Iliac Limb Research Articles

Intramural Great Vessel Lymphoma in a Patient with Left Ventricular Assist Device

<h3>Introduction</h3> Intramural Great Vessel lymphoma (IMGVL) is an extremely rare lymphoma proliferating within the lumina of large vessels like Superior vena cava and Aorta. We present a case of an IMGVL presenting in a patient with a Left Ventricular Assist Device (LVAD). <h3>Case Report</h3> A 63-year-old male with ischemic cardiomyopathy and advanced systolic failure supported by an LVAD as a bridge to transplant, presented to the clinic complaining of claudication symptoms. He has known peripheral vascular disease and underwent Aortobifemoral stenting in the past. Coronary Tomography with Angiography (CTA) showed a large intraluminal thrombus above the iliac limbs with severe narrowing of the lumen thought to be flow-limiting (Figure 1). He underwent a mechanical thrombectomy. Intra-operatively, a large mural thrombus with near occlusion of the descending aorta was noted (Figure 2). Pathology revealed diffuse large B-cell lymphoma (DLBCL) with immunohistochemistry positive for BCL2, MYC, Ki-67 and CD20. EBV status was negative. A whole-body Positron Emission Tomography (PET) scan was negative for malignancy elsewhere. He was initiated on chemotherapy. <h3>Summary</h3> Primary IMGVL is a rare subtype of extranodal lymphoma with only 4 cases reported in literature. It is distinct from Intravascular Large B-cell Lymphoma (IVLBCL) which is limited to small vessels. Furthermore, only a single case of aortic IMGVL found on autopsy of an EBV positive patient, has been reported. DLBCL is known to be an aggressive subtype of lymphoma often requiring a combination of chemotherapy and immune therapy. Long term prognosis in our patient awaiting heart transplant is rather uncertain.

Fabric Tears and Type IIIb Endoleaks After Fenestrated-Branched Endovascular Aortic Aneurysm Repair

Type IIIb endoleaks from fabric tears after fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR) are rare. The aim of this study was to evaluate patients who had undergone F-BEVAR with investigational devices between 2015 and 2021 in our institution. A total of 268 patients who had undergone F-BEVAR between 2015 and 2021 were analyzed. All patients with type IIIb endoleaks were included in the data collection. The end points were presentation of type IIIb endoleaks and secondary interventions. Three patients had developed type IIIb endoleaks (2 women and 1 man; mean age, 75 years). The first patient was a 74-year-old woman who had undergone F-BEVAR for a thoracoabdominal aortic aneurysm with a device with two branches and two fenestrations. The 4-year postoperative computed tomography angiography (CTA) demonstrated an endoleak behind the branches, which was confirmed to be a fabric tear using dynamic volumetric CTA (Fig 1, A). The patient underwent successful redo F-BEVAR. The second patient was a 74-year-old woman who had undergone branched repair with a device with four branches and an inverted limb bifurcated device after failed endovascular repair. On the 30-day follow-up CTA, an endoleak of indeterminate origin was detected. Further imaging studies, including CTA, dynamic volumetric CTA, and diagnostic angiography confirmed a tear in the graft posterior to a renal branch (Fig 1, B). A redo branched repair was successfully performed. The last patient was a 78-year-old man who had undergone four-vessel F-BEVAR with an inverted limb custom-made device after failed endovascular repair. On the 30-day follow-up visit, a type IIIb endoleak around the crutch of the inverted limb device was identified by CTA, contrast-enhanced ultrasound, and color-Doppler ultrasound (Fig 2). The defect was excluded with an iliac limb extension. Technical success of the reinterventions was 100%, with no deaths. Sac growth before reintervention was identified in all three patients. The mean follow-up was 30 months. Endoleak development had occurred at an average of 17 months after the index operation. The overall frequency of type IIIb endoleaks in our series was 1.1%. Type IIIb endoleaks after F-BEVAR are rare. The management of these cases is technically challenging. Proper multimodality imaging and redo F-BEVAR are crucial for the proper diagnosis and treatment of this rare complication.Fig 2Endoleak around the crutch of inverted limb custom-made device.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Case report of type IIIa endoleak after endovascular aortic repair

