Endograft Occlusion Research Articles

Combination of Rotarex Thrombectomy and Angioplasty in the Treatment of Aortic Endograft Occlusion

Objective: The aim of this retrospective single-center study was to assess the effectiveness and safety of Rotarex thrombectomy and angioplasty (balloon dilatation and stenting) in the treatment of aortic endograft occlusion (AEO) after the endovascular repair of abdominal aortic aneurysm (AAA). Methods: Among a total of 683 patients who underwent the endovascular aneurysm repair (EVAR) for AAA between May 2010 and March 2020, 46 (6.7%) patients developed occlusions of the aortic endograft; 16 patients were treated with fogarty embolectomy, 4 were treated with AngioJet aspiration, and 26 patients with mechanical thrombectomy (Rotarex system). The average time for AEO was 5 weeks (range 2-11 weeks). Immediately after angiography, Rotarex thrombectomy was used to remove the thrombus and embolus. After thrombectomy, balloon dilation was performed, followed by stent-graft deployment. The patients’ characteristics, treatment details, and outcomes were collected and analyzed. Results: There were 26 patients with AEO, 20 males (76.9%), and with the mean age of 67 ± 12 years (51-87). The primary reasons for AEO were kinking or extrinsic compression of the graft limb and thrombosis. The circulation was successfully restored in all patients by mechanical thrombectomy. Additional dilation/stents were required for 24 patients (93.3%), and they were placed in the graft limbs, thus re-establishing patency. The complications were observed in five patients and included peripheral embolization blue toe syndrome found in three patients and ischemia-reperfusion injury found in two patients. No mortality or recurrent thrombosis was observed in the follow-up period, which was extended for 12 months. Conclusions: The combination of Rotarex thrombectomy and angioplasty is a safe and effective treatment method for AEO after endovascular AAA repair.

Side-by-side deployment of gore excluder legs at a narrow terminal aorta for endovascular aneurysm repair.

A narrow terminal aorta is a risk factor for endograft occlusion after endovascular aneurysm repair. To minimize limb complications, we used Gore Excluder legs positioned side-by-side at the terminal aorta. We investigated the outcomes of our strategy for endovascular aneurysm repair in patients with a narrow terminal aorta. We enrolled 61 patients who underwent endovascular aneurysm repair with a narrow terminal aorta (defined as < 18mm in diameter) from April 2013 to October 2021. The standard procedure involves complete treatment with the Gore Excluder device. When other types of main body endografts were used, they were deployed proximal to the terminal aorta, and we used the Gore Excluder leg device in the bilateral limbs. Postoperatively, the intraluminal diameter of the legs at the terminal aorta was measured to assess the configuration. During the follow-up period (mean: 2.7 ± 2.0years), there were no aorta-related deaths, endograft occlusions, or leg-related re-interventions. There were no significant differences between the pre- and postoperative ankle-brachial pressure index values in the dominant and non-dominant legs (p = 0.44 and p = 0.17, respectively). Postoperatively, the mean difference rate (defined as [dominant leg diameter-non-dominant leg diameter]/terminal aorta diameter) was 7.5 ± 7.1%. The difference rate was not significantly correlated with the terminal aortic diameter, calcification thickness, or circumferential calcification (r = 0.16, p = 0.22; r = 0.07, p = 0.59; and r = -0.07, p = 0.61, respectively). Side-by-side deployment of Gore Excluder legs produces acceptable outcomes for endovascular aneurysm repair with a narrow terminal aorta. The endograft expansion at the terminal aorta is tolerable without influencing calcification distribution.

Complete Aortic Endograft Occlusion in a Patient with Psoriasis: A Case Report and Systematic Review of the Literature Seeking for a Potential Causal Association

Background: We report a case of a patient with complete aortic endograft occlusion and no morphological characteristic that could explain this event, other than the hypercoagulant status associated with psoriasis. The patient had severe intertriginous psoriasis complicated with cellulitis and sepsis and was treated with endograft excision and replacement with an aortic tube graft.

Symptomatic Aortic Endograft Occlusion in a 70-year-old Male.

