Follow-up Computed Tomography Angiography Research Articles

Clinical Course of Acute Ischemic Stroke Due to Medium Vessel Occlusion With and Without Intravenous Alteplase Treatment.

Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5-12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase (P=0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23-4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88-3.25]). One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in <50% of patients despite intravenous alteplase treatment.

Acute retrograde type A intramural hematoma during severe acute respiratory syndrome coronavirus 2 pandemic

Acute intramural hematomas (IMHs) occur in ∼6% of patients with acute dissections (ADs) and mostly affect the descending aorta.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar Type A IMHs involve the ascending aorta and type B IMHs do not involve the ascending aorta. Retrograde type A IMHs (retro-TAIMHs) originate in the descending aorta and extend into the arch or ascending aorta. TAIMHs with distal AD carry an in-hospital mortality risk of 12% to 26%.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar,2Tolenaar J.L. Harris K.M. Upchurch Jr., G.R. Evangelista A. Moll F.L. Di Eusnio M. et al.The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection.J Vasc Surg. 2013; 58: 1498-1504Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar We report the case of an 85-year-old woman with acute retro-TAIMH and distal AD. The patient provided consent for the report of her case. She was admitted to the emergency room with acute onset dyspnea and chest pain but no evidence of malperfusion. Emergency computed tomography angiography identified a retro-TAIMH with AD and a proximal entry tear above the celiac axis (A/Cover). The patient was hemodynamically stable. She was treated with hypotensive and analgesic therapy and hospitalized for intensive monitoring. Follow-up computed tomography angiography was performed at 24 hours (B) and 7 days (C) showing progressive to complete thrombosis of the entry tear, with a reduction in the aortic diameter, the most important predictor of IMH regression and positive outcomes.3Evangelista A. Dominguez R. Sebastia C. Salas A. Permanyer-Miralda G. Avegliano G. et al.Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma: therapeutic implications.Eur Heart J. 2004; 25: 81-87Crossref PubMed Scopus (100) Google Scholar Complete symptom regression occurred. The event was observed during the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Lombardy, Italy. The patient had tested positive for SARS-CoV-2 at 5 days after symptom onset, with progressive dyspnea and worsening findings on a chest radiograph (D). She died of pulmonary complications at 19 days postoperatively. Hybrid treatment with ascending aortic replacement and distal thoracic aortic endovascular repair (TEVAR) or using the frozen elephant trunk procedure is the most appropriate treatment for acute retro-TAIMH. TEVAR is a valid alternative only for patients with prohibitive surgical risk, although the landing zones could be unsuitable and the risk of neurologic and cardiac complications can be high.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Medical treatment appears to be appropriate for asymptomatic patients, those with noncomplicated retro-TAIMHs, and patients with high open surgical and TEVAR risks.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Considering both the absence of end-organ malperfusion and the advanced age of our patient, we chose medical treatment, which can reduce mortality by 67% to 95%.5Ince H. Nienaber C.A. Diagnosis and management of patients with aortic dissection.Heart. 2007; 93: 266-270Crossref PubMed Scopus (60) Google Scholar This choice proved effective with symptom recovery and clinical stability of the present patient, until the deadly overlap of SARS-CoV-2. Toward a unified pathophysiology in COVID-19 acute aortopathiesJournal of Vascular SurgeryVol. 74Issue 5PreviewThe interesting article by Katsarou et al1 about aortic intramural hematoma complicating a severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection is compelling, and its pathophysiology needs to be elucidated further. Full-Text PDF

Cardiac Computed Tomography Angiography Follow-Up of Resorbable Magnesium Scaffolds

