Endovascular Graft Research Articles

A Canadian Postmarket Study of Zenith Alpha Abdominal Endovascular Graft

A Canadian Postmarket Study of Zenith Alpha Abdominal Endovascular Graft

Surface modification of endovascular stents with rosuvastatin and heparin-loaded biodegradable nanofibers by electrospinning.

This study describes the development of drug-loaded nanofibrous scaffolds as a nanocoating for endovascular stents for the local and sustained delivery of rosuvastatin (Ros) and heparin (Hep) to injured artery walls after endovascular procedures via the electrospinning process.PurposeThe proposed hybrid covered stents can promote re-endothelialization; improve endothelial function; reduce inflammatory reaction; inhibit neointimal hyperplasia of the injured artery wall, due to well-known pleiotropic actions of Ros; and prevent adverse events such as in-stent restenosis (ISR) and stent thrombosis (ST), through the antithrombotic action of Hep.MethodsBiodegradable nanofibers were prepared by dissolving cellulose acetate (AC) and Ros in N,N-dimethylacetamide (DMAc) and acetone-based solvents. The polymeric solution was electrospun (e-spun) into drug-loaded AC nanofibers onto three different commercially available stents (Co–Cr stent, Ni–Ti stent, and stainless steel stent), resulting in nonwoven matrices of submicron-sized fibers. Accordingly, Hep solution was further used for fibrous coating onto the engineered Ros-loaded stent. The functional encapsulation of Ros and Hep drugs into polymeric scaffolds further underwent physicochemical analysis. Morphological characterization took place via scanning electron microscopy (SEM) and atomic force microscopy (AFM) analyses, while scaffolds’ wettability properties were obtained by contact angle (CA) measurements.ResultsThe morphology of the drug-loaded AC nanofibers was smooth, with an average diameter of 200–800 nm, and after CA measurement, we concluded to the superhydrophobic nature of the engineered scaffolds. In vitro release rates of the pharmaceutical drugs were determined using a high-performance liquid chromatography assay, which showed that after the initial burst, drug release was controlled slowly by the degradation of the polymeric materials.ConclusionThese results imply that AC nanofibers encapsulated with Ros and Hep drugs have great potential in the development of endovascular grafts with anti-thrombogenic properties that can accelerate the re-endothelialization, reduce the neointimal hyperplasia and inflammatory reaction, and improve the endothelial function.

A Propensity Score–Matched Analysis of Inflammatory Response With Endovascular Aneurysm Sealing vs Endovascular Aneurysm Repair

Purpose: To evaluate the risk of postimplantation syndrome associated with endovascular aneurysm sealing (EVAS) and endovascular aneurysm repair (EVAR) in patients treated for abdominal aortic aneurysm (AAA). Methods: From December 2013 to May 2015, 41 AAA patients treated with EVAS (mean age 72±9 years; 38 men) and 63 with EVAR (mean age 74±10 years; 55 men) at a single center were retrospectively reviewed. To control for treatment selection bias, propensity score matching was used to compare outcomes by treatment mode. Main outcomes were postimplantation syndrome (defined as temperature >38°C and leukocyte count >12,000/µL), inflammatory response markers [platelets and high-sensitivity C-reactive protein (hs-CRP)], and clinical complications through 30 days. Results: In 39 matched patients per group, the incidences of postimplantation syndrome (p=0.07), mean body temperature (p=0.05), mean leukocyte count (p=0.003), and mean hs-CRP (p<0.001) were proportionally lower with EVAS vs EVAR. Serious adverse events (0% vs 12.8%, p=0.05) and endoleaks (0% vs 10.3%, p=0.13) through 30 days were less frequent with EVAS, but the group differences were not significantly different. The choice of endovascular graft material influenced postoperative and 30-day clinical outcomes, with greater overall risk observed with polyester stent-grafts. Conclusion: Endovascular aneurysm sealing is associated with a blunted systematic inflammatory response compared with EVAR. Polyester stent-grafts induce the greatest periprocedural inflammatory response.

