Covered Stent Placement Research Articles

Prospective, Multicenter Clinical Study of the Covera Vascular Covered Stent in the Treatment of Stenosis at the Graft-Vein Anastomosis of Dysfunctional Hemodialysis Access Grafts

PurposeTo study the use of the self-expanding Covera covered stent for the treatment of stenotic lesions at the venous anastomosis of hemodialysis arteriovenous grafts (AVGs). Materials and MethodsA total of 110 patients with AVG venous anastomotic stenosis of ≥50% and access dysfunction were treated at 14 centers in the United States using percutaneous transluminal angioplasty followed by covered stent placement. The primary end points were 30-day safety and 6-month target lesion primary patency (TLPP). The secondary measures included access circuit primary patency, circuit cumulative patency, and the number of reinterventions through 24 months. ResultsFreedom from a primary safety event at 30 days was 96.4% while the 6-month TLPP rate was 70.3%. Seventy-five patients completed 24-month follow-up (68.2%). The TLPP rates were 54.2% at 365 days and 36.9% at 730 days while the access circuit primary patency rates were 16.7% at 365 days and 7.8% at 730 days (Kaplan-Meier analysis). The access circuit cumulative patency rates were 85.4% at 12 months and 73.6% at 24 months. The number of reinterventions to maintain the patency of the access circuit was 3.6 ± 3.1 at 24 months (1.6 ± 1.9 at the target lesion). ConclusionsUse of the Covera covered stent for hemodialysis graft-vein anastomotic stenosis provided a safe treatment option with a TLPP rate of 70.3% at 6 months and TLPP and cumulative access circuit patency rates of 36.9% and 73.6% at 2 years.

Computational fluid dynamics simulation of hemodynamic changes in a hemodialysis patient with central venous stenosis treated with stent.

It has not been demonstrated that computational fluid dynamics (CFD) can be used to model central venous stenosis (CVS), nor that hemodynamic changes in CVS treated with stent placement can be anticipated. The purpose of this study was to demonstrate the hemodynamic performance of CVS patients treated with stent placement. Patient-specific geometric models were constructed using computed tomography images of veins from hemodialysis patients treated with stent placement. CFD simulation based on geometry was performed using ANSYS-15 to compare pressure quantitatively, wall shear stress (WSS), and flow velocity in the brachial vein before and after stent placement. Following a covered stent placement, the swelling of the left upper extremity was relieved. Prior to stent implantation, the maximum and mean brachial vein wall pressures were 465.2 Pa and 224.609 Pa, respectively. It was determined that the maximum WSS value was 8.449 Pa and that the mean WSS value was 0.743 Pa. The maximum and mean flow velocities were 1.16 and 0.173 m/s, respectively. After stent placement, the maximum wall pressure, maximum WSS, and maximum flow velocity dropped by 59.4%, 71.2%, and 57.8%, respectively. The mean wall pressure, mean WSS, and mean flow rate decreased by 43.5%, 52.7%, and 17.6%, respectively. Hemodynamics of CVS in hemodialysis patients exhibited turbulent, imbalances and disorders, which can be improved by stent placement.

Endoscopic management of esophageal leak post-heller myotomy for achalasia cardia in children

A 9-year-old male child diagnosed to have achalasia cardia when he presented with a history of vomiting of undigested food particles with poor weight gain. He underwent lap Heller myotomy and Dor fundoplication. The immediate postoperative period was uneventful. After discharge, he presented with peritonitis and septic shock. On contrast-enhanced computed tomography abdomen, leak at the lower end of esophagus with intra-abdominal pus collection was identified. After intra-abdominal pus drainage and stabilizing the child, endoscopic covered stent was placed. He recovered well. Endoscopic esophageal covered stent placement is a viable and best option for a sick child with esophageal leak post-Heller myotomy.

