac lesions. An endo-first approach to treat complex aortoiliac lesions seems viable.

Treatment of Aortoiliac Occlusive Disease With the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique: Results of a UK Multicenter Study

Objective This UK multicenter study aims to report early- and medium-term results following covered endovascular reconstruction of aortic bifurcation (CERAB) for the treatment of aortoiliac occlusive disease (AIOD) in patients with chronic limb threatening ischemia (CLTI) or intermittent claudication (IC). Materials and Methods Retrospective case analysis was performed of patients who underwent CERAB between November 1, 2012 and March 31, 2020 in 6 centers across the United Kingdom. Anatomical data, including degree of plaque calcification, were assessed using preoperative imaging. Outcome measures included mortality, perioperative complications, target lesion reintervention (TLR), and major limb amputation. Primary, assisted primary, and secondary patencies were calculated at set intervals. Results A total of 116 patients underwent CERAB over the study period for the following reasons [48% presenting with CLTI (Rutherford 4–6) and 52% with IC (Rutherford 1–3)]; 82% presented had Trans-Atlantic Inter-Society Consensus (TASC) D AIOD disease. Median age was 65 years (range 42–90 years); 76% of the cohort were male. Severely calcified aortic and iliac lesions were noted in 90% and 80% of patients, respectively. Over a median follow-up of 18 months (range 1–91 months), 2 (1.7%) patients were lost to follow up. In total 5, (4.3%) patients died and 2 (1.7%) had a major amputation. Endovascular TLR was required in 14 (12.1%) patients at last follow up. Surgical TLR was performed in 4 (3.4%) patients at last follow-up. Seven (6%) patients developed an aortic/iliac stent occlusion at last follow-up. The Kaplan-Meier (KM) freedom from TLR at 1 year was 94% and KM 1-year primary patency, assisted primary patency, and secondary patency were 88%, 94%, and 98% respectively. Subanalysis found the following features were associated with need for TLR; TASC D disease (OR = 2.45, 95% CI 1.44 to 3.71), severe aortic calcification (OR = 2.01, 95% CI 1.03 to 2.20), and presence of tissue loss at baseline (OR = 1.43, 95% CI 1.01 to 4.63). Conclusion Perioperative (<30 days) and medium-term morbidity, mortality, and patency rates in this pragmatic cohort of patients with severe AIOD lesions show that CERAB is a valid revascularization option. A direct comparison with surgical treatments for AIOD in a randomized controlled trial is justified.

Laparoscopic removal of a large pheochromocytoma-paraganglioma of the Zuckerkandl organ

Paragangliomas represent 15 to 20% of all chromaffin tissue tumors. Most often, paragangliomas are located in the abdominal cavity along the large vessels — in the para-aortic region from the diaphragm to the aortic bifurcation. One of the most common extra-adrenal pheochromocytomas is the Zuckerkandl tumor, originating from the para-aortic accumulation of sympathetic tissue located in the area of the inferior mesenteric artery’s origine or in the zone of the aortic bifurcation itself. Due to the technical difficulty in performing laparoscopic removal of paragangliomas, conversion to laparotomy is frequent and reaches 80%. The article describes a clinical case of a patient suffering from this type of neoplasm, with diagnosis details and treatment by a successful radical laparoscopic intervention with a large chromaffinnoma located in a difficult anatomical zone removal.

