Stent Research Articles

Evaluation of hydrophilic polymer embolization from endovascular sheath devices in an in vitro perfusion system

ObjectiveCase reports, tissue pathology, and autopsies have suggested that the hydrophilic polymer coating designed to improve endovascular deliverability and minimize vessel trauma can embolize and be associated with adverse outcomes such as ischemia, infarction, and death. This study sought to determine whether hydrophilic polymers shed off commercially available sheaths in a controlled in vitro environment, with the hypothesis that significant differences between coated and uncoated (control) sheaths would be found. MethodsSix sheaths from each manufacturer, including Zenith Alpha abdominal endovascular stent grafts (Cook Medical), DrySeal sheaths (W.L. Gore & Associates), and Sentrant Introducer sheaths (Medtronic), were tested in an in vitro environment. Noncoated Check-Flo performer introducer sheaths (Cook Medical) were used as controls. Each test circuit ran for 150 minutes at an output of 3 L/min, the circuit was then drained and the fluid collected. Quantitative analysis included weighing the dried filter paper and using particle size light scattering to quantify the particle size and count. Attenuated total reflectance spectroscopy was also used. ResultsEach of the three coated sheaths had significantly greater shedding compared with the control sheaths. The Cook Zenith alpha sheath had significantly more residue weight (2.87 ± 0.52 mg/L) than the Gore DrySeal (1.07 ± 0.06 mg/L) and Medtronic Sentrant introducer (0.98 ± 0.14 mg/L) sheaths. The average particle size was not significantly different between the coated and uncoated (control) sheaths. Attenuated total reflectance spectroscopy identified sheath particulate in the Cook Zenith Alpha and Medtronic Sentrant samples. ConclusionsPolymer embolization was present and significantly greater in all three commercially available hydrophilic sheaths compared with the control group. Further investigation is needed into the clinical significance of these findings.

Complex, high-risk, and indicated percutaneous coronary angioplasty in essentially calcified stented coronary lesions using excimer laser coronary atherectomy with contrast mix injection.

Complex, coronary stenosis remains a technical challenge that may be responsible for in-stent restenosis and vessel thrombosis. Here we investigated the efficacy and safety of excimer laser coronary atherectomy (ELCA) with contrast mix injection for improving vessel wall stent apposition in undilatable, mostly calcified lesions. To assess ELCA with contrast mix injection in complex, stented, calcified coronary lesions. This prospective single-center observational study enrolled 52 consecutive patients (73 lesions), with suboptimal stents implanted in de novo lesions and lesions requiring in-stent restenosis (ISR) due to stent underexpansion using all available means to achieve an optimal result. Patients presenting with ST-segment elevation myocardial infarction were excluded. All patients underwent coronary angiography 6 months after ELCA with intravascular ultrasound or optical coherence tomography study. We used contrast media mixed with saline (25-75%) to supply maximum laser energy output when a standard approach was unsuccessful. Procedural success was defined as relative stent expansion of > 80% minimal stent area (MSA) divided by average reference lumen area. Procedural success was achieved in all cases. The cross-sectional area measured in treated segment improved significantly from 2.9 (0.72) mm2 to 7.3 (0.79) mm2 after ELCA. The in-hospital device-oriented major adverse cardiac event (DOCE) rate was 9.6%. No vessel perforation occurred during ELCA. After 6 months, the DOCE rate was 13.4%, while the rate of target lesion revascularization (TLR) was 8.2%. This registry confirms the efficacy and safety of ELCA with contrast mix injection as a possible approach for stent expansion/ISR in failed PCI.

Improved Hemocompatibility on Superhemophobic Micro-Nano-Structured Titanium Surfaces.

Blood-contacting titanium-based implants such as endovascular stents and heart valve casings are prone to blood clotting due to improper interactions at the surface level. In complement, the current clinical demand for cardiovascular implants is at a new apex. Hence, there is a crucial necessity to fabricate an implant with optimal mechanical properties and improved blood compatibility, while simultaneously interacting differentially with cells and other microbial agents. The present study intends to develop a superhydrophobic implant surface with the novel micro-nano topography, developed using a facile thermochemical process. The surface topography, apparent contact angle, and crystal structure are characterized on different surfaces. The hemo/blood compatibility on different surfaces is assessed by evaluating hemolysis, fibrinogen adsorption, cell adhesion and identification, thrombin generation, complement activation, and whole blood clotting kinetics. The results indicate that the super-hemo/hydrophobic micro-nano titanium surface improved hemocompatibility by significantly reducing fibrinogen adsorption, platelet adhesion, and leukocyte adhesion. Thus, the developed surface has high potential to be used as an implant. Further studies are directed towards analyzing the mechanisms causing the improved hemocompatibility of micro/nano surface features under dynamic in vitro and in vivo conditions.