Internal Carotid Injury during Transsphenoidal Resection of Pituitary Macroadenoma Managed with Neurointervention Technique

AbstractIatrogenic internal carotid artery (ICA) injuries during transsphenoidal pituitary tumor surgery are extremely rare but are associated with potentially disabling or life-threatening complications. Management options of ICA injuries are sacrifice, embolization, and endoluminal reconstruction. We report a case of ICA injury during transsphenoidal pituitary macroadenoma surgery, which was managed with endovascular covered stent placement for left carotid-ophthalmic pseudoaneurysm.

Oncologic surgical resection with intravascular covered stent placement in patients with carotid artery encased by metastatic cancer-Our experience with 5 patients.

Importance Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, setting, and participants Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main outcomes and measures Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and relevance Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

Delayed cephalic arch rupture following balloon angioplasty

BackgroundVascular access care comes with its substantial cost that include but not limited to poor blood flow during dialysis, stenosis throughout the dialysis circuits, aneurysmal dilatation, clots formation and complete thrombosis. Acute cephalic arch rupture is not that uncommon but delayed rupture is rare presentation that was not discussed previously.Case presentationWe describe a case of a 70-year-old female with end-stage renal disease (ESRD) undergoing a fistulogram and angioplasty of cephalic arch stenosis that resulted in a small vessel rupture that was successfully treated with prolonged balloon inflation initially. Unfortunately, this was complicated with massive venous rupture after initiating hemodialysis. The diseased segment was successfully treated with covered stent placement. This paper review and discuss cephalic arch stenosis, clinical presentation, and available initial and bailout treatment strategies.ConclusionsPrimary management of cephalic arch rupture is a prolong-low pressure balloon angioplasty, with covered stent across the site of extravasation if persisted. This case depicted a delayed vascular rupture following hemodialysis in patient with previously controlled extravasation that necessities covered stent placement. No data in the literature suggested the time that is required to avoid dialysis and improve healing.

Initial experience of endoscopic ultrasound-guided antegrade covered stent placement with long duodenal extension for malignant distal biliary obstruction (with video).

Background/PurposeThis study aimed to evaluate the feasibility of endoscopic ultrasound (EUS)‐guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal biliary obstruction (MDBO) with duodenal obstruction (DO) or surgically altered anatomy (SAA) after failed endoscopic retrograde cholangiopancreatography (ERCP).MethodsOutcomes were technical and clinical success, reintervention rate, adverse events, stent patency, and overall survival. Inverse probability of treatment weighting (IPTW) and competing‐risk analysis were performed to compare with conventional EUS‐BD.ResultsTwenty‐five patients (DO, n = 18; SAA, n = 7) were included. The technical and clinical success rates were 96% and 84%, respectively. Reintervention occurred in two patients (8.3%). Adverse events occurred in six patients (24%; two cholangitis, 16%; four mild postprocedural pancreatitis [24% (n = 4/17) in patients with non‐pancreatic cancers]). The median patency was 9.4 months, and the overall survival was 2.73 months. After IPTW adjustment, the median patency in the EASL (n = 25) and conventional EUS‐BD (n = 29) were 10.1 and 6.5 months, respectively (P = .018).ConclusionsEASL has acceptable clinical outcomes with a low reintervention rate but higher rate of postprocedural pancreatitis in patients with non‐pancreatic cancers. Randomized trials comparing EASL and conventional EUS‐BD for MDBO with pancreatic cancers and DO/SAA after failed ERCP are needed to validate our findings.

Preventive covered stent placement at the gastroduodenal artery stump in angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

