Emergency Endovascular Stent Grafting Research Articles

Emergency endovascular stent grafting for aortic transection following a shotgun injury.

Emergency endovascular stent grafting for aortic transection following a shotgun injury.

Benefit of Emergent Endovascular Stent Grafting Is Undone by Postoperative Renal Dysfunction

Benefit of Emergent Endovascular Stent Grafting Is Undone by Postoperative Renal Dysfunction

Emergent endovascular stent grafting for saccular arch aneurysm complicated by aorto-esophageal fistula

Aneurysms of aortic arch are rare but amenable to endovascular therapy. Arch aneurysm presenting with aorto-esophageal fistula and hematemesis is a feared, but relatively rare complication. The extrapolation of the safety and rapidity of emergent endovascular repair for bleeding arch aneurysms has been infrequently reported. A bovine arch anatomy confers distinct advantages for endovascular therapy often avoiding a preceding debranching surgery. However, its endovascular treatment might be complicated by the nonhealing of fistula and potential risk for mediastinitis. Here, we report a case of a bovine aortic arch cystic aneurysm complicated by bleeding aorto-esophageal fistula, which warranted an emergent endovascular therapy. The prevertebral part of LSCA was plugged to interrupt the retrograde filling and a future endoleak. A nonhealing aorto-mediastinal fistula at follow-up was successfully treated by covered esophageal stenting. This report reiterates the importance of multidisciplinary approach with multispecialty collaboration to such complex spectrum of diseases.

Endovascular Stent-graft Placement for the Emergency Treatment of Ruptured Descending Aortic Aneurysm

Ruptured aortic aneurysm is a condition that requires emergency treatment because of its high mortality rate. In this case, we presented the emergency endovascular treatment of a ruptured descending thoracic aortic aneurysm. A female patient, admitted to the emergency with sudden onset back pain, was treated by emergency endovascular stent-graft after CT angiography examination. According to endovascular treatment, surgical treatment has a high mortality and morbidity rate in the treatment of the ruptured descending thoracic aortic aneurysms. The endovascular stent-graft treatment is applied safely and successfully to the intervention of this pathology. (JAEM 2014; 13: 97-8)

Emergency endovascular stent grafting in acute complicated type B dissection

The objective of this study was to assess midterm results of emergency endovascular stent grafting for patients with life-threatening complications of acute type B aortic dissection. Between March 1999 and November 2011, 110 patients (86 men, 24 women) with complications of acute type B aortic dissection (mean age, 61years; range, 19-87years) were treated with thoracic endovascular aortic repair for malperfusion (55.5%) or aortic rupture (53.6%) in five major European referral centers and one U.S. referral center. Additional comorbidities included hypertension in 90 patients (82%), diabetes in 14 patients (13%), and chronic obstructive pulmonary disease in six patients (6%). Eleven patients (10%) had undergone previous aortic surgery. Overall hospital mortality was 12% (n= 13), with 14 late deaths after hospital discharge. In-hospital complications occurred in 32 patients (36%); 10 patients developed postoperative renal failure, five patients experienced new permanent neurologic symptoms, and six patients (5.4%) experienced retrograde type A aortic dissection. Furthermore, nine patients (8%) developed an early type I endoleak. Actuarial survival at 1 and 5years was 85% and 73%, respectively. Postprocedural computed tomography angiography showed complete or partial thrombosis of the false lumen at the stent graft level in 61% and 23% of all patients, respectively. Freedom from treatment failure according to the Stanford classification was 82%, 75%, and 59% at 1, 3, and 5years. Endovascular repair of complicated acute type B aortic dissection is proven to be a technically feasible and effective treatment modality in this relatively difficult patient cohort. Short-term and midterm results are persuasive; however, the long-term efficacy needs to be further evaluated.

