Failure Of Endovascular Treatment Research Articles

Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation

ObjectiveThe aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). MethodsAll consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients’ baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. ResultsOverall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. ConclusionsSurgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

Observational study of endoluminal mural thrombotic apposition in popliteal artery aneurysm stenting and its relationship with stent-graft geometrical features.

The development of intrastent thrombosis is one of the mechanisms related to medium- to long-term failure of endovascular treatment of popliteal artery aneurysm. The present study aims to investigate possible links between the development of endoluminal mural thrombotic apposition in the stented zone (EMTS) with both geometrical features of stent-graft(s) and time of follow-up. Patients with popliteal artery aneurysm who underwent endovascular treatment were recruited during the follow-up period. Segmentation of computed tomography angiography scan was performed to detect femoropopliteal artery lumen, leg bones, EMTS, and stent-graft(s). The following parameters were assessed: number, diameter, and length of stent-graft(s); and shape, volume, and length of thrombotic apposition within the stent(s). The spiral shape of the thrombotic apposition was evaluated as well. Eighteen male patients were recruited in the study. EMTS was observed in 13 of them (72%) during the follow-up analysis. An average of 1.8 ± 0.79 stents-grafts were implanted per patient with a median diameter and length of 6.2 (1.9) mm and 125 (50) mm, respectively. The percentage of the stent length where EMTS was present was 42.1 on average (interquartile range: 42.4%) with a mean volume of 206.8 mm3. A positive correlation was found between the length and volume of EMTS (R-squared = 0.71, p < 0.01). Moreover, EMTS had a helical shape in 8/13 patients, with 4/5 with counterclockwise rotation with stent-grafts in the left leg and 3/3 with clockwise direction treated in the right leg. A higher frequency of EMTS was observed in patients with longer follow-up and higher risk factors, as well. EMTS is observed in most of the patients under analysis, especially in those with medium- to long-term follow-up. The pattern of such EMTS follows a helical shape having a direction that depends on which leg, right or left, is treated. Our results suggest a close surveillance of popliteal aneurysm stenting by follow-up examinations to control the onset and progression of EMTS.

Outcomes of Intravascular Lithotripsy in the Treatment of Chronic Limb-Threatening Ischemia: A Single-Center Retrospective Study.

Vascular calcification is an important risk factor for endovascular treatment failure and complications in patients with chronic limb-threatening ischemia (CLTI). Intravascular lithotripsy (IVL) is a pulsatile balloon-based device that has emerged as a tool in the treatment of calcified vessels. The purpose of this study is to evaluate the efficacy and safety of IVL in the treatment of peripheral calcified lesions in CLTI patients. A retrospective study was performed within a single institution. Thirty-six CLTI patients treated with IVL for peripheral calcified lesions from 2018 to 2022 were identified. Data on pre- and post-IVL luminal stenosis measured by digital subtraction angiography, lesion location, adjunctive therapies, ankle-brachial index (ABI), and intra-procedural complications were obtained. A total of 41 target lesions in twenty-eight patients were included, with ABI data available in 20 treated lower extremities. Across all 41 target lesions, IVL produced clinically significant luminal gain of 75.5% ± 23.0. Luminal gain by vessel location was 87.3% ± 15.8, 57% ± 25.7, and 78.5% ± 20.6 in the aortoiliac (n = 8), common femoral (n = 9), and femoropopliteal (n = 24) segments, respectively. Lesions treated with IVL alone yielded a luminal gain of 71.4% ± 25.6 (n = 10), while IVL alongside adjunctive therapy produced a luminal gain of 76.8% ± 22.4. In 20 treated lower extremities, ABI improvement of 0.20 ± 0.26 (p = 0.002) was recorded. Intra-procedural complications occurred in 1/36 patients, which was one instance of thrombus occurring prior to IVL. IVL may be an effective option for creating safe luminal gain and vessel preparation in patients with CLTI. Level of Evidence 2: Retrospective Cohort Study.

Atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease patients: a narrative review.

