Balloon Fenestration Research Articles

“Ischemia in Upstream Neighborhood” After Plaque Modification with Intravascular Lithotripsy

Coronary artery calcification impacts outcomes after percutaneous coronary interventions owing to stent under expansion causing increased risk of stent thrombosis and restenosis. Therefore, adequate calcium modification before stent placement is the key to get desired outcomes in the patients with coronary artery calcification. Many devices are available for calcium modification, which includes orbital or rotational atherectomy, cutting balloon, scoring balloon, and intravascular lithotripsy. All these techniques have inherent risks of complications, such as coronary dissection, perforation, and slow or no reflow. We report a case of intravascular lithotripsy in calcified proximal left circumflex artery (LCX) lesion in a 63-year-old female leading to the left anterior descending artery (LAD) with no flow and ischemic ventricular tachycardia requiring DC cardioversion. Intravascular ultrasound from LAD revealed subintimal hematoma from ostium to mid LAD with intimal flap continuation into ostio-proximal LCX. The intimal flap in LAD has not showed any entry or exit tears which might increase the possibility of intramural hematoma shift to adjacent areas and branches leading to no reflow. Hence, cutting balloon fenestration of the intimal flap, followed by left main coronary artery bifurcation stenting was done to get a good result with flowing distal branches.

Imaging-Guided Percutaneous Transperitoneal Balloon Fenestration of Postrenal Transplant Lymphocele: A Case Report of Experience with New Technique

AbstractRenal transplantation is the treatment of choice for improved survival and quality of life in patients with end-stage renal disease. However, perirenal fluid collections are common surgical complications after renal transplant, with about 0.6 to 18% of patients developing a lymphocele. Conventional treatments include percutaneous aspiration and drainage, laparoscopic fenestration, and open surgical decompression stepwise. Recently, a new image-guided percutaneous transperitoneal balloon fenestration technique has been described as an alternative to the laparoscopic or surgical technique. We present the case of a 25-year-old male patient diagnosed with a lymphocele after 2 months of transplantation and no resolution of the lymphocele with percutaneous aspiration and drainage. We used this new technique under ultrasound and fluoroscopy guidance, which resulted in the resolution of the lymphocele at 1 month postprocedure. This case report highlights this new technique's potential role in successfully managing the posttransplant lymphocele in a minimally invasive manner.

Acute failure of cutting balloon fenestration in spontaneous coronary artery dissection

Acute failure of cutting balloon fenestration in spontaneous coronary artery dissection

A Case of Effective Balloon Fenestration for Localized Aortic Dissection Complicated with Acute Renal and Bilateral Limb Ischemia in a Thoracoabdominal Aortic Aneurysm.

An 85-year-old man visited our hospital with bilateral leg weakness. Blood tests revealed an abrupt deterioration of renal function. Computed tomography revealed a 53-mm aortic aneurysm at the level of the diaphragm with an aortic dissection after branching of the superior mesenteric artery. An emergency left axillary–left femoral artery bypass surgery was performed to secure blood flow to the kidneys and lower limbs. Five days later, a transcatheter balloon fenestration for the stenosis was performed, and the blood pressure of the infrarenal aorta was improved. Both the dorsal pedis and posterior tibial arteries became palpable, and renal function was improved.