CT Enterography Using Four Different Endoluminal Contrast Agents: A Comparative Study

Abstract Objectives To determine the most preferable endoluminal contrast agent among mannitol, polyethylene glycol (PEG), iohexol, and water by comparing various qualitative (distension, fold visibility, and homogeneity) and quantitative parameters (distension) along with artifacts and patient feedback for computed tomography enterography (CTE). Methods This was a prospective study including 120 patients of age more than or equal to 18 years who were randomized equally into four groups. Group 1 was given 1500 mL of 3% mannitol solution, group 2 was given 1500 mL of PEG, group 3 was given 20 mL of iohexol dissolved in 1500 mL of water, and group 4 was given 1500 mL of plain water. CTE was done and images were evaluated in axial and coronal planes. Various quantitative and qualitative parameters were taken at the level of second part of duodenum, jejunum, ileum and ileocecal junction (ICJ). Artifacts and patient feedback were also taken into consideration. Results The quantitative distension and grading, qualitative distension, fold visibility, and homogeneity of the second part of duodenum, jejunum at the level of superior mesenteric artery, inferior mesenteric artery and renal artery on both sides of abdomen, ileum at the level of aortic bifurcation, common iliac bifurcation, and deep pelvis on both sides of abdomen and ICJ were significantly more in PEG group as compared with mannitol group, followed by iohexol and water group. The results were calculated by ANOVA test using p-value. In terms of patient feedback and artifacts, water was the best agent. Conclusions PEG is the most suitable contrast agent to carry out CTE. Distension, fold visibility, and homogeneity are the essential features for a better diagnostic outcome of CTE, which was better with PEG.

Management of Subintimal Position of Kissing Stents using Re-entry Catheter with Cone Beam-Computed Tomography Image Overlaid onto Live Fluoroscopy

Background Several endovascular or surgical treatments have been proposed to treat total chronic occlusions of the iliac bifurcation. Nowadays, endovascular options are considered as a first choice because of the decreased per-operative morbi-mortality. Nevertheless, unexpected intraoperative events may occur, such as dissection or rupture of the iliac artery. We report a case of inadvertent bilateral false lumen kissing stents positioning, rescued with stents extensions guided with image fusion guidance. Case presentation A 60-year-old male patient referred to our Department because of a severe bilateral claudication, 8 months after an iliac kissing stent for common iliac arteries occlusion. A CT angiography (CTA) was performed, showing a bilateral dissection of the aorto-iliac bifurcation at the proximal part of the stents, which were placed into the false lumen whereas the distal part was into the true lumens (TL). Lower limb perfusion was maintained by inferior mesenteric and hypogastric arteries. As a CTA performed before the first endovascular intervention showed no dissection of the aortic bifurcation, the flaps were probably created during the previous interventions. An endovascular revision was planned. After a bilateral femoral access, the proximal part of the flap was pierced with a needle-based re-entry device, deployed under three-dimensional cone-beam CT image overlay with bi-planar fluoroscopy. The lumen patency was then restored with stents extensions up to the renal ostia. The final angiography showed stents patency. No complication occurred during the intervention. The patient was dismissed the day after, with good arterial femoral pulse and no further complications. An US color Doppler performed one month after the intervention showed satisfactory blood flow of both iliac and femoral arteries as well as a good flow in the lower limbs. Conclusions The integration of modern 3D image guidance and novel endovascular devices allows the management of adverse events with a minimally-invasive approach.

Hemodynamic Comparison of Stent-Grafts for the Treatment of Aortoiliac Occlusive Disease

