Endovascular Stent-graft Repair Research Articles

Successful surgical treatment for aortoenteric fistula after esophagectomy: a case report

BackgroundAn aortoenteric fistula (AEF) is a rare and lethal complication of esophagectomy. Fistulas frequently result from problems regarding acute infections or leaks, which are typically evident weeks after the treatment. However, some cases exhibit AEF years after the initial operation. Here, we describe a rare case of AEF caused by chronic friction of the stapler toward the aortic arch, in which stent graft repair and surgery were successful.Case presentationA 71-year-old man had undergone esophagectomy for esophageal carcinoma and reconstruction with a gastric conduit through the posterior mediastinal route 11 years previously. He visited our outpatient clinic with the chief complaint of hematemesis. However, after arrival, he experienced massive hematemesis and severe shock due to bleeding from an AEF. Endoscopic hemostasis using a Sengstaken-Blakemore tube followed by stent graft repair controlled the bleeding. We performed a partial resection of the gastric conduit, including the fistula, followed by digestive reconstruction using a jejunal interposition graft. The patient recovered gradually after receiving intensive care and was discharged 115 days after hospitalization.ConclusionsWe present a rare case of bleeding due to AEF long after esophagectomy, which was successfully treated with endovascular stent graft repair and surgery. Endoscopic hemostasis using a Sengstaken-Blakemore tube followed by stent graft repair was effective.

Endovascular Stent-Graft Repair of True and False Aneurysms of the Splenic Artery.

In treatment of aneurysms (SAAs) and pseudoaneurysms (SAPs) of the splenic artery, endovascular coil embolization is the approach most commonly used as it is minimally invasive and safe. However, it carries a significant rate of primary failure (up to 30%) and might be complicated by splenic infarction. The use of stent grafts might represent a valuable alternative when specific anatomical criteria are respected. We report a comprehensive review on technical and clinical outcomes achieved in this setting. Methods: We performed a comprehensive review of the literature through the MedLine and Cochrane databases (from January 2000 to December 2023) on reported cases of stenting for SAAs and SAPs. Outcomes of interest were clinical and technical success and related complications. The durability of the procedure in the long-term was also investigated. Results: Eighteen papers were included in the analysis, totalling 41 patients (n = 20 male 48.8%, mean age 55.5, range 32-82 years; n = 31, 75.6% SAAs). Mean aneurysm diameter in non-ruptured cases was 35 mm (range 20-67 mm), and most lesions were detected at the proximal third of the splenic artery. Stent grafting was performed in an emergent setting in n = 10 (24.3%) cases, achieving immediate clinical and technical success rate in 90.2% (n = 37) of patients regardless of the type of stent-graft used. There were no procedure-related deaths, but one patient died in-hospital from septic shock and n = 2 (4.9%) patients experienced splenic infarction. At the last available follow-up, the complete exclusion of the aneurysm was confirmed in 87.8% of cases (n = 36/41), while no cases of aneurysm growing nor endoleak were reported. None of the patients required re-intervention during follow-up. Conclusions: When specific anatomical criteria are respected, endovascular repair of SAAs and SAAPs using stent grafts appears to be safe and effective, and seems to display a potential advantage in respect to simple coil embolization, preserving the patient from the risk of end-organ ischemia.

Treatment For Infected Frozen Elephant Trunk Prosthesis Caused by Propionibacterium acnes: A Surgical Challenge.

In this article, we present the case of a 47-year-old man who underwent Bentall-Bono procedure and frozen elephant trunk prosthesis implantation due to severe aortic regurgitation and aortic dilatation with a second-time endovascular stent-graft repair in descending aorta. Over eight years, a subacute graft infection by Propionibacterium acnes was developed, culminating in cardiogenic shock secondary to severe aortic regurgitation due to a complete aortic root dehiscence because of multiple aortic pseudoaneurysms. The patient underwent emergency surgery in which the replacement of the graft by a biological valve tube was performed accompanied by a complete debranching of the three supra-aortic vessels.

Outcomes of the Ankura Stent Graft for Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm.