Distal landing zone optimization before endovascular repair of aortic dissection

BackgroundThe general goals of endovascular management in chronic distal thoracic aortic dissection are optimizing the true lumen, maintaining branch patency, and promoting false lumen (FL) thrombosis. Distal seal can be challenging in chronic distal thoracic aortic dissection due to the well-established secondary fenestrations and fibrotic septum. We describe our approach of distal landing zone optimization (DLZO) to enable full-diameter contact of the distal endoprosthesis. Materials and MethodsOur experience includes 19 procedures in 16 patients (12 male, age 68 ± 8 years) between May 2014 and November 2017. A history of previous ascending repair for type A dissection was present in 8 patients. Treatment indication was enlarging aneurysm in all subjects, and 4 patients had associated chronic visceral or distal ischemia. Point septal fenestrations were expanded by serial balloon dilation and/or wire-pull approaches. Balloon molding was used to ensure complete endograft apposition and FL collapse. ResultsOne death occurred due to aortic perforation during wire-pull fenestration in a patient with heavily calcified and angulated aorta. The remaining procedures were accomplished safely and successfully. Balloon fenestration was used in 16 procedures, alone or in combination with a limited wire pull component. Adjunct procedures for distal seal included surgeon-modified fenestrated stent graft (3), iliac branch device (3), parallel superior mesenteric artery stent-graft (1), renal artery or superior mesenteric artery stent-graft (4), iliac stent (3), and plug obliteration of FL (5). Reintervention was required in 3 patients due to delayed loss of seal after the initial procedure (3, 8, and 12 months). Two were managed by repeat DLZO and distal extension. The third had distal extension via a surgeon-modified fenestrated stent-graft component. Follow-up imaging was available in 14 patients (16.0 ± 12.5 months, range: 1-33), with stable or regressed sac diameter with complete or near-complete thrombosis of the FL in all patients. ConclusionsDLZO enabled creation of a distal seal zone in all patients. Residual retrograde filling of the FL is a marker of procedure failure, especially when seal segment length or feasible endoprosthesis oversizing are marginal. Insufficient landing segment can be circumvented with the use of a fenestrated or branched device to accomplish seal in the visceral aorta or iliac bifurcation. Adjunct FL ablation is also a valuable technique to promote FL thrombosis.

3:36 PM Abstract No. 365 Bifurcated Y-stent placement for treatment of superior vena cava syndrome involving both brachiocephalic veins and superior vena cava

To review outcomes after in situ bifurcation Y-stenting for treatment of complex superior vena cava (SVC) syndrome patients with obstruction involving SVC and both brachiocephalic veins (BCV). From January 2001 to August 2017, 18 patients (mean age 54 y; 9 male) with SVC syndrome were treated with the Y-stent technique. All patients had occlusions and/or stenoses of both BCVs and SVC due to malignancy (n = 10), central venous catheterizations (n = 7), or mixed etiologies (n = 1). After recanalization of the obstructive lesions, Y-shaped stents were constructed in situ by placement of a 12 or 14 mm nitinol stent from one BCV to the SVC, selective balloon fenestration of the stent interstices into the other BCV, placement of a contralateral BCV-SVC stent through the fenestration, and symmetrical fenestration of the second stent to minimize exclusion (jailing) of branches. Technical success, clinical success, peri-procedural complications, and long-term outcomes were retrospectively evaluated. All 18 Y-stent deployments were technically successful, resulting in resolution of SVC syndrome symptoms in 100%. Peri-procedural complications included one patient with transient stress-induced cardiomyopathy, but no venous injuries or procedure-related deaths. Of the 12 patients with >30 d follow-up (median 6.4 mo, range 1.1-87.6 mo), 10 (83.3%) had no recurrence of symptoms. Among 7 patients with >30 d contrast-enhanced CTs (median 9.2 mo, range 1.1-70.0 mo), all stents were patent in 5 (71.4%). Two patients, both on chronic hemodialysis with arm arteriovenous fistulas, developed symptom recurrence and in-stent stenoses, requiring secondary interventions. Bifurcation Y-stent placement is a feasible and effective technique for treatment of problematic SVC syndrome caused by obstructive lesions involving bilateral BCVs and SVC. Y-stenting can maintain patency of all branches, and durability appears to be similar to that of simpler anatomy involving only single vessels.

Management of Lymphoceles after Renal Transplant: Case Report of a Novel Percutaneous Image-guided Treatment Technique

A 65-year-old African American man with end-stage renal disease underwent renal transplantation and developed a perigraft lymphocele with an associated progressive increase in serum creatinine 6 weeks after surgery, which failed to resolve with percutaneous drainage and surgical therapy. Fluoroscopic and ultrasound-guided percutaneous transperitoneal balloon fenestration with a 22-mm, 2-cm-long balloon catheter resulted in resolution of the lymphocele as shown by ultrasound at 3 and 5 months.

