Follow-up Computed Tomography Angiography Research Articles

Utility of follow-up ultra-high-resolution CT angiography with model-based iterative reconstruction after flow diverter treatment for cerebral aneurysms.

Follow-up examinations after flow diverter (FD) treatment for cerebral aneurysms typically involve magnetic resonance imaging (MRI) or digital subtraction angiography (DSA). However, MRI is prone to vascular defects due to metal artifacts from FD, and DSA carries a risk of ischemic complications. In the context of computed tomography angiography (CTA), this study compares the efficacy of ultra-high-resolution CT (UHRCT) and novel reconstruction techniques, such as model-based iterative reconstruction (MBIR), against conventional methods such as filtered back projection (FBP) and hybrid iterative reconstruction (IR), to determine if they are a viable alternative to DSA in clinical settings. A phantom study was conducted with the full-width half-maximum considered as the FD thickness. This study compared three reconstruction methods: MBIR, FBP, and hybrid IR. A clinical study was also conducted with 21 patients who underwent follow-up CTA after FD treatment. The FD's visibility was assessed using a 4-point scale in FBP, hybrid IR, and MBIR compared to cone-beam CT (CBCT) with angiographic systems. In the phantom study, FBP, hybrid IR, and MBIR visualized thinner FD thicknesses and improved detail rendering in that order. MBIR proved to be significantly superior in both the phantom and clinical study. UHRCT with MBIR is highly effective for follow-up evaluations after FD treatment and may become the first-choice modality in the future.

A pilot study to evaluate a novel localized treatment to stabilize small- to medium-sized infrarenal abdominal aortic aneurysms

ObjectiveThere is no proven therapy to reduce growth rates of small- to medium-sized abdominal aortic aneurysms (AAAs). Ex vivo and animal studies have demonstrated that a novel stabilizing agent, 1,2,3,4,6-pentagalloyl glucose (PGG), delivered locally to the aneurysm sac, can bind to elastin and collagen to re-establish strength and resist enzymatic degradation. We aimed to demonstrate that a one-time administration of PGG solution to the aneurysm wall is safe and potentially effective to slow the growth of small- to medium-sized AAAs. MethodsPatients with small- to medium-sized infrarenal AAAs (maximum diameter <5.5 cm) were recruited. Via transfemoral access, a 14F or 16F dual-balloon delivery catheter was introduced into the aneurysm sac. A single, 3-minute, localized endoluminal infusion of PGG was delivered via a ‘weeping’ balloon to the aneurysm wall. Independent core laboratory measurements of maximum aneurysm sac diameter and sac volume measurements based on computed tomography angiography (CTA) were used for assessments at 1, 6, 12, 24, and 36 months. The primary endpoints were technical success and safety (major adverse events at 30 days). The secondary endpoint was growth stabilization, defined as freedom from aneurysm sac enlargement (diameter increase >5 mm per year or volume increase of >10% per year). ResultsTwenty patients (19 male) were enrolled at five centers from May 2019 to June 2022 (mean age, 67.8 years; range, 50-87 years). All procedures were technically successful. The safety profile was consistent with standard interventional procedures. Four patients demonstrated transient elevations of liver enzymes levels that returned to normal by 30 days with no clinical symptoms. Through November 2022, follow-up CTA data is available on the first 11 patients. The average changes in maximum aneurysm diameter from baseline to 6, 12, 24, and 36 months were 0.2 mm, 1.1 mm, 1.2 mm, and 0.8 mm, respectively, and the average changes in volume were 2.0%, 9.6%, 18.1%, and 11.6%, respectively. At 12 months, none of the aneurysms showed growth >5.0 mm, and three had volume growth >10%. ConclusionsThe early results of this first-in-human, small cohort study demonstrated that a single, localized PGG administration to patients with small- to medium-sized infrarenal AAAs is safe. Longer term follow-up on all 20 treated patients is needed to better assess the potential impact on aneurysm growth.