The purpose of this retrospective cohort study is to report outcomes of endovascular aortic repair (EVAR) with the novel endograft, Ankura (Lifetech Scientific, Shenzen, China). We identified all patients who underwent elective EVAR with Ankura stent graft in a tertiary unit from January 2015 to November 2021. Patients with ruptured infrarenal and juxtarenal aortic aneurysms were excluded from the study. All patients were anatomically suitable according to the instructions for use (IFU). Follow-up (FU) included computed tomography angiography (CTA) at 1 month, 12 months, and yearly thereafter if endoleak (EL) was not present. Primary outcomes included technical success (primary and secondary) and 30-day overall mortality and morbidity. Secondary outcomes included late overall and aneurysm-related mortality as well as influence of suprarenal fixation of the endograft on renal function at 12 months using eGFR (CKI-EPI formula). The Ankura endograft was successfully implanted in 116 patients (mean age=71.1 years, 96.5% male). Mean aneurysm diameter was 62.3 mm. Median FU was 34 months (2-72 months). Primary and secondary technical success were 95.7% and 100%, respectively. Overall type I EL was 5% (2 proximal, 3 distal) and type II EL was 13%. Thirty days mortality and morbidity were 0% and 5.2%, respectively. All-cause mortality during FU was 13.9% (n=16); aneurysm-related mortality was 2.6% (n=3). Limb endograft patency was 100%. Freedom from reintervention was 98.2% at 2 years, and 97.4% at 4 and 6 years respectively. There was a statistically significant difference between preoperative (73.69 mL/min/1.73 m2) and postoperative (66.66 mL/min/1.73 m2) eGFR at 12 months (p<0.001). Ankura endograft has demonstrated an efficacious durability with low aneurysm-related mortality and high iliac limb patency rate. Elective EVAR is associated with significant decline in renal function at 12 months in our study. Larger series studies are necessary to evaluate long-term safety and efficacy of Ankura endograft. Ankura stent graft is a novel PTFE endograft with suprarenal fixation for infrarenal aneurysm repair. This retrospective cohort study of 116 patients provide a first "picture" of Ankura safety and efficacy in a European tertiary vascular center. High technical success rate, low aneurysm related mortality and high limb patency rate are the main findings of the study with a negative impact of suprarenal fixation on kidney function during follow up.

Endovascular Treatment for Isolated Infected Iliac Artery Aneurysms.

Isolated infected iliac artery aneurysms (IIIAAs) are extremely rare, life-threatening, and intractable. This study aimed to evaluate the outcomes of endovascular treatment in patients with IIIAAs. A retrospective study was conducted for all patients who underwent endovascular treatment for IIIAAs between June 2012 and June 2022 in 3 hospitals. The clinical data and follow-up outcomes were reviewed and assessed. Fifteen patients were included in this study. The median age was 69 years, 12 patients (80%) were men, and 8 (53%) had hypertension. Most of the patients presented with abdominal or lumbar pain (87%) and fever (60%). The offending pathogen was identified in 11 patients (73%). Fifteen patients had a total of 16 IIIAAs, with 12 (75%) involving the common iliac artery. The immediate technical success rate was 100%, and the 30-day mortality was 7%. Infection-related complications occurred in 2 patients (13%) during hospitalization who were treated by open surgery at a later stage. The median follow-up was 23 months (range: 6-80 months, mean: 32 ± 25 months). Aneurysm recurrence was identified in one patient (7%) 5 months after endovascular repair. It was managed by endovascular stent-graft repair with percutaneous catheter drainage. No patients died during the follow-up period. Endovascular treatment is feasible, safe, and effective for patients with IIIAAs, achieving acceptable clinical outcomes. Infection surveillance with essential reintervention should be considered for potential infection-related complications. This study first reported that 15 patients underwent endovascular treatment for primary isolated infected iliac artery aneurysms (IIIAAs). It showed a good early and midterm outcomes. This is the first and largest multi-center study and the first literature review of IIIAAs. It provides an evidence that endovascular treatment is feasible, safe, and effective to treat IIIAAs. It suggests endovascular treatment is a promising alternative or a bridge to conventional open surgery for IIIAAs. This may promote endovascular therapy in the management of IIIAAs. It would help clinicians to make an appropriate treatment choice for IIIAAs.

Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma

BackgroundThe current treatment for retrograde ascending aortic intramural hematoma (RAIMH) remains challenging. This study aims to summarize the short-term results of endovascular repair in the treatment of retrograde ascending aortic intramural hematoma.MethodsBetween June 2019 and June 2021, 21 patients (16 males and 5 females) with a retrograde ascending aortic intramural hematoma, aged 53 ± 14years, received an endovascular repair in our hospital. All cases involved an ascending aortic or aortic arch intramural hematoma. 15 patients had an ulcer on the descending aorta combined with an intramural hematoma in the ascending aorta and 6 patients had typical dissection changes on the descending aorta combined with an intramural hematoma in the ascending aorta. All patients had a successful endovascular stent-graft repair, with 10 cases operated on in the acute phase (<14 days) and 11 cases in the chronic phase (14–35 days).ResultsA single-branched aortic stent graft system was implanted in 10 cases, a straight stent in 2 cases, and a fenestrated stent in 9 cases. All surgeries were technically successful. One of the patients developed a new rupture 2 weeks after surgery and was converted to a total arch replacement. No perioperative stroke, paraplegia, stent fracture or displacement, limb or abdominal organ ischemia occurred. The intramural hematomas started being absorbed on CT angiography images before discharge. There was no incidence of postoperative 30-day mortality, and the intramural hematomas in the ascending aorta and aortic arch were fully or partly absorbed.ConclusionEndovascular repair of retrograde ascending aortic intramural hematoma was shown to be safe and effective, and correlated with favorable short-term results.

Endovascular Management of the Ascending Aorta: State of the Art.

Endovascular stent graft repair (EVAR) has revolutionized the management of aneurysms and dissections of the thoracic and abdominal aorta and is considered the first-line treatment in such pathologies. Initially designed for patients unfit for open repair, EVAR and thoracic endovascular aortic stent graft repair are associated with improved morbidity and mortality and a faster recovery process. The endovascular revolution of the aorta continues moving proximally, with fenestrated and branch stent grafts currently in clinical trials for the management of thoracoabdominal aortic aneurysms, and several branched thoracic devices are either approved or in trial for management of aortic arch pathologies. The final frontier in the endovascular management of the aorta is the aortic root and ascending aorta. The first early feasibility trial for management of type A aortic dissection has recently concluded with a multicenter phase 2 study slated for the spring of 2023. The following article updates the reader on the unique challenges of endovascular management of the ascending aorta and a look at the future technologies that will define this space.

Applicability of endovascular branched and fenestrated aortic arch repair devices to treat residual type A dissection after ascending replacement.

Endovascular repair of post-type A aortic dissection (PTAD) after open ascending replacement has recently been shown as safe and feasible, but with limited anatomic applicability because only one stent graft was evaluated. We assessed anatomic and clinical applicability of six commercially available branched/fenestrated stent grafts for endovascular repair of PTAD. On postoperative CT scans of 101 patients, we measured the aortic diameter at the sinutubular junction, supra-aortic vessels, and descending aorta, as well as the distances between these landmarks along the outer curvature of the arch and the diameters of the supra-aortic vessel. Anatomic applicability was evaluated according to the instructions for use, clinical applicability with regard to supra-aortic and iliac arteries. Assessed devices were the Cook aortic double branch, Terumo double branch, Najuta fenestrated, Endospan Nexus, Medtronic Mona LSA, and Gore TAG thoracic branch. Single devices were anatomically and clinically applicable between 19 of 101 (Mona LSA) and 83 of 101 (Najuta) cases. Reasons for rejection varied considerably across devices. With all devices available, anatomic applicability was 97 of 101 and clinical applicability 95 of 101. Combinations of a fenestrated and a branched device showed the most favorable clinical applicability for a pair of two devices, ranging from 86 of 101 to 94 of101. Anatomic and clinical applicability of endovascular devices for the repair of PTAD is high for fenestrated and branched devices, and very high for the combination of fenestrated and branched devices. Manufacturers should amend specific device requirements for PTAD. Surgeons should emphasize the need for a sufficiently long and straight graft as a potential landing zone.

Zone 0 thoracic endovascular aortic repair in high risk patients: A retrospective case series.

To report our experience applying endovascular stent graft repair to treat ascending aortic diseases in high-risk patients and to evaluate the safety and feasibility of this approach. Patients with comorbid conditions or older age are not suitable for open procedures but may be considered suitable for ascending endovascular repair. Eleven high-risk patients received zone 0 thoracic endovascular aortic repair from September 2014 to May 2020. All patients were followed up until death or December 2021. Primary outcomes were in-hospital and long-term all-cause mortality as well as in-hospital and long-term aorta-related mortality. The mean follow-up duration of all patients was 35.78 months. The cohort comprised of three pathology subgroups: penetrating atherosclerotic ulcer (PAU) (n =6), acute dissection (AD) (n = 3), and chronic dissecting aneurysm (CDA) (n = 2). The in-hospital all-cause mortality rates were 0%, 33.33% and 0% for PAU, AD, and CDA groups, respectively. Long-term all-cause mortality were 33.33%, 33.33%, and 50% for PAU, AD, and CDA groups, respectively. There was only one in-hospital death related to acute aortic dissection, and no long-term aorta-related deaths occurred during the study period. During the follow-up time, the majority of patients had good remodeling of ascending aorta, slow progression in cases with endoleak, and no aorta-related mortality. Ascending endovascular aortic repair appears to be a safe and feasible procedure for emergent aortic repair in carefully selected patients with prohibitive surgical risk who are not candidates for open procedures.