Case PresentationA 70-year-old male with prior aorta endovascular aneurysm repair presented with progressive lower extremity weakness over the course of several hours. There was noted loss of palpable bilateral femoral pulses in the emergency department. Computed tomography angiography revealed a kinked and occluded aortic endograft. He subsequently underwent successful axillobifemoral bypass revascularization.DiscussionKinking of endograft limbs and occlusion has been reported in a small percentage of patients. Bilateral leg ischemia due to aortic endograft occlusion is rare.

Endovascular aneurysm repair(EVAR) : Complication management

Avariety of complications may be experienced during or after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). Acute procedure-related complications include injury to the access vessels, improper endograft placement, ischaemic and systemic complications as well as the postimplantation syndrome. Femoral pseudoaneurysms, endograft migration, kinking or occlusion, endoleaks and endograft infection are complications that have been observed at follow-up. Meticulous patient selection and preprocedural work-up can reduce the incidence of these complications. The majority of the complications, acute as well those at follow-up, can be dealt with endoluminally. It is of essence, however, that awide variety of catheters, guidewires, stents, stent-grafts and embolics are readily available in the repertoire of the interventionalist. In asmall number of patients with endograft occlusion or infection or with bleeding complications/pseudoaneurysms of the access vessels, open surgical intervention may become necessary. To obtain optimal results, close interdisciplinary co-operation, especially between the interventionist, the vascular surgeon and the anaesthetist is mandatory.

Initial Clinical Experience Using the Low-Profile Altura Endograft System With Double D-Shaped Proximal Stents for Endovascular Aneurysm Repair

Purpose: To report the initial clinical results of endovascular aneurysm repair (EVAR) using the low-profile (14-F) Altura Endograft System, which features a double “D-shaped” stent design with suprarenal fixation and modular iliac components that are deployed from distal to proximal. Methods: From 2011 to 2015, 90 patients (mean age 72.8±8.3 years; 79 men) with abdominal aortic aneurysm (AAA; mean diameter 53.8±5.7 mm) were treated at 10 clinical sites in 2 prospective, controlled clinical studies using the Altura endograft. Outcomes evaluated included mortality, major adverse events (MAEs: all-cause death, stroke, paraplegia, myocardial infarction, respiratory failure, bowel ischemia, and blood loss ≥1000 mL), and clinical success (freedom from procedure-related death, type I/III endoleak, migration, thrombosis, and reintervention). Results: Endografts were successfully implanted in 89 (99%) patients; the single failure was due to delivery system malfunction before insertion in the early-generation device. One (1%) patient died and 4 patients underwent reinterventions (1 type I endoleak, 2 iliac limb stenoses, and 1 endograft occlusion) within the first 30 days. During a median follow-up of 12.5 months (range 11.5–50.9), there were no aneurysm ruptures, surgical conversions, or AAA-related deaths. The cumulative MAE rates were 3% (3/89) at 6 months and 7% (6/89) at 1 year. Two patients underwent coil embolization of type II endoleaks at 6.5 months and 2.2 years, respectively. Clinical success was 94% (84/89) at 30 days, 98% (85/87) at 6 months, and 99% (82/83) at 1 year. Conclusion: Early results suggest that properly selected AAA patients can be safely treated using the Altura Endograft System with favorable midterm outcome. Thus, further clinical investigation is warranted to evaluate the role of this device in the treatment of AAA.

Endovascular management of aortic endograft occlusion

Endovascular aortic repair is becoming the standard of care for abdominal aortic aneurysm. Despite aorta being a high flow system, there is still a definite risk of endograft occlusion. Management of occluded aortic endograft is highly controversial. Successful endovascular relining in aortic endograft occlusion is a technically demanding and forthcoming secondary intervention, not been studied extensively. We are reporting a case of aortic endograft thrombosis in a morbidly obese, 64-year-old gentleman with multiple comorbidities presenting with lifestyle-limiting claudication. The patient had a history of abdominal aortic aneurysm repair with aorto-uni-iliac device and femorofemoral bypass. The patient was managed by relining of aortic endograft with graft thrombectomy and snorkeling of the left renal artery. Postoperative course was uneventful. After 1 year of follow-up, the patient is free of symptoms with patent endograft. More empirical evidence is yet required to make the standard guidelines for the management of aortic endograft occlusion.