Invited commentary

The successful use of fenestrated endografts for the treatment of complex aortic aneurysms was first published nearly 2 decades ago, in 1999.1Faruqi R.M. Chuter T.A. Reilly L.M. Sawhney R. Wall S. Canto C. et al.Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft.J Endovasc Surg. 1999; 6: 354-358Crossref PubMed Scopus (102) Google Scholar, 2Browne T.F. Hartley D. Purchas S. Rosenberg M. Van Schie G. Lawrence-Brown M. A fenestrated covered suprarenal aortic stent.Eur J Vasc Endovasc Surg. 1999; 18: 445-449Abstract Full Text PDF PubMed Scopus (166) Google Scholar Now, we are in the midst of a rapid evolution of technical advances in endovascular catheter-based treatments for aortic aneurysms. Endografts designed with scallops, fenestrations, and branches allow for stent grafts to be placed across visceral arteries and great arteries of the arch, while preserving flow to the critical end organs supplied by these arteries. New fabrics and stent materials have allowed for these devices to be packaged and delivered through smaller and smaller sheaths. Preloaded wires and catheters, integrated into the actual endovascular graft delivery system, help streamline these complex procedures. Despite these advances, we remain far from achieving consensus on how best to treat patients with fenestrated and branched endografts. Access to this diverse array of devices remains highly restricted, and substantial resources are required to successfully execute these repairs and care for these complex patients. Very few centers have a large volume of experience with fenestrated and branched endografts. In many ways, we are still working on the basic questions: How do we identify areas of “normal aorta” for a proximal seal, and how much length is required? When is an “off the shelf” fenestrated device appropriate and when is a “patient-specific” custom fenestrated device required? What are the ideal characteristics for a bridging stent that will ensure durability of repairs? In the current state, we have more questions than answers. Timaran et al take an important step toward reducing the technical challenges inherent to endovascular repair of complex aortic aneurysms. They describe the Sequential Catheterization Amid Progressive Endograft Deployment (SCAPED) technique, which can facilitate target artery cannulation via a brachial or axillary approach. This technique is elegant and highlights how anatomic differences between patients necessitate a diverse array of approaches. Serial deployment, by keeping the endograft constrained, creates space outside of the endograft. Increased space between the endograft and the origin of the target artery is key to facilitate catheter/wire mobility and subsequent target artery cannulation. The use of preloaded wires to bring the sheath to, or out of, fenestrations also facilitates target artery cannulation. As the authors carefully acknowledge, this technique is not ideal for all patients (eg, upgoing target arteries) and many patients and physicians may prefer, when appropriate, transfemoral access only. Better understanding the exact anatomic characteristics where the SCAPED technique provides a significant reduction in procedure time, radiation dose, and morbidity is a key next step. The sequential catheterization amid progressive endograft deployment technique for fenestrated endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 66Issue 1PreviewFenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms. Despite promising short-term results, the technical complexities of this procedure remain a considerable challenge. The risk of technical failure with loss of visceral or renal arteries is ubiquitous even in the most experienced hands, and thus many patients with unfavorable anatomy are frequently denied FEVAR. We have adopted a new technique for FEVAR that involves retrograde brachial artery access and stepwise deployment of the endograft during target vessel catheterization, overcoming many anatomic limitations encountered from a transfemoral approach. Full-Text PDF Open Archive

RS03. A Matched Cohort Comparison of Outcomes in Patients Who Underwent Fenestrated Endovascular Aortic Aneurysm Repair Using Physician-Modified Endovascular Grafts vs Company-Manufactured Devices