To evaluate the clinical outcomes of preventive covered stent placement at the gastroduodenal artery stump in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy. Between July 2006 and September 2018, patients undergoing computed tomography angiography or diagnostic angiography for sentinel hemorrhage after pancreaticoduodenectomy were retrospectively reviewed. Patients having angiogram-negative angiography and undergoing preventive covered stent placement or conservative treatment were included. Clinical outcomes, technique success, and complications were evaluated. A total of 25 patients (mean age 62.5years) were evaluated, including 15 patients underwent preventive covered stent placement at the gastroduodenal artery stump and 10 patients received conservative treatments. The clinical success rates were 50% (5/10) and 86.7% (13/15) for conservative treatments and covered stent groups, respectively (p = 0.07). In the conservative treatment group, delayed massive hemorrhage occurred in five patients, two of whom died of recurrent bleeding due to gastroduodenal artery pseudoaneurysm within 16days, and two had intraluminal hemorrhage within 5days. In the covered stent group, one patient had inferior pancreaticoduodenal artery pseudoaneurysm 1day after the placement of the covered stent, and one had recurrent bleeding due to duodenal ulcer within 14days. The 30-day mortality was 40% (4/10) and 0 in the conservative treatment and covered stent groups, respectively (p = 0.02). The difference in the overall survival was nonsignificant between the two groups (p = 0.23). The preventive covered stent placement at the gastroduodenal artery stump is safe and reduces delayed massive hemorrhage and short-term mortality in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

Erroneous placement of central venous catheters in subclavian artery: Retrieval and successful hemostasis with a femoral closure device.

Retrospective evaluation of the safety and efficacy of the retrieval of misplaced central venous catheters (CVCs) in subclavian arteries using the femoral closure device Angio-Seal™. The clinical data of five patients (female, n = 2; mean age, 55.0 years ± 11.9) in whom a misplaced CVC within a subclavian artery was removed followed by closure of the vessel entry site with 8-French (F) Angio-Seal™ was analyzed. In 4/5 patients (80%; CVC diameter, 7-8F) the procedure was technically successful without complications. In 1/5 patients (20%; CVC diameter, 11.5F) the procedure failed and an additional covered stent was placed for successful closure of the vessel entry site. There were no complications associated with the Angio-Seal™ or stent implantation during follow-up. Retrieval of a misplaced CVC within a subclavian artery using the percutaneous closure device Angio-Seal™ is quite safe and effective; however, caution is required if there is a mismatch in the diameter of the Angio-Seal™ and CVC. In the case of procedure failure, successful closure of the vessel entry site can be achieved by covered stent placement.

Venous outcomes at 1 year after using the femoral vein as a conduit for passage of percutaneous femoropopliteal bypass

ObjectiveThe DETOUR 1 study was performed to assess the safety of the femoral vein as a "pass through" conduit for covered stent placement during fully percutaneous femoropopliteal bypass, also known as the DETOUR procedure. MethodsAt eight participating centers in this prospective, single-arm, international trial, 78 patients (82 femoropopliteal lesions) were enrolled. All patients had patent femoral veins measuring ≥10 mm in diameter at baseline. The DETOUR procedure involved delivery of a series of TORUS stent grafts, deployed from contralateral common femoral artery access, to the ipsilateral proximal superficial femoral artery, with entry into the femoral vein and re-entry into the arterial vasculature at the above-the-knee popliteal artery. The TORUS stent grafts are deployed in an overlapping configuration as an arterial-arterial conduit. Due to this novel transvenous approach, we assessed specific considerations related to the venous system to analyze the risk of risk of venous thromboembolic complications. Symptomatic deep vein thrombosis, nonocclusive material associated with the graft such as benign endovenous graft-associated material, pulmonary embolism, Venous Clinical Severity Score (VCSS) and Villalta scores, and luminal occupancy by the stent graft were assessed as the ratio of cross-sectional areas of the stent graft to the native vein at baseline and 1 year after the procedure. ResultsA duplicate femoral vein was present in 20.7% of cases. The majority of patients (86.8%) had a femoral vein luminal area preservation of ≥55%. Thirty-two patients experienced an increase in the vein diameter over time after the procedure, but this pattern of venous remodeling was not uniform. The patients who had a compensatory increase in the vein diameter had a smaller average baseline vein diameter compared with the patients who did not have a compensatory increase in vein diameter (P = .0414). Only two patients (2.4%) developed ipsilateral symptomatic deep vein thrombosis) through 1 year of follow-up. There were no pulmonary embolism in any patient in the series. The overall VCSS and Villata scores did not change during follow-up. Mean VCSS and Villata were 0.8 ± 1.4 and 0.5 ± 1.1 at 1 year, compared with 0.6 ± 1.0 and 0.4 ± 0.9 at baseline, respectively. ConclusionsAs a percutaneous alternative to open surgical bypass for complex femoropopliteal peripheral arterial disease, the transvenous bypass has a low rate of deep venous thrombotic and obstructive complications. Cross-sectional vein area is preserved, and in some patients, the compensatory vein diameter increases with time, supporting the feasibility and safety of using the lower extremity deep venous system as a pass-through conduit for the DETOUR percutaneous femoropopliteal bypass. Trial RegistrationNCT02471638.