Effectiveness of Venous Stenting for the Treatment of Lower Extremity Chronic Thrombotic Venous Obstruction

Patients with venous hypertension have significant morbidity and poor quality of life. Deep venous thrombosis (DVT) and congenital defects that led to chronic outflow blockage are frequent causes of venous hypertension. It is known that the venovenous bypass has been the standard method used in the treatment of chronic iliofemoral vein occlusions. Percutaneous recanalization has earlier been shown to be technically possible. With venoplasty and stenting, we used an aggressive endovascular strategy to treat the iliofemoral venous thrombotic occlusion. This study aims to assess the effectiveness and safety of percutaneous venous stenting performed in our hospital for cases with chronic thrombotic venous outflow blockage of the iliofemoral vein segment. From May 2019 to April 2021, the medical records were reviewed for sixty-three patients diagnosed with symptomatic iliofemoral thrombotic occlusive disease and treated with venous stenting. The procedures' results were analyzed at Al-Azhar University Hospitals. The medical records of 63 cases (44 women with a median age of 49.52 years) with chronic outflow block of iliofemoral vein segment who were treated with endovascular venous stenting were reviewed retrospectively. Optimal success was obtained in 56 cases (88.9%). Twelve months primary, assisted primary, and secondary patency rates were 76.8%, 80.4%, and 87.5%, respectively, while it was 73.2%, 80.4%, and 87.5%, respectively, after 2 years. The procedure-related complication rate was 6.3%. Puncture site hematoma was observed in 2 patients (3.2%). Early (30-days) stent thrombosis occurred in 2 patients (3.2%). Most importantly, there was no procedure-related mortality. Endovascular treatment with balloon angioplasty and stenting of chronic venous thrombotic occlusions is an effective and safe procedure associated with a high technical rate of success and excellent patency rates. Accordingly, it should be considered the first line in the treatment of symptomatic iliofemoral vein occlusion.

The Choice of Optimally Necessary Devices for Endovascular Treatment of Coarctation of the Aorta

The aim. To determine the optimally necessary devices for endovascular stenting of coarctation of the aorta (CoA), considering the anatomical features of the defect and the age of the patient.
 Materials and methods. Examination and endovascular treatment of 189 patients aged 5 to 60 years with CoA of different anatomical and morphological variants was performed.
 Results and discussion. We presented the clinical features of different anatomical andmorphological variants of CoA. Endovascular treatment of CoA with stenting is considered the best method for adolescents and adults, due to the lower risk of aneurysm formation compared to balloon angioplasty. We were able to successfully reduce the invasive pressure gradient in patients of different ages and to establish dependence of the frequency of complications on the type of the stent used. There were no cases of in-hospital death. The effectiveness of the intervention was 99.4 %. All the patients were discharged from the hospital in good condition 3-7 days (3.3 ± 1.9 days) after the procedure. Currently, 95.7 % are being followed up. During the 5-year follow-up period, 1 patient died due to concomitant heart failure, heart rhythm disturbances (atrial fibrillation) and mitral insufficiency. There were 10.1 % patients (n = 19) with complications: 4.9 % (n = 4) with open-cell stents, 12.1 % (n = 13) with closed-cell stents, 2.2 % (n = 4) with stent-grafts, 7.9 % (n = 16) with uncovered stents. The frequency of reinterventions was 45.0 % in patients older than 25 years, 37.2 % in those aged 5-18 years and 17.6 % in those aged 19-25 years.
 Conclusions. The choice of optimally necessary devices for endovascular stenting of the aorta is recommended to be carried out considering the anatomical features of the defect and the age of the patient.

Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection?

Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement. This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches. A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase. TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair. Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.