IntroductionAn ancillary advantage of bioresorbable scaffolds is the possibility of non-invasive imaging assessment of the treated coronary segment. Cardiac computed tomography angiography (CCTA) studies of resorbable magnesium scaffolds (RMS) are scarce. MethodsIn this collaborative, international study, nine patients who had an RMS implanted underwent CCTA as part of follow-up assessment. Core-lab blinded quantitative and qualitative assessment was performed by an independent CCTA investigator. ResultsEight studies were amenable for quantitative analysis, and the blinded CT investigator successfully located and evaluated patency of RMS in all cases. The CCTA follow-up in-scaffold percentage diameter stenosis and area stenosis was 22.2% (12.4–30) and 39.1% (0.23–0.50), in keeping with mild in-scaffold late loss and underlying plaque growth. Moreover, a detailed coronary plaque characterization at treated segments was feasible (fibrous plaque in 69.9%, fibrofatty in 17.13%, necrotic in 4.78% and calcium in 5.72%). As in 6 out of 8 cases, the presentation was an acute coronary syndrome, these preliminary results could suggest plaque stabilization and a good coronary vessel healing with RMS. ConclusionNon-invasive, follow-up assessment of RMS with CCTA is feasible. Further CCTA studies for either clinical or research purposes with the present and upcoming generation of resorbable magnesium scaffolds are warranted.

Multidisciplinary approach to treat ruptured abdominal aortic aneurysm into the vena cava.

A 63-year-old man with a ruptured abdominal aortic aneurysm (AAA) into the inferior vena cava (IVC) underwent aortobifemoral bypass and closure of the aortocaval fistula (ACF). An additional bypass graft from the right iliac limb to the right internal iliac artery was placed to avoid colonic and pelvic ischemia. Preoperative computed tomography angiography (CTA) revealed an 8.6 cm AAA with rupture into the IVC through an 8.5 mm ACF (A). In addition, there was a 5.8 cm right common iliac and a 5.3 cm left common iliac artery aneurysm (B). The patient became hemodynamically unstable during CTA, and suffered a cardiac arrest with prompt cardiac resuscitation, intubation, and immediate transfer to the operating room. Ten hours after successful surgery the patient was awake and stable. He had no cardiac history, no symptoms suggestive of coronary artery disease (CAD) and had no electrocardiographic changes. However, the troponin level increased to 217,479.7 ng/L and the creatine kinase MB level increased to 504.6 ng/mL. Coronary angiography revealed left main coronary stenosis and subocclusion of the right coronary artery (C). Percutaneous coronary revascularization was performed with implantation of drug-eluting stents in the left main and right coronary artery. The patient recovered uneventfully. The 6-month follow-up CTA demonstrated patent aortobifemoral and right internal iliac bypass grafts and the IVC without signs of stenosis (D). Written informed consent was obtained from the patient for his anonymized information to be published in this article. AAA rupture into the IVC is rare and is associated with high mortality.1Davidovic L. Dragas M. Cvetkovic S. Kostic D. Cinara I. Banzic I. Twenty years of experience in the treatment of spontaneous aorto-venous fistulas in a developing country.World J Surg. 2011; 35: 1829-1834Crossref PubMed Scopus (19) Google Scholar, 2Simons J. Baril D. Goodney P. Bertges D. Robinson W. Cronewett J. et al.The effect of postoperative myocardial ischemia on long -term survival after vascular surgery.J Vasc Surg. 2013; 58: 1600-1608Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 3Krievins D. Zellans E. Erglis A. Zvaigzne L. Lacis A. Jegere S. et al.High prevalence of asymptomatic ischemia-producing coronary stenosis in patients with critical limb ischemia: anatomic and functional assessment with coronary CT-derived fractional flow reserve (FFRCT).Vasc Dis Manag. 2018; 15: E96-E101Google Scholar, 4Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur Heart J. 2018; 39: 763-816Crossref PubMed Scopus (1389) Google Scholar Preoperative diagnosis of ACF with CTA facilitated expeditious surgical treatment in this patient. Patients who survive surgery but have biomarker evidence of myocardial injury have reduced long-term survival.2Simons J. Baril D. Goodney P. Bertges D. Robinson W. Cronewett J. et al.The effect of postoperative myocardial ischemia on long -term survival after vascular surgery.J Vasc Surg. 2013; 58: 1600-1608Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Patients with AAA commonly have coexistent CAD. Pre-operative diagnosis of silent coronary ischemia with coronary CTA and fractional flow reserve derived from CT (FFRCT) can identify high risk patients who may benefit from coronary revascularisation.3Krievins D. Zellans E. Erglis A. Zvaigzne L. Lacis A. Jegere S. et al.High prevalence of asymptomatic ischemia-producing coronary stenosis in patients with critical limb ischemia: anatomic and functional assessment with coronary CT-derived fractional flow reserve (FFRCT).Vasc Dis Manag. 2018; 15: E96-E101Google Scholar Ruptured AAA into IVC with unsuspected CAD can be successfully treated with prompt image-based diagnosis and involvement of a multidisciplinary vascular team.4Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur Heart J. 2018; 39: 763-816Crossref PubMed Scopus (1389) Google Scholar