FOLLOW-UP OF VASCULAR LESIONS IN FIBROMUSCULAR DYSPLASIA. NO EVIDENCE FOR PROGRESSION YET

Objective: It is currently unknown whether the vascular lesions in patients with fibromuscular dysplasia (FMD) are progressive in time. Therefore, repeat CT-angiography (CTA) is often necessary to evaluate possible evolution of the abnormalites. It would be unjustified to frequently expose patients to this diagnostic modality with its drawbacks (radiation, contrast material) if the vascular lesions turn out to be stable. The aim of our study was to explore whether vascular FMD lesions (unifocal or multifocal, with or without aneurysms) change in terms of extensiveness or localization over a period of a few years. Design and method: To qualify for the present study, patients had to be diagnosed with FMD in any vascular bed and both the diagnostic and the follow-up CTA had to be performed at the same institution using the same imaging protocol. Patients who had been referred by other hospitals and were followed in our own clinic were excluded from the analysis. On both the basal and the follow-up CTA, we assessed the number of lesions, the site of lesions, and the presence or absence of aneurysms. Results: A total of 161 patients had both a diagnostic and a follow-up CTA at our own clinic. Their mean age at diagnosis was 49 + 11 years (range 19-76) and 63% of the patients had been detected during a work-up for hypertension. On average, FMD was diagnosed nine years after the initial diagnosis of hypertension had been made. In the remainder of the patients, FMD was diagnosed after the patient had experienced a dissection (coronary, carotid). Follow-up CTA after two years was available in 111 patients and after three years in 50 patients. In only three patients we found new vascular lesions after a period of two years. In all the others, the pattern of lesions remained constant. Conclusions: Over a period of two to three years, vascular FMD lesions do not seem to progress in most patients. If repeat CTA scanning is considered, one should respect at least this time period.

Initial experience with a modified "candy-plug" technique for false lumen embolization in chronic type B aortic dissection.

Persistent distal false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) can lead to aneurysmal degeneration and an increased risk of rupture. We have presented our initial experience using a modified "candy-plug" (CP) technique for FL embolization. From February 2021 to July 2022, we treated six patients using the modified CP technique. All the patients had undergone prior or simultaneous TEVAR for chronic TBAD with persistent FL perfusion and aneurysm expansion. Bilateral common femoral artery access was obtained, and intravascular ultrasound was used to confirm wire access in the true lumen (TL) and FL. A conformable TAG device (W.L. Gore & Associates, Flagstaff, AZ) was used in four cases and an Excluder aortic cuff (W.L. Gore & Associates) in two cases. The device was modified by placing a constraining "napkin-ring" suture through the middle segment of the device. Femoral sheaths were placed in the TL and FL. A standard TL TEVAR extension was performed at the level of the celiac artery (zone 5). Next, the CP device was advanced and deployed in the FL, distally aligning it with the TL device. An appropriately sized Amplatzer II plug (Abbot Vascular, Santa Clara, CA) was then deployed in the constrained segment of the modified stent graft. Completion angiography was performed to confirm successful FL embolization. Technical success was defined as successful deployment of the CP device in the FL. The technical success rate was 100% (six of six patients). Clinical success was defined as the cessation of aneurysm growth on follow-up computed tomography angiography. No 30-day mortality, myocardial infarction, stroke, spinal cord ischemia, access site complications, or aortic-related reinterventions occurred. Surveillance imaging at a mean follow-up of 10months confirmed clinical success (stable aneurysm size or shrinkage) for all five patients with follow-up data available. The modified CP embolization technique is a promising solution for persistent distal FL perfusion after TEVAR for TBAD. Further investigation is required to determine the long-term durability of this technique as an adjunct to TEVAR to promote aortic remodeling.

Viabahn-assisted sutureless anastomosis (VASA) repair of a complex internal carotid artery aneurysm.