Purpose: To compare the flow patterns and hemodynamics of the AFX stent-graft and the covered endovascular reconstruction of aortic bifurcation (CERAB) configuration using laser particle image velocimetry (PIV) experiments. Materials and Methods: Two anatomically realistic aortoiliac phantoms were constructed using polydimethylsiloxane polymer. An AFX stent-graft with a transparent cover made with a new method was inserted into one phantom. A CERAB configuration using Atrium’s Avanta V12 with transparent covers made with a previously established method was inserted into the other phantom, both modified stent-grafts were suitable for laser PIV, enabling visualization of the flow fields and quantification of time average wall shear stress (TAWSS), oscillatory shear index (OSI), and relative residence time (RRT). Results: Disturbed flow was observed at the bifurcation region of the AFX, especially at the end systolic velocity (ESV) time-point where recirculation was noticeable due to vortical flow. In contrast, predominantly unidirectional flow was observed at the CERAB bifurcation. These observations were confirmed by the quantified hemodynamic results from PIV analysis where mean TAWSS of 0.078 Pa (range: 0.009–0.242 Pa) was significantly lower in AFX as compared with 0.229 Pa (range: 0.013–0.906 Pa) for CERAB (p<0.001). Mean OSI of 0.318 (range: 0.123–0.496) in AFX was significantly higher than 0.252 (range: 0.055–0.472) in CERAB (p<0.001). Likewise, mean RRT of 180 Pa−1 (range: 9–3603 Pa−1) in AFX was also significantly higher than 88 Pa−1 (range: 2–840 Pa−1) in CERAB (p=0.0086). Conclusion: In this in vitro study, the flow pattern of a modified AFX stent-graft was found to be more disturbed especially at the end systolic phase, its hemodynamic outcomes less desirable than CERAB configuration. Clinical Relevance: While the AFX stent-graft has an advantage over the CERAB configuration in eliminating radial mismatch, and maintaining the anatomical bifurcation for future endovascular intervention, this in vitro study revealed that the associated lower TAWSS, higher OSI and RRT may predispose to thrombosis and are, thus, less desirable as compared to a CERAB configuration. Further investigation is warranted to confirm whether these findings translate into the clinical setting.

Feasibility of anterior pedicle screw fixation in lumbosacral spine: a radiographic and cadaveric study

BackgroundThe anterior pedicle screw (APS) technique for L5 and S1 is crucial for proper anterior lumbar interbody fusion (ALIF). This study aimed to determine the projection, screw trajectory angle, and bone screw passageway length (BSPL), as well as the screw insertion regularity and the operating area within which it is safe to perform insertion.MethodsForty patients with low back pain, all of whom had lumbar computed tomography scans available, was included in this retrospective analysis. Radiographic parameters were measured, including: the distances from the projection to the upper endplate, lower endplate, and midline; the transverse and sagittal screw angles; and the BSPL. In addition, 10 fresh adult cadaveric lumbosacral spine segments were selected to determine the safe anatomic area in which to operate. Finally, APSs were inserted in L5 and S1 to determine the regularity of APS insertion.ResultsWe measured the anterior projection parameters, including: the distances to the upper endplate (L5: 12.5±1.3 mm; S1: 4.54±0.87 mm), lower endplate (L5: 17.3±1.6 mm), and midline (L5: 6.6±0.7 mm; S1: 6.6±0.6 mm); the screw trajectory angle, including the transverse screw angle (L5: 25.3±2.8°; S1: 25.7±2.6°), sagittal screw angle (L5: 17.1±1.7°; S1: 22.4±1.1°); and the BSPL (L5: 48.6±3.5 mm; S1: 48.0±3.5 mm). The regularity of APS insertion in L5 and S1 was determined. Upon the needle reaching a point in the lateral view, it reached the corresponding point in the anteroposterior (AP) view. The anatomic parameters of the safe operating area were as follows: the distance from the abdominal aortic bifurcation to the L5 lower edge (40.50±9.40 mm); the distance from the common iliac vein confluence to the L5 lower edge (27.80±8.60 mm); and the horizontal distance from the inner edge of the common iliac vein to the L5 lower edge (37.50±1.30 mm). We also determined the distance between S1 holes (29.30±1.30 mm), the L5/S1 intervertebral height (17.20±1.50 mm), and the safe operating area (2,058.20±84.30 mm2).ConclusionsThis study has determined the projection, screw trajectory angle, and BSPL of APSs in L5 and S1, their insertion regularity, and the area in which the operation can be safely performed.

Case series and a systematic review concerning the level of the aortic bifurcation.