The impact of type 1a endoleak on the long-term outcome after EVAR

Objective Endoleaks remains a major determinant of outcome after endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysms. The objective of this study is to evaluate the long-term impact of proximal type 1 endoleak encountered at the case end of the EVAR procedure or during follow-up. Methods All patients treated with EVAR between February 2001 and August 2017 in our institution were included. Data were collected retrospectively. A descriptive analysis of subgroups with type 1a endoleak at case end or with type 1a endoleak first encountered during follow-up was performed. Results In total, 468 patients were included for analysis. At the case end of the EVAR procedure, in 5.3% (25/468) of patients, a type 1a endoleak was seen. In 72% of cases (18/25) the type 1a endoleak spontaneously disappeared on the first follow-up computed tomography angiography and never recurred. At the end of the follow-up period, no patient in this subgroup died with a type 1a endoleak on follow-up. In 3.4% (16/468) of all cases, a type 1a endoleak was encountered for the first time during follow-up. In 87.5% (14/16) of these cases, reintervention was performed. Two patients died with a persisting type 1a endoleak during follow-up. Conclusions Clinicians should differentiate between the type 1a endoleak at the case end and the type 1a endoleak first occurring during follow-up. For type 1a endoleak at the case end, expectant management can be adopted. Delayed type 1a endoleak seen during follow-up rarely seals spontaneously and needs reintervention in the majority of cases.

Frozen elephant trunk repair of aortic aneurysms: How to reduce the incidence of endoleak and reintervention.

BackgroundFrozen elephant trunk (FET) enables treatment of arch and proximal descending thoracic aorta aneurysms. In treating patients with single-stage FET, the relationship of distal stent size to endoleak and reintervention has remained unexamined.MethodsIn this retrospective analysis of 63 cases in which FET was used to repair aneurysms between 2008 and 2019, 36 were intended as single-stage procedures. Effective sizing and sealing of distal stents were analyzed by preoperative and postoperative computed tomography angiography (CTA).ResultsDuring a mean of 25.8 ± 5.7 months of CTA follow-up, 10 of 36 (28%) experienced endoleak, and 3 of 36 (8%) had sac expansion. Ultimately, 5 of 13 (38%) underwent thoracic endovascular aneurysm repair. Patients without endoleak or sac expansion were more likely to have stents with >10% oversize and a >30-mm seal in healthy aorta compared with those experiencing these complications (11 of 23 vs 0 of 13; P = .0031). Conversely, 11 of 36 patients (31%) with adequately oversized and sealed stents developed fewer endoleaks compared with those without (0 of 11 vs 10 of 14; P < .0004). Patients with endoleak or sac expansion had smaller mean distal stent oversize and shorter mean sealing length compared with those without endoleak or sac expansion (2.3 ± 3.9% vs 18 ± 2.9% [P = .0023] and 1 ± 0.7 mm vs 34 ± 6 mm [P = .0005], respectively).ConclusionsWe recommend >10% distal stent oversize and >30-mm sealing length to minimize endoleak and reintervention. Increasing multidisciplinary collaboration with endovascular surgeons will improve distal stent planning.

Long-term follow-up of patients with contained annulus ruptures after TAVI: the EuropeaN COntained RupturE (ENCORE) registry.

The purpose of this registry was to determine the long-term outcomes in patients with asymptomatic contained annulus rupture (CR) as a rare complication of transcatheter aortic valve implantation (TAVI). The ENCORE registry is a multicentre registry (six centres across Europe) of patients with CR diagnosed on post-TAVI computed tomography angiography (CTA) or transoesophageal echocardiography (TEE). A total of 21 patients (mean age 81.9±4.1 years, 81% balloon-expandable TAVI prostheses) were diagnosed with CR (mean size of lesions was 15.3±6.9 × 8.5±3.3 × 8.5±2.3 mm). Seventeen were diagnosed among a total of 1,602 consecutive routine post-TAVI CTA (incidence 1.1%), two in TEE and two in post-TAVI CTA (each conducted due to suspicion of peri-interventional complications). During a mean follow-up of 2.3±1.7 years (cumulative 48.6 patient-years), nine patients (43%) died from non-cardiac causes. None of the patients exhibited symptoms or underwent interventional treatment related to the CR; no sudden cardiac death occurred. A follow-up CTA, performed in eleven patients 240±176 days post TAVI, revealed stable CR findings in seven, regression in one, and remission in three patients. The results of our international multicentre registry demonstrate favourable long-term outcomes of CR after TAVI supporting a watch-and-wait strategy in these patients.