Extracranial carotid artery aneurysms (CAAs) are extremely rare and often require surgical intervention to avoid complications such as local compression symptoms and thrombo-embolization. We present the case of a 63-year-old man with a history of hypertension, meningioma, and an incidental finding of a right saccular internal carotid artery aneurysm at the base of the skull. He underwent open surgical repair; nonetheless, end-to-end anastomosis was not feasible. As bailout, the internal carotid artery was successfully reconstructed with a novel Viabahn-assisted sutureless anastomosis technique (GORE, Viabahn). Postoperative clinical assessment revealed no complications, postoperative computed tomography angiography revealed a patent reconstruction, and the patient was discharged home uneventfully with 1-year clinical and computed tomography angiography follow-up without remarks. Hybrid procedure is a viable option for technically challenging carotid anastomoses near the skull base.

Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms.

Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms.

Translumbar type II endoleak embolization with a new liquid iodinated polyvinyl alcohol polymer: Case series and review of current literature.

To describe our experience with the use of a novel iodized Polyvinyl Alcohol Polymer liquid agent (Easyx) in type II endoleak treatment with translumbar approach. Our case series is a retrospective review of patients with type II endoleak (T2E) treated with Easyx from December 2017 to December 2020. Indication for treatment was a persistent T2E with an increasing aneurysm sac ≥5 mm on computed tomography angiography (CTA) over a 6-month interval. Technical success was defined as the embolization of the endoleak nidus with reduction or elimination of the T2E on sequent CTA evaluation. Clinical success was defined as an unchanged or decreased aneurysm sac on follow-up CTA. Secondary endpoints included the presence of artifacts in the postprocedural cross-sectional tomographic imaging and post and intraprocedural complications. Ten patients were included in our retrospective analysis. All T2E were successfully embolized. Clinical success was achieved in 9 out of 10 patients (90%). The mean follow-up was 14 3-20 months. No beam hardening artifact was observed in follow-up CT providing unaltered imaging. Easyx is a novel liquid embolic agent with lava-like characteristics and unaltered visibility on subsequent CT examinations. In our initial experience, Easyx showed to have all the efficacy requisites to be an embolization agent for type II EL management. Its efficacy, however, should be evaluated in more extensive studies and eventually compared with other agents.

Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks

The aim of this study was to assess the initial experience, technical success, and clinical benefit of AneuFix (TripleMed, Geleen, the Netherlands), a novel biocompatible and non-inflammatory elastomer that is directly injected into the aneurysm sac by a translumbar puncture in patients with a type II endoleak and a growing aneurysm. A multicenter, prospective, pivotal study was conducted (ClinicalTrials.gov:NCT02487290). Patients with a type II endoleak and aneurysm growth (>5 mm) were included. Patients with a patent inferior mesenteric artery connected to the endoleak were excluded for initial safety reasons. The endoleak cavity was translumbar punctured with cone-beam computed tomography (CT) and software guidance. Angiography of the endoleak was performed, all lumbar arteries connected to the endoleak were visualized, and AneuFix elastomer was injected into the endoleak cavity and short segment of the lumbar arteries. The primary endpoint was technical success, defined as successful filling of the endoleak cavity with computed tomography angiography (CTA) assessment within 24 hours. Secondary endpoints were clinical success defined as the absence of abdominal aortic aneurysm (AAA) growth at 6 months on CTA, serious adverse events, re-interventions, and neurological abnormalities. Computed tomography angiography follow-up was performed at 1 day and at 3, 6, and 12 months. This analysis reports the initial experience of the first 10 patients treated with AneuFix. Seven men and 3 women with a median age of 78 years (interquartile range (IQR), 74-84) were treated. Median aneurysm growth after endovascular aneurysm repair (EVAR) was 19 mm (IQR, 8-23 mm). Technical success was 100%; it was possible to puncture the endoleak cavity of all treated patients and to inject AneuFix. Clinical success at 6 months was 90%. One patient showed 5 mm growth with persisting endoleak, probably due to insufficient endoleak filling. No serious adverse events related to the procedure or AneuFix material were reported. No neurological disorders were reported. The first results of type II endoleak treatment with AneuFix injectable elastomer in a small number of patients with a growing aneurysm show that it is technically feasible, safe, and clinically effective at 6 months. Effective and durable embolization of type II endoleaks causing abdominal aortic aneurysms (AAA) growth after EVAR is challenging. A novel injectable elastic polymer (elastomer) was developed, specifically designed to treat type II endoleaks (AneuFix, TripleMed, Geleen, the Netherlands). Embolization of the type II endoleak was performed by translumbar puncture. The viscosity changes from paste-like during injection, into an elastic implant after curing. The initial experience of this multicentre prospective pivotal trial demonstrated that the procedure is feasible and safe with a technical success of 100%. Absence of AAA growth was observed in 9 out of 10 treated patients at 6 months.