Translocation of the Isolated Left Vertebral Artery during Thoracic Endovascular Stent-Graft Repair

Translocation of the Isolated Left Vertebral Artery during Thoracic Endovascular Stent-Graft Repair

Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis: Presented at the 2021 Vascular Annual Meeting of the Society of Vascular Surgery, San Diego, Calif, August 18-21, 2021.

Purpose The purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz).

Early results of bare metal extension stent for thoracoabdominal aortic dissection.

ObjectivesDebakey type I and IIIb aortic dissections are complicated by extension along the full length of the aorta. Over the long term, the thoracoabdominal aorta in these patients often continues to degenerate, requiring endovascular or open repair. The purpose of this investigation is to determine the early clinical outcome on aortic remodeling using a composite thoracic stent graft and thoracoabdominal bare metal extension stenting strategy.MethodsFrom April 2019 to April 2021, 73 patients with Debakey I/IIIb aortic dissection underwent endovascular stent graft repair of the descending thoracic aorta and repair of the thoracoabdominal aorta using bare metal extension stenting. Preoperative and follow-up surveillance computed tomography imaging scans were analyzed.ResultsFifty-three (73%) patients had a Debakey I aortic dissection, and 50 (69%) patients underwent surgery during the chronic (time to surgery >30 days) dissection phase. Mortality at 30 days was 4% (3 hyperacute patients). Stroke occurred in 3 (4%), paraparesis in 2 (2.7%), and acute renal failure requiring dialysis occurred in 2 (2.7%) patients. On postoperative and follow-up computed tomography, there was a significant increase in false lumen thrombosis (P < .001). This coincided with a significant increase in true lumen fraction suggestive of positive aortic remodeling (P < .001) at the time of latest follow-up.ConclusionsAltering the course of aortic remodeling, with placement of a dissection stent in the thoracoabdominal aorta simultaneous with descending thoracic aortic repair may promote true lumen re-expansion and false lumen thrombosis during acute and chronic dissection phases.

Perioperative Outcomes Among Major Endovascular Stent Grafts For The Treatment Of Abdominal Aortic Aneurysm

<h3>INTRODUCTION</h3> There are currently six endovascular stent grafts approved by the Food and Drug Administration for the endovascular repair (EVAR) of infra-renal abdominal aortic aneurysms (AAA). There is minimal data comparing the outcomes between devices. <h3>METHODS</h3> The National Surgical Quality Improvement Program (NSQIP) targeted database was queried for patients undergoing EVAR between 2011-2019. Devices used in at least 10% of patients were included (Cook Zenith, Gore Excluder, and Medtronic Endurant). Patient demographics, procedure details, 30-day EVAR specific complications and mortality were compared between devices. Multivariable logistic regression models were used to predict outcomes while adjusting for baseline differences between device cohorts. <h3>RESULTS</h3> 13,416 patients were included. Most patients underwent repair with a Gore Excluder (5,997; 44.7%). There was no difference in the rates of diabetes, hypertension, or end-stage renal disease between cohorts. Unadjusted outcomes are shown in Table 1. The rate of postoperative acute limb ischemia (ALI) was higher in overall patients who underwent repair with a Medtronic Endurant, as well as in subgroup analysis of patients with ruptured AAA. Patients who underwent repair with a Medtronic Endurant were more likely than those who underwent repair with a Gore Excluder (OR=2.06; 95%CI=1.49-2.86) or with a Cook Zenith device (OR=1.56; 95%CI=1.06-2.28), to have postoperative ALI. No differences between devices were associated with death, MACE, ischemic colitis, conversion to open or postoperative dialysis. <h3>CONCLUSION</h3> Overall, safety is similar among major endovascular stent grafts for EVAR, except for a higher rate of ALI following repairs with the Medtronic Endurant. Since with this study we cannot determine if the higher incidence of ALI relates to graft design, patient anatomy, or operative technique, future studies should be aimed to further evaluate this finding.Image, table 1Image, table 1