Venous Intervention

Any overview of the treatment of venous disease should begin with a brief examination of its history. From the first rudimentary attempt at venous thrombectomy in the early 1920s to the evolution of percutaneous and mechanical thrombectomy and endovascular stents in the 21st century. It is the aim of this review to provide a comprehensive summary of the state of the art of venous disease treatment at the turn of the new century.

844: SUCCESSFUL TREATMENT OF TRACHEOINNOMINATE ARTERY FISTULA WITH INNOMINATE ARTERY ANGIOPLASTY/STENT

Introduction: Tracheo-innominate artery fistula(TIF) is an uncommon and life-threatening complication of tracheostomy with a reported incidence of 0.7%. However, the mortality rate is nearly 100% if it is not treated urgently with definitive management. The initial bleeding may be mild, but these sentinel bleeding events often precede a massive hemorrhage. Early diagnosis is the most important factor for successful management of a TIF. Here we describe a patient who presented with TIF after sentinel bleeding and whose condition was stabilized with an endovascular stent. Description: 77 year old female with history of severe mitral regurgitation underwent mitral valve repair with annuloplasty; 2 weeks later she developed shortness of breath secondary to ascending aorta pseudoaneurysm which was repaired. Her hospital course was complicated by chronic respiratory failure secondary to recurrent multifocal pneumonia and ARDS, necessitating the need of percutaneous bronchoscopy. Patient had episode of tracheal bleed 3 weeks after the percutaneous tracheostomy for which immediate CT angiography which showed tracheo-innominate artery fistula with sentinel bleed; for which patient underwent successful innominate artery angioplasty and stent with a Gore 8*39 VBX stent. Post angioplasty, fiberoptic bronchoscopy was performed with extensive blood in airways throughout, which was lavaged. The post operative course was uneventful and she was discharged 4 days later to long term acute care. Discussion: The main treatment of TIF is a surgical procedure with ligation of the innominate artery and bypass grafting of the distal innominate artery. Morbidity and mortality rates are high after surgical operations for TIF. Recently, endovascular procedures involving stent graft implantation have significantly improved, and can be safely performed as an alternative to the traditional open surgical method in selected circumstances. Although endovascular stenting does not guarantee the complete elimination of TIF and it has some complications of graft infection, occlusion, and rebleeding due to tracheal erosion. However, endovascular repair of TIF via stent is a safe, effective, and minimally invasive treatment for patients in poor clinical conditions and is an alternative to traditional open surgical treatment.

Update on Clinical Management with Neurovascular Stents.

Endovascular stenting has continued to evolve given the new trials. Several new stents have recently been developed to address specific purposes. In this focused review, we discuss the concepts of neurointerventional stents and address the clinical implications. Furthermore, each type of stent is discussed with supporting evidence for clinical utility. In the final component, we argue for continued development and utilization.

Heating of Large Endovascular Stents and Stent Grafts in Magnetic Particle Imaging—Influence of Measurement Parameters and Isocenter Distance

PurposeMagnetic particle imaging (MPI) is a tomographic imaging modality with the potential for cardiovascular applications. In this context, the extent to which stents are heated should be estimated from safety perspective. Furthermore, the influence of the measurement parameters and stent distance to the isocenter of the MPI scanner on stent heating were evaluated.Materials and MethodsNine different endovascular stents and stent grafts were tested in polyvinyl-chloride tubes. The stents had diameters from 10 to 31 mm, lengths between 25 and 100 mm and were made from stainless steel, nitinol or cobalt-chromium. The temperature differences were recorded with fiber-optic thermometers. All measurements were performed in a preclinical commercial MPI scanner. The measurement parameters were varied (drive field strengths: 3, 6, 9, 12 mT and selection field gradients: 0, 1.25 and 2.5 T/m). Furthermore, measurements with different distances to the scanner’s isocenter were performed (100 to 0 mm).ResultsAll stents showed heating (maximum 53.1 K, minimum 4.6 K). The stent diameter directly correlated with the temperature increase. The drive field strength influenced the heating of the stents, whereas the selection field gradient had no detectable impact. The heating of the stents decreased with increasing distance from the scanner’s isocenter and thus correlated with the loss of the scanner’s magnetic field.ConclusionStents can cause potentially harmful heating in MPI. In addition to the stent diameter and design, the drive field strength and the distance to the MPI scanner’s isocenter must be kept in mind as influencing parameters.