Coil embolization of asymptomatic left gastric artery aneurysm: Case report and literature review

Patients with visceral artery aneurysms are rare, and the reported incidence of left gastric aneurysm (LGA) is only 4%. At present, although there is little knowledge about such disease, it is generally believed that appropriate treatment should be planned to prevent some dangerous aneurysms from rupturing. We introduced a case of 83-year-old patient with LGA who underwent endovascular aneurysm repair. The 6-month follow-up computed tomography angiography showed complete thrombosis in the aneurysm lumen. In addition, to insight the management strategy on LGAs deeply, a literature review concerning this entity published in recent 35 years was performed.

Endovascular Preservation of Segmental Arteries during Treatment of Thoracoabdominal Aortic Aneurysms with Fenestrated/Branched Stent Grafts: Feasibility and Outcomes

PurposeTo evaluate the technical success, feasibility, and outcomes of endovascular preservation of segmental arteries (SAs) during fenestrated/branched endovascular aortic repair (F/B-EVAR). Materials and MethodsA multicenter, retrospective study was conducted in consecutive patients treated with F/B-EVAR and a branch or fenestration for SA preservation. Eleven patients (median age, 57 years; range, 45–73 years; 7 men) were included. ResultsTwelve SAs were preserved. Stent grafts were custom made with fenestrations, branches, or a combination of both in 1, 2, and 5 patients, respectively. A t-Branch stent graft was used in 2 patients, and a physician-modified thoracic stent graft with a branch was used in 1 patient. Eight branches and 4 fenestrations were used for the preservation of 12 SAs. Four fenestrations and 1 branch for the SAs were not bridged and were left for perfusion of the corresponding SAs. Technical success was achieved in 10 of 11 (91%) patients. No early mortality occurred. Early morbidities included renal insufficiency without dialysis in 1 patient and partially delayed paraplegia in 1 patient. Before discharge, computed tomography angiography (CTA) showed patency of all the SAs. The median follow-up duration was 30 months (range, 10–88 months). Late death occurred in 1 patient. Two SAs were occluded in 1 patient with 2 unstented fenestrations, as determined using 1-year follow-up CTA. This patient did not develop spinal cord ischemia (SCI). Other SAs remained patent during follow-up. One patient with a type IIIc endoleak was treated by relining of bridging stents. ConclusionsEndovascular preservation of SAs with F/B-EVAR for thoracoabdominal aortic aneurysm is feasible and safe in select patients and may add to preventive measures for SCI.

Midterm changes in iliac limb apposition after endovascular aortic aneurysm repair.

Literature is scarce on the course of iliac endograft limb apposition after endovascular aortic aneurysm repair (EVAR), which is why this study was conducted. A retrospective observational imaging study was performed to measure iliac apposition of endograft limbs on the first post-EVAR computed tomography angiography (CTA) scan and on the latest available follow-up CTA scan. With center lumen line reconstructions and CT-applied dedicated software, the shortest apposition length (SAL) of the endograft limbs was assessed as well as the distance between the end of the fabric and the proximal border of the internal iliac artery or the endograft-internal artery distance (EID). Ninety-two iliac endograft limbs were eligible for measurements, with a median follow-up of 3.3 years. At the first post-EVAR CTA, the mean SAL was 31.9±15.6 mm, and the mean EID was 19.5±11.8. At the last follow-up CTA, there was a significant decrease in apposition of 10.5±14.1 mm (P<0.001) and a significant increase in EID of 5.3±9.5 mm (P<0.001). A type Ib endoleak developed in three patients due to a reduced SAL. The apposition was <10 mm in 24% of limbs at the last follow-up vs. 3% at the first post-EVAR CTA. This retrospective study documented a significant decrease in post-EVAR iliac apposition over time, partly due to retraction of iliac endograft limbs at mid-term CTA follow-up. Further research is required to identify whether regular determination of iliac apposition may predict and prevent type IB endoleaks.