Short-term outcome of primary stent graft for peripheral artery aneurysm in patients with Behçet disease

ObjectiveEndovascular treatment of peripheral artery aneurysms (PAAs) in patients with Behçet disease is controversial. We report a single-institution experience of primary stent graft repair of PAAs in Behçet patients. MethodsBehçet patients who had endovascular stent graft repair of PAAs at a single center between January 2012 and December 2018 were identified. Demographics, past medical history, cardiovascular risk profile, and perioperative details were analyzed. ResultsTwenty-two patients (mean age, 38 ± 7 years; 100% male) were included. The distribution of PAAs was external iliac artery in 2 (9%) patients, common femoral artery in 4 (18%) patients, superficial femoral artery in 15 (68%) patients, and above-knee popliteal artery in 1 (5%) patient. Pseudoaneurysm was diagnosed in five (23%) patients. We used antegrade access in the majority of patients (16 [73%]). Technical success was achieved in 21 (95%) patients. The mean hospital stay was 3 ± 2 days. There were no deaths or serious complications, and five (23%) patients experienced access site complications. The mean follow-up was 23 ± 11 months. The early primary and assisted primary patency rate was 91%. However, follow-up computed tomography angiography detected stent graft occlusion in six patients (27%). ConclusionsStent graft for PAA in patients with Behçet disease had a high early patency rate and minimal morbidity. However, the complication and reintervention rates were high during follow-up, with low surgical conversion.

Long-Term Outcome of Chimney Technique Using a Balloon-Expandable Bare-Metal Stent to Preserve Supra-Arch Branches in Type B Aortic Dissection.

This study was performed to investigate the long-term effect of chimney technique using balloon-expandable bare-metal stents (BMSs) to preserve the supra-arch branches in type B aortic dissection (TBAD). Fifty patients with TBAD treated by thoracic endovascular aortic repair with the chimney technique (chTEVAR) using balloon-expandable BMSs from July 2009 to December 2013 were retrospectively assessed. Follow-up computed tomography angiography was performed to assess the postoperative outcomes. The primary end point was a persistent type Ia endoleak (ELIa). The secondary endpoints were chimney stent (CS)-based complications (stenosis, occlusion, fracture, or transposition), all-cause mortality, reintervention, and stroke. Fifty supra-arch branches (left common carotid artery, n = 11; left subclavian artery, n = 39) were preserved via the chimney technique with 50 balloon-expandable BMSs. The technical success rate was 100%. An immediate ELIa was discovered in 9 (18%) patients. The median survival duration during follow-up was 77.3 months. Five (10%) patients had a persistent ELIa; 3 of these patients had an immediate ELIa. Asymptomatic CS-based complications were found in 3 (6%) patients. The all-cause mortality rate was 8% (4/50); 2 deaths were aortic-related deaths. Five (10%) patients underwent a reintervention. During the estimated 36-month survival period, the survival rate, the rate of freedom from persistent ELIa, and the rate of freedom from reintervention were 93.87%, 89.48%, and 95.56%, respectively. The long-term outcomes showed that chTEVAR using balloon-expandable BMSs was safe and feasible for preservation of the supra-arch branches. Evaluation of more patients with a longer follow-up period is needed.

Hemorrhagic complications after percutaneous nephrolithotomy: angiographic diagnosis and management by transcatheter arterial embolization.

