Custom-made Grafts Research Articles

Chondrocutaneous Custom-made Graft for Upper Lateral and Alar Cartilage Nose Reconstruction: The T Graft

AbstractUpper lateral cartilage and alar cartilage nose reconstruction secondary to failed aesthetic procedure or tumor excision, surely represents a reconstructive challenge for plastic surgeons, because of the support needed and for the function of the internal nasal valve (INV).Several scientific publications deal with internal nasal reconstructive techniques, including simple homologous or heterologous tissue grafts.We describe a new hybrid chondrocutaneous graft used for reconstruction of the upper lateral cartilage and a portion of the alar cartilage (cephalic part), excised with the adherent nasal mucosa (in correspondence with INV), included in the tumor mass.

Endovascular Solutions for Abdominal Aortic Aneurysms: Fenestrated, Branched and Custom-Made Devices.

Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities.

Common Designs of Custom-Made Fenestrated Arch Devices and Applicability of an Off-the-Shelf Design.

To analyze device designs, similarities and overlaps of custom-made fenestrated arch endografts intended for mid/distal arch thoracic endovascular aortic repair. A multicenter cross-sectional study analyzing custom-made anonymized graft plans was performed. Graft plans were included from a cohort of mid/distal aortic arch repairs using custom-made fenestrated aortic endografts treated at 8 centers. Grafts targeting >2 arteries were excluded. No patient/clinical data were analyzed. A descriptive analysis was performed followed by an analysis of overlap of the designs to reach a common design in which the greatest number of grafts would overlap. One hundred thirty-one graft plans were included. All grafts were custom-made grafts from the COOK Medical Fenestrated arch platform. Ninety-four (71.8%) had a scallop-and-single-fenestration design, 33 (25.2%) had a single fenestration and 4 (4.3%) a single scallop. For analysis purposes, these latter 4 grafts were excluded. Two main graft plans (Plans 1 and 2) were proposed after analysis with similar configuration (1 scallop with 30 mm width, 20 mm height, 12:00 position; 1 preloaded fenestration with 8 mm diameter, 26 mm from the top of the graft and 12:00 position; tapered, with a 193 mm length and 32 mm distal diameter) but with 2 different proximal diameters of 38 mm (Plan 1) and 44 mm (Plan 2), reaching an overall feasibility of 85.8% (n=109), being 47.2% (n=60) and 38.6% (n=49) for each design, respectively. The degree of overlap between the studied fenestrated and/or scalloped thoracic endovascular aneurysm repair (TEVAR) graft designs was high. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility. In a multicenter study analyzing 127 fenestrated aortic arch endograft plans from 9 aortic centers, we found that the degree of overlap between the studied fenestrated and/or scalloped arch graft designs was high and that 2 proposed graft designs would be theoretically applicable in 85.8% of cases. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.

Komplex endovascularis rekonstrukciók az aortaíven.

Thoracic endovascular aneurysm repair (TEVAR) of the aortic arch has started to spread in recent years. We present our initial experience with TEVAR involving supra-aortic branches using parallel and branched grafts. Parallel grafts are typically used in emergency cases. In the case of Z0 proximal fixation, we can perform a combined hybrid surgery with Z1 debranching and securing of the innominate artery with chimney graft, which can also be used instead of Z0 debranching when the patient is unfit for sternotomy. In the case of TEVAR with planned Z2 position with inadvertent covering of the left common carotid artery, we can perform chimney conversion to rapidly recover the circulation of the left common carotid artery (LCCA). Instead of prior revascularization of the left subclavian artery, chimney graft can be used to recover the lumen, in the case of left upper limb ischemia after Z2 TEVAR. Exclusion of penetrating aortic ulcers located in the lesser curvature can be facilitated by use of a custom-made graft, where a scallop is placed around the origin of the supra-aortic vessel, thus increasing the length of the proximal neck. For elective interventions, custom-made branching grafts can be allowed to save all three branches with Z0 fixation. Technical success was obtained in all cases. Orv Hetil. 2023; 164(11): 426-431.