Fenestrated endografts are customized, patient-specific, endovascular devices with the potential to reduce morbidity and mortality of repair of complex aortic aneurysms. With approval from the United States Food and Drug Administration, our center began performing fenestrated endovascular aneurysm repair through a physician-sponsored investigational device exemption (IDE #G130210), using both physician-modified endografts (PMEG) and company manufactured devices (CMD). Because PMEG and CMD are each associated with specific advantages and disadvantages, we sought to investigate differences in outcomes between PMEG and CMD cases. A single-institution retrospective review of all fenestrated endovascular aneurysm repairs was performed. The cohort was analyzed according to device type (PMEG or CMD) after matching cases based on (1) number of target vessels intended for treatment, (2) extent of aneurysm, (3) aneurysm diameter, (4) device configuration, and (5) date of operation. Outcomes of ruptures, common iliac, and arch aneurysms were excluded. Demographics, operative details, perioperative complications, length of stay, and reinterventions were compared. For patients with >1-year follow-up time, survival, type I or type III endoleak rate, target artery patency, and reintervention rate were analyzed using the Kaplan-Meier method. Between November 30, 2010, and July 30, 2016, 82 patients were identified and matched. The cohort included 41 PMEG and 41 CMD patients who underwent repair of 38 juxtarenal (PMEG, 17; CMD, 21), 14 pararenal (PMEG, 6; CMD, 8), and 30 thoracoabdominal types 1 to 4 (PMEG, 18; CMD, 12) aneurysms. There were significant differences in urgency of presentation (PMEG, 9; CMD, 0; P = .002), total fluoroscopy time (PMEG, 76 minutes; CMD, 61 minutes; P = .02), volume of contrast used (PMEG, 88 mL; CMD, 70 mL; P = .02), in-operating room to out-of-operating room time (PMEG, 391 minutes; CMD, 319 minutes; P = .001), incision-to-surgery-end time (PMEG, 276 minutes; CMD, 224 minutes; P = .002; Table), and 1-year reintervention rate (PMEG, 37%, CMD, 13%; log-rank P = .04; Fig). No differences in perioperative complications, overall length of stay, type I or III endoleak, or survival were observed between PMEG vs CMD. In this single-institution experience of fenestrated endovascular aneurysm repair, the primary differences between PMEG and CMD related only to operative technique and postoperative reinterventions. No clear benefit was associated with one approach over the other, suggesting that both are viable options that may offer benefit compared with open repair of complex aortic aneurysms. Further studies are necessary to determine if this relative equivalence represents a type 2 error and/or lack of long-term durability data or if true equivalence between PMEG and CMD approaches exists.TableOperative characteristics of patients who underwent complex endovascular aneurysm repair with physician-modified endografts (PMEG) or company-manufactured devices (CMD) between 2010 and 2016aVariablesPMEG (n = 41)CMD (n = 41)P valueTarget arteries incorporated in repair (No.)3.3 (0.69)3.2 (0.82).47Stented fenestrations or branches (No.)2.6 (0.95)2.6 (0.95).99Stents placed for target arteries (No.)2.6 (1.3)2.8 (1.2).43Fluoroscopy time (min)76 (35)61 (19).02Dose area product (mGy · cm2)84,087 (39,751)55,211 (47,306).32Exam dose (mGy)5192 (3,462)4277 (2371).18Volume of contrast used (mL)88 (42)70 (21).02Operative times (min) In operating room to incision91 (35)76 (23).02 Incision to surgery end276 (81)224 (59).002 In operating room to out of room391 (104)319 (73).001Operating room direct cost ($)b32,802 (16,314)31,642 (14,672).74Length of stay Intensive care unit1.7 (2.5)0.68 (1.3).02 Hospital (median, range)3 (1, 6)2 (2, 3).12aData are reported as means with standard deviations, unless otherwise noted.bFor patients who underwent a staged procedure with PMEG (n = 3) or CMD (n = 2), operating room direct cost included total operating room costs for both stages of the repair. Costs attributed to operating room usage time were not included in the total cost calculation. Open table in a new tab

Percutaneous Septectomy in Chronic Dissection with Abdominal Aortic Aneurysm Creates Uniluminal Neck for EVAR.

The intent of this report is to describe the technical details and rationale of endovascular septectomy using a wire saw maneuver in cases of chronic aortic dissection and associated infra-renal aortic aneurysm to allow standard endovascular abdominal aortic graft placement; preliminary clinical experience is also retrospectively reviewed. Between June 2013 and June 2016, four consecutive patients (mean age 55.3years; range 52-58years) with chronic type B aortic dissection and isolated infra-renal abdominal aortic aneurysm (AAA) underwent endovascular aneurysm repair (EVAR) following guidewire septectomy to create a suitable proximal aortic landing zone. Technical success was evaluated by angiography performed at the end of the procedure. Procedural safety was determined by assessing any major adverse events through 30days of follow-up. Endoleaks and longer-term efficacy were evaluated. Four patients with chronic aortic dissections had associated AAA with a mean maximum diameter of 60±13mm (range 50-77mm). All underwent guidewire saw septectomy to facilitate EVAR. Following successful septectomy, standard abdominal bifurcated endografts were implanted uneventfully. No major adverse events and no endoleaks were noted on CT angiographic examinations through 30days following the procedure. Also, no rupture, re-intervention or endoleak has been noted during follow-up at a mean of 21.8±15months (range 4-39months). Guidewire saw septectomy is a technique that has the potential to create an anatomically suitable proximal neck for successful EVAR management of AAA in select patients with associated chronic aortic dissection.