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy.

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.

Nitinol stents placed in iliac veins are not associated with prolonged back pain.

Endovascular stenting is the standard of care for the management of symptomatic chronic venous obstruction. The increased radial resistive force and longer lengths of Nitinol stents have led to questions over persistent post-operative back pain. The purpose of this investigation was to assess the incidence and severity of post-operative back pain of Nitinol stents compared to Wallstents. A retrospective review of data at the Center for Vascular Medicine was performed. Patient demographics, pre-operative, oneweek, three-, six,- and 12month visual analog pain scores (VAS) for back pain, stent type, diameter, length, and vein locations were assessed. From April 2014 to November 2021, 627 (412 women/215 men) patients were assessed for the presence of post-operative back pain after an initial iliac vein stent placement. Stents utilized were Wallstents (n = 114), Venovo (n = 342), and Abre (n = 171). The most common Nitinol stent diameter and lengths were 14mm, 16mm, and 120mm, respectively (p ≤ .03). The incidence of back pain at oneweek was 66% (411/627). VAS scores at oneweek and one, three, and sixmonths post-operatively were the following: Wallstents-2.6 ± 3 (n = 66), 1.7 ± 2.6 (n = 43) 0.7 ± 2 (n = 51), and 0 ± 0 (n = 27); Abre-3.5 ± 3 (n = 130), 3.8 ± 3 (n = 19), 1.2 ± 2.5 (n = 12), and 1 ± 2 (n = 5); and Venovo- 2.5 ± 3 (n = 216), 2.4 ± 3 (n = 70), 0.9 ± 2 (n = 68), and 0.6 ± 1.7 (n = 49). There was no difference in the severity of back pain at any time point (p ≥ .99). The development of back pain was unrelated to stent type, diameter, length, or covered vein territory. Post-operative back pain was observed in 66% of patients at oneweek. The average pain score at oneweek for the entire cohort was three, which declined to less than one at onemonth. No difference in the severity of back pain between groups was observed at any time point, and the development of back pain is unrelated to stent type, diameter, length, or covered vein territory.

Ruptured pulmonary artery pseudoaneurysm treated with stent graft: case report and literature review

BackgroundHemoptysis is a severe condition, associated with a high mortality rate from asphyxiation. Less than 5% of cases come from the pulmonary arterial circulation and large pseudoaneurysm are rarely treatable by stent graft.Case presentationWe present the case of a 74-year-old man who suffered from a new onset of hemoptysis despite a prior bronchial artery embolization. He underwent a rescue endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm. A short review of similar situations is provided.ConclusionSalvage endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm is a viable salvage technique for life-threatening hemoptysis.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence.

Patients with cyanotic complex congenital heart defects (CHDs) commonly undergo palliation with interposition of systemic-to-pulmonary shunts (SPSs). These palliative shunts are rarely found in adults with CHDs and can be complicated with progressive obstruction or total occlusion during follow-up. The best treatment option for shunt re-permeabilization is challenging and case-oriented because most patients are high risk candidates for redo surgeries. We aimed to review the current evidence on percutaneous stent implantation to treat failed SPSs. We performed a comprehensive literature review on percutaneous stent implantation to treat failed and occluded SPSs. We also reported the case of a 33-year-old man with cyanotic CHD and a occluded central aorto-pulmonary shunt, who was successfully treated with percutaneous balloon dilatation and subsequently stent implantation at our institution. We identified and included 31 articles reporting on 150 patients and 165 stent implantations in failed SPSs. The age of patients at the time of stent implantation ranged from 6 days to 47 years. The time between the surgical shunt creation and transcatheter intervention ranged from 1 day to 17 years. Overall, 161/165 (97.5%) stent implantations were successful. The most common clinical presentation was cyanosis and decreased atrial oxygen saturations and the indication for stent implantation was shunt obstruction and stenosis. This review highlights the benefits of endovascular stenting to permeabilize failed SPSs in children and adults with complex CHD who are classified as poor candidates for re-surgical repair.