The aim of this study is to present the level of aortic bifurcation in a sample of Greek origin (case series) and to perform an up-to-date systematic review in the existing literature. Seventy-six formalin-fixed adult cadavers were dissected and studied in order to research the level of aortic bifurcation. Additionally, PubMed and Google Scholar databases were searched for eligible articles concerning the level of aortic bifurcation for the period up to February 2020. The mean level of aortic bifurcation according to our case series was the lower third of the L4 vertebral body (21/76, 27.6%). The level of aortic bifurcation ranged between the lower third of the L3 vertebral body and the lower third of the L5 body. No statistically significant correlation was found between the two sexes. The systematic review of the literature revealed 31 articles which were considered eligible and a total number of 3537 specimens were retracted. According to the recorded findings the most common mean level of aortic bifurcation was the body of L4 vertebra (1495/3537 cases, 42.2%), while the range of aortic bifurcation was described to occur from upper third of L3 vertebrae to the upper third of the S1 vertebrae in the 52.8% of the cases (1866/3537). The mean level of AA corresponds to the body of L4 and presents a great range (form L3U to S1U). Knowledge of the mean level of aortic bifurcation and its probable ranges is of great significance for interventional radiologists and especially vascular surgeons that deal with aneurism proximal to the aortic bifurcation.

Two-year single centre results with covered endovascular reconstruction of aortic bifurcation (CERAB) in the treatment of extensive aorto-iliac occlusive disease.

To report the results of a single-centre in the treatment of extensive aorto-iliac occlusive disease (AIOD) by the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients treated with CERAB technique for AIOD between January 2016 and December 2019 in San Giovanni-Addolorata Hospital (Rome, Italy). Clinical examination, duplex ultrasound with ankle-brachial index measurement and contrast-enhanced computed tomography angiography were performed preoperatively. A clinical and ultrasound follow-up was carried out at one month and then half yearly after the intervention to evaluate patients' clinical status, limb salvage, target lesion revascularization rate, primary and secondary patency rate. During the study period, 24 patients (14 men, 58.3%; 10 women, 41.7%; median age 59 years, range 37-79 years) underwent CERAB for AIOD (TASC II C 29.2%, TASC II D 70.8%). Indications for treatment were: intermittent claudication in 18 patients (75%) and critical limb ischemia in 6 (25%). Technical success was achieved in all cases. Perioperative minor complications occurred in three cases (12.5%). One patient reported an intraoperative iliac rupture requiring adjunctive covered stenting. Median hospital length of stay was two days (range 1-9). No patient died perioperatively nor at the last follow-up. At a median follow-up of 18 months (range 6-48 months), mean ankle-brachial index increased significantly (from 0.62 ± 0.15 before the procedure to 0.84 ± 0.18) (P < 0.001) and target lesion revascularization rate was 12.5%. At two years, the limb salvage rate was 100%, and primary and secondary patency rates were 87.5% and 100%, respectively. CERAB technique demonstrated to be effective at the mid-term follow-up with low rate of complications and short length of stay. Long-term results and more robust data are needed to affirm this technique as the first-line treatment for extensive AIOD. However, it could become the preferred option especially in fragile patients and during contemporary COVID-19 pandemic due to the current limitations in vascular and critical care bed capacity.

Radical lymphadenectomy of a para-aorta lymph node metastasis in colorectal cancer prolongs relapse-free survival

It is highly controversial whether a lymphadenectomy for treating distant lymph nodes, such as the para-aortic lymph node, provides clinical benefit in colorectal cancer (CRC). This study aimed to investigate the benefit of a lymphadenectomy for para-aortic lymph node metastasis (PALM) in CRC, by evaluating the extent of dissection. This retrospective cohort study included 28 consecutive patients with pathologically positive PALMs in CRC that underwent lymphadenectomies from October 2001 to March 2018 at our institute. We analyzed the rates of 3-year recurrence-free survival (RFS), postoperative complications, and peri-operative death. We examined RFS in two groups with different operation types. One group received radical resections (radical group), defined as a systematic dissection of para-aortic lymph nodes, which removed the area under the renal vein and above the aortic bifurcation. The other group (targeted group) received targeted dissections, which removed specific swollen para-aortic lymph nodes. The radical group had a significantly better RFS than the targeted group. In addition, females had significantly better RFS prognoses than males. Univariate and multivariate Cox regression analyses identified two clinical factors significantly associated with RFS: sex (P = 0.0100) and surgical procedure (P = 0.0033). Postoperative complications after PALM resections occurred in 35.7% of patients. There was no postoperative mortality. Our study suggested that a radical lymphadenectomy for treating PALMs in CRC could be performed safely and could prolong the RFS. More studies are necessary to strengthen the evidence in support of this conclusion.

