Endovascular Aortic Repair Procedures Research Articles

Role of requests and communication breakdowns in the coordination of teamwork: a video-based observational study of hybrid operating rooms

ObjectivesThis study investigated the functional role of ‘requests’ in the coordination of surgical activities in the operating room (OR). A secondary aim was to describe, closely, instances of potential miscommunication...

Early Results of a Novel Single-Stage Hybrid Aortic Arch Replacement Technique to Reduce Bypass and Circulatory Arrest Duration.

Hybrid repair procedures of the aortic arch have been utilized to reduce surgical risks and apply this therapy to patients who would not traditionally be candidates for open surgical repair. We present a variation on the frozen elephant trunk technique to further reduce cardiopulmonary bypass and circulatory arrest duration. After initiation of cardiopulmonary bypass and during systemic cooling, a wire is advanced from the femoral artery into the aortic arch. In the case of aortic dissection, intravascular ultrasound is used to confirm true lumen placement. Under circulatory arrest, the proximal aortic arch is resected and the wire externalized. Antegrade deployment of a stent graft is performed into the aortic arch and proximal descending aorta. The ascending aortic graft is sewn to the cut end of the aorta, incorporating the stent graft. The graft is cannulated and cardiopulmonary bypass reinitiated. The remainder of the arch replacement is performed during re-warming. Twenty two patients underwent this novel hybrid arch replacement procedure for aortic pseudoaneurysm, aortic dissection, or aneurysm. In comparison to the frozen elephant trunk procedure, where a dacron graft is inserted into the descending aorta, and later fixed with an endograft, this technique allows for immediate distal fixation. In the case of aortic dissection, there is immediate expansion of the true lumen with distal seal, potentially obviating the need for additional procedures. Mean duration of follow up is 12 months (range 1 - 14 months). The mean duration of cardiopulmonary bypass was 109.32 ±3.14 minutes. The mean duration of circulatory arrest was 18.00 ±1.33 minutes at a mean temperature of 23.64 ±0.58 degrees Celsius. There were no mortalities, no permanent disabling strokes, and no renal failure (requiring dialysis). This novel hybrid technique for aortic arch replacement is safe, significantly reduces cardiopulmonary bypass and circulatory arrest times, and is performed readily without need for fluoroscopy. In patients with thoracoabdominal aneurysms, the stent graft can be used as an elephant trunk for further thoracoabdominal aneurysm repair or branched thoracic endovascular aortic repair procedures.

Game changers in vascular and endovascular surgery

Game changers in vascular and endovascular surgery

V-Possum Score as a Predictor of 30-Day Post-Mortality of Endovascular Aortic Aneurysm Repair – Thoracic Endovascular Aneurysm Repair Procedure in Cipto Mangunkusumo Hospital

Introduction: This study aims to know the performance of the Vascular – Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (V-POSSUM) score as a predictor of 30-day mortality after the Endovascular Aortic Aneurysm Repair (EVAR) – Thoracic Endovascular Aortic Repair (TEVAR) procedure in Abdominal Aortic Aneurysms (AAA) and Thoracic Aortic Aneurysms (TAA) patients in Cipto Mangunkusumo Hospital. Method: This was a retrospective cohort study using data from medical records. Data were taken according to the variables contained in the V-POSSUM scoring system in the patient who undergone EVAR – TEVAR procedure, on the period of 2013 to July 2018. Results: The study involved 85 patients who met the study requirements. It was known that physiological scores, morbidity risk, and mortality risk could be used as a model to predict mortality outcomes because they had good accuracy and discrimination performance, while the severity of the operation score cannot. The result of the goodness of fit model’s physiological score, morbidity risk, and mortality risk was significant (p <0.001), while the severity score of the operation was 0.18 (p >0.05). The Area Under the Curve (AUC) was 94%, 93%, 93%, with the cut points at 31, 68.8, and 10.6 for the physiological score, morbidity risk, and mortality risk, respectively. Conclusion: The V-POSSUM score had good accuracy and discrimination for the physiological score, morbidity risk, and mortality risk. Keywords: abdominal aortic aneurysm, thoracic aortic aneurysm, EVAR, TEVAR, V-POSSUM score, validation