Midterm results on a new self-expandable covered stent combined with branched stent grafts: Insights from a multicenter Italian registry

ObjectiveTo investigate the technical periprocedural and midterm outcomes of endovascular repairs with multibranched endovascular repair or iliac branch devices combined with a new self-expanding covered stent. MethodsThe COvera in BRAnch registry is a physician-initiated, multicenter, ambispective, observational registry (ClinicalTrials.gov Identifier: NCT04598802) enrolling patients receiving a multibranched endovascular repair or iliac branch devices procedure mated with Bard Covera Plus (Tempe, AZ) covered stent, designed to evaluate the outcomes of the covered stent mated with patient-specific and off-the-shelf branched stent graft. Primary end points were technical success, branch instability, and freedom from aortic and branch-related reintervention within 30 days and at follow-up. Preoperative characteristics, comorbidities, and outcomes definitions were graded according to the Society for Vascular Surgery reporting standards. ResultsTwo hundred eighty-four patients (76 years; range, 70-80 years; 79% males) in 24 centers were enrolled for a total of 708 target vessels treated. The covered stents were mated with an off-the-shelf graft in 556 vessels (79%) and a custom-made graft in 152 (21%). Three hundred seven adjunctive relining stents in 277 vessels (39%) were deployed, of which 116 (38%) were proximal, 66 (21%) intrastent, and 125 (41%) distal. Adjunctive relining stent placement was more frequent when landing in a vessel branch instead of the main trunk (59% vs 39%; P = .031), performing a percutaneous access (49% vs 35%; P < .001), using a stent with a diameter of 8 mm or greater (44% vs 36%; P = .032) and a length of 80 mm or greater (65% vs 55%; P = .005), when a post-dilatation was not performed (45% vs 29%; P < .001) and when an inner branch configuration was used (55% vs 35%; P < .001). Perioperative technical bridging success was 98%. Eight patients (3%) died in the perioperative period. Two deaths (1%) were associated with renal branch occlusion followed by acute kidney injury and paraplegia. Follow-up data were available for 638 vessels (90%) at a median of 32 months (Q1, Q3, 21, 46). Branch instability was reported in 1% of branches. Forty-six patients (17%) died during follow-up, nine (3%) of them owing to aortic-related causes. Primary patency rates at 1, 2, and 3 years were 99% (581/587), 99% (404/411), and 97% (272/279), respectively. Branch instability was associated with patient-specific devices (9% vs 4%; P = .014) and intrastent adjunctive stent placement (12% vs 2%; P = .003), especially when a bare metal balloon-expandable stent was used (25% vs 3%; P < .001). ConclusionsThe use of this new self-expanding covered stent mated with branched endografts proved to be safe and feasible with high technical procedural success rates. Low rates of branch instability were observed at midterm follow-up. Comparative studies with other commercially available covered stents are warranted.

Treatment of a type Ia endoleak following EVAR using a custom-made inner branch device.

We represent two cases of late proximal type I endoleak following EVAR with aneurysm expansion that were treated with a custom-made graft with inner branches. Two patients of 87 and 82years old were operated by EVAR 6 and 8years ago for abdominal aortic aneurysm. Both had proximal type I endoleak with aneurysm sac expansion. Open surgery had a high risk, and a proximal aortic extension with a simple aortic cuff was not possible neither because previous EVAR grafts were already at the level of the renal arteries. A custom-made endograft with inner branches was planned as a fenestrated graft was not technically possible. We successfully treated both patients using a custom-made graft with four inner branches from Jotec (Cryolife, Kennesaw, GA). Three months' follow-up CT scan did not show any endoleaks. All target vessels were patent with good conformability of the bridging stents. The treatment of proximal type I endoleak using inner branches' endografts is feasible. This novel technology might broaden the indications for complex aortic repair in a group of patients where fenestrated endografts are not possible.

Piezoelectric Bone Surgery. Overview in Applications and Proof of Feasibility in Hand and Plastic Surgery.

Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery. The authors overviewed a variety of applications for Piezosurgery® Device, from Mectron, in bone reconstructive surgery with over the last 8years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects. The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded. Piezosurgery® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques.

Commentary: Keep working: Current endovascular arch-repair technology still has a way to go

Commentary: Keep working: Current endovascular arch-repair technology still has a way to go

In situ three-dimensional printing for reparative and regenerative therapy.