Initial and midterm results of the Bolton Relay Thoracic Aortic Endovascular Pivotal Trial

ObjectiveTo report the initial and midterm results of the Bolton Relay Thoracic Stent Graft for the endovascular treatment of thoracic aortic lesions [thoracic endovascular aortic repair (TEVAR)]. MethodsThe Bolton Relay Thoracic Aortic Endovascular Pivotal Trial was a prospective, nonrandomized, multicenter, U.S. Investigational Device Exemption study conducted at 27 U.S. investigational sites. One hundred twenty TEVAR subjects were treated with the Relay device between January 2007 and May 2010, with 13 patients enrolled during the continued access phase through September 2012. TEVAR outcomes were compared with a prospectively and retrospectively enrolled surgical cohort consisting of 60 patients enrolled under similar inclusion/exclusion criteria. Follow-up examinations were prescribed at 1 month, 6 months, and yearly thereafter for 5 years. Major adverse events (MAEs) included stroke, paralysis/paraplegia, myocardial infarction, procedural bleeding, respiratory failure, renal failure, wound healing complications, and aneurysm-related mortality. ResultsStent grafts were successfully delivered and deployed in 129 of 133 patients (97.0%). At 30 days, a lower rate of mortality was observed in the TEVAR arm (5.3% vs 10.0%; P = .230), and TEVAR was associated with a significantly lower rate of MAEs (20.3% vs 48.3%; P < .001), primarily driven by a lower frequency of respiratory failure in the cohort (5.5% vs 21.6%; P = .007) and procedural bleeding. Freedom from aneurysm-related mortality through 5 years was similar at 91.3% for the TEVAR cohort and 89.4% for the surgical cohort (P = .406); with 5-year freedom from all-cause mortality at 57.1% and 50.2% (P = .289), respectively. Freedom from MAEs through 5 years was significantly higher in the TEVAR cohort (65.7% vs 44.7%; P = .001). Six TEVAR patients (4.5%) experienced core laboratory-reported type I or III endoleaks, and secondary procedures were performed in 10 patients (7.5%), with seven procedures to correct endoleak and one surgical conversion. Endograft migration occurred in three patients (2.3%) and wireform fractures were assessed in two patients (1.5%). Aneurysm sac size decreased or remained stable in 113 patients (85.0%) over 5-year follow-up. There were no instances of rupture or endograft occlusion. A 38-subject subset treated with the newer Relay Plus Delivery System had a significantly reduced MAE rate (15.8% vs 35.8%; P = .035), and fewer perioperative strokes (2.6% vs 12.6%; P = .108). ConclusionsData from the Relay TEVAR clinical trial demonstrate safety and effectiveness of the Relay device compared with surgical controls, indicating continued device durability with a low rate of device-related complications through 5 years.

Total Abdominal Aortic Stent Graft Occlusion

We report a case involving an acute chronic endovascular abdominal aortic stent graft occlusion in which percutaneous angioplasty was performed via bilateral trans femoral approach. This case emphasized that endograft occlusion treatment after endovascular aortic aneurysm repair (EVAR) is feasible.

Promoting False-Lumen Thrombosis after Thoracic Endovascular Aneurysm Repair in Type B Aortic Dissection by Selectively Excluding False-Lumen Distal Entry Tears

PurposeTo evaluate the efficacy and clinical outcomes of ancillary endovascular procedures in promoting false-lumen (FL) thrombosis (FLT) and preventing aortic expansion in patients after thoracic endografting for type B dissections. Materials and MethodsThis retrospective review included 15 patients (12 men and 3 women; mean age, 59.6 y). Mean aortic diameter at the time of ancillary treatment was 47.4 mm. Different techniques were used as single procedures or sequentially: covered stent occlusion of detached visceral artery entry tears, occlusion of single entry tears with vascular plugs, or aortic endograft occlusion of multiple FL entry tears. FL embolization with ethylene vinyl alcohol copolymer was performed when selective occlusion was considered insufficient to close distal entry tears. Apart from endovascular aneurysm repair, all procedures were performed percutaneously under local anesthesia. If FL diameter increase persisted after 6-month follow-up computed tomographic (CT) angiography, another intervention was planned; otherwise, yearly follow-up was performed. ResultsMean clinical follow-up duration was 43.8 months (range, 8 d to 86.8 mo), with no in-hospital mortality. Estimated overall survival rates were 93.3%, 86.6%, and 77% at 12, 24, and 48 months, respectively. Three late deaths occurred, one of which was dissection-related at 40 months. Eight surviving patients (53%) had total FLT and 3 had partial FLT with stable aortic diameter on follow-up CT angiography. FL diameter increased in one patient, requiring further intervention. ConclusionsSelective exclusion of new distal entry tears remaining after thoracic endovascular aneurysm repair can stabilize abdominal aortic expansion and promote FLT.