First Steps into Catheter Guidance Including Shape Sensing for Endovascular Aneurysm Repair Procedures

Introduction: Currently, endovascular aortic repair (EVAR) procedures are guided using fluoroscopy and 2D digital subtraction angiography. The research project Nav EVAR (funded by the German Federal Ministry of Education and Research, grant number 13GW0228C) aims to reduce the x-ray exposure and the administration of contrast agent. This project includes the development of a guidance system based on electromagnetic (EM) tracking for catheter location and Fiber Bragg Gratings (FBG) for catheter shape sensing. The goals of this study were to evaluate the accuracies of the catheter location and the catheter shape sensing separately, and to carry out an initial experiment combining both technologies. Methods: A custom-made 9F catheter was build containing an Aurora EM sensor (Northern Digital Inc.) at its tip and a FBG system (DTG©, FBGS Technologies GmbH). The EM sensor position was obtained by the EM tracking system and then transformed into the computed tomography (CT) planning data by using metallic markers placed on the patient's torso. An optimized shape sensing model was used to reconstruct the first 38 cm of the catheter. The combination of both technologies allowed the localization of the reconstructed shape. The EM tracking system was evaluated with a human torso model including a 3D-printed patient-specific aortic system. The catheter was inserted into the iliac artery and the EM sensor accuracy was assessed at five positions (Figure 1) by obtaining the ground truth from CT scans. The FBG system was evaluated by inserting the catheter into a 3D-printed patient-specific aortic system. The accuracy was assessed by comparing the reconstructed shape with the ground truth from a CT scan. The feasibility of the combined system was tested by visualizing the located shape with MeVisLab software (MeVis Medical Solutions AG). Results: For the EM tracking system, the error was 1.60 ± 0.86 mm (mean ± standard deviation, maximum error 2.56 mm). For the FBG system, the error was 1.13 ± 0.43 mm (maximum error 2.11 mm) over the whole 38 cm. Figure 2 shows the CT scan with the reconstructed shape. Regarding the combined guidance, the located shape moved in the same way as the catheter in the real scenario. Conclusion: Both technologies provided an error of less than 5 mm in realistic endovascular scenarios. This accuracy is required to ensure that the renal arteries are not blocked by the stent placement. The EM sensor accuracy was comparable to other studies [1-2]. Previous studies of FBG systems focused on medical needle shape sensing [3-4]. The shape reconstruction error was higher compared to previous studies, but our endovascular was more complex and realistic [5]. The combined system showed promising results. However, these are initial experiments that do not take into account any anatomical deformations during EVAR procedures. Future work will include the optimization of our catheter guidance system, intraoperative imaging for updating the actual anatomy and further evaluations with patient-specific models. Disclosure: Nothing to disclose

Transcaval Embolization of Type II Endoleak after Infrarenal and Fenestrated/Branched Endovascular Aortic Repair

Introduction - Endoleaks are a common complication after endovascular aortic repair (EVAR), of which type II endoleaks are the most frequent. Although mostly dissolving during follow up, type II endoleaks that are persistent carry the risk of secondary rupture due to aneurysm sac growth. The transcaval embolization (TCE), is one of the most recent approaches for type II endoleak treatment. Currently, there are only few published studies on TCE, that solely include patients with endoleak after infrarenal, but not after fenestrated/branched EVAR. Methods - We retrospectively reviewed all patients undergoing transcaval embolization at our institute from October 2014 to March 2017 after infrarenal or fenestrated/branched EVAR. Results - Since 2014, 14 TCEs have been performed in 13 patients for aneurysm sac expansion from type II endoleak after eight infrarenal EVAR and five fenestrated/branched EVAR procedures. Three of these patients had prior Type IV TAAA with a branched EVAR and two patients prior juxtarenal AAA with a fenestrated endograft repair. Patients were male (92%) and had a mean age of 75,9 years (range, 57-89 years). Mean time of TCE after initial endovascular repair was 37,5 months (range, 3- 120 months). Technical success was 93% (13/14). Six procedures were conducted selectively and eight procedures non-selectively. Mean fluoroscopy time was 23,9 min with 74ml of contrast agent used. A mean number of 7 coils and 2,5ml of histoacryl glue per procedure were used. No periprocedural complications occurred. Re-intervention with TCE was necessary in one patient. At a mean follow-up period of 11,2months (range, 4-16 months, n=7) all aneurysm sac diameters were stable or decreasing with one minor type II endoleak an CT scan. Conclusion - TCE is a safe and feasible technique for treatment of type II endoleak after infrarenal and fenestrated/branched EVAR.