An 81-year-old male presented to our emergency department for abdominal pain and distension. The patient had previously undergone endovascular aortic repair (EVAR) procedure 9 years ago for infrarenal abdominal aortic aneurysm with regular follow-up in postoperative. Three years ago, computed tomography angiography (CT) revealed Type Ib endoleak with right common iliac artery expansion and Type II endoleak from inferior mesenteric artery (IMA). Then, the patient was successfully treated by relining the iliac stent-graft to cover the common iliac expansion and coil embolism to occlude IMA through the Riolan's arch using endovascular technique. Recently, the following up CTA displayed a new Type IIIa endoleak, which the left iliac limb was disconnected with the main body graft. The patient was ultimately successful to treat by implanting stent-grafts using endovascular therapy. This case emphasizes the necessity of follow-up examination for lifelong stent-grafts surveillance. We debated the current late-related complication of EVAR and stent-graft migration treatment choices.

Midterm outcomes of aneurysm repair with the Cook Zenith Alpha abdominal endovascular graft

ObjectiveOutcome reports after endovascular aneurysm repair (EVAR) using the low-profile Zenith Alpha Abdominal Endovascular grafts (Cook Medical, Bjæverskov, Denmark) are sparse. We present results from a single-center cohort treated with the Zenith Alpha, from a period where the graft was the primary EVAR device choice. The aim of the study was to evaluate short- and midterm outcomes of patients treated with the Zenith Alpha. MethodsA retrospective single-center study was performed including all patients treated with the Zenith Alpha graft from October 1, 2015 to September 30, 2018. All patients underwent computed tomography angiography (CTA) imaging preoperatively as well as at 3 and 12 months postoperatively. Hereafter, patients were followed yearly with duplex ultrasound and clinical exams. Additional imaging was performed on indication. All CTAs were analyzed using three-dimensional reconstruction software (Aquarius, TeraRecon, Durham, NC). Data was extracted from electronic charts according to a protocol that remained unchanged until the end of the study (December 31, 2020). The following outcomes were assessed according to Society for Vascular Surgery/International Society of Cardiovascular Surgeons reporting criteria: aortic-related and all-cause mortality, reinterventions, instruction for use (IFU) violations, endoleaks (ELs), and aneurysm shrinkage. ResultsA total of 241 patients were treated with the Zenith Alpha, and 214 (89%) were asymptomatic repairs. Technical success was achieved in 238 patients (99%). One hundred fifty-seven patients (65%) received implantation outside IFU. The median hospital length of stay was 2 days (interquartile range, 2-3 days). The median clinical follow-up was 35.1 months (interquartile range, 28.8-47.5 months). The 4-year Kaplan-Meier estimate of freedom from reintervention was 66% (95% confidence interval, 59%-73%). The main reasons for reinterventions were iliac limb stenosis and occlusion (n = 30; 12%) and type 2 EL (n = 13; 5%). Overall, significantly more patients with grafts implanted outside distal IFU developed type 1B ELs (n = 10/11; P = .009). Aneurysm sac shrinkage was observed in 48 patients (25%) 1 year postoperatively. The Kaplan-Meier estimate of freedom from aortic-related mortality was 99% (95% confidence interval, 98%-100%) 4 years postoperatively. ConclusionsEVAR with the Zenith Alpha shows acceptable freedom from aortic-related mortality up to 4 years postoperatively. The majority of patients were treated outside IFU, and significantly more type 1B ELs appeared in this subgroup of patients. The leading cause for reintervention was impaired limb patency. The root cause for impaired limb patency requires further investigation.

Early and Midterm Results after Endovascular Repair of Non-infected Saccular Lesions of the Infrarenal Aorta

