Contralateral Iliac Research Articles

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Contralateral Snare Cannulation vs. Retrograde Gate Cannulation during Endovascular Aortic Repair in Difficult Iliac Artery Anatomy: A Single Center Experience.

Endovascular aneurysm repair is well established as the gold standard in treating abdominal aortic aneurysms. Generally, endovascular repair is performed using a bi or trimodular stent graft, requiring placement of a contralateral iliac limb. Deployment of the contralateral iliac limb requires retrograde gate cannulation of the endograft main body contralateral limb. This step represents the crucial point of a standard endovascular repair procedure and can become challenging, especially in the case of high iliac tortuosity. This study compares the procedural times between the retrograde gate cannulation and the contralateral snare cannulation to demonstrate the possibility of directly performing the contralateral snare cannulation in the case of a complex iliac anatomy assessed by the iliac tortuosity index. One hundred and forty-eight patients with infrarenal abdominal aortic aneurysms who underwent endovascular aneurysm repair from 2017 to 2022 were analyzed retrospectively. Cannulation times between retrograde gate cannulation and contralateral snare cannulation were compared for each degree of iliac tortuosity. The degree of iliac tortuosity was assessed through the iliac tortuosity index. Cannulation times were detected from inserting the wire into the introducer to passing through the radio-opaque gate markers. The cannulation times were 2.94 min for the retrograde gate cannulation group and 3.15 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.33). Overall cannulation times were 2.98 min. For the iliac tortuosity index grade 0, the cannulation times were 2.71 min for the retrograde gate cannulation group and 3.85 min for the contralateral snare cannulation group, respectively, with a significant difference in favor of the retrograde gate cannulation group (p < 0.0001). For the iliac tortuosity index grade 1, the cannulation times were 2.74 min for the retrograde gate cannulation group and 2.8 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.63). Regarding the iliac tortuosity index grades 2 and 3, the cannulation times were 3.01 and 4.93 min for the retrograde gate cannulation group and 2.71 and 3.28 min for the contralateral snare cannulation group, respectively. The first group's times were significantly higher than the second group's (p = 0.01 and p = 0.0001). In patients with infrarenal abdominal aortic aneurysms undergoing endovascular aortic repair, the gate cannulation times were significantly shorter for the contralateral snare cannulation method than the retrograde gate cannulation method in the iliac tortuosity index grades 2 and 3. Therefore, performing the contralateral snare cannulation method would be appropriate.

276 Favorable Outcomes for Endovascular Aneurysm Repair with Aorto-Uni-Iliac (AUI) Stent Grafts for Treatment of Abdominal Aortic Aneurysms (AAA) by a Single Team in 8 Years at South Mersey Arterial (SMArt): A Tertiary Care Vascular Surgery Centre

Abstract Background Endovascular Aneurysm Repair (EVAR) is established procedure for management of both elective and ruptured abdominal aortic aneurysms (AAA). However, in several cases, standard EVAR with bilateral limb extension cannot be done due to complex anatomy or calcified contralateral iliac artery. In such cases AUI stent graft and Fem-Fem cross over is a feasible option. This study aims to assess the outcomes of AUI with or without fem-fem cross over performed in SMART centre over 8 years Method A retrospective study on patients who had repair of AAA using AUI between 2014-2022, with or without crossover. Demographic, procedural, and radiological data was collected through digital database. The outcomes were based on mode of admission, mortality rate, complications and patency rate of the graft at 2 years. Results A total of 28 patients had AUI between January 2014-January 2022. Median age was 79 years (59-94) with male predominance (85%). 50% of the patients presented with ruptured AAA, 46% had elective repair and 4% of patients presented with Acute limb ischaemia. 30-day mortality was found to be 21%. Local complications included endoleak, graft infection, groin bleeding, lymph leak and wound dehiscence and general complications included a predominance of HAP and cardiac issues. The patency rate was checked at 6 months, 1-2 years. 6-month patency of the graft was found to be 93%. Similarly, 1 and 2-year patency was also found to be 93% Conclusions AUI with or without Fem-Fem crossover is an acceptable alternative treatment modality for ruptured or non-ruptured AAAs despite involving an extra-anatomical bypass.

Access challenge in patient with ruptured infrarenal abdominal aneurysm treated with modified contralateral iliac limb technique

Access challenge in patient with ruptured infrarenal abdominal aneurysm treated with modified contralateral iliac limb technique

Use of steerable sheaths for complex aortic procedures.