Regional variation in endovascular treatment rate and in-hospital mortality of abdominal aortic aneurysms in Germany.

Background: Abdominal aortic aneurysms (AAA) can be treated by either open surgery (OAR) or endovascular aortic repair (EVAR). The aim of this study was to analyze regional variations in application of (EVAR) and in-hospital mortality after intact AAA (iAAA) repair. Methods: Using data provided by the German Federal Statistical Office, a nationwide analysis for 2012 to 2014 was conducted. Patients with a diagnosis of iAAA (I71.4) and corresponding procedure codes for OAR (5-384.5/7) or EVAR (5-38a.1) were included. Odds ratios (ORs) for use of EVAR (proportion of EVAR among total EVAR+OAR cases) and mortality were calculated for all regions in Germany. ORs for EVAR use were adjusted for age, sex, and risk (Elixhauser score). ORs for mortality were additionally adjusted for type of procedure (OAR/EVAR). Results: Finally, 31,757 procedures for iAAA were included. Median age of all patients was 73years (interquartile range 67-78years) and 87.1% were male. The mean proportion of EVAR procedures was 72.6%; however, the application of EVAR for repair of iAAA varied widely depending on region. The lowest unadjusted regional rate of EVAR use was 48.8%, while the highest was 92.5%. After adjustment, the lowest regional OR for EVAR use (compared to the nationwide mean) was 0.23 (95% confidence interval [0.15-0.36]), the highest 5.93 [1.79-19.65]. Overall in-hospital mortality was 2.9% (OAR 6.2%; EVAR 1.7%). The adjusted regional OR for mortality ranged from 0.31 [0.07-1.42] to 4.98 [2.08-11.93]. Conclusions: This study reveals variations in use of EVAR and in-hospital mortality for iAAA treatment in Germany. This may imply that selection of treatment might not only be influenced by patient characteristics, but also by regional location. These results need to be taken into account when discussing centralization of AAA treatment in Germany.

Computational analysis of Nitinol stent-graft for endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA): Crimping, sealing and fluid-structure interaction (FSI)

ObjectivesWe evaluate the crimping strain, sealing stress and contact forces on a Nitinol stent deployed in the aorta during endovascular aortic (or aneurysm) repair (EVAR) procedures. Nitinol shape memory effect (SME) is used. We also study the fluid-structure interaction (FSI) of the blood flow on the stented aorta. MethodsWe employ Solidworks to generate a closed-cell honeycomb stent structure used to treat abdominal aortic aneurysm (AAA). We use the commercial Abaqus/Simulia finite element (FEM) simulation package to study the displacements and stresses experienced by the stent during the crimping phase and deployment into the aortic segment. The Nitinol stent is covered with Dacron, a popular graft material. We implement our own user-material (UMAT) subroutines to model the shape memory effect (SME) of Nitinol. The effect of the stent geometry is analyzed. We use the FSI analysis in Abaqus/Simulia to understand the effect of hemodynamic loading on the stent. ResultsResults indicate that the crimping strain increases as the stent strut spacing increases. This is also the case for the radius of curvature. Maximum strains developed on the stent during crimping are in the order of 10%. Stresses exerted by the stent needed to completely seal the aorta are found to be below the yield stress values of Nitinol (700 MPa). Wall shear stresses (WSS) on the stented aorta are close to WSS obtained on the aorta alone. ConclusionUsing Nitinol's thermo-reactivity property as opposed to its superelasticity causes the stent-graft to deploy more gently.