A methodology for developing anisotropic AAA phantoms via additive manufacturing

An Abdominal Aortic Aneurysm (AAA) is a permanent focal dilatation of the abdominal aorta at least 1.5 times its normal diameter. The criterion of maximum diameter is still used in clinical practice, although numerical studies have demonstrated the importance of biomechanical factors for rupture risk assessment. AAA phantoms could be used for experimental validation of the numerical studies and for pre-intervention testing of endovascular grafts. We have applied multi-material 3D printing technology to manufacture idealized AAA phantoms with anisotropic mechanical behavior. Different composites were fabricated and the phantom specimens were characterized by biaxial tensile tests while using a constitutive model to fit the experimental data. One composite was chosen to manufacture the phantom based on having the same mechanical properties as those reported in the literature for human AAA tissue; the strain energy and anisotropic index were compared to make this choice. The materials for the matrix and fibers of the selected composite are, respectively, the digital materials FLX9940 and FLX9960 developed by Stratasys. The fiber proportion for the composite is equal to 0.15. The differences between the composite behavior and the AAA tissue are small, with a small difference in the strain energy (0.4%) and a maximum difference of 12.4% in the peak Green strain ratio. This work represents a step forward in the application of 3D printing technology for the manufacturing of AAA phantoms with anisotropic mechanical behavior.

Minimally invasive surgery to the aortic arch – endovascular repair combined with debranching: 4 case reports

Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest - allowing detachment of the head vessels off the aneurysm, and their anastomosis onto the graft. The procedure is safe and reproducible, however morbidity is significant and includes air embolism, stroke, excessive bleeding and acidosis. In addition the procedures are time-consuming, and cardioplegic arrest is also necessary, resulting in the potential for low cardiac output. Aortic arch aneurysms are not typically suitable for endovascular intervention. With improving techniques of descending aortic repair with stent grafts, hybrid techniques, which involve aortic arch debranching - thereby creating a proximal landing zone of adequate length, followed by stenting over the aortic arch are becoming popular. Methods: Four cases are presented. The technique involves initial sternotomy or upper sternal split, detachment of the innominate and left common carotid arteries, and their reattachment to the ascending aorta by separate grafts (debranching procedure). During this time a side clamp is placed on the ascending aorta. The left subclavian is usually left intact for technical reasons, unless there is a dominant left vertebral artery. This is safe as the shoulder has adequate collateral circulation, and stenting over this vessel is therefore well tolerated. The aortic arch is then completely covered with a stent graft which is inserted via the femoral artery. Arteriography was performed at the end of the procedure to confirm stent graft position and exclusion of the lesion. Results: All surgical transpositions were successful, and the patients recovered without neurologic, bleeding or cardiac complications. Surgical conversion for aortic graft was never required. There were no endoleaks. Mean duration of follow up was 53.5 months (range 21-77). Conclusions: Endovascular repair of the descending thoracic aorta, initially reserved for inoperable patients, is now becoming the accepted initial management. With improved technology and endografts it is now the safest option, especially for traumatic dissection. These techniques have now extended to the aortic arch. Debranching of the aortic arch enables endovascular grafting in this area, thereby avoiding cardiopulmonary bypass and circulatory arrest. Good pre-operative planning is necessary to make the procedure feasible.

3D Printed Abdominal Aortic Aneurysm Phantom for Image Guided Surgical Planning with a Patient Specific Fenestrated Endovascular Graft System.