To demonstrate the ease with which steerable sheaths, designed for cardiac electrophysiological applications, can be used to aid endovascular treatment of a wide range of non-cardiac vascular disease and to assist with target vessel cannulation in branched and fenestrated aortic grafts. A retrospective medical chart review was carried out to identify cases from a single vascular surgery unit (2019-2022) where the HeartSpan Steerable Sheath (HSS) (Merit Medical, South Jordan, UT, USA) was utilised to enable endovascular management of complex vascular pathology. A case presentation of branch graft insertion performed entirely via distal access is described and used to help identify pertinent sheath characteristics and technical considerations, and to illustrate the advantages and disadvantages of the design for modified use in target vessel cannulation. The HSS was used in the endovascular treatment of different vascular pathologies in 15 patients (23 target vessels) where access to the vessels using standard catheters and approaches was not possible. Cannulation and subsequent stenting were successful for 21 of the 23 target vessels in total. Of these cases, the HSS was used as an adjunct for deployment of fenestrated endovascular graft systems when conventional techniques for canulation of target vessels had failed on five occasions. On another four occasions, the HSS enabled full deployment of the entire Zenith® t-Branch™ Thoracoabdominal Endovascular Graft system from an exclusively femoral approach. An additional three cases involved use of the HSS for superior mesenteric artery cannulation in patients with mesenteric ischaemia. The device was also used once in each of the following cases: contralateral common iliac cannulation, cannulation of contralateral internal iliac artery for coil embolisation, and access of a contralateral iliac branched device. There were no stent dislocations and all aortic branches that were patent at the completion of each case remained so 1-year post procedure. Steerable sheaths designed for cardiac electrophysical applications, like the HSS Introducer, can be successfully utilised for cannulation of challenging target vessels in a wide range of aortic endovascular procedures. This modified approach may salvage cases that would otherwise be considered inoperable in regions of the world where steerable sheaths designed for aortic use are not readily available.

Outcomes of the treatment of contralateral iliac venous thrombosis after stenting across the iliocaval confluence

Among the complications related to the endovascular treatment of the left common iliac vein obstruction, the contralateral deep venous thrombosis consists in a late complication of the procedure. This case series describes the endovascular treatment of four patients with right iliofemoral deep venous thrombosis caused by jailing of the inferior vena cava confluence, due to previous stents implanted in the left common iliac vein. All the four patients were admitted with pain and swelling of the right lower limb, and one patient presented with phlegmasia cerúlea dolens. The patients were evaluated with duplex-scan and angioCT-Scan that confirmed extensive right iliofemoral and femoropopliteal deep venous thrombosis, except for one patient, whose DVT propagated to superficial femoral vein, without popliteal involvement. All patients were submitted to endovascular treatment with pharmacomechanical thrombectomy, previous stent recanalization and stent deployment in the iliocaval confluency. Regarding the post-operative complications, one patient presented with hemoglobinury, which evolved with anuria, and in the first day post-operative with acute kidney failure and necessity of hemodialysis for 8 days, after that evolved with total renal function recovery. During the hemodialysis period, this patient received non-fractioned heparin, instead of enoxaparin. All patients presented with satisfactory improvement on limb edema, in the first day and thereafter in the first week post-operative. The pharmacomechanical thrombectomy technique followed by angioplasty and kissing stenting was a safe and efficient procedure in this case series report.

Ectopic vascularization of the right kidney arising from contralateral common iliac artery

Variant renal arteries have been reported in 20~30% of the entire population. The anatomic variations among advanced patients should be investigated when performing surgery or interventional procedures on the kidney. Most variant renal arteries originated from various level of the abdominal aorta. Very rarely, this case shows renal artery originated from the contralateral common iliac artery with other accessory arteries. MDCT angiography revealed several anatomical variants of the right kidney. There were four right renal arteries. The main renal artery originated from the left proximal common iliac artery and other renal artery originated from the aortic bifurcation. The other two renal arteries arose from the abdominal aorta, lower thoracic T12 level and lower lumbar L4 level. The right kidney was located at the level of the third to fifth lumbar vertebra. And renal pelvis of the right kidney was laterally rotated. This case documented a rare anatomic variant, involving multiple accessory renal arteries, including the main artery originating from the contralateral iliac artery, caused by a specific renal embryological condition. These variants should be analysed to effectively perform surgical and interventional procedures.

