Intentional Coverage Research Articles

TEVAR Extension and Intentional Coverage of Left Subclavian Artery for Rescue of Aortic Coarctation

TEVAR Extension and Intentional Coverage of Left Subclavian Artery for Rescue of Aortic Coarctation

Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results.

Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Tips and tricks about surgeon-modified fenestrated stent grafting for celiac truncus.

Currently, thoracic endovascular aortic repair is usually the first-line treatment option for descending aortic pathologies. Supra-aortic or visceral branches sometimes involve assistive thoracic endovascular aortic repair techniques; hybrid procedures or intentional coverage may be performed during the procedure to achieve a sufficient proximal or distal landing zone. Most surgeons may agree on selective coverage of celiac truncus, but revascularization is preferred to reduce the risk of ischemic complications. Herein, we present the first successful surgeonmodified fenestrated stent graft procedure for celiac truncus in a patient with Crawford type V descending aortic aneurysm in Türkiye.

Early and midterm outcomes of thoracic endovascular aortic repair with Lifetech Ankura™ thoracic endograft: A single tertiary center experience

Aim: Thoracic aortic pathologies describe a wide spectrum of potentially life-threatening diseases almost always in a comorbid aged patient cohort. Thoracic endovascular aortic repair (TEVAR) is a less invasive treatment choice, offering reduced mortality and morbidity compared to open surgery. We decided to reveal our experience over safety and efficacy data with Lifetech Ankura™ Thoracic endografts with early and midterm outcomes, retrospectivelytiology. Material and Methods: Between January 2018 and January 2023, for a 5-year period, 203 patients who experienced TEVAR procedure with Lifetech Ankura™ Thoracic endograft were retrospectively evaluated. For the patients who required revascularization of the vessel branches originating from the aortic segments, all types of assistive techniques were performed. Intentional coverage of Left subclavian artery was also performed mostly in urgent patients. Results: 251 endografts were implanted in 203 patients. The most frequent aortic pathologies were the thoracic aortic fusiform aneurysm (56.6%) and type B aortic dissection (25.6%), respectively. Early (30-day/in-hospital) mortality occurred in 9 patients in total (4.4%). Technical success rate was 100%, and there was no conversion to open surgery. No other major adverse event, including cerebral, cardiac, or renal complication requiring dialysis, was observed. The average intensive care unit time was 16.9±11 hours (2-160), length of stay was 5.1±3.2 days. CSF drainage was performed in 51 patients inserted before the procedure prophylactically (25.1%). All patients who survived the operation were followed for 18.6±9.3 months. In the follow up period, four patients needed extension for endoleaks and two additive petticoat procedures were performed. One patient who had TEVAR due to a malperfused type B aortic dissection in the acute phase experienced RTAD 2 weeks after the initial procedure. Conclusion: TEVAR with LifeTech Ankura™ Thoracic Stent Graft system provides a safe, effective, and durable treatment with successful early outcomes and technical success. Wide spectrum in length and non-identical radiopaque proximal markers seem to facilitate some advanced endovascular skills. Long-term durability of the endograft should be tested.

Endovascular therapy in blunt traumatic aortic injuries

Aim: Blunt traumatic thoracic aortic injury (BTTAI) is a catastrophic life-threatening surgical emergency and the second most common cause of death in trauma patients. We retrospectively revealed our results for endovascularly treated BTTAI with early and long-term results. Material and Methods: During January 2009 and January 2022, patients from the emergency department with diagnosed BTTAI were retrospectively revealed. 38 patients all male except two, experienced BTTAI. 5 patients had grade IV, and 21 patients had grade III aortic injuries. Results: Mean age of the patients was 41.7±12.5 years. Technical success was 100%. Early mortality was 7.9%. The mean follow-up period was 49.7±18.3 months. In the follow-up period, there were no TEVAR-related complications. Conclusion: TEVAR is the most suitable treatment for BTTAI in the modern era. Left subclavian artery (LSA) intentional coverage may be performed however surgeon modified fenestrated stent graft (SMFSG) is an effective, economic, fast, and readily available technique for LSA revascularization without additional time.