With training on the patient-specific 3D printed AAA phantom, the clinical team optimized their procedural strategy. Anatomical landmarks and all devices were visible under x-ray during the simulation mimicking the clinical environment. The actual patient procedure went without complications. With advances in 3D printing, fabrication of patient specific AAA phantoms is possible. Simulation with 3D printed phantoms shows potential to inform clinical interventional procedures in addition to CTA diagnostic imaging.

Fibrin-associated EBV-positive Large B-Cell Lymphoma: An Indolent Neoplasm With Features Distinct From Diffuse Large B-Cell Lymphoma Associated With Chronic Inflammation.

Incidental cases of localized fibrin-associated Epstein-Barr virus (EBV)+ large B-cell proliferations have been described at unusual anatomic sites and have been included in the category of diffuse large B-cell lymphoma associated with chronic inflammation (DLBCL-CI) in the WHO Classification. We describe 12 cases and review the literature to define their clinicopathologic spectrum and compare features with typical cases of DLBCL-CI. Median age was 55.5 years with a M:F ratio of 3. In all 12 cases, the lymphoma was an incidental microscopic finding involving atrial myxomas (n=3), thrombi associated with endovascular grafts (n=3), chronic hematomas (n=2), and pseudocysts (n=4). All cases tested were nongerminal center B-cell origin, type III EBV latency, and were negative for MYC rearrangements and alternative lengthening of telomeres by FISH. Most showed high CD30, Ki67, and PD-L1, and low to moderate MYC and p53 expression. Among 11 patients with detailed follow-up, 6 were treated surgically, 3 with cardiac or vascular lesions had persistent/recurrent disease at intravascular sites, and 4 died of causes not directly attributable to lymphoma. Reports of previously published fibrin-associated cases showed similar features, whereas traditional DLBCL-CI cases with a mass lesion had significantly higher lymphoma-associated mortality. Fibrin-associated EBV+ large B-cell lymphoma is clinicopathologically distinct from DLBCL-CI, warranting separate classification. Most cases, particularly those associated with pseudocysts, behave indolently with the potential for cure by surgery alone and may represent a form of EBV+ lymphoproliferative disease rather than lymphoma. However, primary cardiac or vascular disease may have a higher risk of recurrence despite systemic chemotherapy.

Trends in use of the only Food and Drug Administration-approved commercially available fenestrated endovascular aneurysm repair device in the United States

BackgroundFenestrated endografts are customized, patient-specific, endovascular devices with potential to significantly reduce morbidity and mortality of short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair. The Zenith fenestrated endovascular graft (ZFEN) for abdominal aortic aneurysms (Cook Medical, Bloomington, Ind), Food and Drug Administration-approved in 2012, remains the only fenestrated device available in the United States. This technology is among the most technically complex catheter-based procedures and, therefore, inherently associated with serious risk for device-related complications. We sought to define patterns of physician and hospital adoption of ZFEN. MethodsDeidentified datasets containing numbers of physicians trained, orders by physicians and hospitals, and designs (fenestration/scallop configuration) was provided for U.S. ZFEN devices ordered (April 2012-August 2015). We evaluated the number of physicians trained, the number of devices ordered, hospital characteristics, and fenestration/scallop design configurations. Cook Medical assembled the datasets but played no role in study design, analysis, or interpretation of data. ResultsBetween April 2012 and August 2015, 553 physicians attended formal ZFEN training sessions, 388 (70%) of whom ordered a total of 2669 devices. An increase in orders per month (nine in June 2012 and 91 in August 2015, 911% growth; P < .001) and in number of physicians ordering per month (eight in June 2012 and 62 in August 2015, 675% growth; P < .001) was observed. Teaching hospitals, representing all U.S. regions (Midwest 927, 35%; South 799, 30%; Northeast 547, 20%; West 396, 15%), accounted for 1703 (64%) ZFEN orders. Of 553 trained physicians, 165 (30%) ordered no devices, 116 (21%) ordered 1 device, 144 (26%) ordered 2-5 devices, 61 (11%) ordered 6-10 devices, 39 (7%) ordered 11-20, and 28 (5%) ordered >20 devices. For physicians contributing >6 months of data (n = 336), the average number of devices ordered per year was three (standard deviation, 4); 272 (81%) ordered ≤ 5 devices/year, 15 (4.5%) ordered 11-20 devices/year, and 3 (0.9%) ordered >20 devices/year. Of devices with design details available (2618 of 2669; 98%), most common designs were 2 small fenestrations/1 scallop (1443; 55%), 2 small fenestrations/1 large fenestration (568; 22%), 1 small fenestration/1 scallop (173, 6.6%), and 2 small fenestrations (169; 6.5%). The average number of target vessels incorporated in each design was 2.7/device; 2071 (79%) incorporated three, 398 (15%) incorporated two. ConclusionsSince 2012, ZFEN has demonstrated a ninefold increase in monthly orders, with 553 physicians trained. Unlike the experience of rapid dissemination seen with infrarenal endografts, only 28 (5%) physicians have ordered >20, whereas 165 (30%) have ordered none, and 272 (81%) ordered ≤ 5 devices/year. Assuming that volume, in general, correlates with outcomes, this adoption pattern raises questions whether fenestrated technology should be regionalized to high-volume centers.