Endovascular management of iliac artery aneurysms

Purpose: The aim is to evaluate the role of endovascular interventions in treatment of iliac artery aneurysms with one year follow up. Patients and methods: our study included 20 patients with iliac artery aneurysms defined as (iliac artery with a diameter &gt;3cm) with adequate proximal and distal landing zone. Patients with anastomotic aneurysms, infected aneurysms or with severe renal impairment (GFR &lt;30ml/min/1.73m2) were excluded. FOR ISOLATED ILIAC ANEURYSM: access used through either: 1) Retrograde ipsilateral common femoral artery puncture. 2) Contralateral femoral puncture and performing a crossover technique. Under fluoroscopy, the stent graft devices were advanced into the iliac axis up to the planned graft deployment site, Embolization of the IIA was performed in cases where backflow from the IIA was expected to result in a type II endoleak. For Aorto-Iliac Aneurysms: Bilateral femoral access is needed to place endografts and can be performed via surgical femoral cut down. Once vascular access is established and landmarks for positioning the device are obtained with aortography, the main device is positioned with particular attention paid to the location of the opening for the contralateral iliac limb ("contralateral gate").

Endovascular Repair of Narrow Distal Aortas Using an In Situ Fenestration Technique

PurposeTo demonstrate that in situ fenestration (ISF) of an aorto-uni-iliac endograft to treat aortoiliac disease with narrow distal aorta (NDA) vessels is effective and safe. Materials and MethodsData for all patients treated by use of ISF between August 2014 and December 2019 were retrospectively analyzed. The series included 27 patients, aged 70 years ± standard error (SE) 11. The pathologies treated included aortoiliac occlusive disease (n = 16), asymptomatic abdominal aortic aneurysm (n = 8), and a ruptured abdominal aortic aneurysm (n = 3). The technique consisted of deploying an aorto-uni-iliac graft, which was converted into a bifurcated repair through contralateral iliac ISF. The inclusion criteria encompassed the presence of an abdominal aortic aneurysm (diameter of >50 mm, rapid growth, ruptured or symptomatic) associated with NDA or the presence of severe aortoiliac occlusive disease with NDA. NDA is defined as an aortic diameter of <16 mm. ResultsThe mean aortic bifurcation diameter was 11.9 mm ± SE 1.5. In total, 55% of the fenestrated endografts were performed with a multifilament polyester endograft and 45% with expanded polytetrafluoroethylene endograft. Technical success was 100%. Fluoroscopy time was 28 minutes ± SE 12, and 94 mL ± SE 43 of iodinated contrast medium was used. In the postoperative course, a single minor retroperitoneal hematoma was identified. The mean hospital stay was 5 days ± SE 3. At the mean follow-up of 26 months ± SE 22, overall primary patency was 94% and no endoleak was observed at the ISF site. ConclusionsThe ISF technique is safe and effective in the treatment of aortoiliac disease with NDA. Comparisons with alternative techniques are needed to determine the long-term durability.

Feasibility and safety of a novel indwelling catheter system via the femoral artery for intermittent transarterial therapy for treating malignant liver tumors.

An indwelling arterial access system via the brachial artery, System-i, has been previously reported. We have modified the technique for the femoral artery approach. This study aimed to evaluate the feasibility and safety of the modified System-i for patients with malignant liver tumors. The modified System-i is an indwelling catheter that provides vascular access for inserting a microcatheter without repeated punctures to the femoral artery. Between 2018 and 2020, the system was implanted for 50 patients with malignant liver tumors. We used the system for patients with difficulty in inserting the conventional indwelling catheter system. To place the system, a side-holed catheter was implanted in the femoral artery, and the tip of the catheter was placed in the superficial femoral artery through the contralateral iliac artery. Using this system, transcatheter arterial chemoembolization or hepatic arterial infusion chemotherapy was performed. A shaped high-flow microcatheter and a non-tapered microcatheter were used with the system. The technical aspects and outcomes of the system were also assessed. Implantation of the system was successful in all patients. The median implantation time was 40min. The main reason for implantation was obstruction or stenosis of the hepatic artery. Among the 50 patients, 11 (22%) showed complications, of which four had major complications/class C based on the SIR criteria. The modified System-i is a safe system that can be a feasible repeated interventional radiological treatment via the femoral approach. We need to evaluate the efficacy of this system in the treatment of advanced cancers in the future. The modified System-i is a novel indwelling catheter system that allows vascular access to perform intermittent transarterial therapy, such as transcatheter arterial chemoembolization and hepatic arterial infusion chemotherapy via the femoral approach. In this study, we report the technical details and safety of the system.

Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair

Purpose Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. Technique The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. Conclusion Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.

Mechanically tuned vascular graft demonstrates rapid endothelialization and integration into the porcine iliac artery wall

Mechanical properties of vascular grafts likely play important roles in healing and tissue regeneration. Healthy arteries are compliant at low pressures but stiffen rapidly with increasing load, ensuring sufficient volumetric expansion without overstretching the vessel. Commercial synthetic vascular grafts are stiff and unable to expand under physiologic loads, which may result in altered hemodynamics, deleterious cellular responses, and compromised clinical performance. The goal of this study was to develop an Elastomeric Nanofibrillar Graft (ENG) with artery-tuned nonlinear compliance and compare its healing responses to conventional expanded polytetrafluoroethylene (ePTFE) grafts in a porcine iliac artery model. Human and porcine iliac arteries were mechanically characterized, and an ENG with similar properties was created by utilizing residual strains within electrospun nanofibers. The ENG was tested for implantation suitability and implanted onto n = 5 domestic swine iliac arteries, with control ePTFE grafts implanted onto the contralateral iliac arteries. After two weeks in vivo, all iliac arteries and grafts remained patent with no signs of thrombosis or dilation. The mechanically tuned ENG implants exhibited a more confluent CD31-positive cell monolayer (1.53 ± 0.73 µm2/mm vs 0.52 ± 0.55 µm2/mm, p = 0.042) on the graft lumenal surface and a higher fraction of αSMA-positive cells (16.2 ± 8.6% vs 1.4 ± 0.7%, p = 0.018) within the graft wall than the ePTFE controls. Despite heavy cellular infiltration, the ENG retained its artery-like mechanical characteristics after two weeks in vivo. These short-term results demonstrate potential advantages of mechanically tuned biomimetic vascular grafts over standard ePTFE grafts. Statement of SignificanceOff-the-shelf synthetic vascular grafts are often the only option available for treating advanced stages of vascular disease. Despite significant efforts devoted to improving their biochemical characteristics, synthetic peripheral arterial grafts continue to demonstrate poor clinical outcomes leading to costly reinterventions. Here, we hypothesized that a synthetic vascular graft with elastomeric mechanical properties tuned to a healthy peripheral artery promotes better healing responses than a synthetic stiff graft. To test this hypothesis, we developed an Elastomeric Nanofibrillar Graft (ENG) with artery-tuned mechanical properties and compared its performance to a commercial ePTFE graft in a preclinical porcine iliac artery model. Our results suggest that mechanically tuned ENGs can offer better healing responses, potentially leading to better clinical outcomes for peripheral arterial repairs.

A Case of Giant Aortoiliac Aneurysm Rupture when Open Repair Seems a One-Way Street.

Giant aortoiliac aneurysm is a rare nosological entity. Owing to the increased diameter, the risk of rupture is extremely high and, similarly, the repair is extremely challenging. In this article, open surgical repair of a ruptured giant aortoiliac aneurysm in a 72-year-old male is described. A bifurcated Dacron graft was used with left internal iliac artery revascularization, while the contralateral internal iliac artery was ligated. The patient had an uneventful recovery.

The Efficacy of a Protocol of Iliac Artery and Limb Treatment During EVAR in Minimising Early and Late Iliac Occlusion