Single-center results of the Gore Excluder Conformable Endoprosthesis with active control system in endovascular aneurysm repair.

The GORE EXCLUDER Conformable Endoprosthesis with active control (CEXC) was developed to treat challenging aortic neck anatomy. This study investigated the clinical results and changes in endograft (ap)position during follow-up. Patients treated with the CEXC between 2018 and 2022 were included in this prospective single-center study. Computed tomography angiography (CTA) follow-up was grouped into three categories: 0 to 6 (FU1), 7 to 18 (FU2), and 19 to 30 (FU3) months. Clinical end points were endograft-associated complications and reinterventions. CTA analysis included the shortest apposition length (SAL) between the endograft fabric and the first slice where circumferential apposition was lost, shortest fabric distance (SFD) between both renal arteries and the endograft fabric, and maximum infrarenal and suprarenal aortic curvature. FU2 and FU3 were compared with FU1 to establish changes. Included were 46 patients, of whom 36 (78%) had at least one hostile neck feature and 13 (28%) were treated outside instructions for use. Technical success was 100%. Median CTA follow-up was 10 months (2-20 months); 39 patients had a CTA available at FU1, 22 at FU2, and 12 at FU3. At FU1, the median SAL was 21.4 mm (13.2-27.4 mm), which did not significantly change during follow-up. No type I endoleaks, and one type III endoleak at an IBD occurred during follow-up. Two cases of endograft migration (SFD increase >10 mm) were seen during follow-up (one treated outside the instructions for use). Maximum infrarenal and suprarenal aortic curvature did not significantly change during follow-up. The use of the CEXC in challenging aortic necks enables stable apposition without significant changes in aortic morphology at short-term follow-up.

Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella

Purpose: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms. Materials and Methods: The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed. Results: Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak. Conclusion: EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms. Clinical Impact Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%–40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Hyperrealistic Rendering of Type II Endoleak.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologyHyperrealistic Rendering of Type II EndoleakBaolei Guo , Liying PengBaolei Guo , Liying PengAuthor AffiliationsFrom the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, No. 180 Fenglin Rd, Xuhui District, Shanghai 200032, China (B.G.); and Central Research Institute, United Imaging Healthcare, Shanghai, China (L.P.).Address correspondence to B.G. (email: [email protected]).Baolei Guo Liying PengPublished Online:Feb 14 2023https://doi.org/10.1148/radiol.222150MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Supplemental material is available for this article.A 71-year-old man with a history of abdominal aortic aneurysm status after endovascular aortic repair (EVAR) presented for follow-up CT angiography (CTA) at 19 months. Hyperrealistic rendering (HRR) (United Imaging Healthcare) visually demonstrated an enlarged aneurysm sac measuring 7.2 cm in maximum diameter (previously 6.1 cm, before EVAR), with type II endoleaks involving the bilateral L4 lumbar arteries and the inferior mesenteric artery (Figure, Figure S1, Movie). The patient was admitted to the hospital and underwent embolization of the aforementioned feeding vessels. Follow-up CTA at 6 months after the embolization procedure showed complete thrombosis of the aneurysm sac with no residual endoleak.Images in a 71-year-old man diagnosed with type II endoleak 19 months after the endovascular aortic repair for an abdominal aortic aneurysm. The hyperrealistic rendering from CT angiography provides a clear representation of the endoleak (black arrows) and the three major feeding vessels (white arrows) (ie, bilateral lumbar arteries [LA] and the inferior mesenteric artery [IMA]). (A) The hyperrealistic rendering in posterior view demonstrates the feeding lumbar arteries and the associated iliolumbar-lumbar pathway arising from the internal iliac arteries. (B) The hyperrealistic rendering in anterior view reveals a pathway from the superior mesenteric artery to the inferior mesenteric artery by means of the arc of Riolan feeding into the aneurysm sac (shown as a semitransparent cavity).Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie: Hyper-realistic rendering from CT angiography in a 71-year-old man diagnosed with type II endoleak.Download Original Video (97.3 MB)Endoleaks, in particular type II endoleaks defined as aneurysm sac backfilling from aortic branches (1), are the most common complications of EVAR and pose persistent risk of aortic rupture. Visualization of the inflow vessels is crucial for preoperative planning. As an advanced three-dimensional visualization technique with use of physically based volume rendering, HRR can generate photorealistic images with enhanced display of complex spatial relationships and lifelike surface details. By assisting proceduralists in identifying the endoleak feeding vessels, HRR provides value in developing treatment strategies.Disclosures of conflicts of interest: B.G. No relevant relationships. L.P. No relevant relationships.Supported by the National Natural Science Foundation of China (grant 82000436) and the Science and Technology Commission of Shanghai Municipality (grants 201409004800 and 21410710500).Reference1. Veith FJ, Baum RA, Ohki T, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 2002;35(5):1029–1035. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 29 2022Revision requested: Oct 10 2022Revision received: Oct 21 2022Accepted: Oct 31 2022Published online: Feb 14 2023 FiguresReferencesRelatedDetailsRecommended Articles RSNA Education Exhibits RSNA Case Collection Recently Published Supplemental MaterialMetrics Altmetric Score PDF download