Fenestrated endovascular aneurysm repair among octogenarians at high and standard risk for open repair

BackgroundOctogenarians with complex abdominal aortic aneurysms are at higher risk of death and morbidity after open repair. Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair for high-risk patients, such as octogenarians. The aim of this study was to evaluate perioperative and midterm outcomes of FEVAR among octogenarians at high and standard risk for open repair. MethodsDuring a 2-year period, 85 patients (68 men [78%] and 17 women [22%]) underwent FEVAR using Zenith (Cook Medical, Bloomington, Ind) Fenestrated AAA Endovascular Grafts (70%), Zenith p-Branch (7%), and fenestrated custom-made devices (22%). Demographics and perioperative and follow-up outcomes of patients aged >80 years (n = 18 [21%]) and patients aged <80 years (n = 67 [79%]) were compared. The χ2 or Fisher test was used for categorical variables, and nonparametric tests were used for continuous variables. Kaplan-Meir curve was used for survival analysis. ResultsMedian age was 73 years (interquartile range [IQR], 68-79 years) for the entire cohort, 84 years (IQR, 81-86 years) among octogenarians, and 71 years (IQR, 67-75) for younger patients. Median aneurysm size was 56 mm (IQR, 53-62 mm). The median number of fenestrations was three. Preoperatively, octogenarians had higher Society for Vascular Surgery score (5.5 [IQR, 5-7] vs 5 [IQR, 3-6]; P = .01) and lower body mass index (26 [IQR, 21-27] vs 28 [24-32]; P = .04). Intraoperatively, technical success was 100% for both groups. The median operative time for octogenarians was 224 minutes (IQR, 160-272) vs 212 minutes (IQR, 177-281) in patients <80 years (P = .59). The median hospital length of stay was 3.5 days (IQR, 2-5) for octogenarians vs 4 days (IQR, 2-5) in younger patients (P = .87). Intensive care unit length of stay was 2 days for patients from both groups (IQR, 1-3). The rate of postoperative complications was 28% for octogenarians and 36% for patients aged <80 years (P = .5). None of the patients in this series required dialysis. No 30-day deaths occurred. The 20-month estimated survival rate was 75% in octogenarians and 91% in patients <80 years (P = .1). The rate of reinterventions at 20 months was 10% for octogenarians and 57% for younger patients (P = .09). ConclusionsFEVAR is a safe and effective procedure in octogenarians at high and standard risk for open repair and those who are not eligible for standard endovascular aneurysm repair. Octogenarians have a similar technical success and low major adverse events similar to patients younger than 80 years.

Feasability of contrast-enhanced ultrasound with image fusion of CEUS and MS-CT for endovascular grafting in infrarenal abdominal aortic aneurysm in a single patient