Intraprocedural endothelial cell seeding of arterial stents via biotin/avidin targeting mitigates in-stent restenosis

Impaired endothelialization of endovascular stents has been established as a major cause of in-stent restenosis and late stent thrombosis. Attempts to enhance endothelialization of inner stent surfaces by pre-seeding the stents with endothelial cells in vitro prior to implantation are compromised by cell destruction during high-pressure stent deployment. Herein, we report on the novel stent endothelialization strategy of post-deployment seeding of biotin-modified endothelial cells to avidin-functionalized stents. Acquisition of an avidin monolayer on the stent surface was achieved by consecutive treatments of bare metal stents (BMS) with polyallylamine bisphosphonate, an amine-reactive biotinylation reagent and avidin. Biotin-modified endothelial cells retain growth characteristics of normal endothelium and can express reporter transgenes. Under physiological shear conditions, a 50-fold higher number of recirculating biotinylated cells attached to the avidin-modified metal surfaces compared to bare metal counterparts. Delivery of biotinylated endothelial cells to the carotid arterial segment containing the implanted avidin-modified stent in rats results in immediate cell binding to the stent struts and is associated with a 30% reduction of in-stent restenosis in comparison with BMS.

A Case of a Systemic Lupus Erythematosus Patient with a Right Common Iliac Artery (CIA) Aneurysm after Endovascular Stenting for an Occluded Right CIA

A Case of a Systemic Lupus Erythematosus Patient with a Right Common Iliac Artery (CIA) Aneurysm after Endovascular Stenting for an Occluded Right CIA

Abstract 12175: A Migrated External Iliac Stent - To Retrieve or Not to Retrieve

Endovascular venous stenting has become a more favorable intervention for occlusive, symptomatic deep vein thromboses (DVTs), especially given its decreased complication rate and shorter recovery time than its predecessor, open venous bypass. Risks, however, still exist and can include stent fragmentation and dislodgement causing cardiopulmonary complications. A 57-year-old man with bilateral lower extremity DVTs status post left external ilio-femoral stent and inferior vena cava (IVC) filter placement presented with one month of atypical chest discomfort. CT chest showed migration of his 40cm iliac stent to the IVC and right atrium. Interventional radiology visualized both a patent stent and IVC, however, attempted endovascular removal from the distal margin failed with initial retrieval of fragments only. Other fragments subsequently embolized to the pulmonary and lower lobe arteries and right ventricles. Extraction of more distal fragments was deferred due to risks of structural damage, arrhythmias, and pulmonary vasculature perforation. Fragment analysis by pathology demonstrated evidence of clot, yet cardiothoracic surgical intervention was deferred.The patient continued to experience chest pain and underwent a repeat CT chest three months later that demonstrated the stent extending from the right atrial junction to the infrahepatic IVC. Fragmented portions of the filter in the right ventricle and multiple stent fragments retained in the right upper and bilateral lower pulmonary lobes remained as prior with no evidence of pulmonary embolism (PE), pericardial effusion, or tamponade. Although rare, stent removal complications can occur with increased risk of long-term sequelae. Stent fracturing and dislodgement can result in foreign bodies showering the pulmonary vasculature and cardiac chambers, ultimately placing patients at risk for arterial perforation or dissection, pulmonary hemorrhage, intracardiac damage, tamponade, PE, and chronic thromboembolic pulmonary hypertension (CTEPH). The consideration of such risks, in addition to early involvement of interdisciplinary teams and thorough risk-benefit discussions between patients and providers are essential when undergoing stent removal and related interventions.

Management of traumatic peripheral artery pseudoaneurysm: A 10-year experience at a single center

PurposeThis study aimed to report our 10-year experience with the management of iatrogenic (penetrating trauma) and traumatic (blunt or penetrating trauma) peripheral artery pseudoaneurysms, based on data from a tertiary referral center. MethodsFrom January 2012 to December 2021, the medical records of consecutive patients with iatrogenic and traumatic peripheral artery pseudoaneurysms were retrospectively reviewed. Patient demographics, clinical features, imaging data, treatment details, and follow-up results were analyzed. ResultsSixty-one consecutive patients were included in this study; 48 (79%) were men and 13 (21%) women, with a mean age of 49.4 ​± ​13.4 years (range 24–73 years). There were 42 patients (69%) who underwent open surgery, 18 (29%) undergoing endovascular embolization or stent implantation, and one (2%) undergoing ultrasound-guided thrombin injection. All patients successfully underwent open or interventional treatment. The median follow-up was 46.8 months (2.5–117.9 months), and the overall reintervention rate was 10%. Of these, one (5%) patient in the interventional treatment group and five (12%) patients in the open surgery group underwent reintervention. The overall complication rate was 8%, with complications occurring only in the open surgery group. No deaths occurred in the peri-operative period. No late complications, such as thrombosis or pseudoaneurysm recurrence, were observed. ConclusionPeripheral artery pseudoaneurysms arising from iatrogenic or traumatic causes can be effectively treated by both open surgery and interventional procedures in selected patients with acceptable mid- and long-term outcomes.