A Modern Series of Acute Aortic Occlusion

Acute aortic occlusion (AAO) is rare with the last large series published in 1998 which included patients dating back to the 1980’s. These studies report that 50% of AAOs secondary to embolization with an approximate mortality rate of 50%. We reviewed our recent experience with AAO to identify current etiologies and outcomes in a modern era. CPT codes were used to identify patients with AAO from 2005-2012 from a prospectively maintained surgical database. AAOs secondary to trauma, dissection or endograft occlusion were excluded. We identified 22 patients with AAO as outlined in Table. Seventeen presented with isolated occlusion and five with occlusion extending above the renal arteries. Significant lower extremity neurologic deficits were noted in 12 patients, six with complete paralysis. Mean time from symptom onset to diagnosis was 36 hours (range, 6-72 hours). 16 (73%) presented to our institution as a transfer. Etiology was aortoiliac thrombosis in 17 (77%) cases, embolic occlusion in 1, and indeterminate in 4. Extra-anatomic bypass was performed in 14 patients, thromboembolectomy in 4 and aortobifemoral bypass in 3. One patient died prior to intervention. Acute renal failure developed in 14 patients (68%) and eight had rhabdomyolysis. Fasciotomy was performed in 14 (68%) extremities and nine extremities required amputation (41%). All cause mortality was 41% with all deaths occurring within 3 months of AAO. AAO is an infrequent but devastating event. Our experience demonstrates that the etiology of AAO the etiology has shifted from embolic to aortoiliac thrombosis. Despite advances in vascular surgery over the past decades, however, the morbidity and mortality remain significant with a high rate of limb loss, acute renal failure, rhabdomyolysis and death. Contributing factors to poor outcomes continue to be delays in diagnosis and the need for highly skilled tertiary centers.TablePatient characteristicsN = 22 (%)Median age at diagnosis66.8Male12 (55)PAD13 (59)CAD13 (59)CVA/TIA5 (23)HTN17 (77)CHF5 (23)Diabetes9 (41)Smoker16 (76)Thrombophilia5 (23)Atrial fibrillation4 (18) Open table in a new tab

Incidence and treatment results of Endurant endograft occlusion

The Endurant endograft (Medtronic Inc, Minneapolis, Minn) is a new-generation device specifically developed to perform well in complex abdominal aortic aneurysm anatomy. Previous reports on the 1- and 2-year results of endovascular aneurysm repair (EVAR) with the Endurant endograft showed excellent outcome, including prevention of migration and type I endoleaks, but occurrence and outcome of post-EVAR occlusion have not been determined in a large multicenter patient cohort with midterm follow-up, which is the objective of this study. Data of consecutive patients treated with the Endurant from December 2007 to April 2012 in three Dutch tertiary vascular referral hospitals were prospectively gathered and retrospectively analyzed. Follow-up consisted of regular office visits, computed tomography angiography at 1 and 12 months after EVAR, and subsequently, duplex ultrasound imaging or computed tomography angiography at regular intervals. Patients with ruptured aneurysms or with earlier abdominal aortic surgery were excluded. The incidence and clinical outcome of endograft occlusions were analyzed. An expert review board assessed all cases in the search for possible causes of occlusion. Included were 496 patients (87.7% male), who were a median age of 74 years (range, 68-78 years). Median follow-up was 1.7 years (range, 0-4.6 years). Twenty graft occlusions (4.0%) occurred during follow-up. Median time between primary EVAR and detection of the occlusion was 1 month, with 55% occurring ≤ 60 postoperative days and 90% ≤ 1 year. No association was found between occlusion and sex (P = .28), age (P = .96), or use of an aortouniiliac device (P = .66). Technical error was the considered cause of the occlusion in 12 patients (60%). The estimated freedom from occlusion was 98.4% at 30 days, 95.7% at 1 year, and 95.3% at 3 years. Presenting symptoms of occlusion were acute limb ischemia in 50%. Treatment was surgical (75%) or percutaneous (25%). Successful revascularization was achieved in 17 of 20 patients, but reocclusions occurred in five, resulting in a transfemoral amputation in one patient. Occlusion-related mortality was 0.6% (3 of 496). At a median follow-up of 1.7 years, Endurant endograft occlusion occurred in 4.0% of 496 patients. Most occlusions occurred ≤ 2 months after EVAR, and rarely after 1 year. A technical justification for occlusion could be found for 60% of patients. A more liberal intraoperative and early postoperative (re)intervention strategy may reduce the occlusion rates and improve outcome.