Currently methods to reduce radiation and contrast media application in endovascular repair of aortic aneurysms (EVAR) are investigated. First positive results for real-time contrast medium-enhanced ultrasonography (CEUS) guided endovascular aortic repair have been reported. Acombination with image fusion of CEUS and preoperative multi-slice computed tomography (MS-CT) might offer added safety regarding stent-graft positioning and sealing of the landing zones.EVAR was performed in apatient with an asymptomatic infrarenal aortic aneurysm and apenetrating aortic ulcer in the neck region. The precise placement of the stent-graft was performed with CEUS using image fusion and native intraprocedural angiographic fluoroscopy and confirmed with digital subtraction angiography (DSA) using iondinated contrast media. At follow-up, CEUS was used to exclude endoleaks and stent-graft failure or malposition.The precise CEUS-guided placement of the stent-graft was technically successful. No artifacts due to electrical noise and metallic parts of the operating table and surgical instruments occurred. The amount of iodinated contrast media was reduced as intraoperative follow-up was performed using CEUS.CEUS with image fusion combined with intraprocedural angiographic fluoroscopy enables accurate stent-graft placement without use of any nephrotoxic contrast media. This allows EVAR in patients with renal insufficiency or allergic reactions to contrast media.

Spondylitis transmitted from infected aortic grafts: a review.

Graft infection following aortic aneurysms repair is an uncommon but devastating complication; its incidence ranges from <1% to 6% (mean 4%), with an associated perioperative and overall mortality of 12% and 17.5-20%, respectively. The most common causative organisms are Staphylococcus aureus and Escherichia coli; causative bacteria typically arise from the skin or gastrointestinal tract. The pathogenetic mechanisms of aortic graft infections are mainly breaks in sterile technique during its implantation, superinfection during bacteremia from a variety of sources, severe intraperitoneal or retroperitoneal inflammation, inoculation of bacteria during postoperative percutaneous interventions to manage various types of endoleaks, and external injury of the vascular graft. Mechanical forces in direct relation to the device were implicated in fistula formation in 35% of cases of graft infection. Partial rupture and graft migration leading to gradual erosion of the bowel wall and aortoenteric fistulas have been reported in 30.8% of cases.Rarely, infection via continuous tissues may affect the spine, resulting in spondylitis. Even though graft explantation and surgical debridement is usually the preferred course of action, comorbidities and increased perioperative risk may preclude patients from surgery and endorse a conservative approach as the treatment of choice. In contrast, conservative treatment is the treatment of choice for spondylitis; surgery may be indicated in approximately 8.5% of patients with neural compression or excessive spinal infection. To enhance the literature, we searched the related literature for published studies on continuous spondylitis from infected endovascular grafts aiming to summarize the pathogenesis and diagnosis, and to discuss the treatment and outcome of the patients with these rare and complex infections.

ЭНДОВАСКУЛЯРНЫЕ ВМЕШАТЕЛЬСТВА НА ВЕНОЗНЫХ ШУНТАХ (обзор литературы)

In the first year occlusion occurs 10-15% of coronary artery bypass graft in 10 years - 50%, which causes the resumption of anginal patients after CABG. One of the most effective and safe methods of treatment of these patients is recognized endovascular intervention artery bypass graft failure or inter-vention of native coronary artery. In contrast classical percutaneous coronary reconstructions, for which there exist algorithms endovascular treatment for minimizing intraoperative risk and achieving the best long term results, treatment of saphenous vein grafts (SVG) still remains a challenging clinical problem. This article is a summary review of the literature dedicated to endovascular interventions for myocardial revascularization on the coronary artery bypass graft in patient after CABG. Analysis of the research allowed us to draw conclusions about the tactics of endovascular treatment of patients with return of angina after CABG, as well as about the defeat of the saphenous vein grafts lesions for endovascular interventions, and to identify the technical features of the SVG stenting.

Yersinia enterocolitica Bloodstream Infection

An elderly male presented with abdominal pain and constipation. He was diagnosed with Yersinia enterocolitica bloodstream infection associated with an abdominal aortic aneurysm and synthetic endovascular graft. This demonstrates a rare but known complication of Y. enterocolitica bloodstream infection. J Med Cases. 2017;8(11):359-360 doi: https://doi.org/10.14740/jmc2931w

Aortic Dissection as a Complication in Patients on Maintenance Haemodialysis: Two Cases Report

Aortic dissection (AD) is a rare disease that may result in a fatal outcome. Uremic patients are often associated with factors susceptible to AD. We herein report two cases of AD occurring in maintenance haemodialysis patients. The two male Chinese had history of smoking and poor uncontrolled hypertension for many years. One patient died of the aortic wall rupture with conservative treatment. The other patient had a history of myocardial infarction and long-term administration of anti-platelet drugs. The patient survives after prompt stenting and continuous maintenance haemodialysis. It is important to improve our understanding about aortic dissection (AD) in haemodialysis patients because of the high mortality and morbidity. Once a patient on maintenance haemodialysis is diagnosed with AD, surgery or endovascular graft exclusion should be considered according to the actual situation of individual patients, and the mode of dialysis should be converted in conservation treatment patients.