Endovascular treatment of descending thoracic aortic rupture

To update our experience with descending thoracic aortic rupture (DTAR) endovascular repair over a 6-year period. This was a prospective, non-randomized, single-centre study. We included all patients diagnosed with rupture of the thoracic aorta, who underwent endovascular grafting between January 2005 and January 2011. Data were analysed using SPSS version 15.0. During the study interval 25 patients were diagnosed with DTAR. Sixteen patients with ruptured degenerative aneurysm (64%), four traumatic transection (16%), three acute complicated type B dissection (12%) and two acute complicated penetrating ulcer (8%). Nineteen patients (76%) were men, six women; the mean age was 62.96 (±19.75) years. At admission, mean standard euroSCORE was 8.46 (±3.55), and mean APACHE II 14.96 (±8.53). Emergent endovascular stent grafting was successfully performed in all patients, no conversion to open repair was necessary. Mortality at Intensive Care Unit was 16% (four patients). Overall follow-up (mean 26.6 months, range 3-68) mortality in our series was 28%. Only one patient suffered a severe neurological complication (stroke). Late complications of endovascular procedure and need for reoperation appeared in one patient because of a secondary leak. Although this study is not a comparative analysis of DTAR, mortality and morbidity rates were lower than previously reported with emergent open surgical repair. One-year treatment results indicate a low incidence of graft-related complications. Endovascular treatment of the thoracic aortic rupture should be considered feasible and well tolerated in the short and medium term.

Emergency endovascular Stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

Background An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery. Case Description We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day. Conclusions Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.

Complicated acute type B aortic dissection: Midterm results of emergency endovascular stent–grafting

Complicated acute type B aortic dissection: Midterm results of emergency endovascular stent–grafting

Emergency treatment of the thoracic aorta: results in 113 consecutive acute patients (the Talent Thoracic Retrospective Registry)☆

Elective thoracic endovascular aortic repair in selected patients with suitable aortic anatomy is associated with low morbidity and mortality, and is gaining widespread acceptance. Its benefit in acute thoracic aorta diseases, however, has not yet been demonstrated in high-numbered studies. This report presents data of the Talent Thoracic Retrospective Registry (TTR) of all patients who underwent endovascular stent grafting for acute thoracic aorta pathology. Between December 1996 and July 2004 data were collected regarding 113 consecutive patients who underwent emergent endovascular stent grafting of the thoracic aorta using the Talent thoracic stent graft (Medtronic, Inc., Santa Rosa, California) in 7 European referral centers. Acute thoracic aorta pathology consisted of 41 (36.3 %) traumatic aortic injuries, 37 (32.7 %) Stanford type B dissections, 5 (4.4 %) intramural hematomas, 18 (15.9 %) thoracic aorta aneurysms, 4 (3.5 %) pseudoaneurysms and 8 (7.1 %) penetrating ulcers. In all patients the stent graft system could be introduced via the common femoral artery. Conversion to open surgical repair was necessary in 2 patients, one in the early phase due to persistent bleeding via backflow in the false lumen from a distal entry tear, and another patient in a late phase due to retrograde dissection. Intraoperative mortality was 1.8%, one patient suffered a massive myocardial infarction, and another died of tamponade secondary to retrograde dissection. Overall hospital mortality was 8.0% (9 patients). In only 2 of them, it was considered a stent graft procedure related death. New neurological symptoms were seen in 6.2% (7 patients), with complete recovery in 5 patients. Mean follow-up was 15 months (range 1-69 months). Late mortality was 8.7% (9 patients). Only one late death was considered aorta related. Overall re-intervention rate was 8.9% (n=10) and was mainly for type I endoleak or persistent false lumen perfusion. Sub-analysis of the Talent Thoracic Retrospective Registry for endovascular stent grafting of acute thoracic aorta pathology in over 100 consecutive patients demonstrated its feasibility, with low morbidity and acceptable low mortality rates.