Outcomes after endovascular abdominal aortic aneurysm repair are equivalent between genders despite anatomic differences in women

Prior work confirms gender-specific anatomic differences in patients undergoing endovascular aneurysm repair, but the clinical implications remain ill defined. The purpose of this study was to compare gender-specific early outcomes after endovascular aneurysm repair using a large international registry. Over the 2-year period ending in 2011, 1,262 patients (131 women, 10.4%; 1,131 men, 89.6%) with infrarenal aneurysms treated with the Endurant stent graft were prospectively enrolled in the ENGAGE registry and followed clinically and radiographically. Women were older (75.5± 7.0 vs 72.8± 8.1; P= .0003) and had smaller aneurysms (57.8± 9.5 vs 60.6±11.9mm; P= .01). Women's infrarenal aortic necks were of narrower diameter (21.8± 3.4 vs 24.0± 3.5 mm; P<.0001), shorter length (24.3± 11.8 vs 27.3± 12.4 mm; P= .009), and greater angulation (37.7± 26.2° vs 29.4±23.3°; P=.0002). More women had an infrarenal neck angle >60° (19.2% vs 9.1%; P= .001). Technical success was achieved in equal numbers of women and men (97.7% vs 99.2%; P= .10). On completion angiography, the incidence of any endoleak (21.5% vs 15.4%; P= .08) and type I endoleak (1.5% vs 1.1%; P= .60) did not differ between genders. At the 1-month follow-up, there were no differences between women and men with respect to endograft occlusion (2.5% vs 1.9%; P=.70), and differences observed in any endoleak (17.2% vs 11.4%; P= .08) and type I endoleaks (3.3% vs 1.2%; P=.08) did not reach statistical significance. Freedom from major adverse events was similar for women and men at 30days (98.5% vs 95.8%; P= .23) and 1 year (85% vs 89.8%; P= .40). Survival at 30 days (100% vs 98.6%) and 1 year (92.5% vs 91.6%; P= .99) was similar for women and men. This large multinational registry confirms the previously observed prevalence of suboptimal neck anatomy in women. Even though women have shorter and more angulated infrarenal necks, their technical outcomes at 30 days and clinical outcomes at 1 year were similar to those of men. Much longer follow-up is necessary to determine whether these outcomes proved durable.

Endovascular Repair of Iatrogenic Subclavian Artery Perforations Using Stent-Graft: Report of a Case

Purpose: To report a case of iatrogenic subclavian artery perforation treated with Vascular Stent-Graft.Case Report: A 54-year-old married male was admitted to Chung Shin Hospital with the chief complaint of severe sharp pain in his right clavicular region after a traffic accident on April 6, 2009. Fracture of the right clavicle was diagnosed after X-ray examination. The patient immediately underwent open reduction and internal fixation (ORIF) with a Kirschner wire with an uneventful postoperative course. The K-wire was removed 4 weeks later, on May 8, 2009. However, pain in the right clavicular area recurred and lasted for almost one month. A repeated X-ray was showed ”Non-union of the right clavicular fracture”. The patient underwent a ”redo” open reduction (ORIF) on June 2, 2009. During the operation, the patient sustained an accidental right subclavian artery injury resulting in active bleeding and pseudo-aneurysm formation there of; he was transferred to Chung Shan Medical University Hospital, and after CT angiography, he underwent endovascular repair of his right subclavian artery perforation.Results: The endovascular prosthesis (Fluency Plus Vascular Stent Graft 10 60 mm, Bard®) was successfully deployed at the site of the pseudoaneurysm via ipsilateral femoral artery access. No signs of endograft occlusion, migration, deformation, or fracrture have been observed during the follow-up period of eleven months.Conclusion: Endovascular repair of the subclavian artery injury may be an acceptable alternative to other more invasive modes of therapy. A sufficiently long follow-up, however, is needed to determine if the design of this endograft will resist compression in this vascular location.