The aim was to report short and midterm outcomes of a cohort of consecutive patients treated by endovascular aortic repair (EVAR) for saccular lesion of the abdominal aorta (sl-AA). This was a multicentre, retrospective, financially unsupported physician initiated, observational cohort study that involved tertiary referral from Italian hospitals. For this study, between January 2010 and December 2020, only those patients treated by EVAR for non-infected sl-AA, namely blister/ulcer like projection and/or penetrating aortic ulcer, were analysed. Primary outcomes of interest were overall survival and freedom from aorta related mortality (ARM). The final cohort included 120 of 3 982 eligible aortic lesions. There were 103 (85.8%) males and 17 (14.2%) females. The median age was 76 years (interquartile range [IQR] 69, 80). Rupture on admission was observed in 10 (8.3%) cases. Early (≤ 30 days) death occurred in two (1.7%) patients. There were five (4.2%) complications requiring surgical re-intervention (iliac limb occlusion n= 4; groin haematoma, n= 1). The median duration of follow up was 20 months (IQR 4, 59.5): the estimated overall survival was 85.5% (standard error [SE] 0.035; 95% confidence interval [CI] 77.3 - 91.1) at 12 months, 78.7% (SE 0.044; 95% CI 69.0 - 86.0) at 36 months, and 74% (SE 0.050; 95% CI 63.2 - 82.5) at 60 months. Only one (0.8%) patient required aortic re-intervention during follow up because of a late endograft infection. The estimated freedom from ARM was 96% (SE 0.050; 95% CI 90.3 - 98.2) at 36 and 60 months. Cox's regression analysis identified that death was associated with age > 70 years (hazard ratio [HR] 1.10; 95% CI 1.04 - 1.17, p= .001), and coronary artery disease (HR 1.14; 95% CI 1.04 - 1.26, p= .006). EVAR for sl-AA proved to be safe and effective. The mortality rate was low for a group of patients known to be at high risk from open repair, and EVAR remained stable with no ARM during midterm follow up, and an acceptably low 0.8% endograft related re-intervention rate.

Reversed and Antegrade Iliac Side Branch Stentgraft as an Alternative or Rescue Maneuver in Complex (Thoraco)Abdominal Endovascular Aortic Repair to Preserve Renal Perfusion

Purpose To describe a technique that can preserve renal perfusion in failed bridging stent implantation of renal arteries or as intentional procedure in emergency cases, when the (thoraco)abdominal aneurysm anatomy does not meet the criteria for instructions for use of an “off-the-shelf” graft. The technique is based on reversed or antegrade integration of a standard iliac side branch graft into the aortic stentgraft system, which allows cannulation of (accessory) renal vessels. Technique A standard iliac side branch prosthesis is deployed and re-sheathed in reversed direction on the back table. The endograft is then implanted in the unibody in analogy to an iliac limb. The iliac side branch is cannulated followed by target vessel cannulation and covered bridging stents are deployed for completion. Furthermore, an iliac side branch prothesis can also be used to preserve relevant accessory renal arteries, when implanted in delivered antegrade loading position. Conclusion The use of a reversed and antegrade iliac side branch technique to revascularize renal vessels is feasible and safe in selected patients. This technique may also allow to extend the range of an “offthe- shelf” (multibranch) stentgraft, when immediate treatment is required.

Outcomes of Gore iliac branch endoprosthesis with internal iliac component versus Gore Viabahn VBX

ObjectiveThe Gore Excluder iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) is the only iliac branch device approved in the United States to preserve blood flow to the external and internal iliac arteries (IIAs). Some surgeons have used the Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associates) in the IIA rather than the self-expanding endograft designed for the IBE, the internal iliac component (IIC). The objective of the present study was to examine the outcomes for patients treated for aortoiliac artery aneurysms using the IBE with either the IIC or VBX stent. MethodsWe performed a retrospective, single-center review of patients treated for aortoiliac artery aneurysms using the Gore IBE device, with either the IIC or VBX stent into the IIA, from February 2016 to March 2021. The patient demographics, procedure details, 30-day morbidity and mortality, and 6-month and 1-year outcomes and mortality were analyzed. The categorical factors are summarized using frequencies and proportions. Continuous measures are summarized as the mean ± standard deviation. A significance level of P = .05 was assumed for all test results. The analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, NC). ResultsA total of 62 patients (64 arteries) had undergone elective aortoiliac artery aneurysm repair with the IBE. The IIC was used exclusively in 35 cases (55%) and the VBX in 29 (45%). The patients who had received the VBX had had a higher American Society of Anesthesiologists class (P = .006). Upper extremity access was used for VBX delivery in 24.1% of the procedures. No return to the operating room was required in either group. No differences were found in technical success (IIC, 97.1%; VBX, 93.1%; P = .59), the presence of endoleak on completion (20.0% vs 6.9%; P = .17), readmission (97.1% vs 93.1%; P = .59), or mortality (1.6% vs 0%; P = .45) at 30 days. No differences were found in the requirement for any IBE reintervention after 30 days. No type Ia, Ib, or III endoleaks had occurred in either group at any follow-up point. No significant difference was found in internal iliac limb primary patency (IIC, 100%; VBX, 96.3%) between groups. A nonstatistically significant trend was found toward fewer trunk–ipsilateral leg type II endoleaks in the VBX group during follow-up. ConclusionsThese data suggest that the VBX is a reasonable substitute for the IIC, with a comparable safety and efficacy profile. Given its inherent conformability, greater range of diameters, and longer working length, the VBX stent offers expanded IIA branch options with the IBE.