Catheter pose-dependent virtual angioscopy images visualized on augmented reality glasses

Abstract Fluoroscopy and digital subtraction angiography provide guidance in endovascular aortic repair (EVAR) but introduce radiation exposure and require the administration of contrast agent. To overcome these disadvantages, previous studies proposed to display the pose of an electromagnetically (EM) tracked catheter tip within a three-dimensional virtual aorta on augmented reality (AR) glasses. For further guidance, we propose to create virtual angioscopy images based on the catheter tip pose within the aorta and to display them on HoloLens. The aorta was segmented from the computed tomography (CT) data using MeVisLab software. A landmarkbased registration allowed the calculation of the pose of the EM sensor in the CT coordinate system. The sensor pose was sent to MeVisLab running on a computer and a virtual angioscopy image was created at runtime based on the segmented aorta. When requested by HoloLens, the last encoded image was sent from MeVisLab to the AR glasses via Wi-Fi using a remote procedure call (gRPC), and then decoded and displayed on HoloLens. For evaluation purposes, the latency of transmitting and displaying the images was measured using two different lossy compression formats (namely JPEG and DXT1). A mean latency of 82 ms was measured for the JPEG format. On the other hand, using the DXT1 format, the mean latency was reduced by 87 %. This study proved the feasibility of creating pose-dependent virtual angioscopy images and displaying them on HoloLens. Additionally, the results showed that the DXT1 format outperformed the JPEG format regarding latency. The virtual angioscopy may add valuable additional information for guidance in radiation-sparing EVAR procedure approaches.

Understanding patients' experiences of recovery after staged complex aortic repair: A phenomenological study.

To explore patients' with complex aortic diseases lived experiences of recovery between and after staged endovascular aortic repair (EVAR) procedures, including adjunctive open surgery. Qualitative descriptive phenomenological design, applying person-centred care and lifeworld-led health care. Patients operated on in a staged fashion between 2012-2017 were invited to participate. Six participants underwent in-depth interviews 1-5years postoperatively. The interviews were analysed using descriptive phenomenological method. The essence of the patients' experiences was described as: a necessary, overwhelming, hard, and prolonged process with life changing consequences. Between the operations: expected tiredness where life goes on as usual and insufficient time for recovery. Short-term after all operations: overwhelming tiredness, pain and complications, mostly from neurological deficits. Losing 'yourself' and struggling to manage daily life one day to another. Long-term after all operations: gradually recovering back to 'yourself' and having to accept life with permanent setbacks and limitations. Patients with complex aortic diseases struggle with physical and psychological setbacks, continuing years after their operations. There is a need to prospectively assess different aspects of these patients' recovery, identify those with impaired recovery and establish preventive and supporting strategies. Patients' experience of recovery after staged aortic repair has not previously been investigated. The findings indicate that these patients struggle with various physical and psychological setbacks continuing years after their operations. These results will inform further research on this group of patients and guide healthcare professionals in the care of these patients in their transition back to recovery.

Simulation of Endovascular Aortic Repair Using 3D Printed Abdominal Aortic Aneurysm Model and Fluid Pump

Abdominal aortic aneurysm (AAA) models can be manufactured with 3D printing technology. This study describes detailed methodology and validation of endovascular aortic repair (EVAR) simulation using 3D printed AAA model connected to hemodynamic pump. The AAA model was printed with Objet500 Connex3 (Stratasys, Eden Prairie, MN) and connected to BDC PD-0500 fluid pump (BDC Laboratories, Wheat Ridge, CO). EVAR procedure metrics were benchmarked in two expert implanters and compared to 20 vascular surgical trainees with different levels of EVAR experience (< 20 or ≥ 20 cases). All simulations were performed using commercially available stent grafts, guidewires, catheters, fluoroscopic guidance and digital subtraction angiography. Studied outcomes included ability to complete the procedure independently, time to deploy aortic component, ability to cannulate contralateral gate and complete the repair, and total fluoroscopy and procedure times. A total of 22 EVAR simulation procedures were performed with mean procedure time of 37 ± 12min. Experienced trainees had significantly lower total procedural time (32 ± 9 vs. 44 ± 6min, P = 0.003) and fluoroscopic time (13 ± 5 vs. 23 ± 8min, P = 0.005). All experienced trainees completed the procedure independently in < 45min, compared to six (46%) of those with less EVAR experience (P = 0.016). Among less experienced trainees, only two (15%) completed the entire procedure independently (P < 0.001). Benchmark implanters performed significantly better than both trainee groups in nearly all EVAR metrics. EVAR simulation was feasible and simulated all procedural steps with high fidelity. This model may be applicable for assessment of technical competencies and standard endovascular skill acquisition within vascular surgery training curricula.

