Graft Aneurysm Research Articles

P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain

Abstract A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities. Abstract P1329 Figure 1

Contemporary results with the biosynthetic glutaraldehyde denatured ovine collagen graft (Omniflow II) in femoropopliteal position

ObjectiveThe objective of this study was to analyze the outcome of a contemporary series of femoropopliteal bypass operations with the glutaraldehyde denatured polyester mesh-reinforced ovine collagen prosthesis (OCP; Omniflow II [LeMaitre Vascular, Inc, Burlington, Mass]). The experience of two tertiary centers regarding long-term graft function, secondary reinterventions, and biodegeneration of the OCP prosthesis is presented. MethodsBetween January 2006 and January 2014, a series of 205 consecutive operations with the OCP in the femoropopliteal position (54 above knee and 151 below knee) were performed in 194 patients in 202 limbs for disabling claudication (72), chronic critical ischemia (105), acute ischemia (18), popliteal artery aneurysm (4), degeneration of a venous or prosthetic graft (5), and infection of a synthetic bypass graft (1). Grafts were observed with duplex ultrasound scan supplemented by additional angiography in case of recurrent ischemia with prospective documentation of follow-up data in a computerized vascular database. Retrospective analysis of graft patency, limb salvage, and diagnosis of aneurysmal graft degeneration was performed. ResultsThe 30-day mortality was 3.9%. Early thrombotic bypass occlusion occurred in 8.2% of cases. Four early graft infections could be successfully managed by local treatment with graft preservation. After a mean (median) follow-up of 56 (55) months (range, 1-135 months), primary patency, primary assisted patency, secondary patency, and limb salvage were 71%, 78%, 78%, and 91% for above-knee bypass and 40%, 50%, 63%, and 87% for below-knee bypass at 5 years. Biodegeneration in the form of graft aneurysm or graft stenosis was detected in 26 grafts (12.6%), resulting in secondary open or endovascular procedures in 16 cases. ConclusionsThe OCP provides satisfactory medium- and long-term patency and limb salvage in the femoropopliteal position. Aneurysmal degeneration or graft stenosis may develop over time, demanding lifelong duplex ultrasound surveillance and secondary intervention if needed. Its possible infection-resistant behavior in a contaminated field combined with an acceptable graft patency and limb salvage justifies the use of this graft in the absence of autologous vein.

Result of Cold Stored Venous Graft for Popliteal Aneurysm

Introduction - Popliteal aneurysm are the most common of peripheral aneurysm and accounting for at the least 70% of them. Autogenous great saphenous vein (GSV) remains the optimal conduit for popliteal aneurysm treatment. Therefor GSV is unavailable in up to 20% and sometimes present a great under sizing in comparison with the arteries in those patients. The aim of this study was to evaluate the safety and efficacy of the cold stored vein bypass in this indication. Methods - This is a retrospective analysis of 20 exclusions of popliteal aneurysm with cold stored venous allografts in a single institution between January 2007 to December 2017. Results - The mean age was 80,4 (+/-9,7) years , all patients were males. None had a suitable autogenous conduit for a vein by pass. Seventy percent of patients ( n=14) were treated for acute or critical limb ischemia. The distal anastomosis was performed to an infrapopliteal artery in 13 cases (65%). At 30 days, perioperative death rate was 10% (n = 2) and major adverse limb event was 20% (n=4). the mean follow-up was 34,15(+/-30.5) months ; at 1 year freedom for major adverse limb or perioperative death , survival , amputation free survival, primary and secondary patency rates were, respectively, 75%, 85%, 85%, 55% and 60% . Three patients had a major amputation with a permeable bypass. Acute ischemia was the most significant factor predicting failure of revascularisation. Conclusion - Cold stored allograft may be used for popliteal aneurysm treatment with safety and efficacy, this conduit may be usefully in emergency when its available. Their ease of use and avaibility are a major advantage compared with other biologic alternative sources.