Vascular calcification (VC) and resulting vascular disease is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). CKD itself is increasingly recognized as a risk factor for cardiac and peripheral arterial disease (PAD). This paper examines the atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease (ESRD) patients. The literature was reviewed regarding the current status of medical and interventional management arteriosclerotic disease in patients with CKD. Lastly, three representative cases displaying typical endovascular treatment options are provided. A literature search was performed in PubMed covering publications up to September 2021 as well as discussion with experts in the field. The high prevalence of atherosclerotic lesions in patients with chronic renal failure and high (re-)stenosis cause problems in the medium and long term as vascular calcium load represents one of the most widely encountered predictors of failure of endovascular treatment of PAD and future cardiovascular events (e.g., coronary calcium score). Patients with CKD also suffer from a greater risk for major vascular adverse events in general and worse revascularization outcomes following peripheral vascular intervention. A correlation between calcium burden and drug-coated balloon (DCB) performance has been established for PAD necessitating the need for different tools to cope with vascular calcium such as endoprosthesis or braided stents. Patients with CKD are at a higher risk of developing contrast-induced nephropathy (CIN). In addition to recommendations such as the administration of intravenous fluids, carbon dioxide (CO2) angiography is one option to potentially provide an effective and safe alternative both to iodine-based contrast media allergy and to the use of iodine-based contrast media in patients with CKD. Management and endovascular procedures of patients with ESRD are complex. In the course of time, new endovascular therapy methods have been developed such as directional atherectomy (DA) and the so-called "pave-and-crack" technique to deal with high vascular calcium burden. Besides interventional therapy, vascular patients with CKD benefit from aggressive medical management.

Ilio-mesenteric bypass for chronic mesenteric ischaemia where prior endovascular treatment has failed: a case series

Background: Symptomatic chronic mesenteric ischaemia is a rare but debilitating disease, and its diagnosis is often delayed by the time taken to rule out underlying malignancy or other abdominal pathology. Once diagnosed, definitive revascularisation should not be delayed to avoid future bowel infarction. There is no consensus on the best treatment option, but most centres use angioplasty as the first choice, leaving open surgery for those who are unsuitable for or failed endovascular treatment. Failure of endovascular treatment does not seem to preclude open surgical bypass. Methods: This series includes four patients who presented with symptomatic chronic mesenteric ischaemia in whom endovascular treatment failed and who were then managed successfully with ilio-mesenteric bypass, with average follow-up of 4 years. Results: The average age of the patients was 57 years; three of the four patients were female. Two patients had initial successful angioplasty but required bypass later for recurrent symptoms. In the other two cases the endovascular approach failed immediately, with one developing acute ischaemia requiring bowel resection followed by mesenteric bypass. Conclusion: Mesenteric bypass for symptomatic chronic mesenteric ischaemia is feasible after failed angioplasty. Immediate or delayed failure of endovascular treatment does not seem to preclude future surgery.

Surgical treatment of traumatic arteriovenous fistula after failed endovascular treatment

Endovascular interventional therapy is the first choice for the treatment of the traumatic arteriovenous fistula (AVF) because of its small trauma, fast recovery, exact effect, and low incidence of complications. However, surgery is still an important option for patients with contraindications to endovascular treatment or failure of endovascular treatment. We present the case of a 64-year-old male who was carried out with traumatic AVF and given endovascular treatment in other hospital 10 years ago. However, AVF did not disappear after surgery, and symptoms of venous hypertension such as lower limb swelling and ulcers appeared. We removed the stent and repaired the AVF with opening surgery. AVF did not recur after 1-year follow-up.