SS08. Cerebrospinal Fluid Drainage Complications During First Stage and Completion Fenestrated-Branched Endovascular Aortic Repair

To determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. We reviewed outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR or completion temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if these were life threatening, escalated the level of care or prolonged hospital stay. Presence of degenerative lumbar disease (DLD) was identified based on review of computed tomography scans. End points included technical difficulties during CSFD placement and CSFD-related complications. A total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 severe to moderate CSFD-related complications after 21 aortic procedures (9%). There were 12 patients (6%) with intracranial hypotension, including 3 (2%) who had intracranial hemorrhage (Fig 1) and 9 (5%) with severe headache requiring blood patches in 6. Another six patients (3%) developed spinal hematomas (Fig 2) resulting in paraplegia in two (1%) or transient paraparesis in two (1%). Other complications were cerebrospinal fluid leakage in one patient (no intervention) and bleeding during attempted CSFD placement requiring postponement of index F-BEVAR in three. In addition, 20 patients (11%) had blood-tinged drainage or bleeding at the puncture site without any clinical sequela. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD compared with those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 CSFD placements (18%) with lower rate of technical difficulties compared with blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of the 13 patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD placement. Although CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. Use of fluoroscopic guidance may reduce the risk of CSFD complications.Fig 2Spinal hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 188: Burden of Complications After Thoracic Aortic Repair Surgery Among Medicare Beneficiaries

Objective: Despite the growth in thoracic aortic repair surgery, there remain concerns about the clinical and financial impact of complications secondary to these procedures. Therefore, we leveraged Medicare administrative claims to estimate the incidence, outcomes, and spending associated with complications during 90-day episodes of thoracic aortic repair surgery. Methods and Results: Using a previously validated claims-based algorithm, we identified 11,240 Medicare fee-for-service beneficiaries hospitalized for thoracic aortic repair surgery [open type A (n=4,538), open type B (n=4,091), and thoracic endovascular aortic repair procedures (TEVAR, n=2,611)] from April 2014 to March 2015. We identified any (and total number) of the following complications within 30-day of surgery: renal failure, stroke/transient ischemic attack, respiratory failure, bleeding, pneumonia, deep vein thrombosis or pulmonary embolism, surgical site infection, paralysis, or acute myocardial infarction. Overall, 5,525 patients (49.2%) developed any complication (zero complications: 50.9%, one: 28.4%, two: 13.0%, three: 5.3%, or four or more: 2.4%). For the entire sample, 90-day episode mortality was 15.4%, which was higher in patients with any complication (23.0%) compared to patients without complications (8.1%). Adjusting for patient demographics, admission status, comorbidities, and hospital random effects, the relative odds of mortality comparing patients with and without complications was 2.41 (95% CI: 2.11-2.76) (Table). On average, 90-day episode spending was $54,668±$43,287, which was also higher among patients with any complication ($69,243 vs. $40,578, p&lt;0.001). After similar adjustment, 90-day episode spending was 50% higher on a relative scale (95% CI: 46% to 54%), largely attributed to inpatient stays, post-acute care spending, and more frequent readmissions. Both mortality and spending increased significantly as the number of complications increased from zero to four or more. Conclusions: Complications after thoracic aortic repair were common and associated with worse outcomes and higher episode spending. Identifying and intervening upon patient and provider factors predictive of complications is essential to improving the value of thoracic aortic repair procedures.