Urgent Late Open Conversions after Endovascular Abdominal Aneurysm Repair: A Multicentre Experience

Introduction - Late open conversions (LOC) after EVAR are associated with a considerably increased perioperative morbidity and mortality as compared to standard EVAR or open repair. Additionally, since the number of patients undergoing EVAR is increasing, the incidence of LOC performed for ruptured aneurysms or infected endografts will likely rise in the future. Here we report a multicentre experience of urgent LOC, with the goal of identifying technical aspects and outcomes that may alter clinical management. Methods - A retrospective analysis of EVAR requiring urgent LOC (>30 days after implantation) from 1996 to 2016 in six Vascular Centres was performed. Specifically, patients who presented with aneurysm rupture or other conditions (such as graft thrombosis, infection or aneurysm growth associated with pain) which required urgent surgery (<24h) were selectively included. Patients' demographics, duration of implant, type of endograft, previous attempts of endovascular correction, reason for LOC, operative technique (clamping site, partial or complete graft removal), 30-day mortality and post-operative complications were obtained for analysis. Long-term survival was also evaluated. Results - During the study period, 140 patients underwent LOC in the participant institutions. Among these, 42 were operated in a urgent setting and were therefore analyzed. Mean age at conversion was 75.8±9 years; 88.1% were male. Grafts were excised after a median of 37 months (range: 1.6-132.1). Multiple types of endografts have been explanted: 30/42 bifurcated endografts, 5/42 tubes, 5/42 aorto-uni-iliac and 2/42 iliac side-branch devices. A suprarenal fixation was present in the 66.7% of the endografts. Eleven patients (26.2%) underwent endovascular reintervention for endoleak repair prior to LOC. Indications for urgent LOC were: aneurysm rupture in 24/42 cases (57.1%), endograft infection in 10/42 (23.8%), endoleaks associated with aneurysm growth and pain in 6/42 (14.3%) and recurrent endograft thrombosis in 2/42 (4.8%). Proximal aortic cross-clamping site was infrarenal in 38.1% of the cases, suprarenal in 19% and supraceliac in 42.9%. Complete removal of the stent-graft was performed in 32 patients (72.6%), partial removal in the remaining 10 cases (with preservation of the proximal portion in 7/10 cases). Reconstructions were performed with dacron grafts in 33/42 cases, cryopreserved arterial allografts in 5/42 and endograft removal associated with prosthetic axillo-bi-femoral bypass in 4/42. Overall 30-day mortality was 21.4%. A suprarenal clamping site was associated with a statistically significant higher mortality rate of 34.6% (p=.007). During follow-up, we experienced 1 aneurysm-related death due to the rupture of an aortic stump. The estimated 1- and 5-year survival rates were 62% and 46%, respectively. Conclusion - Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. The need of a suprarenal clamping is associated with worse outcomes. A close follow-up after EVAR is mandatory, since early decision for elective LOC may improve postoperative outcomes in this subgroup of patients. Further studies are eagerly awaited to better define the timing and the best treatment option for failing EVAR, since a standardization of the surgical technique may improve patients' survival.

Intraoperative adverse events and early outcomes of custom-made fenestrated stent grafts and physician-modified stent grafts for complex aortic aneurysms

ObjectivePhysician-modified fenestrated stent grafts (PMSGs) are a useful option for urgent or semiurgent treatment of complex abdominal aortic aneurysms (CAAAs). The aim of this study was to describe in-hospital outcomes of custom-made fenestrated stent grafts (CMSGs) and PMSGs for the treatment of CAAAs and thoracoabdominal aortic aneurysms (TAAAs). MethodsIn this single-center, retrospective study, all consecutives patients with CAAAs or TAAAs undergoing endovascular repair using Zenith CMSGs (Cook Medical, Bloomington, Ind) or PMSGs between January 2012 and November 2017 were included. End points were intraoperative adverse events, in-hospital mortality, postoperative complications, reinterventions, target vessel patency, and endoleaks. ResultsNinety-seven patients were included (CMSGs, n = 69; PMSGs, n = 28). The PMSG group included more patients assigned to American Society of Anesthesiologists class 4 (n = 14 [50%] vs n = 16 [23%]; P = .006) and more TAAAs (n = 17 [61%] vs n = 10 [15%]; P < .0001). Intraoperative adverse events were recorded in eight (11%) patients in the CMSG group vs six (21%) patients in the PMSG group. No intraoperative death or open conversion occurred. In-hospital mortality rates were of 4% (n = 3) in the CMSG group and 14% in the PMSG group (n = 4). Chronic renal failure was an independent preoperative risk factor of postoperative death or complications (odds ratio, 4.88; 95% confidence interval, 1.65-14.43; P = .004). Rates of postoperative complications were 22% (n = 15) and 25% (n = 7) in the CMSG and PMSG groups. Spinal cord ischemia rates were 4% (n = 3) and 7% (n = 2) in the CMSG and PMSG groups. Reintervention rates were 16% (n = 11) in the CMSG group and 32% (n = 9) in the PMSG group. At discharge, target vessel patency rate in CMSGs was 98% (n = 207/210). All target vessels (n = 98) were patent in the PMSG group. Endoleaks at discharge were observed in 24% of the CMSG group (n = 16) vs 8% of the PMSG group (n = 2). ConclusionsOur study showed clinically relevant differences of several important in-hospital outcomes in the CMSG and PMSG groups. Larger cohorts and longer follow-up are needed to allow direct comparison. PMSGs may offer acceptable in-hospital results in patients requiring urgent interventions when CMSGs are not available or possible.