Three-dimensional (3D) bioprinting is an emerging biofabrication technology, driving many innovations and opening new avenues in regenerative therapeutics. The aim of 3D bioprinting is to fabricate grafts in vitro, which can then be implanted in vivo. However, the tissue culture ex vivo carries safety risks and thereby complicated manufacturing equipment and practice are required for tissues to be implanted in the humans. The implantation of printed tissues also adds complexities due to the difficulty in maintaining the structural integrity of fabricated constructs. To tackle this challenge, the concept of in situ 3D bioprinting has been suggested in which tissues are directly printed at the site of injury or defect. Such approach could be combined with cells freshly isolated from patients to produce custom-made grafts that resemble target tissue and fit precisely to target defects. Moreover, the natural cellular microenvironment in the body can be harnessed for tissue maturation resulting in the tissue regeneration and repair. Here, we discuss literature reports on in situ 3D printing and we describe future directions and challenges for in situ 3D bioprinting. We expect that this novel technology would find great attention in different biomedical fields in near future.

Single-Stage Hybrid Repair of Right Aortic Arch With Kommerell’s Diverticulum

Kommerell diverticulum is uncommon, and it carries risks of dissection or rupture. Hybrid aortic arch repair is being used increasingly for this pathology. We report the hybrid arch repair of Kommerell diverticulum in a 72-year-old woman known for muscular dystrophy and right aortic arch with aberrant left subclavian artery. Head-vessel debranching was performed through median sternotomy using a handmade, bifurcated, Dacron graft. Stent-grafting was performed from the ascending aorta to the proximal descending aorta. To our knowledge, this report is the first description of debranching using a custom-made graft for hybrid repair of Kommerell diverticulum.

Physician Modification to Shorten a TAG Thoracic Endoprosthesis for Treatment of a Pseudoaneurysm in the Ascending Aorta

Purpose:To report initial use of a physician-modified Gore TAG Thoracic Endoprosthesis for the treatment of pseudoaneurysm in the ascending aorta. Technique: This technique is demonstrated in a 42-year-old man with a pseudoaneurysm of the ascending aorta after a Bentall operation. The treatable length extending from the sinotubular junction to the anastomotic aneurysm edge was only 5 cm. A 45×100-mm TAG endograft for the pseudoaneurysm was modified on a back table to shorten its length. The delivery shaft was incised, and the 2 threads that fasten the top and bottom portions of the stent-graft to the sleeve were pulled out. The unfolded half of the stent-graft was cut back after pulling out the strand for the back half. Next, this custom-made graft was deployed via a transcarotid approach with cardiopulmonary bypass; no endoleak was observed. Postoperative computed tomography showed a minute type Ib endoleak. The patient was doing well at postoperative month 6. Conclusion: Physician modification of a TAG endograft facilitated effective management of this ascending aortic lesion by shortening the length of aortic coverage.

Invited commentary

To create on-table fenestrated stent grafts requires a perfect knowledge of the technical aspects involved with this technology. The authors have previously written a number of articles on this topic, describing technical aspects and results in elective patients. Now, they present results in 12 acute patients with both complex abdominal and thoracoabdominal aneurysms. The results are such that one might be tempted to start using this method. Nevertheless, readers should understand all the risks involving homemade modifications (eg, exact orientation of the fenestrations in an oversized graft, the use of diameter-reducing ties, and reloading the device). In addition, back-table modification of a graft may compromise its sterility. Is it barely possible to match the safety and precision of a commercial professional organization. I am therefore tempted to say: do not copy this at home! That the article suffers from heterogeneity and that branches may be more forgiving and easier than fenestrations in thoracoabdominal aortic aneurysms (TAAAs), with not all symptomatic or even ruptured TAAAs requiring urgent treatment, does not temper my admiration for the skills and dedication of the authors and their team. Nevertheless, the homemade technique is not here to stay, but merely an incentive for commercial companies to develop off-the-shelf fenestrated and branched grafts. At this moment, with the custom-made fenestrated graft being released in the United States, the Cook (Bloomington, Ind) off-the-shelf four-branched graft has just received European community approval (CE mark). It is likely that a completely endovascular approach for acute TAAAs will compete well with the other available technical options (open, hybrid, and snorkels). In pararenal aneurysms, several off-the-shelf fenestrated devices have recently been made available for use in Europe. Over the years, it has proved very difficult to establish guidelines and minimum requirements before centers were allowed to use fenestrated and branched grafts. With custom-made grafts, however, there was some control, as planning and ordering of the graft involved the manufacturer. With grafts available off-the-shelf, it might become even more difficult to control the process. Using off-the-shelf grafts in less suitable, acute, or elective patients, especially by less experienced operators, will undoubtedly carry a high risk of failure. Controlled distribution of these grafts is therefore mandatory. Interested physicians have to understand the need to invest in these techniques before applying them to their patients. In conclusion, I can only applaud Dr Ricotta et al for their fantastic homemade work. I am eagerly awaiting further commercial developments but also realize the risks involved with these new products. Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patientsJournal of Vascular SurgeryVol. 56Issue 6PreviewFenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms. Full-Text PDF Open Archive