Long-term outcomes of endovascular aortic repair with flared iliac limb endografts in patients with abdominal aortic aneurysm and aneurysmal common iliac arteries.

The aim of this study was to evaluate the long-term outcomes of endovascular aneurysm repair with flared iliac limb grafts in patients with abdominal aortic aneurysm (AAA) and aneurysmal common iliac arteries (CIAs). This is a multicenter, retrospective, observational cohort study that involves four tertiary referral hospitals between May 1, 2005, and April 30, 2019. Primary outcomes were freedom from aneurysm-related mortality (ARM), and freedom from iliac-related reintervention. We studied 995 aneurysmal iliac limbs in 795 (85.2%) patients who met the inclusion criteria. Median AAA diameter was 55mm (IQR: 51-60). Early mortality occurred in 3 (0.4%) patients. The median of follow-up time was 52 months (IQR: 26-88). Estimated freedom from ARM was 99±0.002% (95% CI: 99-99.9) at 1 year, and 99±0.004% (95% CI: 97.9-99.6) at 5-years. Chronic obstructive pulmonary disease (HR=6.4, 95% CI: 1.7-24.0, P=0.006), chronic kidney disease (HR=5.5, 95% CI: 1.4-21.9, P=0.016), and the presence of an aneurysmal left CIA (HR=5.3, 95% CI: 1.0.5-27.4, P=0.044) was associated with ARM. There were 42 (7.3%) late iliac-related events (limb occlusion, N.=5; iliac-related endoleaks, N.=37). Estimated freedom from iliac-related reintervention was 98±0.003% (95% CI: 97-99) at 1 year, and 95±0.01% (95% CI: 92.7-96.7) at 5-years, which was associated with an aneurysmal right CIA (HR=2.2, 95% CI: 1.3-3.9; P=0.005), and age ≥78 years (HR=1.9, 95% CI: 1.01-1.3; P=0.039). EVAR flared iliac limb grafts showed a high rate of freedom from ARM and a low reintervention rate. Owing to these results, it can be a durable and stable alternative for patients aged >78 years.

Chimney endovascular aneurysm repair (ChEVAR) for hostile neck complex aneurysm.

Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR. Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery. Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5mm; p = 0.059), iliac diameter (7.3 vs 7.1mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7mm3; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71). Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

Endovascular management of acute postprocedural abdominal aortic – Iliac limb endograft occlusions: A case series

Endovascular management of acute postprocedural abdominal aortic – Iliac limb endograft occlusions: A case series

Clinical Analysis of the Treatment of Iliac Limb Occlusion Following Endovascular Abdominal Aortic Aneurysm Repair

Objective To explore the cause and the treatment strategies of iliac limb occlusion after endovascular abdominal aortic aneurysm repair(EVAR). Methods The patients receiving EVAR in PUMC Hospital from January 2015 to December 2020 were retrospectively analyzed.Sixteen(2.7%)cases of iliac limb occlusion were identified,among which 6,9,and 1 cases underwent surgical bypass,endovascular or hybrid procedure,and conservative treatment,respectively. Results Fifteen cases were successfully treated.During the 10.6-month follow-up,2 cases receiving hybrid treatment underwent femoral-femoral bypass due to re-occlusion of the iliac limb. Conclusions Iliac limb occlusion mostly occurs in the acute phase after EVAR,and endovascular or hybrid treatment can be the first choice for iliac limb occlusion.It is suggested to focus on the risk factors for prevention.

Intraoperative cone beam computed tomography to improve outcomes after infrarenal endovascular aortic repair

ObjectiveWe evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft–related complications and, consequently, reintervention. MethodsAll consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft–related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft–related reinterventions. All-cause and aneurysm-related deaths were also recorded. ResultsOverall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft–related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft–related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft–related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47). ConclusionsTo the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft–related complications associated.