Management of Hemodialysis Graft/Fistula Aneurysms

Renal failure patients are obligated to have constant life-saving dialysis access. This retrospective review was designed to evaluate graft and fistula aneurysms. Once the dialysis access procedures are performed, care of patients is relegated to the nephrologists and dialysis clinics. This review is designed to validate surgical intervention of dialysis access procedures as a safe and durable procedure and determine if proactive steps could be taken to avoid this complication.

LEA 17. Short-term Outcome of Primary Stent Graft for Peripheral Artery Aneurysm in Patients With Behçet Disease

LEA 17. Short-term Outcome of Primary Stent Graft for Peripheral Artery Aneurysm in Patients With Behçet Disease

Prophylactic prosthetic wrapping for vascular anastomosis in patients with Behçet's aortic aneurysms: an experience from a resource-challenged setting.

The objectives of the current study were to evaluate our technical and clinical results of surgical treatment of infrarenal Behçet's abdominal aortic aneurysm (AAA). In addition to the prosthetic wrapping of the constructed anastomosis as a prophylactic measure for patients with vasculo-Behçet's disease, together with the administration of per- and postoperative immunosuppressive therapy. A single-center retrospective case series included 16 patients with vasculo-Behçet's AAA who treated with open surgical repair, between January 2005 and December 2013. The administration of immunosuppressive treatment was done preoperatively to achieve complete remission of the disease activity before starting the surgical repair. Patients' data were retrieved and analyzed emphasizing the diagnostic procedures, the used surgical techniques, and suitable graft selection, as well as, graft-related complications. The patients were followed up for one month to a maximum of 72 months. The median follow-up period was 24.83±9.4 months. This study included 16 patients, 10 (63%) males, and 6 (37%) females, with the median age of (30.50 years, range: 21-37 years). Moreover, all patients were anticoagulated and discharged on warfarin and aspirin therapy. All surgical procedures were done on an elective basis except for only one emergency laparotomy, which was performed for a life-threatening ruptured aneurysm. The vascular anastomoses were performed using either interposition tube graft (for isolated AAA), or Y-shaped graft (for concomitant aorto-iliac aneurysms). Furthermore, prophylactic prosthetic wrapping was applied encircling the graft to the host artery. In addition, all patients received systemic immunosuppressive therapy post-surgical intervention to prevent anastomotic site complications. Technical success was obtained in 100% of cases. Moreover, the patients were followed up for a period of 12-72 months. Two anastomotic pseudoaneurysms were developed postoperatively. More interesting is that both were infected (one low-virulent that was conservatively treated and one overt that was surgically repaired). Furthermore, there was no aneurysm-related mortality. Prophylactic prosthetic wrapping of vascular anastomosis in patients with Behçet's AAA in resource-challenged settings, where the proximal anastomoses were all end-to-end with wrapping, is an affordable, simple, reliable, and feasible technique, and commonly associated with a lower incidence of anastomotic site false aneurysms and different complications related to the implanted graft, where endovascular procedures might not be applicable. Moreover, the proper preoperative medical preparation for controlling the activity of Behçet's disease, with the administration of immunosuppressive agents, followed by immediate postoperative therapy, may have a good impact on the operative technical success and the prevention of the development of serious postoperative complications; especially anastomotic pseudoaneurysms (which may be complicated by fatal hemorrhage), as well as other graft-related complications.

Saphenous Vein Graft Aneurysm and Coronary Artery Disease: Case Report

Despite a general reduction in the number of myocardial revascularization surgeries in recent decades, more than 150,000 are still performed annually in the United States. Early complications of venous graft use include an occlusion rate of up to 25% in the first year. The aneurysmal dilatation of the great saphenous vein, when used in aorto-coronary venous bridges, is rare and requires important care by the cardiology team.