Iliac limb occlusion (ILO) is a complication of endovascular aortic repair (EVAR) and requires re-intervention in most cases. Attention to any intra-operative defect of iliac limbs and arteries may prevent ILO. The study aimed to analyse the long term effect of an intra-operative protocol of iliac limb treatment during EVAR on ILO. Patients treated from 2012 to 2017 for abdominal aortic aneurysm (AAA) with standard EVAR were collected prospectively. Pre-operative computed tomography angiography anatomical characteristics were evaluated. The protocol for intra-operative iliac limb management was: a. pre-EVAR angioplasty of common/external iliac artery stenosis; b. precise contralateral iliac limb deployment at the same level of the flow divider; c. iliac limb kissing ballooning with high pressure non-compliant balloons; d. iliac limb stenting for residual tortuosity/kink and adjunctive external iliac stenting for residual stenosis/dissection after EVAR. ILO was evaluated at 30 days and at follow up, which was performed by duplex ultrasonography before discharge, at three, six, and 12 months and yearly thereafter. Kaplan-Meier and Cox linear regression were used. Four hundred and forty-two patients and 884 iliac limbs were included in the study. Severe iliac tortuosity and calcification were present in 15% (132/884) and 8% (70/884), respectively. External iliac angioplasty and stenting of iliac limb were performed in 2% (18/884) and 9.5% (84/884) of limbs. The thirty day mortality was 1.6%, with no ILO. At a mean follow up of 33±12 months, ILO occurred in 7/884 (0.8%) limbs of six patients. Five ILO were treated by endovascular relining, two surgically: one by femorofemoral bypass and one by surgical explant. On univariable analysis, sac shrinkage was significantly associated with ILO (HR 1, 95% CI 0.8-2.5, p=.043). A protocol of aggressive iliac limb treatment in EVAR leads to a very low rate of late ILO. The role of sac shrinkage in ILO should be investigated further.

Two Renal Transplants From Living Donors With Horseshoe Kidneys

To present details of 2 living-related donors and our fusion division technique, where half of the horseshoe kidney (HSK) was retrieved and transplanted. Since January 2018, 461 renal transplantations have been performed at our center. In 2 of these 461 renal transplantations, which were analyzed retrospectively, a living donor, who had HSK, was used. Both donors had vascular anomalies, and the first donor also had urinary anomalies. The transplanted kidney was placed in the recipient's contralateral iliac fossa. After perfusing for both grafts, no urine leakage was detected from the transected surfaces, and the graft began producing urine. There were no complications after surgery in the donor and recipients. The recipients were discharged on the 7th and 5th day after surgery with a creatinine level of 0.8 mg/dL and 0.9 mg/dL, respectively. The follow-up period was 24 months for the first recipient, and 12 months for the second. At the time of writing, both recipients and donors were alive with normal renal function. In addition to expanding the donor pool for end-stage renal disease patients, a donor with HSK can be accepted for transplantation if no other donor option presents. Preoperative evaluation should be undertaken carefully for anatomy and HSK complications.

Contralateral internal iliac artery transposition for retroperitoneal sarcoma involving common iliac artery.

Complete resection for retroperitoneal sarcoma (RPS) involving major vessels frequently requires vascular resection and reconstruction. The use of artificial grafts often leads to postoperative vascular graft infection (VGI), which usually requires reoperation and sometimes leads to death. In the present study, the data of RPS patients who underwent contralateral iliac artery (IIA) transposition for reconstruction of the common iliac artery (CIA) after RPS resection from 2015-2019 were retrospectively analyzed. Clinical, intraoperative, and postoperative outcomes were described. Contralateral IIA transposition was performed to reconstruct the CIA after segmental resection in three patients. All patients underwent concomitant organ resection. Colon resection was performed for all patients, nephrectomy was performed for two patients, and segmental resection of the left ureter with transurethral ureterostomy was performed for one patient. Complete resection was achieved in all patients, and microscopic tumor infiltration to the CIA was observed in all patients (tunica adventitia: 2, tunica media: 1). No major complications occurred during the hospital stay. During the follow-up period (6.0-29.1months), one patient died from tumor recurrence, and the other two patients did not have any evidence of recurrence or metastatic disease at the latest follow-up. The level of lower limb function was favorable (MSTS93 scores: 28-30). The pelvic organ functions, including bowel, bladder, and sexual functions, were not impaired in any of the patients. This novel technique in which contralateral IIA transposition is performed to reconstruct the CIA after RPS resection is simple and reliable and may be a good alternative to artificial grafts.

Effects of a Matrix Metalloproteinase Inhibitor-Eluting Stent on In-Stent Restenosis.