Radiotherapy Dose Received by the Internal Mammary Chain Lymph Nodes in Cases with Relapse at this Site: A Case-Control Study

<h3>Purpose/Objective(s)</h3> Studies of sentinel lymph node biopsy of internal mammary nodes (IMN) in breast cancer show a 15% positivity rate, if untreated these may serve as a reservoir for regional recurrence (RR) and/or distant metastases. Randomized clinical trials examining the benefit of IMN radiotherapy (RT) haven't demonstrated an overall survival or disease-free survival benefit. However, in one study an ad hoc sub-analysis of patients with inner/central tumors showed a 7-year breast cancer mortality of 10.2% without IMNRT and 4.9% with IMNRT (Kim Y. JAMA Oncol 2022;8(1):96-105). IMNs often get some incidental dose from tangent RT, but this dose isn't known and we hypothesize that it might diminish the apparent benefit of deliberate IMNRT. <h3>Materials/Methods</h3> Patients diagnosed with non-metastatic breast cancer between 2005 and 2014, who relapsed with IMN disease, were identified in a population-based database. They were matched 1:3 by age, diagnosis year, pathological features and treatment received. An IMN CTV was outlined on planning CT scans covering the internal mammary vessels in the first 3 intercostal spaces. The equivalent dose in 2 Gy fractions to the IMNs was calculated to account for different RT prescriptions. A two-sample t-test and Cox regression analysis were used to evaluate the effect of IMN dose as a continuous variable on RR and breast cancer-specific survival (BCSS). <h3>Results</h3> 70 patients with IMN relapse were identified and 210 cases without relapse were matched. Median follow up was 10.8 years and median age 59 years. The matching of relapse and non-relapse cases, respectively, gave well balanced cohorts: most were pT2 (47.1% and 47.6%), pN2 and pN3 comprised 25.7% and 20.5% and tumor location was inner/central in 35.3% and 35.2%. RT was delivered to 43 (61.4%) relapse patients and 130 (61.9%) matched patients with 11 (15.7%) and 52 (24.8%) receiving intentional IMN coverage. The mean IMN dose was 44.9 Gy (94.1%) for intentional coverage and 13.3 Gy (28.3%) for incidental coverage. The average minimum dose to the IMNs was 6.8 Gy (14.4%) for the relapse cases and 14.7 Gy (31.0%) for the matches (p = 0.008). The average mean dose to the IMNs was 18.4 Gy (38.7%) for the relapse cases and 26.9 Gy (56.7%) for the matches (p <0.001). For the whole cohort, Cox regression modelling showed that the mean IMN dose was not significantly associated with RR (HR 0.87, 95% CI 0.74-1.02, p=0.08) or BCSS (HR 0.94, 95% CI 0.82-1.09, p=0.4). Similar results were shown for an N2/N3 subset, RR (HR 0.80, 95% CI 0.62-1.03, p=0.08) and BCSS (HR 0.86, 95% CI 0.70-1.07, p=0.2), and for a subset with inner/central tumors, RR (HR 0.87, 95% CI 0.65-1.17, p=0.4) and BCSS (HR 0.99, 95% CI 0.78-1.25, p=1.0). <h3>Conclusion</h3> Patients with IMN relapse received significantly lower mean IMN doses than those without IMN relapse, however, our sample size did not show a difference in clinical outcomes. The impact on IMN relapse from incidental RT dose should be considered when planning future studies in this field.

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair

ObjectiveThe objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms. MethodsWe analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts. ResultsThere were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD. ConclusionsIntentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.