Complicated acute type B aortic dissection: Midterm results of emergency endovascular stent–grafting

This study assessed midterm results of emergency endovascular stent-grafting for patients with life-threatening complications of acute type B aortic dissection. Between November 1996 and June 2004, 16 patients with complicated acute type B aortic dissections (mean age 57 years, range 16-88 years) underwent endovascular stent-grafting within 48 hours of presentation. Complications included contained rupture, hemothorax, refractory chest pain, and severe visceral or lower limb ischemia. Stent-graft types included custom-made first-generation endografts and second-generation commercial stent-grafts (Gore Excluder or TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz.). Follow-up was 100% complete, averaged 36 +/- 36 months, and included postprocedural surveillance computed tomographic scans. Early mortality was 25% +/- 11% (70% confidence limit), with no late deaths. No new neurologic complications occurred. According to the latest scan, 4 patients (25%) had complete thrombosis of the false lumen; the lumen was partially thrombosed in 6 patients (38%). Distal aortic diameter was increased in only 1 patient. Actuarial survival at 1 and 5 years was 73% +/- 11%; freedom from treatment failure (including aortic rupture, device fault, reintervention, aortic death, or sudden, unexplained late death) was 67% +/- 14% at 5 years. With follow-up to 9 years, endovascular stent-grafting for patients with complicated acute type B aortic dissection conferred benefit. Consideration of emergency stent-grafting may improve the dismal outlook for these patients; future refinements in stent-graft design and technology and earlier diagnosis and intervention should be associated with improved results.

Fatal cerebellar stroke following emergency endovascular stent grafting of a leaking thoracic aortic aneurysm: A case report

Stent-grafting of thoracic aortic diseases has developed as an alternative therapeutic modality in thoracic aneurysm management. Postprocedural complications include mortality, endoleaks, paraplegia and stroke. Other complications that may arise in cases of overstenting the origin of the left subclavian arther include left upper limb ischemia, subclavian steal syndrome and stroke. Posterior circulation strokes due to vertebral artery insufficiency have been reported in the past. In the present case, a fatal stroke caused by a cerebellar infarct culminating in the death of a patient with a leaking thoracic aortic aneurysm is reported. Medical personnel as well as patients should be aware of this possible complication. Vigilance in assessing the contralateral cerebral circulation before the procedure is a prerequisite in less acute circumstances.

High output heart failure due to an iatrogenic arterio-venous fistula after lumbar disc surgery

Vascular injury is a rare but not uncommon complication of spinal surgery and associated with dramatic consequences. Congestive heart failure secondary to a hyperkinetic circulation can occur in systemic diseases and in arterio-venous fistulae. A 57-year-old man was admitted to hospital complaining of dyspnoea and oedema of the left leg. Eight days previously he had undergone a discectomy at L4-L5. On auscultation a systolic-diastolic murmur was noted over the entire abdomen. An echocardiogram demonstrated an enlarged right atrium, severe mitral and tricuspid regurgitation and increased pulmonary artery pressure. An abdominal CT demonstrated irregular dilatation of the left common iliac vein and through a fistula and simultaneous opacification of the right common iliac artery; subsequently, this was also confirmed by angiography. The patient underwent an emergency endovascular stent-graft of the right common iliac artery with normalization of the venous return pressure and quick resolution of the heart failure. It is important for the physician involved in clinical work to keep in mind all the possible post-surgical complications that can occur in symptomatic patients who have recently undergone an intervention.

Endovascular Treatment of Traumatic Thoracic Aortic Transection—Role of Timing: A Case Report

Clinical management of traumatic thoracic aortic transection gains importance because of controversial approaches regarding diagnosis, treatment choices, and the timing of treatment modalities. We report on an emergency endovascular stent graft implacement for a patient with acute traumatic thoracic aortic transection and discuss the role of timing for this kind of procedure.