Total resection of an infected aortic arch aneurysm caused by Mycobacterium avium: a case report

BackgroundInfected aortic arch aneurysms caused by Mycobacterium avium are rare in immunocompetent individuals. Promptly recognizing these aneurysms is important because delays in treatment result in aneurysm rupture and a high fatality rate. Although Salmonella species, Streptococcus species, Staphylococcus aureus, and S. epidermis are commonly found in immunocompetent individuals, to our knowledge, infected aortic arch aneurysms caused by M. avium have not yet been reported.Case presentationWe report the case of a 63-year old immunocompetent man who underwent total arch replacement following infection by the nontuberculous mycobacteria M. avium. The procedure involved total aneurysmal resection and arch replacement with a rifampicin-bonded gelatin-sealed woven Dacron graft. He was discharged without complications and remained asymptomatic after 30 months.ConclusionIn this brief report, we outline and discuss the rare successful case of total arch replacement using total aneurysmal resection and rifampicin-bonded gelatin-sealed woven Dacron graft for an infected aortic arch aneurysm resulting from M. avium in an immunocompetent patient.

Comparison of Patient Radiation Dose and Contrast Use during EVAR in a Dedicated Hybrid Vascular OR and Mobile Imaging

The aim of the study is to determine whether performing endovascular aortic aneurysm repair (EVAR) in a dedicated vascular hybrid operating room (OR) is associated with a decreased patient radiation and contrast dose compared with mobile C-arm imaging in a conventional OR. This is a retrospective study of patients undergoing standard EVAR from 2009-2016. "Standard EVAR" was defined as the elective EVAR performed with bifurcated graft for infrarenal aneurysm with no iliac aneurysms. Patients were divided into 2 groups. Group 1 included EVARs performed in conventional theater with a mobile C-arm (January 2009 to June 2012) and group 2 EVARs performed in the dedicated vascular hybrid OR (July 2012 to December 2016). Data collected included patient demographics, aneurysm diameter, neck length, radiation dose, screening time, and contrast use of each patient. There were 286 patients, 78 and 208 patients in group 1 and 2, respectively. There was no difference in age (77.6years [76.3-78.9] vs. 76.6years [75.9-77.9], P>0.05), body mass index (26.5kg/m2 [25.1-28.0] vs. 27.9kg/m2 [27.1-28.7] P>0.05), and mean aneurysm diameter (6.48cms [6.13-6.82] vs. 6.81cms [6.0-7.7], P>0.05) between groups. Patients in group 2 received approximately half the mean radiation dose (16,807cGycm2 [±11,078] vs. 8,233cGycm2 [±7,471], P<0.001), shorter fluoroscopy time (36.02min [±21.3] vs. 26.96min [±19], P=0.001), and less contrast use (114mls [±44.2] vs. 158mls [±63.9], P<0.001). Performing EVAR in a dedicated vascular Hybrid OR may be associated with a lower patient radiation dose, shorter screening time, and less contrast use than performing EVAR in a conventional OR.

Endovascular Treatment with Stent Graft for Left Subclavian Artery Aneurysm

Endovascular Treatment with Stent Graft for Left Subclavian Artery Aneurysm

UNUSUAL COMPLICATION OF CABG

Saphenous vein graft (SVG) aneurysms occur as a rare complication of coronary artery bypass graft (CABG) with the likelihood of important mortality consequences and mortality. 69 year old male with established history of coronary artery disease(2 vessel bypass) was found to have an incidental large

USING LEFT-HEART OPACIFICATION CONTRAST WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHY TO DIAGNOSE A SAPHENOUS VEIN GRAFT ANEURYSM

Saphenous vein graft (SVG) aneurysms are rare and late complications of coronary artery bypass grafting (CABG). We present a case using transesophageal echocardiogram (TEE) with color Doppler and left-heart opacification contrast agent (Optison) to visualize the flow and lumen of the graft. A 74-

SAPHENOUS VEIN GRAFT ANEURYSM RESULTING IN EXTRINSIC PULMONARY ARTERY COMPRESSION AND RIGHT HEART FAILURE REQUIRING RIGHT VENTRICULAR IMPELLA SUPPORT

Saphenous vein graft aneurysm (SVGA) is uncommon and cardiogenic shock is a rare manifestation of SVGA. A 57 year old male with bypass surgery 8 years ago presented with worsening dyspnea despite diuresis. Transthoracic echocardiogram revealed flow acceleration across the right ventricular outflow

Percutaneous Management of Acquired Right Ventricular Outflow Tract Obstruction due to Giant Coronary Vein Graft Aneurysm

A 56-year-old fireman previously revascularized by coronary artery bypass presented unable to work 9 years following index surgery. Investigations revealed extrinsic compression of the right ventri...