A new method using surface landmarks to locate resuscitative endovascular balloon occlusion of the aorta based on a retrospective CTA study.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) can timely prevent the wounded from fatal hemorrhage. However, blind insertion of REBOA in field or emergency room may result in catheter malposition and serious complications. We aim to develop a new method based on surface landmarks to guide the accurate placement of REBOA in zone III of aorta without fluoroscopy. A retrospective study was conducted in a university hospital, including 57 subjects who underwent computed tomography angiography (CTA) from April to December in 2019. External distances and intravascular lengths were measured by three-dimensional reconstruction of CT images, including the distances from the insertion site of femoral artery to the xiphoid process (FA-Xi), the midpoint between the xiphoid process and the umbilicus (FA-mXU), the umbilicus (FA-Ui), the midpoint of the zone III of aorta (FA-mZIII), the lowest renal artery (FA-LRA), and aortic bifurcation (FA-AB). The distal and proximal ideal margin and predicted accuracy were calculated by curvature plane reconstruction. The predicted probability of balloon positioning in zone III by different methods was compared. The mean age of all patients was 60 years (SD = 9.4). The average length of zone III of aorta was 9.4 cm (SD = 1.0), and the length of FA-mZIII on the right and left sides were 24.4 cm (SD = 2.1), 23.8 cm (SD = 2.1), respectively. FA-Xi was longer than FA-LRA, and FA-Ui was shorter than FA-AB (paired two-tailed test, p < 0.001). Using three methods including the optimal quartering distances, the optimal distances below the xiphoid and above the umbilicus to predict the length of REBOA catheter positioning in zone III showed no statistically significant difference. The predicted accuracy of catheter positioning in zone III on the left and right sides guided by FA-mXU were 84.2% and 86%. The midpoint between the xiphoid process and the umbilicus may be a new surface landmark for people of normal weight to guide rapid positioning REBOA in zone III of aorta without fluoroscopy.

Layer-Specific Residual Deformations and Their Variation Along the Human Aorta.

This study described the regional distribution of layer-specific residual deformations in fifteen human aortas collected during autopsy. Circumferentially and axially cut strips of standardized dimensions from the anterior quadrant of nine consecutive aortic levels were photographed to obtain the zero-stress state for the intact wall. The strips were then dissected into layers that were also photographed to obtain their zero-stress state. Changes in layer-specific opening angle, residual stretches, and thickness at each aortic level and direction were determined via image analysis. The circumferential and axial opening angles of the intima were ∼240 deg and ∼30 deg, respectively, throughout the aorta; those of the adventitia were ∼150 deg and -20 deg to 70 deg. The opening angles of the intact wall and media were similar in either direction. The circumferential residual stretches of the intima and the axial residual stretches of the media showed high values in the aortic arch, decreasing in the descending thoracic aorta and increasing toward the iliac artery bifurcation, while the axial residual stretches of the adventitia increased distally. The remaining residual stretches did not vary significantly with aortic level, suggesting an intimal role in determining circumferential, as well as medial and adventitial roles in determining axial residual stretches. We conclude that the tensile residual stretches released in the intima and media upon separation, and the compressive residual stretches released in the adventitia may moderate the inverse transmural stress gradients under physiologic loads, resulting from the >180 deg circumferential opening angle of the intact wall.