La revascularización de la arteria subclavia izquierda con un bypass axiloaxilar cruzado para la reparación híbrida de aneurismas de la aorta torácica

We present our subclavian artery revascularization experiences in the patients with thoracic aortic aneurysm who underwent hybrid repair. Between May 2015-December 2018,4 patients underwent TEVAR procedure following axilloaxillary bypass grafting.The mean age of the patients was 72.5 ± 3.01 years.One patient was female and 3 patients were male.Patients had thoracic aortic aneurysms including the left subclavian artery or aberrant right subclavian artery. All patients underwent endovascular stent graft repair following axilloaxillary bypass grafting in the same day.Mortality did not occur in the perioperative period.One patient had graft infection at 8th month of the operation and the graft was removed.He was lost due to pneumonia following the operation.The control computed tomographies of the other 3 patients revealed patent grafts together with successful endovascular interventions and they have been following uneventfully a mean of 27±6.2 months (range:24-32,median:29). The risk of stroke,spinal cord ischemia, and upper extremity ischemia are found higher in the patients who underwent coverage of the left subclavian artery without revascularization.The axilloaxillary bypass grafting may be performed in the patients with high risk to prevent carotid artery manipulation and clamping during carotid-subclavian bypass with long term promising patency rates.

Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis

PurposeThe purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz). MethodsWe retrospectively reviewed all consecutive patients treated for aortoiliac aneurysms using IBE between 2014 and 2020. IIA stenting was performed using either the IIA side branch SESG or a Gore VBX BESG (W. L. Gore). Indications for use of BESGs were “up-and-over” IBE technique for type IB endoleak after prior endovascular aortic aneurysm repair (EVAR), short IIA length, and need for IIA extension into divisional branches (outside instructions for use). End points included technical success, freedom from buttock claudication, primary IIA patency, and freedom from IIA branch instability (eg, branch-related death or rupture, occlusion, disconnection, or reintervention for stenosis, kink, or endoleak), freedom from type IC/IIIC endoleak, and freedom from secondary interventions. ResultsThere were 90 patients (86 males and 4 females) with a mean age of 74 ± 7 years treated by EVAR with 108 IBEs. Choice of stent was BESG in 43 and SESG in 65 targeted IIAs. BESGs were used more frequently in patients with prior EVAR (22% vs 2%; P = .003,), isolated IBEs (31% vs 2%; P < .001), and in patients with IIA aneurysms requiring stenting into divisional branches (36% vs 5%; P < .001). Technical success was similar for BESGs and SESGs (97% vs 100%; P = .40), respectively. The mean follow-up was 25 ± 16 months (range, 11-34 months). At 2 years, freedom from buttock claudication was 100% for BESG and 95 ± 3% for SESG (Log-rank 0.26), with no difference in primary patency (BESG, 100% vs SESG, 94 ± 4%; Log-rank 0.94). There were four (9%) IIA-related endoleaks in the BESG group and one (2%) in the SESG group (P = .08). Freedom from IIA branch instability was 87 ± 6% for BESG and 96 ± 3% for SESG at 2 years (Log-rank 0.043). Freedom from type IC/IIIC endoleak was 87 ± 7% for BESG and 98 ± 2% for SESG at the same interval (Log-rank 0.06). There was no difference in freedom from reinterventions for BESG and SESG (92 ± 6% vs 98 ± 2%; Log-rank 0.34), respectively. ConclusionsBESGs were used more frequently during IBE procedures indicated for failed EVAR, isolated common iliac aneurysms, and IIA aneurysms requiring extension into divisional branches. Despite these differences and BESG being used outside instructions for use, both stent types had similar primary patency, freedom from buttock claudication, and freedom from reinterventions. However, BESGs were associated with higher rates of IIA-related branch instability.