Chimney Endovascular Repair of Primary Mycotic Aneurysms Involving the Paravisceral Aorta

Primary mycotic aneurysm of the aorta (MAA) is a rare and potentially life-threatening disease. Endovascular aneurysm repair (EVAR) of MAAs involving the paravisceral aorta has been rarely reported. The purpose of this study is to report our experience with chimney EVAR (CHEVAR) in patients with MAAs involving the paravisceral aorta. We performed a retrospective review of all patients treated with EVAR at our institution during the years 2009-2019. Of those, we identified the patients who were treated with CHEVAR for MAAs. Diagnosis of MAAs was based on clinical presentation, abnormal laboratory results, and a computed tomography scan suggestive of a MAA. The data collected included patient demographics, clinical presentation, the antibiotic regimen before and after the surgery, preoperative imaging, surgical details, and perioperative and long-term morbidity and mortality. During the study period, we performed 54 cases of CHEVARs for aortic aneurysms. Of those, 8 (15%) were performed for mycotic aneurysms involving the visceral segment. Six (75%) were men, and the mean age was 68 years (range: 59-76). All patients were symptomatic at the time of diagnosis, presenting with either back or abdominal pain. A total of 16 visceral vessels (celiac trunk, 2; superior mesenteric artery, 7; right renal artery, 4; and left renal artery, 3) were revascularized with parallel grafts (PGs). Six patients required 2 PGs, 1 patient required 3 PGs, and 1 patient had a single PG inserted. Fifteen (94%) PGs were upward-pointing chimney stent grafts, and 1 was placed in a downward-pointing "periscope" configuration. Eight visceral arteries in 6 patients were sacrificed, either by preoperative occlusion or intentional coverage with the endograft during the procedure. The vessels sacrificed included 4 celiac trunks and 4 renal arteries (3 main branches and 1 accessory renal artery). Technical success was achieved in all patients. One patient expired in the perioperative period. One patient developed an infection-related complication. One patient experienced worsening of his renal function and eventually required dialysis. Of the 4 patients who underwent intentional sacrifice of a kidney, all experienced a moderate decrease in renal function from the baseline ( mean preoperative and postoperative serum creatinine 0.76mg/dL and 1.2mg/dL, respectively, increase of 43%). The mean follow-up was 8months (range: 3-28months). During this period, 2 patients expired, 1 from an aneurysm-related cause. No stent occlusion of the PGs occurred and no reintervention due to endoleaks was required. No patient required explanation of the stent grafts or conversion to an open repair. CHEVAR is a feasible and safe treatment modality for MAAs involving the visceral segment. Occasionally, intentional occlusion of the selected visceral arteries may be required to minimize the risk of gutter endoleaks in this urgent setting. Further follow-up is needed to accurately assess the durability of this repair.

Impact of Intentional Coverage of Accessory Renal Arteries on Renal Function Among Patients Treated by Fenestrated-Branched Endografts

The objective of this study was to evaluate the impact of intentional accessory renal artery (ARA) coverage on renal function after fenestrated-branched endovascular aneurysm repair (F-BEVAR) for pararenal aneurysm or thoracoabdominal aortic aneurysm (TAAA). We analyzed the clinical data of 289 patients enrolled in a prospectively nonrandomized study to evaluate outcomes of F-BEVAR between 2013 and 2018. Thirty-two patients with solitary kidneys were excluded. Outcomes were analyzed in patients with intentional ARA coverage and controls who had preservation of all renal arteries, including patients with no ARAs and those who had preservation of ARAs. Acute kidney injury (AKI) was defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease), and renal function deterioration (RFD) was determined by >30% decline in estimated glomerular filtration rate. End points included 30-day mortality and major adverse events, AKI, and freedom from RFD. There were 257 patients (183 male; mean age, 75 ± 8 years) included in the study, 51 (20%) with ARA coverage (Ø = 2.6 ± 0.7 mm) and 206 controls (13 with ARA preservation; Ø = 3.5 ± 0.5 mm). There were no differences in demographics, cardiovascular risk factors, and aneurysm extent. Technical success was achieved in all patients with ARA coverage and in 99% of controls (P = 1.0). Neither of the two technical failures was attributed to the ARA incorporation. There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (35% vs 22%; P = .04) due to higher incidence of AKI (22% vs 10%; P = .03). None of the 13 patients who had ARA preservation developed AKI. Mean follow-up was 18 ± 15 months. At 3 years, there was no significant difference in freedom from RFD for ARA coverage and controls (65% ± 9% vs 73% ± 5%; P = .08), respectively. By multivariate analysis, ARA coverage (odds ratio [OR], 2.4; P = .03) was a predictor for AKI, and renal reintervention for stenosis (OR, 2.7; P = .007), extent II TAAA (OR, 3.3; P = .001), and postprocedure AKI (OR, 5.0; P < .001) were predictors for RFD. Intentional ARA covered during F-BEVAR was associated with twofold higher incidence of AKI, with a nonsignificant trend toward lower freedom from RFD. Factors associated with RFD included renal reinterventions for stenosis, extent II TAAA, and postprocedure AKI. Incorporation of ARAs during F-BEVAR, when technically feasible, may help decrease risk of AKI.