Aortic Intussusception Complicating Diagnostic Angiography: Recognition and Management

During the diagnostic evaluation of a 31-year-old male with Marfan syndrome, an acute type B aortic dissection, and rising creatinine, the retrograde loop of our selective catheter inadvertently engaged the entry tear of the dissection in the mid-descending aorta. Traction on the catheter led to a full circumferential dehiscence of the remaining lumen, causing an intimointimal intussusception down to the level of the celiac artery with complete collapse of the true lumen and visceral and renal artery obstruction. Balloon fenestration and supramesenteric stenting of the true lumen decompressed the intussuscepted intimal flap and restored normal perfusion pressures.

Recanalization of Iatrogenic Dissection of the Superior Mesenteric Artery

We present a case of acute abdominal pain due to a long-segment iatrogenic superior mesenteric artery dissection, which was immediately treated successfully with balloon fenestration of the intimal flap, resulting in complete resolution of the symptoms without recurrence during the 2-year follow-up period.

Simultaneous Fenestration with Stent Implantation for Acute Limb Ischemia due to Type B Acute Aortic Dissection Complicated with Both Static and Dynamic Obstructions

Stanford type B acute aortic dissection is sometimes complicated with compressed true lumen of the descending aorta (Dynamic obstruction) and stenosis of a major aortic branch (Static obstruction), which cause organ malperfusion. In such a case, medical therapy alone is usually not effective and endovascular treatments are required including stent implantation and balloon fenestration. However, it is difficult to determine which strategy should be selected, that is, only stent implantation at dissected branch or simultaneous fenestration with stent implantation. We report a case of a 54-year-old man with lower leg ischemia due to type B aortic dissection, who was successfully treated with stent implantation plus balloon fenestration. This case suggests that balloon fenestration plus stent implantation should be considered when static obstruction in the aortic branches is accompanied by dynamic obstruction in the descending aorta.

Fenestration of an Iatrogenic Aortic Dissection After Endovascular Aneurysm Repair

To present a case of percutaneous fenestration of a type B aortic dissection after endovascular aneurysm repair (EVAR). An 82-year-old patient with an earlier conventionally inserted aortobi-iliac prosthesis presented with a proximal anastomotic pseudoaneurysm, which was excluded successfully by EVAR. Standard follow-up computed tomographic angiography (CTA) 48 hours after the procedure, however, revealed a type B aortic dissection. Despite conservative antihypertensive therapy, the patient developed abdominal and back pain, and intervention was indicated. Endovascular balloon fenestration of the intimal flap was performed, resulting in relief of pain even though the false lumen remained patent. At 8 months after the procedure, the patient was symptom free, and CTA showed no progression of the persistent type B dissection. Percutaneous fenestration can be used as a therapy of first choice in patients with an acute aortic dissection post EVAR.

Percutaneous Balloon Fenestration of Flow-limiting Iatrogenic Dissection of the Common Femoral Artery: Report of Two Cases

Acute iatrogenic arterial dissection is a known complication of endovascular techniques and can be treated with prolonged ballooning, stent placement, or balloon fenestration. Treatment of common femoral artery (CFA) dissection needs special attention because of the potential compromise of either the deep or superficial femoral artery origin and the enhanced mechanical stress to arteries in the groin. The authors report two cases with percutaneous balloon fenestration of flow-limiting localized iatrogenic dissection of the CFA with initial technical success in both cases and favorable short- to midterm outcomes.

Abstract No. 280: 4-year experience in the endovascular treatment for a variety of thoracic aortic pathologies: A single institution experience