Endovascular Treatment of TASC C- D Aorto-Iliac Occlusions: Analysis of Pre-Operative CT-Scan Can Predict Technical Failure

Introduction - While the outcomes of recanalization of TASC C-D aorto-iliac chronic total occlusions (CTO) are satisfying in high-volume centers, the risk of technical failure and the fear of iliac rupture especially in heavily calcified lesions limit the widespread use of this technique. To our knowledge, risks factor of technical failure or iliac rupture were poorly studied in the literature. We hypothesized that features of occlusion analyzable on pre-operative CT-scan could predict risks of technical failure or iliac rupture of endovascular treatment of TASC C-D aorto-iliac CTO. Methods - This is a retrospective study of a prospective cohort. All patients treated in our department by endovascular techniques for aTASC C-D aorto-iliac CTO between December 2009 and June 2016 were analyzed. Patients with no pre-operative CT-scan were excluded. We included 107 patients and 148 iliac arteries. All CT-scan were analyzed by 2 independent surgeons. Each side was analyzed independently. We evaluated the location of the occlusion and the degree of arterial calcifications. For this factor, patients were divided into 3 groups : the Black occlusion group (BO) defined by the presence of mild non protrusive calcifications or the complete absence of calcifications in all the aorta and iliac artery, the white occlusion group (WO) defined by moderate calcifications of more of 50 % of the arterial circumference but little or no protrusive in all the occlusion and the white protrusive occlusion group (WPO) defined by the presence of heavy endoluminal calcifications of more of 50 % of the arterial lumen in the occluded arterial segment. All patients had antegrade approach in case of failure of transfemoral approach. Primary endpoint was technical failure rate and secondary was iliac rupture rate. Wilcoxon, fisher exact test, univariate and multivariate regression model were performed. Results - CTO are located on the external iliac artery (EIA) in 37 cases, on the common iliac artery (CIA) in 41 cases, on both in 42 cases and on the aortic bifurcation in 14 cases. There were 66 iliac artery in the BO group, 45 in the WO group and 37 in the WPO group. Technical failure occurred in 8 patients that’s 11 iliac arteries. Per-operative iliac rupture occurred in 6 patients. In univariate analysis, only the location in the EIA is a significate risk factor of technical failure (OR = 9,93 and p = 0,0012). In multivariate analysis, this parameter is also an independant significate risk factor (OR = 15,26 and p = 0,0006). The presence of heavy calcifications is a further significate risk factor (OR = 13,88 and p = 0,0365). Rupture rate was comparable between the 3 groups (p = 0,881). Iliac rupture occur more for long lesions when both EIA and CIA were occluded but this is no significate (p = 0,282). Conclusion - The location of the CTO in the EIA is the major risk factor of technical failure of endovascular treatment for TASC C-D aorto-iliac CTO. The presence of heavy endoluminal calcifications is also a risk factor of technical failure. However, this parameter is not a risk factor of iliac rupture. The detailed analysis of pre-operative CT-scan can permit a better selection of patients for endovascular treatment of aorto-iliac CTO especially in low-volume centers. Referencesendovascular treatment, chronic total occlusion, aorto-iliac, technical failure, iliac rupture, predictors

Open Surgery as First-Line Treatment of Infrainguinal Multilevel TASC D Arterial Disease With Critical Limb Ischemia