Covered Endovascular Reconstruction of the Popliteal Artery Bifurcation in a Patient with a Popliteal Aneurysm

Popliteal artery aneurysms (PAAs) can present as extensive disease entities that predispose to distal ischaemic complications. Endovascular repair has become a common intervention but is typically limited to a single tube exclusion of the PAA that necessitates a distal landing zone. Presented is a technique of covered endovascular reconstruction of the popliteal artery bifurcation (CERPAB) using Viabahn Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA) covered stent grafts delivered via a percutaneous femoral approach in a patient with extensive PAA with anterior tibial artery (ATA) and tibioperoneal trunk (TPT) involvement. A 79 year old patient presented with a PAA (20 mm diameter) with irregular luminal narrowing extending into the proximal ATA (5 mm diameter) and TPT (6 mm diameter), which was regarded as aneurysmal (normal diameter 3 mm). The patient was asymptomatic but showed growth under surveillance. Under general anaesthesia and through a percutaneous antegrade left femoral approach a 9 × 150 mm standard profile Viabahn stent graft was placed in the popliteal artery as a main body through a 10 F sheath using a 0.035 inch wire. The ATA and TPT were cannulated separately with subsequent placement, simultaneous deployment and kissing balloon dilatation of 6 × 50 mm and 7 × 50 mm low profile stent grafts in the respective arteries using a 0.018 inch platform through a single sheath, overlapping the popliteal stent graft by 3 cm. Procedural angiography (Fig. 1) showed successful exclusion of the PAA with adequate run off distally. Post-operatively, dual antiplatelet therapy with clopidogrel and aspirin was started and the patient was discharged home the next day. Follow up computed tomography at three months showed adequate patency (Fig. 2) with no complications during this period.Figure 2(A) Computed tomography angiography at the three month follow up showing a patent covered reconstruction of the popliteal artery bifurcation by Viabahn stent grafts with 3 cm of overlap. (B) Volume rendered computed tomography scan reconstruction of the covered endovascular reconstruction at the three month follow up.View Large Image Figure ViewerDownload Hi-res image Download (PPT) CERPAB seems to be a possible modality for treatment of patients with PAAs and involvement of the ATA and TPT by reconstructing the popliteal bifurcation and successfully excluding the aneurysmal tract from the peripheral circulation. This procedure is reminiscent of covered endovascular repair of the aortic or femoral bifurcation and allowed exclusion of the PAA without a distal landing zone. To the best of the authors’ knowledge, this is the first time such a procedure has been reported.

Effects of inlet velocity profile on the hemodynamics of the abdominal aorta bifurcation

Effects of inlet velocity profile on the hemodynamics of the abdominal aorta bifurcation

298 Incidence and Causes of Aneurysm Growth Following Endovascular Sealing of Abdominal Aortic Aneurysms

Abstract Objective To analyse the incidence of aneurysm growth after endovascular aneurysm sealing (EVAS) and its relationship with adherence to the instructions for use (IFU). Method This study observed the clinical outcomes of patients who had an elective infrarenal EVAS procedure performed at the Royal Liverpool Hospital between 2013 and 2018. The primary outcome measure was the occurrence of aneurysm growth after EVAS. Aneurysm growth was defined as a 5% increase in the aortic volume between the renal arteries and the aortic bifurcation from the 1-month scan to subsequent annual scans. Results There were 71 patients with a mean (standard deviation) age of 76 (6) years who were eligible for inclusion in this study. Aneurysm growth was observed in 8 of 19 (42%) within IFU and 14 of 52 (27%) outside IFU (P ¼ .35). There was no relationship between aneurysm growth and adherence to IFU. Among the patients with aneurysm growth, the median (range) increase in abdominal aortic aneurysm volume was 11% (5%-20%). Conclusions Abdominal aortic aneurysm growth occurs in a significant proportion of patients at 1 year after EVAS and is not associated with adherence to IFU. Longer follow-up on a larger sample size is essential to understand the long-term clinical outcomes after EVAS.