(Endo)Anchors Aweigh

An 83 year old man had undergone endostapled endovascular aneurysm repair of an abdominal aortic aneurysm, with deployment of four Heli-FX EndoAnchors (Medtronic, Minneapolis, MN, USA), six years previously. Under regular surveillance, his most recent abdominal X-ray indicated that one EndoAnchor had dislodged, travelling down the right iliac limb (A). A computed tomography scan revealed it to be in a gluteal artery (B). It is likely that this event resulted from inadequate aortic wall penetration with continuing aortic neck dilatation and the shearing effect of aortic blood flow. The patient was asymptomatic and thus no further treatment was deemed necessary.Image 1

Iliac on a Stick: A Rare but Devastating Complication of Aortic Endografting

An 86 year old man with a previous endovascular aortic repair presented with a type Ia endoleak five years after his intervention. Proximal extension with a custom made branched endograft with four inner branches was planned (E-xtra DESIGN MultiBranch; Jotec, Cryolife, Kennesaw, GA, USA). The 24 F graft was introduced using a through and through wire with significant resistance. (A) Upon retrieval of the introducer, there was complete avulsion of the left external iliac artery. (B) A 12 mm occlusion balloon was rapidly placed in the left iliac limb while the endovascular repair continued. Finally, an iliofemoral bypass was performed.Image 1

Percutaneous EVAR for Ruptured Abdominal Aortic Aneurysms Using the Cordis INCRAFT Endograft

Low profile endovascular aneurysm repair (EVAR) devices such as the Cordis INCRAFT AAA Stent Graft System may expand the category of patients suitable for endovascular repair. We report our experience with the INCRAFT system in treating ruptured abdominal aortic aneurysms (rAAA). We included all patients presenting with rAAA from 2015 to 2019 in our hospital who were treated by percutaneous EVAR with the INCRAFT system.The primary outcome was technical success, referring to adequate stent graft placement. Secondary outcomes included completion of the procedure under local anesthesia and mortality at 30-days, one year and long-term follow-up. Fifteen male patients (mean age: 74 years, SD 6.7) were treated for rAAA with a median aneurysm diameter of 8.25 cm (SD 1.66). The device was successfully delivered and deployed in all subjects. Per-procedurally one type I endoleak required additional stent placement and one patient developed an acute thrombosis of the device main body and iliac limbs requiring thrombectomy. 80.0% of patients were successfully treated under local anesthesia only. The 30 day and one year mortality were 26.6% and 33.3% respectively. Long-term survival was 60.0% at a median follow-up period of 57 months, with two patients requiring late reintervention for an endoleak. The INCRAFT system can be used to percutaneously treat rAAA with a high technical success rate and mortality similar to reported in the literature for other devices. The large majority of procedures can be completed with only local anesthesia.

The Dilemma after Sealing an Endovascular Aortic Aneurysm - Three Ways Out.

Endovascular aneurysm sealing (EVAS) was commercially introduced in 2013. The initial results of EVAS were positive, leading to its widespread use. The mid- and long-term reports showed greater than expected rates of migration, which led to a recall of the device. In the present article, we describe our experience in managing type Ia endoleaks and migration occurring with the Nellix system in three different ways: open repair with Nellix explantation, Nellix-in-Nellix application (NINA technique), and the use of the multibranched Colt device originally dedicated to the treatment of thoracoabdominal aneurysms. From February 2014 to June 2021, we performed 20 procedures for failed EVAS or ChEVAS (migration, type Ia endoleak, secondary aneurysm rupture). All patients treated for EVAS failure were male, aged 65 - 79. Seven Nellix explantations were performed. Three patients were admitted to our hospital with ruptured aneurysms that occurred 3 weeks to 4 years (mean 124 weeks) after EVAS, and another four with type Ia endoleak. In all but one case, removal of the Nellix system was easy. In two patients, tube grafts were implanted and in the remaining five cases, bifurcated grafts were implanted. In four patients, graft legs were anastomosed with the internal iliac arteries. One patient with secondary aneurysm rupture died from multiorgan failure on the 4th postoperative day. In two cases, transient renal failure was noticed in the perioperative period. All patients were admitted to the intensive care unit for 1 to 4 days (mean 2 days). The mean hospital stay was 9 days. All patients stayed in follow-up (3 - 56 months), but no other complications occurred. Eight patients were treated with the NINA technique: five for distal migration of the Nellix and three for failed ChEVAS. Four patients had a NINA procedure performed with three chimneys, three with two and one with one chimney. In one case, two iliac limbs were implanted to avoid kinking of the external iliac arteries. The median hospitalization time after the procedure was 9 days (range 3 - 12). Four patients developed transient acute renal insufficiency in the perioperative period. The follow-up ranged between 4 and 72 months. In one patient, deterioration of preexisting chronic renal insufficiency developed 5 months after the procedure, but dialysis was not required. One patient died from exacerbation of heart failure 7 months after the NINA procedure. The Colt device was implanted in five patients for the treatment of distal migration with type Ia endoleaks. None of the patients developed any signs of spinal cord ischemia. All patients were admitted to the intensive care unit for 1 or 2 days. In two cases, transient acute renal failure was noticed in the perioperative period. The mean hospital stay was 9 days. All patients remained in follow-up (6 - 22 months). In one case, the occlusion of the celiac trunk branch was found in contrast computed tomography 1 month after implantation of the Colt device, but without any symptoms. No other complications occurred. Normal strategies for the management of complications for late failure of EVAR, including stent-graft extensions, are not suitable after EVAS; therefore, alternatives are necessary. Conversion to open repair carries an extensive burden on the patient, so it is not recommended for patients with high surgical risk. The use of a Nellix-in-Nellix application to treat late failure of EVAS is not within the instructions for use but could be an effective strategy for a type Ia endoleak with or without migration. The use of this technique has been extremely limited since the Nellix system was recalled from the market. The use of the Colt multibranched device may be an alternative option, but due to the small number of patients, this method needs further evaluation.