To report our early and midterm results of endovascular intervention in patients with a variety of thoracic aortic pathology at a single center. Between September 2005 and July 2009, 27 consecutive patients underwent endovascular repair for 28 thoracic aortic lesions. Twenty-five patients underwent endovascular stent graft placement, two patients underwent endovascular fenestration for complicated Type B dissection, one with balloon fenestration and one underwent vertical slit fenestration. Follow up protocol included clinical evaluations and computed tomographies at 1 month, 6 months, and annually. There were 16 men and 11 women with median age 69 (range 40-84). There were 11 thoracic aneurysms (1 ruptured aneurysm), 6 Type B dissections/intramural hematomas, 1 pseudoaneurysm, 5 penetrating aortic ulcers, 2 traumatic aortic injuries, one aortic transection related to a previously placed stent graft for a penetrating ulcer, and one patient had an angiosarcoma that was initially thought to be a penetrating aortic ulcer. The average size of the thoracic aneurysms at time of treatment was 6.1 ± 2.1 cm. Technical success was 85%. Immediate complications included three type 1 endoleaks, one type 3 endoleak, and three type 2 endoleaks. There were 4 cases of post-operative retroperitoneal hemorrhages, 2 strokes, and 2 cases of post-operative sepsis. There were no cases of paraplegia. To date there have been 9 deaths, only two during the perioperative period. The remaining patients expired due to causes related to their co-morbidities. Thoracic endovascular intervention is a feasible and effective option for a variety of thoracic aortic pathologies, particularly in patients with high co-morbidities.

Aortic Dissection Complicating Intraaortic Balloon Pumping: Percutaneous Management of Delayed Spinal Cord Ischemia

Iatrogenic acute type B dissection is a rare complication of intraaortic balloon pumping. Delayed visceral and spinal cord malperfusion can occur for distal progression of the dissection or relative hypotension. Cerebrospinal fluid drainage and percutaneous balloon fenestration provide a safe and effective method for managing ischemic complications.

Endovascular stent placement for acute type-B aortic dissection with malperfusion - an intentional surgical delay and a possible 'bridging therapy'

Acute aortic dissection frequently causes life-threatening organ ischemia. The optimal therapy for acute type-B aortic dissection is still controversial. Early surgery for acute dissections with organ malperfusion is known to carry a high morbidity and mortality. Endovascular treatment, such as stent placement for branch stenosis, percutaneous balloon fenestration for compression of the true channel and aortic stent placement to support collapsed true channel, is becoming an alternative form of treatment. However, it is not clear whether endovascular intervention alone is effective in the long term. We herein report a case of emergency percutaneous endovascular stenting with intentional surgical delay in a patient who had visceral and lower extremity malperfusion due to acute type-B dissection. A 10x57 mm bare metal stent was inserted into the obliterated true channel of the thoracoabdominal aorta 3 h after onset of symptoms. It immediately relieved the abdominal and lower limb ischemic symptoms. The advantage of small-sized stent placement is its easiness and being gentle to fragile intima. The small-sized stent placement for patients with acute aortic dissection with visceral organ ischemia may be a promising 'bridging therapy' before they undergo traditional central repair.

Percutaneous interventions for treating ischemic complications of aortic dissection

The aim of this study was to evaluate the role of percutaneous interventions in treating ischemia complicating aortic dissection. Forty-five patients with ischemia complicating aortic dissection were treated by balloon fenestration, true lumen stenting, angioplasty, or thrombolysis. Clinical and laboratory examinations were performed before and after intervention, and at the end of follow-up (median 37 months). Eighteen dissections were acute, 9 sub-acute, and 18 chronic. Mesenterohepatic ischemia resolved in 16 of 18 patients; lactate and SGOT values fell from 2.89 to 1.23 mmol/L (p=0.006) and from 165.9 to 59.7 U/L (p=0.034), respectively. In patients with renal ischemia, creatinine levels fell from 360.1 to 196.3 micromol/L (p=0.007) accompanied by a significant reduction in blood pressure. Limb-threatening ischemia resolved in three of four patients; in 21 claudicants, the mean walking distance improved from 272 to 1,283 m (p=0.001). Spinal ischemia resolved completely or partially in six of eight patients. Adjunctive surgical measures were necessary in six patients. Overall 30-day mortality in the 45 patients was 6.7%; all three deaths were in patients with acute dissections (mortality in this subgroup 16.7%). Ischemia complicating aortic dissection can be effectively treated by percutaneous interventions resulting in good early and mid-term outcomes.