Introduction - Patients with Critical Limb Ischemia(CLI) associated with Multilevel TASC-D Arterial Disease(MTDAD) are usually treated by major amputation, given the high risk of technical failure of endovascular treatment and the high morbidity-mortality of surgical treatment. In this study we examined patient survival and limb salvage of surgically treated MTDAD. Methods - A prospectively maintained database, including all patients treated between November-2011 and October-2016, for Critical Limb Ischemia(CLI), associated with MTDAD was analyzed retrospectively. Arterial disease extension was determined and classified by Duplex scan ± DSA. Patient's characteristics and comorbidities were examined. Tissue loss was classified according to Texas University Wound Classification(TWC). Clinical and Duplex follow-up were performed at 1,3,6 and every 6 months thereafter. Primary endpoints were: Technical Success(TS); Perioperative Patient Survival(S), Limb Salvage(LS), Primary(PP), Assisted(AP) and Secondary Patency(SP). Secondary endopints were: S,LS,PP,AP and SP during follow-up and associated risk factors for endpoints. Descriptive statistics, Kaplan-Meier and Cox regression analyses were performed. Univariate and Multivariate analysis were used to define risk factors. Results - Out of 1102 revascularizations for infrainguinal obstructive arterial disease performed in the study period, 62(5.6%) patients(mean age 72years, Male 76%) were treated for MTDAD with CLI(Rutherford 5-6 in 47%>44%, tissue loss TWC stage D:40.3%). Coronary artery disease, renal failure, diabetes Mellitus, dislipidemia and ASA 4 were present in 61.3%, 41.3%, 72.6%, 71%, 37.1%, respectively. All cases were treated surgically as follows: Common-deep femoral artery Endarterectomy(CDFE)+Femoro-tibial bypass in 10 cases(16.1%); Femoro-Pedal Bypass in 48 cases(77.4%) and CFAE+Femoro-Pedal Bypass in 4 cases(6.5%). Technical Success was obtained in 61/62 cases(98.4%). At 1-month, S, LS, PP, AP, SP were 95.2%, 98.4%, 90.3%, 93.5%, 96.8%, respectively. Mean Follow-up was 24.6 months. At 1-year and 2-year follow-up S, LS, PP, AP, SP were 88.4% and 77.7%, 85% and 82.7%, 57.4% and 55%, 74.2% and 69.2%, 83% and 78%, respectively. AP and SP were found protective factors for Limb Salvage(P=0.008, 0.002, respectively). Limb loss during follow-up was a negative predictor for patient survival(P=0.007). Rutherford stage 6 was negative predictor for primary patency(P=0.04) and secondary patency(P=0.008). Conclusion - Our study shows that open surgery revascularization as a first-line treatment of MTDAD with CLI has good perioperative patient survival and limb salvage rates. High limb salvage can be obtained through better assisted and secondary patency rates guaranteed by a continuous clinical and Duplex follow-up.

Practice Trends in Intracranial Bypass Surgery in a 21-Year Experience

The aim of this study was to analyze practice trends in specific intracranial bypass types in a large, consecutive bypass experience. This retrospective review of a prospectively maintained database included all intracranial bypasses performed by a single surgeon over 21 years. Bypass types were grouped into 7 categories and analyzed in seven 3-year time intervals: type 1= extracranial-to-intracranial (EC-IC) bypass with scalp arteries as donors; type 2= EC-IC bypass with interposition graft to cervical carotid arteries; type 3= arterial reimplantation; type 4= in situ bypass; type 5= reanastomosis; type 6= intracranial-to-intracranial bypass with interposition graft; and type 7= combination bypass. In total, 598 intracranial bypasses were performed including 359 type 1, 59 type 2, 24 type 3, 30 type 4, 37 type 5, 36 type 6, and 53 type 7. Although type 1 and type 3-7 bypasses increased, type 2 bypasses decrease in frequency. Aneurysms were the most common bypass indication (41.8%), followed by moyamoya disease (31.8%), and intracranial arterial stenosis or occlusion (24.9%). Endovascular treatment failure was observed in 10.8% of the aneurysm patients treated with a bypass procedure. Intracranial bypass remains an essential technique for open vascular neurosurgeons. The classic low-flow EC-IC bypasses, intracranial-to-intracranial, and combination bypasses increased over time, whereas the high-flow EC-IC interpositional bypasses decreased over time. These trends reflect the increasing use of flow diverters as well as the need for surgical revascularization for complex aneurysms, and those that failed previous endovascular therapy.

Multidisciplinary therapeutic and active follow-up protocols to reduce the rate of amputations and cardiovascular morbidities in patients with critical limb ischemia: IRANCLI study design and rationale – A prospective single-center registry in Iran