Percutaneous Subclavian Artery Covered Stent Placement Following Inadvertent Subclavian Arterial Cannulation

Inadvertent subclavian artery canulation although rare is a life threatening complication of central venouscanulation. Its prompt recognition and management by stent placement, thrombin injection, Angio seal orgel foam embolization is essential to minimize fatal complications. We describe a case report of subclavianarterial canulation which was recognized and managed percutaneously by covered stent placement withoutcomplications.

Drug-coated balloon angioplasty for the treatment of edge stenosis after self-expanding covered stent placement for superficial femoral artery occlusive disease.

Edge stenoses are the predominant limitation of self-expanding covered stent treatment of superficial femoral artery (SFA) occlusive disease, necessitating reinterventions. Angioplasty of an edge stenosis is associated with a high recurrence rate. Drug-coated balloon (DCB) treatment of edge stenoses might improve outcomes by decreasing the incidence of restenosis. The aim of this study was to evaluate the outcomes of using a DCB for the treatment of edge stenoses after self-expanding covered stent placement for SFA occlusive disease. We performed a retrospective analysis of patients treated with a DCB for edge stenoses after self-expanding covered stent placement. The primary endpoint was primary patency at one year. The secondary endpoints included procedure-related complications, secondary patency, and freedom from target lesion revascularization (TLR). A total of 21 patients with 28 edge stenoses were included. The time from primary treatment to treatment of the edge stenosis was 19 months (interquartile range (IQR) 8; 52 months). Primary patency and assisted primary patency at one year were 66.7% with a secondary patency of 90.9%. Freedom from TLR was 86.1%, and freedom from clinically driven TLR was 89.4%. Four patients presented with a hemodynamically significant restenosis, and three of those patients had an occlusion. Median time to failure was six months (IQR 3.5; 7.0 months), and median time to occlusion was four months (IQR 3.0; 6.0 months). The treatment of edge stenoses using a DCB is associated with a safe one-year outcome; however, this has to be confirmed in larger prospective studies. The continuous surveillance of patients is indicated.

Radiotherapy-induced Acute Carotid Blowout Syndrome in Base of Tongue Cancer

Carotid blowout syndrome is an uncommon and fatal medical emergency in patients with head and neck cancer. Tumor progression, previous surgery, and radiotherapy on the head and the neck regions are some of the predisposing factors that affect its presentation. An early suspicion of a carotid blowout syndrome allows early safety measurements to prevent catastrophic events. A 71-year-old man with advanced base of tongue cancer was presented with a self- limiting oral bleeding 18 months after receiving chemoradiotherapy. Fiberoptic laryngoscopy and contrast-enhanced computed tomography revealed the presence of edema of the hypopharynx and thyroid cartilage fracture and necrosis. The patient developed acute oral hemorrhage. Surgical intervention was insufficient to achieve hemostasis. The carotid angiography revealed a common carotid artery rupture, and a covered stent was placed endovascularly. The covered stent placement was enough to stop the bleeding. However, the patient died from perioperative complications. Experience is necessary for the early detection and prevention of a carotid blowout syndrome.