ObjectiveTo identify the main hemorrhagic complications after percutaneous nephrolithotomy, as well as the results obtained with transcatheter arterial embolization (TAE) at an interventional radiology center.Materials and MethodsThis was a retrospective analysis of patients undergoing TAE for the treatment of hemorrhagic complications after percutaneous nephrolithotomy. All patients underwent computed tomography angiography (CTA).ResultsWe evaluated a total of nine patients. At emergency department readmission, the most common symptom was macroscopic hematuria, which was seen in five patients. Three patients had an isolated pseudoaneurysm, two had a pseudoaneurysm together with active bleeding (perirenal hematoma), and one had a pseudoaneurysm together with arteriocalyceal fistula. Arteriovenous fistula was diagnosed in three patients and was not seen in combination with other vascular lesions. We did not identify arteriocalyceal fistula in isolation. Five patients underwent TAE with 6 × 15 mm and 6 × 20 mm microcoils. Four patients underwent TAE with n-butyl-2-cyanoacrylate and ethiodized oil. Follow-up CTAs revealed no complications.ConclusionBecause of its high diagnostic accuracy, CTA provides the interventional radiologist with valuable data for individualized therapeutic planning. The TAE procedure is safe and effective. It can therefore be used as a first-line treatment for hemorrhagic complications resulting from percutaneous renal procedures.

CAR 14. Hybrid Surgery for Symptomatic Chronic Near-Total or Total Occlusion of Internal Carotid Artery

Chronic symptomatic near-total or total occlusion of the carotid artery is relatively difficult to treat compared with routine carotid artery stenosis by either endarterectomy or endovascular procedures. Herein, we present our hybrid surgery strategies for the purpose of improving operational safety and recanalization rate. Six cases with total carotid occlusion and seven cases with near-total carotid occlusions were treated by hybrid surgery, combining endarterectomy of the proximal segment of the internal carotid artery with endovascular angioplasty of the distal segments of the internal carotid artery. Five of the six total occlusions were recanalized successfully, and six of the seven near-total occlusions were recanalized. The symptoms of the recanalized patients were resolved. Follow-up computed tomography angiography found good patency rate of the treated carotid artery. We believe that hybrid surgery for the treatment of total or near-total carotid artery occlusion is feasible, with a satisfactory operational safety and patency rate.

Accurate diagnosis and treatment of isolated mesenteric artery dissections.

Objectives Diagnosis and treatment of isolated mesenteric artery dissections (IMAD) are overlooked. The purpose of this study was to assess the clinical feature, possible diagnostic errors and treatment methods. Methods From January 2010 to December 2017, 99 consecutive patients who were diagnosed with IMAD on computed tomography angiography were enrolled retrospectively. Thirty-nine misdiagnosed patients, false negative, and 60 accurate diagnosis patients with revealed IMAD were compared. In addition, therapeutic schemes were evaluated. Results Ninety-nine patients participated in this study; 39 patients (34 men, 5 women; median age, 51.41 years, range 38–64 years) were included in group A who were misdiagnosed initial visit; the remaining 60 patients (52 men, 8 women; median age, 52.07 years, range 38–68 years) with IMAD who were diagnosed accurately initial visit were included in group B. Significant differences were observed between the two groups with respect to dissection length (55.26 ± 3.88 mm vs. 43.37 ± 2.75 mm; p = 0.01), and branch involvement (14 and 9, respectively; p = 0.04). Ultimately, 33 patients (group A 14 patients and group B 19 patients) underwent invasive interventional therapy, and 66 patients with conservative treatment with antithrombotic agents (group A 25 patients and group B 41 patients). A total of 86 (86.87%) had follow-up computed tomography angiography with a median duration of 24.51 months (range 2–71 months). Three patients died during follow-up. The remaining patients recovered smoothly. Conclusion Physicians should raise the awareness of IMAD and use the optimal treatment time frame. Diagnosis of IMAD depends on imaging examinations, especially computed tomography angiography. Additionally, conservative management is the most common initial treatment. For patients in whom conservative treatment fails, endovascular and/or surgery may be necessary.