Objectives: The endovascular treatment (EVT) of patients with critical limb ischemia (CLI) has received considerable interest in recent years and has significantly affected the associated amputation and survival rates. Nonetheless, that this management modality may be influenced by various logistical and regional situations prompted us to design a local registry to evaluate its applicability and efficacy in our community.Methods: The IRANCLI study is a prospective, observational study that has been established as a registry. The therapeutic and follow-up protocols of this study have been approved by a multidisciplinary team. Recruited patients with CLI are followed up after in-hospital therapeutic management, endovascular revascularization, or minor amputations or debridement in cases with ulcers. The follow-up consists of active monitoring to spot patients with a recurrence of CLI signs and symptoms at early stages. Within 3 years, eligible patients are recruited to the study and are followed up for 3 years. Analyses are carried out to evaluate outcomes – comprising major adverse limb events (the primary outcome), amputation-free survival, limb salvage, event-free survival, major adverse cardiovascular and cerebrovascular events, 30 days' postprocedural adverse events, and procedural success. The predictors of procedural failure and long-term follow-up adverse events are assessed. Result and Conclusion: The IRANCLI study evaluates postendovascular revascularization outcomes and the long-term follow-up of patients with CLI. Uncovering the predictors of EVT failure and adverse events during the follow-up may improve the prospect of cases with CLI by streamlining the determination of both the patients who would benefit the most from EVT and those who would need a closer active follow-up.

Reinterventions after Endovascular Revascularization in Elderly Patients with Critical Limb Ischemia: An Observational Study

Endovascular-first strategy for critical limb ischemia is widely accepted, especially in elderly patients, because of the increasing patency rates and minimally invasive character. Nonetheless, the impact of reinterventions because of endovascular treatment failure in this population is not well known. The aim of this study was to evaluate the reintervention rate and outcomes following reinterventions. Patients aged >70years with critical limb ischemia as a result of aortoiliac, femoropopliteal, and/or crural disease, treated by "endovascular-first strategy" between 2006 and 2013, were retrospectively analyzed. Follow-up was until 31 December 2014. Primary end point was freedom from reintervention or major amputation. Secondary outcome measures were limb salvage and mortality after reintervention. Reintervention was defined as endovascular or surgical re-revascularization and categorized into early reintervention (<3months) and late reintervention (>3months). In total, 263 patients were treated by endovascular revascularization. The majority (60%) of the treated lesion was located in the femoropopliteal segment. In total, a reintervention was performed in 32%, with 48% performed within 3 months. Freedom from reintervention or major amputation at 1 and 3years was 0.71±0.03 and 0.61±0.03, respectively. The 1-year Kaplan-Meier estimate amputation-free survival was 0.35±0.06 in the early reintervention group, compared with 0.73±0.06 in the late reintervention group and 0.71±0.04 in the no reintervention group (P<0.001; log rank). The 1-year mortality in the early reintervention group was 0.35±0.06, compared with 0.14±0.05 in the late reintervention group and 0.29±0.04 in the group who did not require reintervention (P=0.047; log rank). Endovascular revascularization first strategy for critical limb ischemia results in high reintervention rates in elderly patients. Failure of the endovascular revascularization requiring early reintervention is associated with lower amputation-free survival.

Determination of Risk Factors and Establishment of a Prediction Model for Immediate Technical Failure during Endovascular Treatment of Femoropopliteal Occlusive Disease

For long femoropopliteal occlusive lesions, the immediate technical failure (ITF) of endovascular treatment (EVT) is relatively high. Therefore, this study aims to reveal risk factors and establish a prediction model of ITF of EVT in femoropopliteal occlusive disease (FPOD) patients based on preoperative clinical date that may be helpful to the clinical procedures. A retrospective analysis of 1,563 FPOD patients who underwent above-the-knee EVT was undertaken. Univariate analysis with chi-squared test was used to screen risk factors from preoperative clinical data. Multivariable analysis with logistic regression was used to generate a model for predicting the ITF rate of EVT, which was evaluated through the receiver operating characteristic curve and another independent cohort of 242 FPOD patients. Risk factors for ITF during EVT in FPOD included age (>80years, X1), the absence of diabetes mellitus (X2), low-density lipoprotein (>160mg/dL, X3), lesion calcification (X4), lesion length (>20cm, X5), ostial occlusion of superficial femoral artery (SFA) (X6), and SFA lesion involving the popliteal artery (X7). A logistic regression model was established based on the equation: -6.504+1.236X1 + 0.945X2 + 1.406X3 + 1.136X4 + 1.059X5 + 2.307X6 + 2.194X7. Scores were given to risk factors as follows: X1 (yes=12, no=0), X2 (yes=9, no=0), X3 (yes=14, no=0), X4 (yes=11, no=0), X5 (yes=11, no=0), X6 (yes=23, no=0), and X7 (yes=22, no=0). We determined that the optimal comprehensive score for predicting EVT failure was 39, with a sensitivity of 0.847 and a specificity of 0.8. Among these 242 peripheral arterial disease patients, 12 of 14 patients who had failed EVT had a comprehensive score of >39. We identified a number of risk factors of ITF during the above-the-knee EVT and established a prediction model that may be used for guidance in clinical practice.