Scalloped Thoracic Stent-Graft for Treatment of Aortic Arch Aneurysms With Unfavourable Landing Zones

Endovascular treatments are limited in cases of thoracic aortic aneurysms extending up or proximal to the origin of the left subclavian artery (LSCA). In such cases, the LSCA is usually either occluded or revascularised. We report our first experience of four patients who underwent thoracic aneursym treatment with new custom-made grafts with a scallop in situ for the LSCA. The graft is tailor made per case, and a re-enforced scallop is positioned proximally allowing for the stent to be deployed beyond the origin of the LSCA; the origin of the LSCA remains patent, thus negating the need for revascularisation of the head and neck vessels on the left. The stent contains markers for identifying the scallop and are located along the midline to ensure correct alignment. All of the patients who underwent this procedure had technical success with flow through the LSCA both immediately after stent deployment and on follow-up imaging. This new stent has further expanded endovascular treatment options for patients with thoracic aneurysms extending up to and beyond the LSCA, which can play a part in improving outcome and decreasing mortality rates because surgery for revascularization will not be needed.

Polyelectrolyte multilayer surface functionalization of poly(dimethylsiloxane) (PDMS) for reduction of yeast cell adhesion in microfluidic devices.

Polyelectrolyte multilayers (PEMs) based on the combinations poly(diallyldimethylammonium chloride)∕poly(acrylic acid) (PDADMAC∕PAA) and poly(allylamine hydrochloride)∕PAA (PAH∕PAA) were adsorbed on poly(dimethylsiloxane) (PDMS) and tested for nonspecific surface attachment of hydrophobic yeast cells using a parallel plate flow chamber. A custom-made graft copolymer containing poly(ethylene glycol) (PEG) side chains (PAA-g-PEG) was additionally adsorbed on the PEMs as a terminal layer. A suitable PEM modification effectively decreased the adhesion strength of Saccharomyces cerevisiae DSM 2155 to the channel walls. However, a further decrease in initial cell attachment and adhesion strength was observed after adsorption of PAA-g-PEG copolymer onto PEMs from aqueous solution. The results demonstrate that a facile layer-by-layer surface functionalization from aqueous solutions can be successfully applied to reduce cell adhesion strength of S. cerevisiae by at least two orders of magnitude compared to bare PDMS. Therefore, this method is potentially suitable to promote planktonic growth inside capped PDMS-based microfluidic devices if the PEM deposition is completed by a dynamic flow-through process.

Thoracic aortic stent grafting: Is it ready for prime time?