Preoperative risk score for access site failure in ultrasound-guided percutaneous aortic procedures

ObjectiveThe factors associated with access site failure after ultrasound-guided percutaneous access for aortic endograft procedures remain poorly characterized. We developed a prediction model to risk stratify patients for access site failure. MethodsWe performed a retrospective institutional review of consecutive patients who underwent endovascular aneurysm repair (EVAR), fenestrated EVAR (FEVAR), or thoracic endovascular aortic repair (TEVAR) from 2014 to 2016. We excluded patients undergoing direct aortic access through sternotomy and patients treated with physician-modified endografts, given reporting restrictions. Our primary outcome was groin access site failure, which included bleeding and thrombosis. An 8-point risk model was created for access site failure using multivariable fractional polynomials and internally validated using bootstrapping. ResultsWe identified 469 femoral arteries from 247 patients undergoing endovascular aortic repair procedures (EVAR, 75%; FEVAR, 8.0%; TEVAR, 17%). Surgeons performed percutaneous access in 97.2% of the femoral arteries, with 99.6% ultrasound use. Twenty-seven (5.9%) access site failures occurred (17 bleeding, 10 thrombosis), all treated with groin cutdown, for a successful percutaneous femoral artery access rate of 94%. Of the 215 patients with attempted bilateral percutaneous access, 90% had successful bilateral access. However, FEVAR had lower rates of successful bilateral access (FEVAR, 78%; EVAR, 91%; TEVAR, 94%; P = .03). Factors independently associated with percutaneous access site failure were femoral artery outer wall diameter (per millimeter increase: odds ratio [OR], 0.003 [0.0002-0.1]; P < .001), femoral artery stenosis >50% (OR, 22.3 [2.7-183.2]; P < .01), and urgent/emergent intervention (OR, 3.6 [1.2-11.0]; P = .03). A risk prediction model based on these criteria produced a C statistic of 0.89, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of 0.04. Excluding treatment for ruptured aneurysms, cutdown for access failure and planned initial groin cutdown resulted in longer postoperative lengths of stay and higher rates of access-related readmission, return to operating room, groin infection, and myocardial infarction compared with successful percutaneous access. There was no difference in major adverse events between planned initial groin cutdown and cutdown after failure; however, the small number of patients in these two comparison groups limits the statistical power to detect a difference. ConclusionsPercutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures, but access site failures do occur. This risk score can help users select patients with high likelihood of success, identify patients who need close scrutiny with postclosure femoral duplex ultrasound, and provide patient guidance about risk of unplanned groin cutdown.

Management of type B aortic dissection with an isolated left vertebral artery

ObjectiveThe objective of this study was to report our single-center experience of thoracic endovascular aortic repair (TEVAR) and concomitant procedures in patients with type B aortic dissection (TBAD) with an isolated left vertebral artery (ILVA) and the early to midterm outcomes in these patients. MethodsBetween March 2011 and June 2018, there were 31 patients (27 men; median age, 55 years; range, 31-66 years) with TBAD and an ILVA who received TEVAR and concomitant procedures in our center. Demographics, coexisting medical conditions, imaging features, operation details, and follow-up outcomes in these patients were retrospectively collected and analyzed. ResultsAll patients received aortic stent grafts; nine patients also received chimney stents, and 10 patients received aortic arch bypasses. The technical success rate was 96.8% (30/31), with only one patient (3.2%) showing immediate type IA endoleak. One patient experienced transient neurologic deficit, and a puncture-related femoral artery pseudoaneurysm was observed in one patient; both recovered completely before their hospital discharge. There was no death in the early term. The median duration of follow-up was 33 months (range, 2-90 months). Reintervention for a type II endoleak by using coils to seal the origin of the left subclavian artery was performed in one (3.1%) case 72 months postoperatively. One (3.2%) death occurred 42 months after operation as a result of rectal cancer. No neurologic deficits, chimney stent occlusions, or bypass occlusions were observed during the follow-up period. ConclusionsOur limited experience reveals that TEVAR and concomitant procedures are relatively safe and viable for treatment of TBAD with an ILVA. Further studies with larger samples of patients and longer follow-ups are needed to confirm these findings.