BackgroundThe aim of this study was to compare changes in the extracellular matrix after implantation of a stent that elutes a matrix metalloproteinase (MMP) inhibitor (GM6001); and to determine the effects of the GM6001-eluting stent upon prevention of in-stent restenosis (ISR).Material/MethodsWe included 48 Guangxi Bama mini-pigs in this study. A GM6001-eluting stent was placed in one iliac artery and a stent that did not elute GM6001 was placed in the contralateral iliac artery. The iliac arteries were removed at 6 hours as well as 1, 7, 14, 56, 84, and 336 days after stent placement. Arteries were analyzed for morphometry, gelatinase content, different phenotypes of vascular smooth muscle cells (VSMCs), collagen content, apoptotic rate, and cell density.ResultsThe vascular lumen areas of the GM6001 group were significantly increased and the neointimal areas were significantly reduced compared with the control group from the 7 days to the 336 days. In the 2 groups, expression of MMP-2 and MMP-9 peaked simultaneously, but GM6001-eluting stents inhibited expression of MMP-2 and MMP-9 in the vascular media and neointima (especially around the struts) significantly. In the GM6001 group, expression of tissue inhibitor of matrix metalloproteinase (TIMP)-1, TIMP-2, myosin heavy chain 10 (MYH-10, marker of the proliferative phenotype of VSMCs), collagen content, percentage of apoptotic cells, and cell density were also decreased significantly compared with those in the control group.ConclusionUse of GM6001-eluting stents resulted in persistent and potent inhibition of intimal hyperplasia, an increase in luminal area, and no obvious thrombosis in the arteries of the mini-pigs.

Prospective Assessment of a Protocol using Neuromonitoring, Early Limb Reperfusion and Selective Temporary Aneurysm Sac Perfusion to Prevent Spinal Cord Injury During Fenestrated-branched Endovascular Aortic Repair

Introduction - Spinal cord injury (SCI) is a devastating complication of thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this study was to analyze the outcomes of a standardized protocol using continuous neuromonitoring, lower limb (LL) reperfusion and selective temporary aneurysm sac perfusion (TASP) to prevent SCI in patients undergoing fenestrated-branched endovascular repair (F-BEVAR). Methods - Patients enrolled in a prospective, non-randomized single-center study between 2014 and 2017 underwent a SCI prevention protocol for TAAAs or >5-cm supraceliac coverage, including staged thoracic endovascular aortic repair (TEVAR) for Extent I-II TAAAs, cerebrospinal fluid (CSF) drainage, permissive hypertension (mean arterial pressure [MAP] >80 mmHg), LL reperfusion and neuromonitoring. A >75% decrease in motor evoked (MEP) and somatosensory evoked potential (SSEP) amplitude triggered standardized maneuvers. Selective TASP was indicated in patients with persistent decline or delayed recovery (>10 min) in MEP/SSEPs despite maneuvers. End-points adjudicated by independent clinical event committee and included mortality and rates of immediate and delayed (>6 hours) SCI. Results - SCI prevention protocol was indicated in 166 of 232 patients (72%) treated by F-BEVAR for pararenal aneurysms in 22 patients, Extent IV TAAAs in 59 and Extent I-III TAAAs in 85 (Figure). CSF drainage was successful in 162 patients (98%) and stable neuromonitoring was achieved in all patients. Eighty-eight patients (53%) had changes in neuromonitoring starting 50±37 minutes after introduction of the aortic device. Changes in neuromonitoring improved with maneuvers in all except for 10 patients (11%) who had persistent decline in MEP/SSEPs after LL reperfusion. All 10 patients had TASP by leaving a renal-mesenteric branch or contralateral iliac gate incomplete. There was one 30-day or in-hospital mortality (0.4%) due to a subarachnoid hemorrhage from CSF drainage. Ten patients (4%) developed SCIs, including 6 paraplegia and 4 paraparesis. SCIs were immediate in 4 and delayed in 6 with an incidence of 1% for pararenal, 0% for Extent IV, 13% for Extent III and 10% for Extent I-II TAAAs. The probable cause of SCI was hemodynamic compromise in 6 patients, embolic in 2 and epidural hematoma in 2. SCIs occurred in 1/78 patients (1%) with normal neuromonitoring and in 9/88 patients (10%) who had decline in MEP/SSEPs (P=0.02). Among the 10 patients with TASP, neurologic exam was normal in 8 and showed SCI in 2. TASP closure was completed in all patients at 22±16 days, with one SCI 2 days after completion. All 3 patients with post-TASP SCI had complete recovery to ambulatory status. Overall, 2 patients (1%) had permanent paraplegia, which was immediate and probably embolic in both. Factors associated with SCI included extent I-III TAAAs, change in neuromonitoring and need for TASP. Conclusion - This prospective non-randomized study showed that a standardized protocol was associated with low rate of permanent paraplegia (1%). The predominance of SCIs among patients with Extent I-III TAAAs confirms that this protocol may be avoided in lower risk patients (e.g. pararenal and Extent IV TAAAs) due to potential risk of spinal and cerebral hemorrhagic complications from CSF drainage. Although TASP does not completely prevent SCI, it may optimize recovery to ambulatory status. Further investigation is needed to evaluate the benefits of TASP to prevent permanent paraplegia.