16 The Journal of Thoracic and Cardiov Ricco and colleagues 1 are to be congratulated for their comprehensive reporting of the operative results of the French thoracic aortic stent grafting experience over the 2-year period from 1999 through 2001. This is the only report of its kind that depicts the results of an entire country’s experience. It was designed by the French National Health Insurance Fund, with the data verified by third-party advisors. The report is both timely and provocative in the wake of the US Food and Drug Administration’s recent approval of the use of the Gore TAG endograft for thoracic aortic aneurysms in an elective setting. A total of 166 thoracic aortic stent grafts were placed in 29 centers, with no center performing more than 15 cases, and most centers inserting 5 or less grafts in the 2-year period. Although presumably capturing all or most thoracic aortic stent-grafting cases performed in France during the time period, the report is limited in both its scope and its analysis. The most relevant limitations are the report’s retrospective nature and its inherent lack of follow-up data. Despite these flaws, the article reveals several important findings. Devices used included both industrial products (Gore [53%], Medtronic [32%], Stenford [4%], and Boston Scientific [0.5%]) and custom-made grafts designed by the implanting physicians (10%), a profile that is representative of trends around the world. The morbidity and mortality rates by device implanted or by physician specialty (ie, surgeon, radiologist, or cardiologist) are not provided. The overall mortality and major complication rates were significant at 10% and 29%, respectively (although 3 patients were not followed to 30 days). Type I or II endoleaks occurred in 16.3%, but among patients who had proximal descending thoracic aortic coverage (23 patients), 26% had a type I endoleak. Fifteen of the 23 had concomitant left subclavian artery transposition. All type I leaks required additional intervention either by means of open or endovascular techniques. The details of how and when these endoleaks were diagnosed are not provided. Two cases of proximal stent graft migration occurred, but it is not clear whether this migration occurred intraoperatively or postoperatively. None of the type II endoleaks (18 cases) were treated. Follow-up is not provided to demonstrate the natural history or prognosis of these type II leaks in this series. Type III endoleaks were not reported, although 3 of the type I leaks apparently occurred between 2 stent grafts. Paraplegia occurred in 6 (3.6%) patients. Although the anatomic detail and extent of aneurysm coverage is not provided for the patients who had paraplegia, 3 had concomitant abdominal aortic aneurysm repairs. Five of these 6 patients died. Neither spinal drainage nor perioperative evoked potential monitoring was used in any case, a practice that would seem prudent in high-risk cases. Chronic type B aortic dissection was present in 20% of the cases, and the mortality rate among this cohort was 15.2%. There were 17 cases of acute traumatic disruption treated with endografting, with a mortality rate of 6%. There were 3 cases of postoperative aortoesophageal or aortotracheal fistulae, a complication that is less common after conventional open repair. Endografts were placed in 3 patients with known septic aneurysms, and 2 of these patients died within 30 days. Finally, the authors appropriately highlight the fact that at least 17% of the aneurysms treated among the entire group were smaller than 50 mm, and the mortality rate among these cases was 5%. In summary, the report by Ricco and colleagues provides an unbiased glance of what the results of this new technology are likely to be when applied across a wide range of pathology, experience, and expertise. Despite the many advances in the

Initial Results of Endovascular Repair of Abdominal Aortic Aneurysms with a Self-expanding Stent-Graft

This study was performed to evaluate the authors' experience with the endovascular treatment of abdominal aortic aneurysm (AAA) with use of a self-expanding nitinol stent covered with a polyester fabric device and to report the implant's technical features, the immediate results, and the outcome 30 days after device implantation. From June 1997 to December 2001, we admitted 169 patients diagnosed with AAA. Of these, 134 were suitable to undergo endovascular repair with use of the Talent stent-graft. In one patient, it was technically impossible to proceed with the implantation procedure. Therefore, a total of 133 patients were treated with use of this technique (78.7%). The average age was 70.7 years (range, 52-88 y). There were 119 men and 14 women. Computed tomographic follow-up was done between the 15th and 30th postoperative days. The stent-grafts were successfully implanted in all 133 patients. Complications during the procedure included three type-I endoleaks (2.3%) and four iliac artery ruptures (3.0%), which were effectively treated by means of aortic or iliac extension grafts, respectively. The average surgical time was 2.92 hours (from 1.67 h to 7 h). Of the stent-grafts used, 125 were bifurcated (94.0%), two were straight tube grafts (1.5%), and six were conical aortouniiliac grafts (4.5%). Custom-made grafts were used in 62 patients (46.6%) and standard grafts were used in 71 (53.4%). Suprarenal fixation was performed in 117 patients (88%). One female patient developed a serious pulmonary embolism. Eight patients (6.0%) developed serious systemic inflammatory syndrome; two died of disseminated intravascular coagulopathy. There were two additional deaths, one from refractory shock and one suddenly from an unknown cause (total mortality rate, 3.0%). During the postoperative period, 70.3% of the patients developed mild fever (37.6 degrees C-38.9 degrees C). The average length of stay in the intensive care unit was 1.3 days (ranging from 1 d to 12 d) and the total hospitalization time was 4.2 days. Six type-II endoleaks were observed: two were corrected by video laparoscopy-assisted inferior mesenteric artery interruption and the other four were clinically followed up. The exclusion of AAA by endovascular techniques with use of the Talent device was possible in the majority of cases with a low incidence of complications. The most common serious postprocedural complication was systemic inflammatory syndrome.

Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms

Purpose: The purpose of this study was to assess the incidence and management of intra-operative technical problems during endovascular repair (EVR) of complex abdominal aortic aneurysms (AAA).Methods: From February 1995 to March 1999, 204 EVRs of nonruptured AAA were performed at our institution. One hundred seventy-six patients had an in-house custom-made graft; 172 were aorto-uni-iliac grafts, and four were aortoaortic grafts. Twenty-eight patients had a bifurcated graft. One hundred fourteen patients (56%) were high risk for conventional open repair. One hundred nine patients (53%) were not suitable for most commercially available devices.Results: Intraoperative technical problems occurred in 81 patients (40%). There were 37 endoleaks (27 proximal, 10 distal), 15 graft stenoses, one failure of graft deployment, two graft thromboses, three aortoiliac ruptures, five renal artery occlusions (one bilateral, four unilateral), and 18 internal iliac occlusions (five bilateral, 13 unilateral). Endovascular management of these problems was successful in 37 of the 81 patients (46%) and included 15 balloon dilatations, 21 additional stent placements, and one graft thrombectomy. Fifteen of the 81 patients (19%) had open procedures (four periaortic ligature placements, six open aneurysm repairs, three common iliac ligations, and two extra-anatomic bypass grafts). In the remaining 29 patients, the on-table problem was managed expectantly. During follow-up, two of 37 patients (5%) who were treated successfully with endovascular procedures experienced recurrence. There were five deaths (33%) among the 15 patients who underwent open procedures.Conclusion: Intraoperative problems occur frequently during the endovascular management of complex aneurysms. Many of these problems can be managed with additional endovascular techniques without an increased risk of recurrence or procedure-related complications. Open procedures in high-risk patients carry a high mortality rate. The team performing EVR of AAA should be skillful in advanced endovascular and open surgical procedures.

Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms.

The purpose of this study was to assess the incidence and management of intraoperative technical problems during endovascular repair (EVR) of complex abdominal aortic aneurysms (AAA). From February 1995 to March 1999, 204 EVRs of nonruptured AAA were performed at our institution. One hundred seventy-six patients had an in-house custom-made graft; 172 were aorto-uni-iliac grafts, and four were aortoaortic grafts. Twenty- eight patients had a bifurcated graft. One hundred fourteen patients (56%) were high risk for conventional open repair. One hundred nine patients (53%) were not suitable for most commercially available devices. Intraoperative technical problems occurred in 81 patients (40%). There were 37 endoleaks (27 proximal, 10 distal), 15 graft stenoses, one failure of graft deployment, two graft thromboses, three aortoiliac ruptures, five renal artery occlusions (one bilateral, four unilateral), and 18 internal iliac occlusions (five bilateral, 13 unilateral). Endovascular management of these problems was successful in 37 of the 81 patients (46%) and included 15 balloon dilatations, 21 additional stent placements, and one graft thrombectomy. Fifteen of the 81 patients (19%) had open procedures (four periaortic ligature placements, six open aneurysm repairs, three common iliac ligations, and two extra-anatomic bypass grafts). In the remaining 29 patients, the on-table problem was managed expectantly. During follow-up, two of 37 patients (5%) who were treated successfully with endovascular procedures experienced recurrence. There were five deaths (33%) among the 15 patients who underwent open procedures. Intraoperative problems occur frequently during the endovascular management of complex aneurysms. Many of these problems can be managed with additional endovascular techniques without an increased risk of recurrence or procedure-related complications. Open procedures in high-risk patients carry a high mortality rate. The team performing EVR of AAA should be skillful in advanced endovascular and open surgical procedures.

Total hip arthroplasty with a custom-made graft for a rheumatoid arthritis patient with severe protrusio acetabuli

Total hip arthroplasty with a custom-made graft for a rheumatoid arthritis patient with severe protrusio acetabuli

Total hip arthroplasty with a custom-made graft for a rheumatoid arthritis patient with severe protrusio acetabuli

When performing total hip arthroplasty (THA) for a rheumatoid arthritis patient with protrusio acetabuli, we made an acetabular model by computerized reconstruction of CT scan data. Using this model, a graft of dense hydroxyapatite plus tricalcium phosphate was made to fit the defect in the acetabular roof. Surgery was relatively easy and the graft fitted well. This method appears useful for THA when there is a large acetabular roof defect.