Endovascular Management of an Aortacaval Fistula in Penetrating Trauma

We report the case of a 16-year-old boy who had presented after sustaining a gunshot wound to the abdomen. He was brought on arrival to the operating room for damage control laparotomy. The next morning, he underwent postoperative computed tomography, which demonstrated an aortocaval fistula (ACF) with an aortic pseudoaneurysm measuring 3.2 × 4.3 × 3.7 cm (Fig). The computed tomography scan was also notable for an accessory left renal artery. We took the patient expeditiously to the hybrid operating room for aortic stent-graft repair using a 16 × 45-mm Ovation iliac limb stent-graft (Endologix Inc, Irvine, Calif). The use of an endovascular approach to his traumatic aortic injury allowed for expedient repair without further hemodynamic compromise. We have reported this case because endovascular repair of traumatic ACFs has not been well reported, with only four other cases in the literature from 1992 to 2017. A retrospective medical record review was performed. The patient's parents had provided written informed consent for the medical record review and the report of his case. A literature review was performed using PubMed and the search terms “aorto-caval fistula” and “traumatic aorto-caval fistula.” From our literature review, we found only four other reports of the use of endovascular stent-graft repair for the treatment of traumatic ACFs. Only one other case had used an iliac limb for repair, and in that case, it was to address a complication after an open repair. Thus, we have reported our case as an infrequently reported method to manage a devastating traumatic injury. Although endovascular management has been previously reported in the setting of aortic aneurysm repair with a concomitant ACF, it has not been well described in the management of traumatic ACFs. In our review of the literature, we found only four cases reported from 1992 to 2017. Also, to the best of our knowledge, our patient is the youngest reported. Our patient's young age added a layer of difficulty in sizing the stent-graft. With the novel use of an ovation iliac limb stent-graft, we were able to appropriately size the stent-graft for our young patient and obtain successful repair of his ACF. The present case adds to the literature on the endovascular management of traumatic ACFs.

Application of the AngioJet Ultra Thrombectomy Device for the Percutaneous Mechanical Treatment (PMT) of Iliac Limb Occlusion after Endovascular Aneurysm Repair (EVAR)