Abstract 12462: Percutaneous Repair of Chronic Aortic Pseudoaneurysm: A Single Center Experience

Introduction: Aortic pseudoaneurysm (AP) is a late complication of aortic repair. Without intervention, it carries a mortality rate up to 61%. Surgical repair has significant in-hospital mortality (6.9-12.6%) and high healthcare costs. Endovascular stent grafting has 15.2% all-cause mortality and 9.3% re-intervention rates. Percutaneous vascular plug/occluder technology emerged as a potentially safer and cheaper alternative to surgical AP closure. We will share our experience with this technology to enhance its success rate, safety, and cost-effectiveness. Methods: We retrospectively reviewed percutaneous AP closure cases with vascular plug/occluder technology published (2005 - 2016) and analyzed them alongside those performed at our institution (2017 - 2019). Results: We identified 40 cases of percutaneous AP closure with vascular plug/occluder technology in the literature and 10 performed at our institution. Our patients had a 1.9-day average length of stay with 100% successful targeted AP closure compared to 92% in the literature group. Over a 12-month median follow-up period (range 3-47 months), AP demonstrated stable or reduced sac size in 6 (60%) of our cases but increased in 4 (40%), necessitating surgical intervention. Literature cases had a 2-month median follow-up period with a 65% success rate. Death occurred in 40% of our patients from non-AP-related causes and in 8% of the literature group from AP closure-related complications. The cost per procedure was $49,580, which is hypothetically less than open surgical repair. Conclusion: Our experience shows a viable option for vascular plug/occluder technology in percutaneous AP repair, given its initial safety and cost-effectiveness. Our results highlight the critical role of follow-up imaging in identifying AP expansion and the need for further intervention. The high non-aorta-related mortality seen in follow-up emphasizes the high-risk nature of the population due to co-morbidities. .

Abstract 14105: Stent Ahoy: Ventricular Tachycardia Due to Stent Migration Into the Right Ventricle

Case: A 46-year-old female with PMHx of ESRD on dialysis and prothrombin gene mutation presented with acute onset of left breast swelling, redness and pain for nearly 24 hours. She was found to have SVC occlusion and underwent successful SVC recanalization and stent placement with an uncovered 14x40 mm nitinol stent. She presented 4 days later with complaints of chest pain and shortness of breath. Initial vitals were notable for tachypnea with oxygen saturations of nearly 70%, and a blood pressure of 114/71 mmHg. Physical exam demonstrated an obese female in distress. Shortly after arrival in the emergency department, she developed a non-sustained episode of ventricular tachycardia (NSVT). Amiodarone and lidocaine were started, however, she continued to have runs of NSVT. Initial CXR found no acute process but failed to demonstrate the previously placed SVC stent. ECG demonstrated normal sinus rhythm with frequent PVCs and runs of NSVT. A limited echo demonstrated a free edge of an endovascular stent within the right ventricle. TEE demonstrated the stent appeared to be tethered to the septal leaflet of the tricuspid valve with the leading edge free within the right ventricle. Endovascular retrieval was proposed but given the degree of entanglement within the tricuspid leaflets, large stent size, and recurrent NSVT, was deemed an unsuitable therapeutic strategy. Urgent open-heart surgery was performed for removal. The patient tolerated the procedure well and had no further recurrence of NSVT. Discussion: Stent migration is a rare but feared complication of venous stent deployment, with only 32 reported cases over the past 30 years. While NSVT is often attributed to the RVOT, the etiology being the result of migrated stents has been rarely reported. This is the first case to our knowledge of SVC stent migration leading to runs of NSVT. Conclusion: Clinicians must remain cognizant of the risk for venous stent migration and unusual clinical presentations resulting from migration.