Management of the False Lumen in Post Type A Aortic Dissection Arch Aneurysms Treated With Branched Endografts

Introduction: The treatment of chronic postdissection aneurysms of the aortic arch is a challenge. This study aims to describe false lumen management after aortic arch endovascular repair of post-type A dissection aneurysms treated with a branched endograft. Methods: In this single-center retrospective observational study, all consecutive patients undergoing endovascular treatment of aneurysmal degeneration of chronic type A aortic dissections following open repair were enrolled. The primary endpoint was maximal aortic diameter evolution measured on computed tomography angiography (CTA) performed during follow-up. Secondary endpoints included procedural success, aortic re intervention, and remodeling during follow-up. Results: Between January 2017 and June 2020, 22 patients underwent endovascular branched arch repair for post type A dissection aneurysms. Technical success was 100%. Thirteen patients (59%) had dissection involvement of at least 1 supra-aortic vessel. Midterm follow-up CTA was performed for 20 patients, 23.1 (±13.3) months after the procedure. Maximal aortic diameter at the level of the repair was decreasing in 13 (65%) patients, increasing in 2 (10%) patients, and no change was observed in 5 (25%) patients. During follow-up, 7 patients (35%) required aortic reintervention. Thoracic candy plugs were implanted for distal false lumen occlusion in 15 patients and associated with a high rate of complete remodeling (6/15 patients, 40%). Conclusion: Arch branch endografting of aneurysmal evolution of a post type A dissection aortic arch is a safe and feasible option in experienced hands. Candy plug use in favorable anatomies seems to be associated with accelerated remodeling of the aorta. Clinical Impact There are currently no recommendations on dissected supra- aortic vessels management and the use of thoracic aorta false lumen occlusion devices during endovascular repair of chronic post dissection aneurysm of the aortic arch with branched endografts. Based on our clinical experience reported in the current manuscript, we propose a treatment algorithm for the management of the false lumen in this setting.