Severe Hemoptysis Associated with Bacterial Pulmonary Infection: Clinical Features, Significance of Parenchymal Necrosis, and Outcome.

Severe hemoptysis (SH) associated with non-tuberculosis bacterial lower respiratory tract infection (LRTI) is poorly described, and the efficacy of the usual decision-making process is unknown. This study aimed at describing the clinical, radiological patterns, mechanism, and microbiological spectrum of SH related to bacterial LRTI, and assessing whether the severity of hemoptysis and the results of usual therapeutic strategy are influenced by the presence of parenchymal necrosis. A single-center analysis of patients with SH related to bacterial LRTI from a prospective registry of consecutive patients with SH admitted to the intensive care unit of a tertiary referral center between November 1996 and May 2013. Of 1504 patients with SH during the study period, 65 (4.3%) had SH related to bacterial LRTI, including non-necrotizing infections (n=31), necrotizing pneumonia (n=23), pulmonary abscess (n=10), and excavated nodule (n=1). The presence of parenchymal necrosis (n=34, 52%) was associated with a more abundant bleeding (volume: 200ml [70-300] vs. 80ml [30-170]; p=0.01) and a more frequent need for endovascular procedure (26/34; 76% vs. 9/31; 29%; p<0.001). Additionally, in case of parenchymal necrosis, the pulmonary artery vasculature was involved in 16 patients (47%), and the failure rate of endovascular treatment was up to 25% despite multiple procedures. Bacterial LRTI is a rare cause of SH. The presence of parenchymal necrosis is more likely associated with bleeding severity, pulmonary vasculature involvement, and endovascular treatment failure.

Primary Management of Large Pancreatic Pseudoaneurysm by Ultrasound-Guided Percutaneous Thrombin Injection after Failure of Transarterial Pseudoaneurysm Embolization

AbstractPancreatic pseudoaneurysm is a rare but life-threatening complication secondary to pancreatitis, surgery, trauma, or infection. Early treatment is advocated due to high risk of rupture and bleeding. Surgical treatment has traditionally been the first line but is associated with high morbidity. Transarterial embolization or exclusion is the treatment of choice; however, in cases with failure of endovascular treatment, percutaneous thrombin injection can be used successfully. We present a case of a large pancreatic pseudoaneurysm managed successfully with percutaneous ultrasound-guided thrombin injection after failure of transarterial management.

Causes and Solutions of Endovascular Treatment Failure.

In a meta-analysis of individual patient data from 5 randomized controlled trials, endovascular treatment (EVT) mainly using a stent retriever achieved successful recanalization in 71.1% of patients suffering from acute stroke due to anterior circulation large artery occlusion (LAO). However, EVT still failed in 28.9% of LAO cases in those 5 successful trials. Stent retriever failure may occur due to anatomical challenges (e.g., a tortuous arterial tree from the aortic arch to a target occlusion site), a large quantity of clots, tandem occlusion, clot characteristics (fresh versus organized clots), different pathomechanisms (embolic versus non-embolic occlusion), etc. Given that recanalization success is the most important factor in the neurological outcome of acute stroke patients, it is important to seek solutions for such difficult cases. In this review, the basic technique of EVT is briefly summarized and then various difficult cases with diverse conditions are discussed along with suggested solutions.

Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices

Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51±8years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4years (0.3-7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2years after the procedure from nonaortic causes (endocarditis). The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered.

Transposition of Subclavian Artery – Is It the Appropriate Choice?

To present patients with symptomatic subclavian artery disease and treatment possibility. A 53-year-old female was admitted with vertigo and left arm claudication. Duplex-scan and MSCT arteriography verified subclavian artery occlusion. After the endovascular treatment failure, the patient was switched to surgical treatment - subclavian artery transposition. After the successful surgical treatment, the patient was discharged on the second postoperative day. If the patient is a candidate for surgery, the literature review shows good initial and long-term results after the subclavian artery transposition, and emphasizes this technique as superior. Subclavian carotid transposition is a safe and effective method of treatment in patients after endovascular treatment failure or other indication. Also, the surgical treatment is technically demanding because of the difficult access to the vessel origin, and it requires experienced surgeons.

Results of primary stent therapy for femoropopliteal peripheral arterial disease at 7 years

ObjectivePrimary stenting is a well-established treatment option for femoropopliteal arterial disease. However, there is a paucity of data concerning the performance of this modality at ≥5 years. This study evaluated the long-term clinical and radiologic outcomes of primary stent therapy in patients with femoropopliteal arterial disease. MethodsA prospective data collection and analysis was conducted in patients undergoing primary stent placement in femoropopliteal lesions between September 2006 and September 2007. The EverFlex (Medtronic/Covidien, Plymouth, Minn) bare-metal stent was used. The primary outcome of this study was the primary patency rate. Secondary outcomes were secondary patency rate, amputation-free-survival (AFS), and freedom from target lesion revascularization (TLR). A Cox regression analysis identified risk factors for the primary and the secondary measure outcomes. ResultsIncluded were 89 patients (102 stents). The prevalence of critical limb ischemia was 34% (n = 30). The initial angiography revealed a TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease C/D lesion in 31 patients (35%). Occlusions were present in 49 patients (55%), and the mean lesion length was 116 ± 33 mm. Popliteal artery disease was present in 39 treated limbs (35%). The primary patency rate at 1, 3, 5, and 7 years was 73%, 64%, 47%, and 33% respectively. At 7 years, secondary patency rate was 67%, freedom from TLR was 47%, and the AFS was 73%. Cox regression analysis revealed a decreased AFS among diabetic patients (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.08-6.28; P = .03), whereas secondary endovascular interventions showed a protective effect for AFS (HR, 0.14; 95% CI, 0.03-0.65; P = .01). Popliteal artery disease was identified as independent risk factor for secondary interventions (HR, 2.07; 95% CI, 1.05-4.06; P = .04) and TLR (HR, 1.99; 95% CI, 1.03-3.83; P = .04). Critical limb ischemia was associated with an increased incidence of surgical conversion owing to endovascular treatment failure (HR, 5.46; 95% CI, 2.44-12.17; P < .001). ConclusionsThis study found primary stenting was associated with acceptable clinical and radiologic long-term outcomes. Diabetes was associated with poor AFS, and popliteal artery involvement correlated with an increased need for reinterventions. AFS was better among patients undergoing secondary procedures.

Outcomes of the Endovascular Treatment of Stenotic Lesions versus Chronic Total Occlusions in the Iliac Sector