Using Nuclear Medicine Imaging Wisely in Diagnosing Infectious Diseases.

In recent years, there has been an increasing emphasis on efficient and accurate diagnostic testing, exemplified by the American Board of Internal Medicine’s “Choosing Wisely” campaign. Nuclear imaging studies can provide early and accurate diagnoses of many infectious disease syndromes, particularly in complex cases where the differential remains broad.This review paper offers clinicians a rational, evidence-based guide to approaching nuclear medicine tests, using an example case of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia in a patient with multiple potential sources. Fluorodeoxyglucose-positron emission tomography (FDG-PET) with computed tomography (CT) and sulfur colloid imaging with tagged white blood cell (WBC) scanning offer the most promise in facilitating rapid and accurate diagnoses of endovascular graft infections, vertebral osteomyelitis (V-OM), diabetic foot infections, and prosthetic joint infections (PJIs). However, radiologists at different institutions may have varying degrees of expertise with these modalities. Regardless, infectious disease consultants would benefit from knowing what nuclear medicine tests to order when considering patients with complex infectious disease syndromes.

Technique for treating complex aneurysms with Hercules stent graft modified by the surgeon

Endovascular treatment of thoracoabdominal aneurysms with fenestrated stent grafts expands its applicability because of good technical results. However, stent graft customization requires an average of 6 to 12 weeks, which makes this technique ineligible for symptomatic or ruptured aneurysms. Authors advocate perioperative fenestration by the surgeon, allowing this technique to be used for emergency cases with good results and favorable prognosis. This article describes a technique for intraoperative changes of the Hercules stent graft (MicroPort Scientific Corporation, Shanghai, China) to include the ostia of visceral arteries by making fenestrations and scallops, with a temporary diameter-reducing wire as a further modification to facilitate positioning and catheterization of fenestrations with guidewires.

In Vitro Study of a Superhydrophilic Thin Film Nitinol Endograft that is Electrostatically Endothelialized in the Catheter Prior to the Endovascular Procedure.

Electrostatic endothelial cell seeding has evolved as an exceptional technique to improve the efficiency of cell seeding in terms of frequency of attached cells and the amount of cell adhesion for the treatment of vascular diseases. In the recent times, both untreated and superhydrophilic thin film nitinol (TFN) have exhibited strong prospects as substrates for creation of small-diameter endovascular grafts due to their hallmark properties of superelasticity, ultra low-profile character, and grown hemocompatible oxide layer with the presence of a uniform endothelial layer on the surface. The purpose of the current study is to understand the effects of endothelial cell seeding parameters (i.e., applied voltage, incubation time, substrate chemistry, and cell suspension solution) to investigate the cell seeding phenomenon and to improve the cell adhesion and growth on the TFN surface under electrostatic transplantation. Both parallel plate and cylindrical capacitor models were used along with the Taguchi Design of Experiment (DOE) methods to design in vitro test parameters. A novel in vitro system for a cylindrical capacitor model was created using a micro flow pump, micro incubation system, and silicone tubings. The augmented endothelialization on thin film nitinol was developed to determine the effect of cell seeding and deployed in a 6 Fr intravascular catheter setup. Cell viability along with morphology and proliferation of adhered cells were evaluated using fluorescent and scanning electron microscopy. Our results demonstrated that the maximum number of cells attached on STFN in the catheter was observed in 5 V with the 2 h exposure of in the cell culture medium (CCM) solution. The condition showed 5 V voltage with 0.68 × 10−6 µC electrostatic charge and 5.11 V·mm−1 electric field. Our findings have first demonstrated that the electrostatic endothelialization on the superhydrophilic thin film nitinol endograft within the catheter prior to the endovascular procedure could enhance the biocompatibility for low-profile endovascular applications.