Compressed Amplatzer Vascular Plug II Embolization of the Left Subclavian Artery for Thoracic Endovascular Aortic Repair is Efficient and Safety Method Comparable to Conventional Coil Embolization

Left subclavian artery (LSA) embolization is occasionally required to prevent type II endoleak in the thoracic endovascular aortic repair (TEVAR) procedure. This is a retrospective study comparing compressed Amplatzer Vascular Plug II embolization (CAE) and conventional coil embolization (CCE) in preventing retrograde flow into the aneurysmal sac through the LSA after TEVAR. We retrospectively reviewed the records of patients who underwent CAE or CCE of the LSA during TEVAR from June 2013 to March 2016 in our hospital. The efficacy, safety and cost of each method were compared between two groups. Thirty patients underwent LSA embolization during TEVAR. Six CCEs in 6 patients were performed from June 2013 to November 2013, while twenty-four CAEs in 24 patients were performed from December 2013 to March 2016. Technical success was achieved in all patients in both groups. No embolization-related complications or type II endoleaks from LSA were recorded during the follow-up period in all patients. In both groups, all embolic materials were detected in the proximal portion of the LSA from the LSA orifice to the vertebral artery origin and no vertebral artery occlusions were detected. The mean compression ratio of AVP II was 58 ± 5.9% of predicted length of standard procedure. In the CAE group, one AVP II was sufficient to achieve complete LSA occlusion in all patients. On the other hand, multiple coils (10.2 ± 2.7) were used in the CCE group (P < .01), resulting in a significantly lower cost incurred in the CAE group (CAE: 129,000 JPY vs. CCE: 639,600 ± 140,060 JPY; P < .01). The CAE is a useful and cost-effective procedure for TEVAR-related LSA embolization.

Postoperative thoracic and low back pain following endovascular aortic repair associated with stenting location.

We have noted that patients frequently complain of thoracic or low back pain after undergoing an endovascular aortic repair, which we speculated was caused by the indwelling stent. We investigated the patients who underwent an elective thoracic or abdominal endovascular aortic repair (TEVAR or EVAR) and noted the location of stent, and postoperative pain. The incidence of either thoracic or low back pain at individual vertebra levels was determined, after which we fitted the sigmoidal function to the discrete data to obtain a cut-off line. The study patients were then divided into 2 groups using the cut-off line to compare the incidence of pain. We analyzed 96 patients (68 TEVAR, 28 EVAR). The incidence of thoracic pain was significantly higher in TEVAR as compared to EVAR (26.5% vs. 3.6%, P = 0.01), while that of low back pain was significantly higher in EVAR (35.7% vs. 16.2%, P = 0.04). With the cut-off line for thoracic pain set at the 12th thoracic vertebra, the incidence of thoracic pain was significantly higher in patients with the upper end of the stent above the cut-off as compared to at a lower point (26.5% vs. 3.6%, P = 0.01). As for low back pain, the cut-off line was set at the 9th thoracic vertebra, and the incidence of that pain was significantly higher in patients with the lower end of the stent below that line (30.9% vs. 0.0%, P < 0.01). Thoracic and low back pain after an endovascular aortic repair procedure were associated with stenting site.

Cross-wire technique for difficult contralateral limb cannulation during endovascular abdominal aneurysm repair for tortuous proximal aortic neck.

In selected cases of endovascular aortic repair (EVAR) of an abdominal aortic aneurysm, such as patients with tortuous proximal aortic neck, achieving a successful cannulation can sometimes be difficult. Herein, we described a novel cross-wire technique to help overcome such anatomical variations. During the EVAR procedure among our 5 cases, the main body of the Gore Excluder Stent Graft was deployed through an ipsilateral guidewire. Because of a large angle between the contralateral guidewire and the contralateral short limb of the main body, a successful traditional cannulation was unfeasible. Therefore, the contralateral guidewire was cannulated into the ipsilateral long limb, and the ipsilateral guidewire was cannulated into the contralateral short limb. The contralateral and ipsilateral iliac limb components of the stent graft were deployed through the ipsilateral and contralateral guidewires, respectively. All 5 patients receiving this technique during EVAR of an abdominal aortic aneurysm were free of mortality or any kind of complication at the 1-year follow-up. In conclusion, the cross-wire technique might be safe and effective for EVAR of an abdominal aortic aneurysm when a traditional cannulation is unachievable in selected cases without creating additional percutaneous access or using extra devices.