Endovascular Management of an Aortacaval Fistula in Penetrating Trauma

We report the case of a 16-year-old boy who had presented after sustaining a gunshot wound to the abdomen. He was brought on arrival to the operating room for damage control laparotomy. The next morning, he underwent postoperative computed tomography, which demonstrated an aortocaval fistula (ACF) with an aortic pseudoaneurysm measuring 3.2 × 4.3 × 3.7 cm (Fig). The computed tomography scan was also notable for an accessory left renal artery. We took the patient expeditiously to the hybrid operating room for aortic stent-graft repair using a 16 × 45-mm Ovation iliac limb stent-graft (Endologix Inc, Irvine, Calif). The use of an endovascular approach to his traumatic aortic injury allowed for expedient repair without further hemodynamic compromise. We have reported this case because endovascular repair of traumatic ACFs has not been well reported, with only four other cases in the literature from 1992 to 2017. A retrospective medical record review was performed. The patient's parents had provided written informed consent for the medical record review and the report of his case. A literature review was performed using PubMed and the search terms “aorto-caval fistula” and “traumatic aorto-caval fistula.” From our literature review, we found only four other reports of the use of endovascular stent-graft repair for the treatment of traumatic ACFs. Only one other case had used an iliac limb for repair, and in that case, it was to address a complication after an open repair. Thus, we have reported our case as an infrequently reported method to manage a devastating traumatic injury. Although endovascular management has been previously reported in the setting of aortic aneurysm repair with a concomitant ACF, it has not been well described in the management of traumatic ACFs. In our review of the literature, we found only four cases reported from 1992 to 2017. Also, to the best of our knowledge, our patient is the youngest reported. Our patient's young age added a layer of difficulty in sizing the stent-graft. With the novel use of an ovation iliac limb stent-graft, we were able to appropriately size the stent-graft for our young patient and obtain successful repair of his ACF. The present case adds to the literature on the endovascular management of traumatic ACFs.

Investigation of Three-dimensional Printing Materials for Printing Aorta Model Replicating Type B Aortic Dissection.

This study aims to determine a printing material that has both elastic property and radiology equivalence close to the real aorta for simulation of endovascular stent-graft repair of aortic dissection. With the rapid development of Three-Dimensional (3D) printing technology, a patient- specific 3D printed model is able to help surgeons to make a better treatment plan for Type B aortic dissection patients. However, the radiological properties of most 3D printing materials have not been well characterized. This study aims to investigate the appropriate materials for printing human aorta with mechanical and radiological properties similar to the real aortic Computed Tomography (CT) attenuation. Quantitative assessment of CT attenuation of different materials used in 3D printed models of aortic dissection for developing patient-specific 3D printed aorta models to simulate type B aortic dissection. A 25-mm length of aorta model was segmented from a patient's image dataset with a diagnosis of type B aortic dissection. Four different elastic commercial 3D printing materials, namely Agilus A40 and A50, Visijet CE-NT A30 and A70 were selected and printed with different hardness. Totally four models were printed out and CT scanned twice on a 192-slice CT scanner using the standard aortic CT angiography protocol, with and without contrast inside the lumen. Five reference points with the Region Of Interest (ROI) of 1.77 mm2 were selected at the aortic wall, and intimal flap and their Hounsfield units (HU) were measured and compared with the CT attenuation of original CT images. The comparison between the patient's aorta and models was performed through a paired-sample t-test to determine if there is any significant difference. The mean CT attenuation of the aortic wall of the original CT images was 80.7 HU. Analysis of images without using contrast medium showed that the material of Agilus A50 produced the mean CT attenuation of 82.6 HU, which is similar to that of original CT images. The CT attenuation measured at images acquired with the other three materials was significantly lower than that of the original images (p<0.05). After adding contrast medium, Visijet CE-NT A30 had an average CT attenuation of 90.6 HU, which is close to that of the original images without a statistically significant difference (p>0.05). In contrast, the CT attenuation measured at images acquired with other three materials (Agilus A40, A50 and Visiject CE-NT A70) was 129 HU, 135 HU and 129.6 HU, respectively, which is significantly higher than that of original CT images (p<0.05). Both Visijet CE-NT and Agilus have tensile strength and elongation close to actual patient's tissue properties producing similar CT attenuation. Visijet CE-NT A30 is considered the appropriate material for printing aorta to simulate contrast-enhanced CT imaging of type B aortic dissection. Due to the lack of body phantoms in the experiments, further research with the simulation of realistic anatomical body environment should be conducted.

Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application

PurposeTo test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices.MethodsA stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement.ResultsThe stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications.ConclusionThe novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis.Level of EvidenceNo level of evidence.

Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center.

BackgroundComplicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes.MethodsWe reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12–80 months).ResultsThe median interval from aortic dissection to TEVAR was 5.50 days (range, 0–32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%).ConclusionTEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.

One-year results of stent graft repair for carotid artery pseudo-aneurysm in patients with Behcet's disease.

Behcet's disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet's disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit. During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention. The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%). Stent graft repair for carotid artery pseudo-aneurysm in Behcet's disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.