Immediate Endovascular Stent-grafting for Leg Ischemia secondary to Acute Aortic Dissection: Report of a Case

Generally, extra-anatomical bypass grafting has been chosen for patients with leg ischemia secondary to acute aortic dissection. However, these patients are high-risk candidates for visceral vessel compromise as well. We present a case of leg ischemia secondary to acute aortic dissection, which was able to be treated by immediate stent-grafting. A 58-year-old male was transferred to our hospital for acute right-leg ischemia. Computed tomography revealed partial infarction of right kidney and severely compressed true lumen of abdominal aorta. Emergency endovascular stent-grafting was chosen to consider possible visceral vessel compromises instead of contemporary bypass grafting for leg ischemia. Pulsation of the right femoral artery was immediately achieved following stent-grafting. Primary entry closure using a Stent graft could be a treatment of choice for complications due to acute aortic dissection.

Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study

To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting. Retrospective case control study in two surgical intensive care units of a university hospital. 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46+/-18 vs. 35+/-15 years). In the surgical group time spent in the operating theater was longer (310+/-130 vs. 140+/-48 min) and blood losses higher (2000+/-1300 vs. no significant bleeding); aortic clamping time was 48+/-20 min. The mortality rate was 15% with ESG (n=2) and 23% with surgery (n=4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups. Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.

Emergency Endovascular Stent-Grafting for Life-Threatening Acute Type B Aortic Dissections

Background There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection. Methods In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 ± 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 ± 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography. Results In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths. Conclusions Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.

Endovascular Treatment of a MRSA Infected Left External Iliac Artery Pseudoaneurysm

Infected aneurysms and pseudoaneurysms pose a therapeutic conundrum. Conventional practice avoids the placement of foreign material in infected sites, however, there are reports of the use of endovascular stent-grafts in this situation. We describe the successful immediate and 1 year outcome of emergency endovascular stent-grafting of a methicillin resistant Staphylococcus aureus (MRSA) infected pseudoaneurysm.

Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms

Background The purpose of our study was to demonstrate the effectiveness of endovascular stent grafts in the treatment of acutely ruptured thoracic aortic aneurysms and type B dissections as an alternative to the conventional surgical approach in an emergency setting. Methods From January 2001 to October 2001, we deployed 11 emergent endovascular stent grafts into the thoracic aorta. We treated seven ruptured aortic aneurysms and four acutely perforated type B dissections. Aortic rupture was confirmed preoperatively by spiral computed tomography. In all cases, hemothorax was present. The average interval from onset of symptoms to treatment was 28.5 hours. We used nine Talent and two Excluder stent grafts. Results Deployment of the stent grafts was successful in nine cases. There were two cases of access failure due to small caliber of iliac arteries, and 1 of these patients died shortly after the procedure was abandoned, At 12 months of follow-up, there were no cases of paraplegia, stent migration, or endoleaks. There was, however, one temporary renal failure, and 2 patients required mechanical ventilation for more than 48 hours. Conclusions Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in high-risk patients.

Emergency endovascular interventions for ruptured thoracic and abdominal aortic aneurysms

Background The purpose of our study was to show the effectiveness of endovascular stent grafts in the treatment of acutely ruptured abdominal and thoracic aortic aneurysms as an alternative to the conventional surgical approach in an emergency setting. Methods From October 1996 to October 1998 we deployed 9 emergent endovascular stent grafts—6 in the abdominal aorta and 3 in the thoracic aorta. Aortic rupture was confirmed before surgery with spiral-computed tomographic scan. The average interval from onset of symptoms to treatment was 4.5 hours. We used commercially manufactured stent grafts: 4 Corvita (Corvita Inc/Schneider Corp/Boston Scientific Corp, Natick, Mass), 3 Talent (World Medical Inc, Surise, Fla/Medtronic, Sunnyvale, Calif), and 2 Vanguard (Boston Scientific Corp, Natick, Mass). Results Deployment of the stent grafts was successful in all cases. Two patients died in the follow-up period (120 months) from myocardial infarction. No cases were seen of paraplegia or stent migration. However, 2 endoleaks, 1 in-stent stenosis, 1 temporary renal failure, and 1 brief episode of myocardial ischemia occurred. Conclusion Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in selected patients. (Am Heart J 2002;144:544-8.)