A case of hemostasis with covered stent placement for brachiocephalic artery injury at tracheostomy

A case of hemostasis with covered stent placement for brachiocephalic artery injury at tracheostomy

Application of the Willis Covered Stent in the treatment of intracranial unruptured aneurysms in internal carotid artery: A retrospective single-center experience

The purpose of this study was to retrospectively analyse the clinical and angiographic outcomes of Willis covered stent placement for unruptured aneurysms in internal carotid artery. Forty-six consecutive patients with internal carotid artery aneurysms (49 cases) were included to evaluate clinical and angiographic outcomes. Covered stent placement was successful in 47 cases, whereas stent navigation failed in 2 cases. Of the 49 aneurysms (mean aneurysm size, 7.9 mm), 5, 6, and 38 were located in the petrous, cavernous, and ophthalmic segments, respectively. Immediate angiography revealed complete aneurysm exclusion in 36 (76.6%) cases, whereas minimal endoleak was observed in 11 cases. Four patients had procedure-related complications, including 1 patient with acute in-stent thrombosis, 2 with a post-operative subarachnoid haemorrhage, and 1 with artery rupture. Angiographic and clinical follow-up was available for 36 patients (38 aneurysms). Complete aneurysm occlusion was achieved in 34 (89.5%) cases, endoleak was present in 2 cases, and aneurysm recurrence occurred in 2 cases. Asymptomatic in-stent stenosis was observed in 3 patients. No hemorrhagic or ischemic events occurred during the follow-up period. At follow-up, the modified Rankin scores were 0–2 for 35 patients and >2 for 1 patient. Satisfactory angiographic outcomes were achieved in our study. However, the risks of stent navigation failure, endoleak after balloon re-inflation, procedure-related complications and coverage of side branches should be considered when choosing the best therapeutic option for internal carotid artery aneurysms.

Iliac-enteric fistula managed by endovascular covered stent placement using extra-vascular microwire snaring: a case report

BackgroundAlthough snaring technique is a commonly used tool in the interventional radiologists’ armamentarium, there are no reports of its use in an extra-vascular space to achieve access across a pseudoaneurysm that was otherwise non-traversable.Case presentationWe describe a case of an iliac-enteric fistula between a ruptured pseudoaneurysm of the external iliac artery and a surrounding contained colonic perforation, where access across the pseudoaneurysm was achieved only after snaring of the microwire from within the contained colonic perforation and back into the intra-vascular space, allowing the placement of a covered stent and control of the bleeding.ConclusionsThe described technique may be useful in situations where other, more conventional, endovascular techniques fail to achieve access across the bleeding pseudoaneurysm. While it was life-saving in this case, this technique should only be used in very limited scenarios, specifically in the palliative setting and when surgical management is not an option.

Covered stent placement for hepatic artery pseudoaneurysm.

To evaluate the efficacy and safety of covered stent placement for the treatment of hepatic artery pseudoaneurysm (HAP). Between March 2006 and March 2019, 17 consecutive patients underwent emergency covered stent placement for treatment of HAP. There were 12 men and 5 women aged 24-71years, with an average age of 49.4years. Eleven patients had undergone Whipple procedure, 3 had hepatic abscess following hepatectomy, 2 had undergone hepatectomy under extracorporeal circulation, and 1 had received surgical exploration after a car accident. The average interval from surgical intervention to massive bleeding was 15.3days (range: 6-35days). After HAP was confirmed by angiography, 1-3 covered stent grafts (3-8mm in diameter and 13mm-5cm in length) were implanted. Adequate drainage, anti-infection treatment, and symptomatic treatment were offered after stent placement, and no anticoagulation or antiplatelet drug was used. The interventions were successful in all 17 patients. Angiography revealed pseudoaneurysms in common hepatic artery in 16 patients (in gastroduodenal artery stumps in 4 patients) and hemorrhage from a ruptured right hepatic artery in 1 patient. All patients were successfully implanted with 1-3 covered stent grafts. Bleeding was completely controlled in 12 patients (stent diameter: 4.5-8mm). Four patients (stent diameter: 3-4.5mm) experienced bleeding recurrence 1h to 3days after stent implantation, and type 1 endoleaks were identified during second angiography. Finally, these 4 patients died of multiple organ failure 2-10days after embolization/blockage. The remaining patient suffered from abdominal hemorrhage again 2weeks after stent implantation, and second angiography showed hemorrhage from a branch of the superior mesenteric artery; no bleeding occurred after embolization. Thirteen patients survived at discharge, and the average length of hospital stay was 26.53days (range: 11-58days). The average follow-up time was 23months (range: 16-37months), during which 6 patients died of tumor progression. No bleeding recurred during the follow-up period, and routine color Doppler ultrasound revealed that the common hepatic artery was patent and the blood flow was smooth at the stent implantation site. Covered stent placement is a safe and effective alternative for treating HAP patients with high risk of severe complications after hepatic artery embolization. Larger stent grafts (> 4mm in diameter) may achieve better prognosis.