94Course of contained annulus ruptures after TAVI: the ENCORE (European contained rupture)-registry

Abstract Background An asymptomatic contained rupture (CR) of the aortic annulus is a rare complication of transcatheter aortic valve implantation (TAVI). Their clinical implication is unclear so far. Purpose To determine the long-term outcomes in patients with CR. Methods The ENCORE-registry is a multicenter registry (6 centers across Europe) of patients with CR diagnosed on post-TAVI computed tomography angiography (CTA) or transesophageal echocardiography (TEE). Results A total of 21 patients (mean age 81.9±4.1 years, 81% balloon-expandable TAVI-prostheses) were diagnosed with CR (62% located adjacent to the left coronary cusp, mean size of lesions was 15.3±6.9 x 8.5±3.3 x 8.5±2.3 mm). Seventeen were diagnosed among a total of 1602 consecutive routine post-TAVI CTA (incidence 1.1%), two in TEE and two in post-TAVI CTA (each conducted due to suspicion of periinterventional complications). During a mean follow-up of 2.3±1.7 years nine patients (43%) died from non-cardiac causes. None of the patients exhibited symptoms or underwent interventional treatment related to the CR, no sudden cardiac death occurred. A follow-up CTA, performed in eleven patients 240±176 days post-TAVI, revealed stable CR findings in seven, regression in one, and remission in three patients. Conclusion The results of our ENCORE-registry demonstrate a benign course of initially asymptomatic contained ruptures of the aortic annulus after TAVI supporting a watch-and-wait approach in these patients. Thus, no specific treatment seems to be necessary.

Endovascular Repair of Aortoiliac or Common Iliac Artery Aneurysm Using the Lifetech Iliac Bifurcation Stent Graft System: A Prospective Multicenter Clinical Study

Sacrifice of the internal iliac artery (IIA) may result in ischemic manifestations after aortoiliac aneurysm (AIA) or common iliac artery aneurysm (CIAA) endovascular repair. This study sought to evaluate the safety and efficacy of a new Iliac Bifurcation Stent Graft (IBSG; Lifetech Scientific, Shenzhen, China) system for revascularization of the IIA. Patients who underwent implantation of the IBSG at 8 centers in China from September 2015 to June 2018 were enrolled. Clinical and computed tomography angiography follow-up assessments were conducted at 30 and 180days postoperatively. The primary end point was the IIA patency rate of the IBSG device at 180days postoperatively. Secondary end points comprised the postoperative technical success rate and clinical success rate at 30 and 180days. Descriptive statistics and the Clopper-Pearson exact method were used to analyze the data. Seventy-three patients (mean age, 69.6years; 91.8% men) were eligible for this trial, and 59 patients were eligible for primary effectiveness end-point analysis. AIA was present in 55 patients (75.34%) and CIAA in 18 patients (24.66%). The iliac artery aneurysms were unilateral in 69 patients (94.52%) and bilateral in 4 patients (5.48%). Overall technical success was 89.04% (65 of 73 patients). IIA patency at 180days was 96.61% (57 of 59 patients). Sexual dysfunction occurred in 1 patient (1.69%), and 2 patients (3.39%) experienced buttock claudication. There was no mortality, type III endoleak, stent migration, kinking, or fracture during the procedure and follow-up. The IBSG implantation system is a safe and effective technique for IIA preservation during AIA or CIAA endovascular repair. The high technical success rate, IIA patency rate, and low complication rate are promising. Follow-up will be continued for 5years to confirm the durability of the device.

Dural adhesion as a cause of late clip slippage from the medial cerebral artery aneurysm.

A properly placed clip may slip off the aneurysm during the postoperative period. Many factors have been attributed to this complication, although clip adherence to the dural stitch has not been reported. Following the single occurrence of such unusual complication, 64 similar medial cerebral artery (MCA) aneurysms were retrospectively investigated at a single institution. Clip adherence to the dura demonstrated in early postoperative computed tomography (CT) was a presumed factor of a late clip migration in this study. In the series, there were 4 (6.3%) aneurysm remnants and 1 slipped clip that firmly adhered to the dura. In this particular case, the revision surgery revealed the spring coil firmly adhering to the dura in the previous suture line. Neither the occurrence of an aneurysm neck remnant nor clip slippage were related to the clip's adherence to the dura in the analysis of the entire group (p > 0.05). On the contrary, application of a fenestrated clip did contribute to that finding in multivariate analysis (p < 0.01). Unlike the rest, two surgeons unintentionally tended to position the clip close to the dura (p < 0.01). The clip-to-dura distance measured in the follow-up CT angiography 1 year after the surgery differed from that in the postoperative CT in 83.8% of the cases and decreased by an average of 0.5 mm. Clip-to-dura adherence should be regarded as a normal finding in the postoperative CT following MCA aneurysm clipping. Surgeons should consider the possibility of clip head protrusion into the dural stitch line.