Incidence and Evolution of Mural Thrombus in Abdominal Aortic Endografts

The aims of this study were to analyze the predictive factors for intragraft mural thrombus formation and evolution during follow-up after endovascular treatment of abdominal aortic aneurysms and to evaluate its relationship with the subsequent appearance of complications. A retrospective study was performed by selecting those patients who underwent endovascular repair of an abdominal aortoiliac aneurysm between June 1998 and September 2004, with a minimum follow-up of 24 months. Preoperative clinical data, anatomical characteristics of the aneurysm, and endograft type were analyzed. In addition, clinical evaluation and abdominal computed tomography angiography (CT scans) performed at 1, 6, 12, and 24 months after the surgery were reviewed. Eighty-nine patients were submitted for endovascular aneurysm repair in this period, and 75 completed the 24-month follow-up. Eighteen patients developed intragraft mural thrombus (24% incidence), 13 (72.2%) appearing at 1 month of follow-up, and up to 16 (88.9%) appearing during the first 6 months. Logistic regression analysis showed that the lumen percentage of mural thrombus in the native aorta and the use of aortouniiliac endografts were independent predictors of intragraft mural thrombus formation (odds ratio, 1.065; 95% confidence interval, 1.022-1.110, and odds ratio, 8.014; 95% confidence interval, 1.598-40.181, respectively). No spontaneous regression of the thrombus was observed. The area of intragraft mural thrombus had increased at 12 and 18-24 months after their diagnosis (Wilcoxon signed rank test, p = 0.028 and 0.028, respectively). The presence of intragraft mural thrombus was associated with a greater tendency to endograft body or branch occlusion (5 of 18 cases with intragraft mural thrombus (27.8%) versus 1 of 57 cases without it (1.8%), (p = 0.003). Intragraft formation of mural thrombus is a common finding during the follow-up of abdominal aortic endografts, particularly in aneurysms with large mural thrombus of the native aorta, and is associated with the use of aortouniiliac endografts. The area occupied by the mural thrombus was shown to gradually increase during follow-up and was associated with a greater tendency for endograft occlusion.

Aortic endograft thrombosis after colorectal surgery in lithotomy position

Aortic endograft limb occlusion is a serious complication after endovascular abdominal aortic aneurysm repair. We describe a yet unreported cause of endograft limb occlusion, the lithotomy position. Two patients with abdominal aortic aneurysm and colorectal cancer underwent an initial endovascular repair followed by cancer resection in the lithotomy position. Aortic endograft limb occlusion occurred in both patients immediately after the cancer operation. Percutaneous rheolytic thrombectomy was performed successfully in both patients. Pelvic surgery requiring the lithotomy position should be performed with caution in patients with aortic endografts, because it can result in endograft occlusion.

Endovascular Repair of Iatrogenic Subclavian Artery Perforations Using the Hemobahn Stent-Graft

PURPOSE To report the use of a new self-expanding endograft for percutaneous treatment of iatrogenic subclavian artery perforations. CASE REPORTS The subclavian artery of 2 patients was inadvertently cannulated during percutaneous attempts to implant a permanent pacemaker in one and catheterize the subclavian vein in the other. Because both patients had serious comorbidities, endovascular repair of the subclavian perforations was performed using the Hemobahn endograft, a nitinol stent covered internally with expanded polytetrafluoroethylene. The endoprostheses were successfully deployed via an ipsilateral brachial artery access. No signs of endograft occlusion, migration, deformation, or fracture have been observed during follow-up at 12 and 10 months, respectively, in these patients. CONCLUSIONS The Hemobahn stent-graft appears well suited to repairing subclavian artery injuries. Longer follow-up will determine if the design of this endograft will resist compression in this vascular location.