Abstract No. 2 ■ ABSTRACT OF THE YEAR Interim results from the prospective, randomized AVeNEW study

To assess the results using the ePTFE-covered, self-expanding COVERA Vascular Covered Stent for the treatment of stenotic lesions in the venous outflow of upper extremity hemodialysis arteriovenous (AV) fistulae. Thirty-five centers in the United States, Europe, Australia, and New Zealand randomized 280 patients with stenotic lesions (≥ 50%) and clinical or hemodynamic evidence of AV fistula dysfunction to either PTA alone (n = 138) or PTA followed by covered stent placement (n = 142). Primary endpoints were 6-month target lesion primary patency (TLPP) and 30-day safety. Secondary measures included TLPP, access circuit primary patency (ACPP), index of patency function (IPF), and the number of reinterventions needed to maintain patency at 12 months, with ongoing data collection to 3 years. Safety at 30 days was non-inferior between groups (P = 0.002) while TLPP at 180 days (Kaplan-Meier analysis) was superior for the covered-stent group (78.7%) compared with the PTA group (47.9%; one-sided P < 0.001). 83.9% of patients were followed to 12 months; 34 patients died (10.6% covered-stent group; 14.5% PTA group) while 10 patients withdrew or were lost to follow-up (4.2% covered-stent group; 2.9% PTA group) prior to 12-month evaluation. TLPP (K-M analysis) was superior for the covered stent group (57.5%) compared to the PTA (21.2%; P < 0.001) at 365 days. ACPP was also significantly better for the covered-stent group at 12 months, 28.9% versus 17.7% respectively (P = 0.02). The mean number of reinterventions in the access circuit to maintain patency was 0.8 + 1.0 for the covered-stent group compared to 1.7 + 1.3 for the PTA group. AVeNEW is the first level-one clinical trial dedicated to the use of a covered stent designed to treat stenoses in AV fistulae. The covered stent provided significantly better TLPP and non-inferior safety compared to the randomized PTA group at 6 months. At 12 months, TLPP was statistically better for the covered-stent group (P < 0.001) as was ACPP (P = 0.02) while about half as many reinterventions were required to maintain secondary circuit patency.

Safety and Effectiveness of Percutaneous Axillary Artery Access for Complex Aortic Interventions

The aim of this study is to evaluate the safety and effectiveness of percutaneous axillary artery access in patients requiring upper extremity large sheath access during complex aortic interventions. Consecutive patients who had percutaneous axillary artery access with a large-bore sheath during endovascular thoracoabdominal aortic artery aneurysm repair within an Food and Drug Administration-approved, physician-sponsored investigational device exemption study or visceral artery interventions during other complex aortic interventions were included in the study. All patients had percutaneous axillary artery ultrasound-guided access and deployment of 2 Perclose ProGlide devices (Abbott Vascular, Santa Clara, CA) prior to introduction of a large sheath. Completion angiography was performed to assess technical success of percutaneous access site closure, which was defined as hemostatic arterial closure without evidence of axillary artery stenosis or occlusion requiring intervention. Follow-up computed tomography scans and patient records were also reviewed for access site associated complications. A total of 46 patients underwent percutaneous axillary artery access. Largest sheath profile was 16F in 1 (2%), 12F in 42 (91%), 10F in 1 (2%), 9F in 1 (2%), and 8F in 1 (2%) patient. Technical success was achieved in 41 of 46 patients (89%). Five patients required endovascular covered stent placement during the index operation to control persistent access site bleeding. Two of 46 patients (4%) suffered access-related complications; both patients experienced ipsilateral upper extremity paresthesias without motor weakness, with persistent digit numbness in one. There was no incidence of conversion to open axillary artery repair and no additional access site complications (stenosis, occlusion, or dissection) but neurologic complications were observed during follow-up. Percutaneous axillary artery access can be used to provide upper extremity arterial access during complex aortic interventions with high rates of safety and technical success. Overall complication rates are low and occurred mainly during the early experience, indicating that there is an associated learning curve effect. Elimination of surgical cutdown incisions and arterial conduits by using percutaneous axillary access may reduce operative times and wound-related complications during complex aortic interventions requiring large-bore upper extremity access.