Free vascularized iliac bone flap based on deep circumflex iliac vessels graft for the treatment of osteonecrosis of femoral head

BackgroundTo investigate the feasibility and clinical efficacy of free vascularized iliac bone flap based on deep iliac circumflex vessels graft for the treatment of osteonecrosis of femoral head (ONFH) in young adults.MethodsEighteen patients (19 hips) undergoing ONFH were included from January 2016 to May 2017. After the debridement of the necrotic bones, the contralateral vascularized iliac bone flap was designed and harvested before grafting, in which the deep circumflex iliac vessels and the transverse branch (or ascending branch) of the lateral circumflex femoral artery and their accompanying veins were anastomosed. X-ray was obtained at 1, 3, 6, 9, and 12 months respectively for evaluation of the bone flap healing. Hip function was evaluated with Harris hip score at 18 months postoperatively.ResultsNone of the patients is lost to follow-up. All the hips healed well except for four complications: one patient developed superficial wound infection, one patient had subcutaneous hematoma, and two patients developed anterolateral femoral cutaneous nerve injury. X-ray films at 12 months showed improvement in 13 hips (68.4%), five hips (26.3%) were unchanged, and one femoral head collapse with conversion to total hip arthroplasty (THA) at 14 months postoperatively (5.3%). Postoperative mean Harris hip scores were significantly improved compared to the preoperative results (P < 0.05).ConclusionFree vascularized iliac bone flap based on deep circumflex iliac vessels graft is an acceptable treatment option for young adult ONFH in mid-late stage with low conversion to THA rate at short-term follow-up.

PO 18124 - Large orthopedic surgery and its correlation with Cockett syndrome

Introduction: Cockett syndrome (CS) is characterized by compression of the left common iliac vein by the right common iliac artery against the spinal wall, causing obstruction of left lower limb (LLL) blood flow. The clinical condition is mainly manifested by pain and edema of the LLL and, in more severe cases, even by left iliofemoral venous thrombosis. It is already well established in the literature that in cases such as Cockett syndrome, orthopedic surgeries also corroborate the occurrence of deep vein thrombosis (DVT), mainly by the positioning and manipulation of the limb during the intervention; by the continuous reaction secondary to the use of cement; by significant blood loss; by postoperative (PO) edema; and by the mobility limitations PO. Case report: A 42-year-old patient complained of left foot pain and repetitive sprains for 2 years. After a complete physical examination indicating a cavovarus foot and a pointed hindfoot, an AP and profile radiograph of the limb was requested, which revealed data compatible with a foot cavity. The nuclear magnetic resonance demonstrated the necessity for cavo foot correction surgery and reconstruction of the structure of the ankle. The patient was classified as ASA 1 and had no indication for prophylaxis for DVT according to the Hospital Protocol. The surgical procedure occurred without intercurrences, and the patient was discharged in good general condition in the 2nd PO with guidelines and prescriptions. The patient returned to the foot clinic on the 7th PO complaining of abrupt pain in the LLL, accompanied by edema, hyperemia and cyanosis of the limb. A Doppler ultrasonography was performed, which detected extensive thrombosis of the iliac vein and compression of the same by the contralateral iliac artery, raising the hypothesis of CS. In the present paper, the exam images, surgery, PO and evolution for the DVT will be presented and discussed, as well as the resolution of this condition through endovascular surgery with angioplasty and stent implantation. Conclusion: CS and orthopedic surgeries are, in isolation, important risk factors for the development of DVT and, above all, when overlapped, they increase this risk exponentially. Endovascular surgery with angioplasty and stent implantation is the main form of treatment, presenting excellent clinical results.