Adult-type Aortic Coarctation with Multiple Cardiovascular Anomalies.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologyAdult-type Aortic Coarctation with Multiple Cardiovascular AnomaliesXuehan Hu, Zhidong Yuan Xuehan Hu, Zhidong Yuan Author AffiliationsFrom the Department of Radiology, Peking University Shenzhen Hospital, 1120 Lianhua Rd, Futian District, Shenzhen 518036, China (X.H., Z.Y.); and Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China (X.H.).Address correspondence to Z.Y. (email: [email protected]).Xuehan HuZhidong Yuan Published Online:Jan 3 2023https://doi.org/10.1148/radiol.221882MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Supplemental material is available for this article.An 18-year-old man presented with hypertension of 160/100 mm Hg for 5 years, without abnormal serum laboratory findings. Aortic CT angiography (CTA) showed stenosis of the juxtaductal distal aortic arch (Figure, A, B), with a narrow diameter of 3.5 mm. Abundant collateral pathways formed by means of the posterior intercostal arteries, internal thoracic arteries, and a bronchial artery vascular mass connected with the right subclavian artery and circumflex coronary artery (Figure, A; Movie 1). Moreover, both the left and right coronary arteries originated anomalously from the ascending aorta high above the left aortic sinus of a bicuspid aortic valve (Figure, A). Digital subtraction angiography confirmed the diagnosis of coarctation of the aorta before treatment with balloon angioplasty (Figure, C; Movie 2). The blood pressure immediately returned to nearly normal. The abundant collateral vessels were significantly reduced at 6-month follow-up CTA (Fig S1). In patients with coarctation of the aorta, the prevalence of bicuspid aortic valve is 50%–75% (1), while the anomalous aortic origin of a coronary artery is rare. These anomalies may complicate coronary angiography and aortic valve replacement (2).Images show coarctation of the aorta (CoA) accompanied by multiple cardiovascular anomalies. (A) CT angiogram volume rendering with colored segmentation shows coarctation of the aorta (solid arrow) with abundant collateral pathways by means of the posterior intercostal arteries (green), internal thoracic arteries (purple), and an anastomosis of the bronchial artery and circumflex coronary artery (yellow). A coronary artery anomaly (CAA) (arrowhead) and bicuspid aortic valve (BAV) (dotted arrow) are also depicted. (B) Sagittal CT angiogram and (C) digital subtraction angiogram show the severe stenosis (white arrows on B and C) of the juxtaductal distal aortic arch and abundant dilated collateral pathways (black arrows on C).Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie 1: Three hundred sixty-degree spin of advanced three-dimensional volume rendering reconstruction image.Download Original Video (12.4 MB)Get the Flash Player to see this video.Movie 2: Digital subtraction angiograms of before and after balloon angioplasty.Download Original Video (7.3 MB)Disclosures of conflicts of interest: X.H. No relevant relationships. Z.Y. No relevant relationships.AcknowledgmentThe authors thank Dr Min Chen, MD, PhD, from the Department of Radiology, Peking University Shenzhen Hospital for her help in image interpretation and language editing.Supported by the China Postdoctoral Science Foundation (grant 2021M703373) and the Shenzhen High-level Hospital Construction Fund.

Congenital absence of splenic artery: a rare cause of upper gastrointestinal bleed

A 21-year-old woman presented as an emergency with upper abdominal discomfort and one episode of haematemesis. Physical examination, blood results and oesophagogastroduodenoscopy (OGD) were unremarkable. The patient collapsed following a large haematemesis 24 hours later and was intubated, ventilated and resuscitated. Repeat OGD demonstrated multiple areas of gastric angiodysplasia with active bleeding. Attempted haemostasis was unsuccessful. computed tomography angiography (CTA) demonstrated an absent splenic artery and multiple abnormal collaterals supplying the stomach, pancreas and spleen originating from a hypertrophied left gastric artery and gastro-epiploic arteries. Angiography demonstrated active bleeding from these abnormal collaterals, which were successfully embolised and haemostasis attained. On follow-up CTA, no evidence of further bleeding or infarction was noted. Congenital absence of the splenic artery is rare, with only four reported cases, and is an extremely rare cause of upper gastrointestinal bleeding.