Percutaneous balloon fenestration and stent placement for lower limb ischemia complicated with type B aortic dissection

We report a case of lower limb ischemia secondary to type B aortic dissection, which was successfully treated with endovascular aortic fenestration and stent placement. In this case, we were not able to restore adequate flow to the ischemic limb by means of aortic balloon fenestration alone, so additional stent placement was required to buttress the true lumen and fenestra. There was no recurrence of lower limb ischemia complications during the follow-up period. Aortic balloon fenestration with stent placement seems to be a safe and effective technique to salvage an ischemic lower limb complicated by acute aortic dissection.

Percutaneous fenestration for the treatment of ischemia caused by aortic dissection

目的 评价经皮开窗术治疗主动脉夹层引起的内脏及下肢缺血.方法 6例主动夹层并发内脏及下肢缺血患者行经皮开窗术,所有患者皆是 Stanford B型夹层,累及的血管有肾动脉(3条)、肠系膜动脉(1条)和下肢动脉(6条).4例行单纯经皮开窗术,1例行开窗及左肾动脉支架置入治疗,1例行开窗及腹主动脉和双侧髂总动脉支架置入治疗.1例患者于开窗后1个月行支架移植物复合体(stent-graft)腔内隔绝术.结果所有6例患者血管重建均成功,其中4例缺血症状消失,2例明显减轻.随访4～12个月,平均 7.6个月,1例患者术后3个月死于主动脉破裂出血,余5例仍存活.无严重的手术相关并发症.结论经皮开窗术或经皮开窗结合支架置入是1种安全、有效的治疗主动脉夹层引起的内脏及下肢缺血的方法。

Intimal Dehiscence in the Abdominal Aorta Following Balloon Fenestration for Type B Dissection

To report a case of intimal dehiscence associated with endovascular intervention in patients with aortic dissection. A 65-year-old man presented with a type B dissection extending to the level of the common iliac arteries. Two Talent stent-grafts were placed in the descending thoracic aorta to close the entry point, but 2 lumens remained. Three days later, abdominal pain prompted another imaging session, which demonstrated a large cylindrical filling defect in the abdominal aorta ("tube-in-tube") assumed to be a partially or completely dehisced intima. Fenestration marginally improved flow to the visceral vessels, and the patient improved clinically. However, 4 days later, recurrent ischemic symptoms prompted surgery; a complete dehiscence of the aortic intima starting at the descending aorta extended to the distal abdominal aorta. The aorta was resected, but the patient died from disseminated intravascular coagulation. Intimal flap dehiscence associated with an endovascular procedure in the management of aortic dissection is an uncommon complication. Early detection and prompt surgical intervention of such a complication could save the patient's life. Endovascular procedures are unlikely to resolve the hemodynamic problem caused by a dehisced, distally migrated, collapsed intima.

Endoluminal treatment of aortic dissection.

Aortic dissection is most often a catastrophic medical emergency which, if untreated, can be potentially fatal. The intention of therapy in patients with aortic dissection is to prevent aortic rupture or aneurysm formation as well as to relieve branch vessel ischaemia. Patients with aortic dissection are often poor candidates for anaesthesia and surgery and the surgical procedure itself is challenging requiring thoracotomy, aortic cross clamping, blood transfusion as well as prolonged hospital stay in some cases. Operative mortality is especially high in patients with critical mesenteric or renal ischaemia. The past decade has experienced the emergence of a number of interventional radiological or minimally invasive techniques which have significantly improved the management of patients with aortic dissection. These include stent grafting for entry site closure to prevent aneurysmatic widening of the false lumen as well as percutaneous techniques such as balloon fenestration of the intimal flap and aortic true lumen stenting to alleviate branch vessel ischaemia. False lumen thrombosis following entry closure with stent grafts has been observed in 86-100% of patients, whereas percutaneous interventions are able to effectively relieve organ ischaemia in approximately 90% of the cases. In the years to come, it is to be expected that these endoluminal techniques will become the method of choice for treating most type-B dissections and will assist in significantly reducing the number of open surgical procedures required for type-A dissections. The intention of this article is to provide an overview of the current status of these endoluminal techniques based on our own experience as well as on a review of the relevant literature.