To investigate the safety and efficacy of applying the AngioJet Ultra thrombectomy device in treating endograft occlusions in the iliac arteries following endovascular aneurysm repair (EVAR). This study utilized a retrospective analysis of 452 patients with infrarenal abdominal aortic aneurysm (AAA). Twelve of the patients experienced iliac limb occlusion during their follow-up period, and the AngioJet Ultra thrombectomy device was used in tandem with iliac angioplasty to treat these patients. The safety of the device was assessed through the amount of blood drawn, the duration of the procedure, and the occurrence of post-operative complications, while its efficacy was assessed through aortic computed tomography angiography (CTA) imaging and post-operative symptomatology results. All 12 patients were male, and they had a mean age of 62.8 ± 11.8 years. Iliac limb occlusion occurred on the left side of 4 patients and on the right side of 8 patients. The AngioJet Ultra thrombectomy device was used together with iliac angioplasty during surgery, with a success rate of 100%. A bifurcated endograft was successfully implanted in 9 patients following AngioJet Ultra thrombectomy and balloon dilation angioplasty, while a unibody endograft was successfully implanted in 3 patients following AngioJet Ultra thrombectomy and balloon dilation angioplasty. The mean surgery duration was 2.4 hrs, and the patients were hospitalized for an average of 4.5 days. After surgery, the patients' intermittent claudication/buttock claudication gradually vanished. Two patients experienced hemoglobinuria, with one of them developing mild renal dysfunction. Currently, the twelve patients have been followed up for an average of 12 months, and none have experienced any lower extremity ischemia. The use of the AngioJet Ultra thrombectomy device as a supplementary treatment for iliac limb occlusion following abdominal EVAR is safe, effective, and minimally invasive.

Transbrachial and transfemoral approaches combined with visceral protection for the treatment of juxtarenal aortoiliac occlusive disease: Technical issues and clinical outcomes.

To evaluate the safety and efficacy of transbrachial and transfemoral approaches combined with visceral protection for the endovascular treatment of juxtarenal aortoiliac occlusive disease (AIOD) over an average 19-month follow-up period. In this retrospective analysis, all patients with juxtarenal AIOD at a single institution were reviewed from June 2015 to January 2020. Patient characteristics, angiographic results, and follow-up outcomes were retrospectively recorded. The indications for treatment were critical limb threatening ischemia in 12 patients and bilateral claudication in five patients. Percutaneous access via the left brachial artery was first obtained to recanalize the infrarenal occluded lesions. After that, femoral accesses were achieved. A 4-Fr catheter, a 4mm balloon, or a 6-Fr 90-cm-long sheath was used to complete visceral artery protection. A total of 17 juxtarenal AIOD patients (14 males; mean age, 63.4 ± 8.1years) underwent endovascular treatment. The technical success rate was 100%. Complete reconstruction was achieved in 15 (88.2%) patients. The infrarenal aorta was reconstructed with kissing covered stent grafts (n = 7), kissing bare-metal stents (n = 2), covered stent grafts (n = 2), bare-metal stents (n = 1), or the off-label use of iliac limb stent grafts (n = 5). Renal embolization was found in 3 (17.6%) patients during intraoperative angiography. There was 1 (5.9%) case of distal runoff embolization after CDT and 1 (5.9%) case of left iliac artery rupture. One (5.9%) death occurred due to acute myocardial infarction 20 days after the operation. The average follow-up period was 19.3 ± 16.7months (range, 1-54months) in the remaining 16 cases. The renal artery patency rate was 100%. The estimated cumulative primary patency rates were 92.3% at 12months and 59.3% at 36months according to the Kaplan-Meier method. Transbrachial and transfemoral approaches combined with visceral protection offer a safe and effective alternative to open revascularization for the endovascular treatment of juxtarenal AIOD.

The Potential of AFX Iliac Extension in Abdominal Aortic Aneurysms with High Iliac Tortuosity.

Recently, endovascular aortic aneurysm repair (EVAR) is the most common surgery for abdominal aortic aneurysm (AAA). However, iliac limb complications of EVAR often cause problems in patients with high iliac tortuosity. There is no difference of rate of iliac limb complication among EVAR devices, such as Excluder, Endurant, and Zenith in high iliac tortuosity. But there has been not reported about AFX. We studied AFX iliac extension as it is the only stent graft with an endoskeletal framework. This study aimed to evaluate the AFX iliac extension patency in a case in vitro and to use it in seven cases of AAA with high iliac tortuosity. The silicon tube inserted in the AFX iliac extension was flexed at 30, 60, 90, and 120 degrees, and the lumen of the iliac extension was monitored using an underwater camera in the circulatory system. During the experiment, the Iwaki Bellows Pump (IWAKI CO., LTD., Tokyo, Japan) produced a pulsating flow. We used this in seven patients with AAA high iliac tortuosity cases between November 2018 and May 2019. If the silicon tube inserted in the AFX iliac extension was flexed at 60 and 120 degrees, the stent protruded into the lumen. However, the graft was dilated at all degrees. All seven patients with AFX iliac extension had no complications and a patent iliac artery. The AFX iliac extension can reduce iliac limb complications in cases of high iliac tortuosity.