Comparison of diametric and volumetric changes in Stanford type B aortic dissection patients in assessing aortic remodeling post-stent graft treatment.

The study aims to analyze the correlation between the maximal diameter (both axial and orthogonal) and volume changes in the true (TL) and false lumens (FL) after stent-grafting for Stanford type B aortic dissection. Computed tomography angiography was performed on 13 type B aortic dissection patients before and after procedure, and at 6 and 12 months follow-up. The lumens were divided into three regions: the stented area (Region 1), distal to the stent graft to the celiac artery (Region 2), and between the celiac artery and the iliac bifurcation (Region 3). Changes in aortic morphology were quantified by the increase or decrease of diametric and volumetric percentages from baseline measurements. At Region 1, the TL diameter and volume increased (pre-treatment: volume =51.4±41.9 mL, maximal axial diameter =22.4±6.8 mm, maximal orthogonal diameter =21.6±7.2 mm; follow-up: volume =130.7±69.2 mL, maximal axial diameter =40.1±8.1 mm, maximal orthogonal diameter =31.9+2.6 mm, P<0.05 for all comparisons), while FL decreased (pre-treatment: volume =129.6±150.5 mL; maximal axial diameter =43.0±15.8 mm; maximal orthogonal diameter =28.3±12.6 mm; follow-up: volume =66.6±95.0 mL, maximal axial diameter =24.5±19.9 mm, maximal orthogonal diameter =16.9±13.7, P<0.05 for all comparisons). Due to the uniformity in size throughout the vessel, high concordance was observed between diametric and volumetric measurements in the stented region with 93% and 92% between maximal axial diameter and volume for the true/false lumens, and 90% and 92% between maximal orthogonal diameter and volume for the true/false lumens. Large discrepancies were observed between the different measurement methods at regions distal to the stent graft, with up to 46% differences between maximal orthogonal diameter and volume. Volume measurement was shown to be a much more sensitive indicator in identifying lumen expansion/shrinkage at the distal stented region.

Endovascular Treatment of Aortic Bifurcation Occlusive Disease 10 Years After Open Surgical Repair of an Infrarenal Abdominal Aortic Aneurysm

A 74 year old man, a moderate smoker treated 10 years previously by open infrarenal abdominal aortic aneurysm tube graft, presented with left leg rest pain. (A) Computed tomography angiography revealed dilatation of the infrarenal aortic segment (31 mm) with a newly developed left common iliac artery occlusion and right common iliac artery sub-occlusion. (B) Two balloon expandable stents (8 × 59 mm; Omnilink Elite [Abbott Vascular, Santa Clara, CA, USA]) were deployed in a kissing stent configuration with good results and no complications. The patient received dual antiplatelet therapy for three months and after this period was asymptomatic.Image 1

Custom-Made Bifurcated Prosthetic Graft for Aortoiliac Aneurysm Repair.

Revascularization of the internal iliac artery during open repair of aortoiliac aneurysms can be challenging, especially if there is a significant distance between the orifices of the internal and external iliac arteries owing to common iliac aneurysmal dilatation. We describe a technique involving insertion of an 18-mm tube graft between the proximal aortic neck and aneurysmal common iliac artery bifurcation. Revascularization of the contralateral external iliac artery is accomplished through an 8-mm side arm graft.

Determination of the dominant arch by computational fluid dynamics analysis using computed tomography images in double aortic arch.

Computational fluid dynamics (CFD) analysis using computed tomography images can reveal the details of the blood flow in cardiovascular disease. In double aortic arch, it is difficult to assess the hemodynamics because of the strong influence of various anatomical features, such as the angle of the aortic bifurcation. In the present study, we reported that CFD analysis is a valuable method for hemodynamic assessment in patients with double aortic arch.

Abdominal paraaortic paraganglioma: Management of intraoperative hemodynamic emergencies during elective resection procedures (A case presentation).

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.