Implantation of a fenestriated stent-graft in a patient with thoracic aortic aneurysm

The authors present endovascular treatment of a patient with stenosis of the left anterior descending artery, chronic DeBakey type III aortic dissection and thoracic aortic aneurysm. The first stage was percutaneous coronary intervention with stenting of the left anterior descending artery. The second stage implied implantation of a fenestrated stent-graft. The follow-up CT angiography after 6 months revealed occlusion of the left subclavian artery that required stenting. Control CT angiography confirmed adequate stent-graft placement without endoleaks and stenosis of the artery. The choice of these reconstructions and stages of interventions are substantiated. The authors concluded effectiveness of treatment strategy, as well as the need for preventive subclavian artery stenting after implantation of a fenestrated graft.

Natural history and clinical significance of aortic focal intimal flaps.

ObjectiveFocal intimal flaps (FIF) are a variety of defects of the aorta that result in a short, flap-like projection into the lumen, and are often encountered in asymptomatic patients undergoing computed tomography angiography (CTA) surveillance for aortic aneurysm, but the natural history and clinical significance of such lesions has not yet been studied.MethodsWe retrospectively identified patients with an asymptomatic FIF and available imaging follow-up (>1 year). FIF was defined as flap-like intimal irregularity < 4 cm in length involving the thoracic aorta (TA), abdominal aorta (AA) or common iliac arteries (CIA). FIF characteristics included length and circumferential extent as well as the presence and size (width and depth) of associated penetrating aortic ulcers (PAUs). Patient characteristics, adverse events and history of surgical repair was determined by chart review. FIFs and associated PAUs were assessed for progression by comparing baseline and follow-up CTA studies.ResultsA total of 84 FIFs were identified in 77 patients. Average age was 69.2 ± 10.1 years, and 81% were male (81%). Common co-morbidities included: hypertension (78%), hyperlipidemia (68%), smoking (60%), coronary artery disease (41%), aortic aneurysm (34%), type II diabetes mellitus (27%) and prior cardiovascular surgery (25%). FIFs were most commonly located in the abdominal aorta (n = 50, 60%). Nearly all FIFs were associated with local atherosclerotic plaque (93%). Mean follow-up interval was 3.5 ± 2.6 years (259 cumulative follow-up years). Change in FIF length and local aortic diameter over follow-up were 0.7 ± 2.3 mm and 0.8 ± 1.1 mm, respectively. Nearly half (47%) of FIFs were associated with penetrating aortic ulcers (PAU) with baseline depth of 7.3 mm (IQR: 6.1–10.2) and change in depth of 0.5 ± 1.4 mm. Only 12% of FIFs and 0% of associated PAUs demonstrated growth (≥3 mm) at follow-up. No acute pathology developed in the location of FIFs and no aortic interventions were performed specifically to treat FIFs.ConclusionFocal intimal flaps identified in asymptomatic patients with aortic disease were co-localized with atherosclerotic plaque and PAUs, and demonstrated indolent behavior, not leading to significant growth or acute aortic events, supporting a conservative management approach.

Modified Double-Fenestrated Stent Graft for Branched Thoracic Endovascular Aortic Repair of an Irregular Aortic Arch Aneurysm: A Case Report

A 43-year-old male was admitted to General Hospital of Northern Theater Command with exacerbation of chest pain for 10 d. Computed tomographic angiography (CTA) showed an irregular aortic arch aneurysm involving the left subclavian artery (LSA), with penetrating aortic ulcer and intramural hematoma. A modified fenestrated thoracic endovascular aortic repair (TEVAR) technique was performed successfully. Follow-up CTA showed that stent grafts were well-apposed, without endoleaks, migration, or branch artery occlusion, and the hematoma was almost completely absorbed. In this case, precise fenestrations were created by measurements based on three-dimensional CT reconstruction and angiography. Furthermore, the physician chose an LSA approach to catch the guide wire and deployed branched stent grafts, considering the oblique direction of this branch and the small size of the fenestration. This case shows that pre-fenestrated and inner bare stent enhancing TEVAR is a safe and feasible technique for repair of complicated aortic arch aneurysm.