Endovascular treatment of pulmonary sequestration with thoracic endograft

Introduction:Pulmonary sequestration (PS) is a rare congenital lung malformation. The classical treatment of the disease has been conventional surgery with resection of abnormal parenchyma. Recently, the endovascular embolization has been proposed for the treatment of this disease. Here we present 2 cases of PS successfully treated with thoracic endograft.Patient concerns:Two patients with abnormal consolidation in the left lower lobe were admitted in our hospital.Diagnosis:Chest computed tomography angiography (CTA) showed abnormal consolidation in the left lower lobe, which received systemic blood supply from the descending aorta in both patients. So the diagnosis of PS was confirmed.Interventions:Endovascular treatment with thoracic endograft was successfully performed.Outcomes:The patients recovered well and were completely free of symptoms. And the CTA follow-up showed the abnormal pulmonary parenchyma shrunk significantly.Conclusions:Endovascular treatment with thoracic endograft is a promising treatment option for PS.

Cost-Effectiveness of Computed Tomography Angiography in Management of Tiny Unruptured Intracranial Aneurysms in the United States.

Background and Purpose- Our study aims to evaluate the cost-effectiveness of computed tomography angiography (CTA) for surveillance of tiny unruptured intracranial aneurysms and the impact of CTA radiation-induced brain tumor on the overall effectiveness of CTA. Methods- A Markov decision model was constructed from a societal perspective starting with patients 30-, 40-, or 50-year-old, with incidental detection of unruptured intracranial aneurysm ≤3 mm and no prior history of subarachnoid hemorrhage. Five different management strategies were assessed (1) annual CTA surveillance, (2) biennial CTA, (3) CTA follow-up every 5 years, (4) coiling and subsequent magnetic resonance imaging follow-up, and (5) annual CTA surveillance for the first 2 years, followed by every 5-year CTA follow-up. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. Results- The base case calculation shows every 5-year CTA follow-up to be the most cost-effective strategy, and the conclusion remains robust in probabilistic sensitivity analysis. It remains the dominant strategy when the annual rupture risk of nongrowing unruptured intracranial aneurysms is smaller than 2.66% or the rupture risk in growing aneurysms is <57.4%. The radiation-induced brain cancer risk is relatively low, and sensitivity analysis shows that the radiation-induced cancer risk does not influence the conclusions unless the risk exceeds 663-fold of the base case values. Conclusions- Given the current literature, every 5-year CTA imaging follow-up is the cost-effective strategy in patients with aneurysms ≤3 mm, resulting in better health outcomes and lower healthcare spending. Patients with aneurysms at high risk of rupture might need more aggressive management.

Radiological Management of Angiographically Negative, Spontaneous Intracranial Subarachnoid Hemorrhage: A Multicenter Study of Utilization and Diagnostic Yield.

The optimal diagnostic evaluation for patients with angiographically negative subarachnoid hemorrhage (AN-SAH) remains controversial. To assess the utilization rate and diagnostic yield of imaging tests routinely obtained in identifying a structural cause for AN-SAH. In this retrospective multicenter study, consecutive adult patients admitted with nontraumatic, AN-SAH between 01/2010 and 12/2015 were included. Patients with intraparenchymal, subdural, or epidural hematomas in addition to SAH were excluded. Outcomes studied included utilization rate, diagnostic yield, and median time from admission for the following imaging tests: initial computed tomography angiography (CTA) and digital subtraction angiography (DSA), brain and cervical spine magnetic resonance imaging (MRI), and any repeat DSA or CTA performed either during initial admission or at long-term follow-up. A total of 752 patients were included (mean age, 53 yr; 54% male). Initial CTA and DSA were performed in 89% and 100% of patients, respectively. Brain MRI was performed in 75% of patients and was positive in 0.7% of cases. Cervical spine MRI was performed in 61% of patients and was positive in 0.2% of cases. Repeat, same-admission follow-up DSA and CTA were performed in 48% and 51% of patients and were positive in 3.3% and 1% of cases, respectively. Delayed follow-up DSA and CTA after discharge were performed in 26% and 7% of patients and were positive in 2% and 3.7% of cases, respectively, all with negative prior imaging studies. Cervical spine and brain MRI have extremely low diagnostic yield, both are commonly utilized in patients with AN-SAH; while repeat DSA and CTA are utilized less commonly and have slightly higher diagnostic yield.

Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks

ObjectivesTo evaluate the influence of baseline parameters on the occurrence of stent-graft surface movement after endovascular aneurysm repair (EVAR) and to investigate its association with migration and stent-graft-related endoleaks (srEL).MethodsIn this retrospective, cross-sectional study, three-dimensional surface models of the stent-graft, delimited by landmarks using custom-built software, were derived from the pre-discharge and last follow-up computed tomography angiography (CTA). Stent-graft surface movement in the proximal anchoring zone between these examinations was considered significant at a threshold of 9 mm. The Cox proportional hazards model was used to determine baseline variables associated with the occurrence of stent-graft surface movement. The association between migration and srEL with stent-graft surface movement was tested with the chi-square and the Fisher exact test, respectively.ResultsStent-graft surface movement was observed in 54 (28.9%) of 187 patients. Multivariate analysis revealed that age ([HR] 1.05; p = 0.017), proximal neck diameter ([HR] 5.07; p < 0.001), infrarenal aortic neck angulation ([HR] 1.02, p = 0.002), and proximal neck length ([HR] 0.62, p < 0.001) were significantly associated with the occurrence of stent-graft surface movement. Migration and srEL occurred in 17 (31.5%) and 5 (9.3%) patients, with and 11 (8.3%) and 2 (1.5%) without stent-graft surface movement (p < 0.001, p = 0.022).ConclusionsAge, neck diameter, infrarenal neck angulation, and proximal neck length were significantly associated with the occurrence of stent-graft surface movement. Apart from possible use of adjunctive sealing systems, concerned patients may benefit from regular CTA surveillance, enabling timely diagnosis of subtle changes of stent-graft position.Key Points• Stent-graft surface movement, demonstrating subtle, three-dimensional changes in stent-graft position in the proximal anchoring zone, can be derived from CTA examinations.• Age, proximal neck diameter, and infrarenal neck angulation were significantly associated with an increased incidence of stent-graft surface movement. Stent-graft surface movement is significantly more frequent in patients with stent-graft migration and stent-graft-related endoleaks.• Consideration of risk factors for stent-graft surface movement may help to identify patients who might benefit from regular CTA surveillance and timely diagnosis of subtle changes of stent-graft position, enabling re-interventions to prevent migration and srEL.

Complication Incidences and Treatment Outcomes of Endovascular Aneurysm Repair-A Single-Center Long-Time Follow-Up Study.

Few long-time follow-up studies describe all complications, treatment outcome of complications, and mortality in relation to endovascular aneurysm repair (EVAR). The purpose of this study was to evaluate the incidence and treatment outcome including mortality of radiological visible complications related to the EVAR procedure at a single center with up to 10 years' surveillance. Patients treated with EVAR from March 2006 to March 2016 at a Danish university hospital, 421 in total, were included. Patient and aneurysm characteristics, follow-up, and secondary intervention data were collected from a national database and medical records. Follow-up computed tomography angiography and plain abdominal X-ray reports were reviewed for complications. Scans and X-rays with suspected complications were evaluated by an interventional radiologist. A total of 172 complications in 147 patients, mainly in the beginning of the follow-up period, were found; 35% had a least one complication. The main part of complications (62%) was type II endoleaks, followed by stent graft stenosis (11%), type I endoleaks (9%), and stent graft occlusion (7%). A total of 66 (38%) complications, observed in 55 patients, were treated with reintervention, of which 77% were treated with endovascular procedures and 23% with surgical treatment, that is, 13% of all studied patients had a complication that required a reintervention. The remaining 2 of the 3 complications were treated conservatively. We found no increased all-cause mortality in connection with having a complication including those requiring reintervention. We presented a 10-year single-center study of EVAR. Many patients treated with EVAR had a radiological visible complication, mainly in the beginning of the follow-up period. Only a smaller fraction required reintervention and having a reintervention-requiring complication was not connected to increased mortality.