Trans-Caval Impella 5.0: A Bridge to Recovery in Peripartum Cardiomyopathy

Introduction The incidence of peripartum cardiomyopathy (PPCMP) varies worldwide, the etiology is thought to be related to both environmental and genetic factors. The mortality rates are reported up to 16.7% and transplant rates up to 11%. The Interagency Registry for Mechanically Assisted Circulatory Support demonstrated improved myocardial recovery in PPCMP patients compared to non-PPCMP patients (6% vs. 1%) who required durable mechanical circulatory support devices (MCS). Our case demonstrates the use of trans-caval Impella 5.0 as a bridge to recovery in a PPCMP patient with cardiogenic shock post delivery. Clinical Presentation 37-year-old woman with a history of PPCMP presented with progressive shortness of breath during the third trimester of pregnancy. She was found to have a decrease in left ventricular ejection fraction (LVEF) to 30-35% at 30 weeks gestation. Right heart catheterization showed RA 12 mmHg, PA 75/38 (50) mmHg, PCWP 30 mmHg, and CI 1.99 L/min/m2. She was transferred to Cardiac Intensive Care Unit (CICU) for invasive hemodynamic monitoring and tailored therapy. Nitroprusside was started with up titration of oral afterload reduction medications and continued intravenous diuresis. Due to preeclampsia, labor induction was initiated during week 34 of gestation. Secondary to multiple decelerations on fetal monitoring, an emergent primary C-section with bilateral tubal ligation was performed. Immediately after delivery, patient suffered hemodynamic collapse requiring emergent placement of a right femoral 2.5L Impella; noting small ilio-femoral arteries on angiography. There was no significant hemodynamic improvement (low cardiac index, elevated PA pressure, and progressive hypotension); patient was emergently upgraded to an Impella 5.0 via trans-caval approach under transesophageal echocardiogram guidance. Patient experienced cardiac arrest during procedure, with immediate ROSC. The Impella 5.0 placement was successful without complications and with improvement in hemodynamics (Improved CI from 1.3 to 1.6 L/min/m2, MAP from 55 to 88 mmHg, cardiac power output from 0.29 to 0.42 W), pH from 7.02 to 7.30. The 2.5L Impella removal was complicated by a right iliac artery rupture requiring a covered stent placement. CICU course was complicated by retroperitoneal hematoma, and acute renal failure requiring hemodialysis. Impella 5.0 was removed four days later; a 12/10 mm amplatz ductal occluder was used to close the trans-caval arteriotomy site. Hemodialysis was discontinued 12 days post-delivery and her LVEF improved to 40-45%. She was discharged to rehab and had significant improvement in her functional capacity on her 6-week follow up. Conclusion Close monitoring and prompt action to escalate hemodynamic support, with temporary MCS to achieve better outcomes in cardiogenic shock is imperative. Trans-caval Impella 5.0 is a feasible alternative to extracorporeal membrane oxygenation and provides a high level of hemodynamic support which could bridge to myocardial recovery in PPCMP patients suffering from cardiogenic shock.