This study compares outcomes of the endovascular treatment (EVT) of iliac artery occlusive disease according to whether the treated lesion is a stenosis or a chronic total occlusion (CTO). Patients undergoing EVT from 2003 to 2013 for iliac artery occlusive disease were identified and the lesions treated stratified into stenotic (Group 1, n=375) or CTO (Group 2, n=87). Patients were followed clinically and hemodynamically (thigh-brachial index, TBI). Comorbidities, procedural factors, and outcomes were compared between the 2 groups using Kaplan-Meier, Breslow, and Cox models. Four hundred sixty-two iliac endovascular procedures in 378 patients were included in a retrospective study. The 2 groups only differed in preprocedural TBI [0.77 (Group 1) vs. 0.67 (Group 2), P<0.001], lesion length [39.7 mm (Group 1) vs. 49.9mm (Group 2), P<0.001], and the use of a covered stent [11.6% (Group 1) vs. 46.2% (Group 2), P<0.001]. The technical success rate was higher in Group 1 (99.2% vs. 89.7%, P<0.001). Five early occlusions were recorded in Group 1 and 3 in Group 2 (1.3% vs. 3.8%, P = 0.146). Median follow-up was 34months (1-113). At 12 and 36months, stenotic lesions showed better primary (P1) and secondary (P2) patency rates [P1 93.0% and 85.8% vs. 83.1% and 74.7%, hazard ratio (HR) 1.90 (1.15-3.14), P = 0.018; P2 97.8% and 96.8% vs. 93.0% and 87.4%, HR 2.86 (1.39-5.90), P = 0.007] and freedom from reintervention (FFR) rates [91.6% and 83.5% vs. 84.1% and 78.9%, HR 1.51 (0.90-2.53), P = 0.132]. In a multivariate analysis, CTO showed a worse P2 than stenotic lesions [HR 2.81 (1.17-6.76), P = 0.021], yet no differences emerged in P1 [HR 1.41 (0.76-2.63), P = 0.277] or FFR [HR 1.43 (0.79-2.57), P = 0.237]. A lower preprocedural TBI was correlated with a greater risk of EVT failure in terms of patency and FFR (P<0.05). The use of a stent shorter than 40mm emerged as a protective factor with an HR for P1 of 3.68 (1.53-8.87) (P = 0.004). EVT for iliac artery disease offers good outcomes in terms of long-term patency, although improved results were observed here for the treatment of stenotic lesions over CTO. Procedures performed in patients with a lower TBI and the use of a stent >40mm were related to a worse stent patency.

Clinical Outcomes after Endovascular Treatment Failure in Patients with Femoropopliteal Occlusive Disease

To analyze the clinical impact derived from endovascular treatment failure on patients with femoropopliteal occlusive disease (FPOD) regarding their preoperative clinical stage. Retrospective review for primary endovascular procedures for FPOD from 2008 to 2013. Primary end point included clinical deterioration defined as acute limb ischemia (ALI) or clinical worsening by, at least, one Rutherford's classification category, related to procedure's failure (restenosis >70% or occlusion). Ninety procedures were analyzed in 85 patients, 87.8% operated due to critical limb ischemia. The lesion treated was classified as Trans-Atlantic Inter-Society Consensus (TASC)-A/B in 76.7%, with a mean length of 98.5 ± 54 mm. Covered stent graft (SG) was used in 31.1% of the cases. Median follow-up was 14.5 months and treatment failure occurred in 33.3% of cases (n = 30, 9 restenosis and 21 occlusions). Clinical worsening was assessed in 40% of treatment failures and 6 of 21 (28.6%) presented as ALI. Twenty-two major adverse limb events (MALEs) were recorded and 8 major amputations. Regarding the type of stent, more occlusions were recorded on patients treated with SG compared with bare metal stent (39.3% vs. 16%; P = 0.02). However, no differences were found between groups regarding clinical worsening attributable to treatment failure (HR, 1.33; CI 95%, 0.5-3.5; P = 0.5). On multivariate analysis, TASC-C/D lesions (HR, 5.5; CI 95%, 2.3-13.3; P < 0.001) and female sex (HR, 4.9; CI 95%, 1.9-12.5; P = 0.001) behaved as significant predictors for failure and dual-antiplatelet therapy as a protective factor (HR, 0.3; CI 95%, 0.3-0.13; P = 0.03). No predictors were obtained regarding clinical worsening and occurrence of MALEs in our series. Patients with failure of endovascular procedures on FPOD appeared with clinical worsening in a no negligible number of cases in our sample regarding their preoperative clinical situation. Thus, we believe that endovascular treatment should be carefully deliberated.