RS01. Planned Exclusion of the Celiac Artery During Complex Thoracic Endovascular Aortic Repair Procedures: Is It Safe?

Achieving adequate proximal and distal fixation and maintaining visceral branch flow make thoracic endovascular aortic repair (TEVAR) procedures for thoracoabdominal aneurysm (TAAA) complex. Whereas superior mesenteric artery (SMA) and renal vessels must be preserved, there may be selected cases in which patent celiac arteries may be intentionally excluded. We sought to define the incidence of ischemic complications of celiac exclusion during complex TEVAR procedures and to define specific conditions in which the celiac can be safely covered. We performed a retrospective 12-year audit in two tertiary care institutions of patients with a suprarenal aneurysm or TAAA treated by standard TEVAR involving the distal thoracic aorta with intentional celiac fabric coverage or bare distal stent across the celiac (preserved), custom or modified aortic endografts (complex TEVAR/fenestrated EVAR [FEVAR]) involving multiple visceral branch endoprostheses with and without planned celiac exclusion, or a transabdominal hybrid approach with visceral debranching bypasses (with or without celiac revascularization) from distal inflow sites and staged or simultaneous long length thoracoabdominal endografting. The decision to exclude celiac arteries was made from preoperative computed tomography findings of a small diameter, stenotic origin, presence of replaced right hepatic artery, or existing large SMA celiac collaterals. Cases with a chronically occluded celiac were excluded. Primary end points were 30-day mortality, spinal cord ischemia, and any foregut ischemia occurring early or during late follow-up (ischemic acalculous cholecystitis or splenic infarction). There were 223 patients who met inclusion criteria (Table I). In the standard/complex TEVAR/FEVAR group, 26 patients (15%) had celiac coverage with 144 cases of celiac preservation. In the hybrid group, 11 cases (21%) had celiac exclusion, whereas 42 patients had a separate celiac bypass. In the standard/complex TEVAR/FEVAR group, celiac coverage did not result in significant increase in foregut ischemic events (3.8% vs 2.1%; P = .6; Table II). However, exclusion of the celiac artery during hybrid cases resulted in an increase in foregut ischemia (two early and one case presenting 1 year later) compared with patients having celiac bypass revascularization (27% vs 7%; P = .06). The incidence of spinal cord ischemia and 30-day all-cause mortality was not different with regard to celiac exclusion or between treatment groups. Selected celiac exclusion appears safe during standard/complex TEVAR/FEVAR procedures as long as SMA patency is ensured. A hybrid approach to complex TAAA requires separate bypass to all patent visceral branches including the celiac to minimize foregut ischemia.Table IDemographicsVariableTEVAR with celiac coverageTEVAR with celiac revascularizationHybrid without celiac revascularizationHybrid with celiac revascularizationNo.261441142M/F69/3174/2655/4568/32Urgent/emergent35131810History of aortic surgery27515536Dissection present12102710TEVAR, Thoracic endovascular aortic repair.Values are reported as percentage. Open table in a new tab Table IIPostoperative outcomesVariableTEVAR with celiac coverageTEVAR with celiac revascularizationTEVAR covered celiac vs TEVAR revascularized celiac, χ2 comparison P valueHybrid without celiac revascularizationHybrid with celiac revascularizationHybrid with and without revascularization, χ2 comparison P valueNo.26144114230-Day mortality7.7 (2)3.5 (5).319.1 (1)11.9 (5).79SCI3.8 (1)15.3 (22).120 (0)11.9 (5).57Foregut ischemia3.8 (1)2.1 (3).5927.2 (3)7.1 (3).06SCI, Spinal cord ischemia; TEVAR, thoracic endovascular aortic repair.Values are reported as % (No.). Open table in a new tab

IP007. Feasibility of Endovascular Abdominal Aortic Aneurysm Repair Procedure Supported by Very-Low-Dose Stationary Acquisition Protocols∗

IP007. Feasibility of Endovascular Abdominal Aortic Aneurysm Repair Procedure Supported by Very-Low-Dose Stationary Acquisition Protocols∗