The Current Status and Future Prospects of Stent Grafting for Aortic Aneurysms

The Current Status and Future Prospects of Stent Grafting for Aortic Aneurysms

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent Graft

ObjectiveThe aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft. MethodsA single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter. ResultsA total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted. ConclusionsThis novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms.

Cerebral embolization during endovascular infrarenal, juxtarenal, and suprarenal aortic aneurysm repair, high-risk maneuvers, and associated neurologic outcomes

BackgroundRisk factors for postoperative cognitive decline after noncardiac surgery are multifactorial and poorly understood. Evidence suggests that perioperative microembolic damage to the brain on movement of wires and catheters during endovascular aortic procedures may play an important role. Endovascular aortic aneurysm repair requires invasive manipulation of wires and cannulas within the aorta, but research into cerebral emboli during aortic aneurysm repair and cognitive or neurologic injury is scarce and limited to thoracic aneurysms. This study prospectively studied embolic phenomena detected in the middle cerebral artery during infrarenal, juxtarenal, and thoracic endovascular aortic repair (TEVAR) and investigated links to delirium, stroke, and postoperative cognitive decline. MethodsThere were 60 patients who received continuous left-sided perioperative transcranial Doppler monitoring during endovascular aortic aneurysm repair (bifurcated graft for infrarenal aneurysm, n = 18; endovascular aneurysm sealing graft, n = 16; endovascular aneurysm sealing and renal “chimney” stent, n = 17; and thoracic aneurysm, n = 3). The procedure was time stamped for events such as stiff wire insertion and graft deployment. A battery of cognitive tests designed to test several cognitive domains were performed preoperatively and at 90 days postoperatively. ResultsTEVAR and chimney grafts demonstrated significantly greater numbers of total procedural emboli compared with standard bifurcated grafts (mean emboli, 36.2 and 13.39, respectively; bifurcated graft, 5.81; P < .05). The highest risk maneuvers were guidewire and pigtail catheter insertion. This was the case for all procedures including infrarenal aneurysm repair. A higher perioperative embolic load was associated with medium-term cognitive decline in list recall but not with incidence of delirium or stroke. Risk of cognitive decline did not relate to procedure type. Antiplatelet use failed to demonstrate a protective effect. ConclusionsPatients are at risk of cerebral emboli during several types of endovascular aortic surgery, although TEVAR remains the highest risk procedure. As yet, there are no validated protective measures available to prevent cerebral emboli and their associated risks of clinical and subclinical neurologic injury.

Histological and Mechanical Assessment of Decellularized Porcine Biografts, and Its Biological Evaluation following Aortic Implantation during Mid-Term Follow-Up

Aims: Prosthetic graft infection frequently requires graft replacement. Among other options, a biological graft could serve as an alternative choice. Decellularization reduces tissue immunogenicity. Our aim was to determine an efficient decellularization method and to evaluate the decellularized porcine biografts’ adaptability. Methods: Four different protocols were implemented to decellularize porcine aortic segments (n = 4). Cell removal effectiveness and matrix structure preservation were histologically examined. Mechanical tests were performed. Decellularized porcine grafts were interpositioned in a porcine aorta. After a 6-month period, implanted samples were removed and evaluated using light and electron microscopy. Results: Histological results showed complete removal of cells and preserved connective tissue fiber structure following decellularization, using sodium dodecyl sulfate and sodium azide. Pressure tests demonstrated similar compliance to fresh vessels. In 9 out of 10 cases, pigs survived the follow-up period. Graft rejection, intimal hyperplasia, reocclusion and/or aneurysm formation were not observed. Presence of host cells and neoendothelialization were microscopically confirmed. Conclusions: This decellularization protocol enables a cost-effective preparation of biological grafts featuring reduced immunogenicity. The implanted grafts did not degenerate during the 6-month follow-up period, the lack of graft rejection suggests acceptable immunological tolerance, while recipient cells migrate into, proliferate and differentiate, thus creating the possibility for further use as an optional vascular graft.