Impact Of Accessory Renal Artery Exclusion During Fenestrated Endovascular Repair For Juxtarenal Aortic Aneurysm

Introduction - The purpose of this study is to determine the clinical impact of accessory renal artery coverage on the renal function after fenestrated endovascular repair (f-EVAR) for juxtarenal aortic aneurysm. Methods - Between January 2005 and December 2016, 77 patients had f-EVAR for juxtarenal aneurysm with the Cook Zenith fenestrated endograft. Retrospectively, pre-operative CT was reviewed for the number and the diameter of accessory renal artery and post-operative CT was analyzed for accessory renal artery thrombosis and renal infarct. Patients with at least one renal accessory artery covered by the endograft were in group Acc and patients without renal accessory artery covered were in group NoAcc. Immediate postoperative renal insufficiency was compared between both groups. During follow-up, significant renal dysfunction was defined by a 25% or more deterioration of estimated glomerular filtration rate asses on two or more successive control. Results - Sixty-one patients (79%) were included in group NoAcc and sixteen patients (21%) were included in group Acc, 21 accessory renal arteries were covered, 8 had a diameter ≥ 3mm and 4 patients had 2 renal accessory arteries. The demographics of the patients were similar, the median pre-operative serum creatinine levels (group NoAcc vs group Acc) were 92 mmol/L (range 49-156 mmol/L) and 99 mmol/L (range 72-163 mmol/L) (p = .692), median aneurysm diameters were 54 mm (range 50-89 mm) and 55.5 mm (range 52 - 63 mm) (p=.138), respectively. Median quantity of contrast medium was 204 ml (range 67 – 540) and 230 ml (range 120 – 450) (p=.526). On post f-EVAR CT, 4 patients had an identified renal infarct, all of them were secondary to intentional coverage of an accessory renal artery, no immediate renal stent thrombosis was observed. New onset of postoperative renal insufficiency was detected in 8% versus 12% (p=.630), mortality was 2% vs 6% (p=.374), in NoAcc and Acc groups, respectively. At 3 years, patient survival was 89% vs 84% (p=.358), freedom from renal function deterioration was 78% vs 74% (p=.702). Conclusion - This retrospective analysis found no immediate postoperative renal failure or late renal function deterioration resulting from accessory renal arteries coverage during f-EVAR for Juxta renal aneurysms.

Left subclavian artery occlusion during endovascular repair of traumatic thoracic aortic injury, cohort study

BackgroundThoracic endovascular aortic repair (TEVAR) is superior to open techniques, as it is a minimally invasive procedure with low morbidity and mortality rates. The aortic isthmus is usually the rupture site in aortic thoracic injuries. Therefore, the distance from the left subclavian artery (LSA) usually allows proximal stent graft fixation. The main challenge is the intentional coverage of the LSA without revascularization, which is necessary to expand the proximal landing zone and to achieve an adequate seal. Acute arm ischemia, claudication, stroke, and/or left subclavian steal syndrome may occur during intentional occlusion of the LSA without revascularization when performing thoracic aorta lesion endovascular repair. The present study was conducted to analyze the safety of coverage of the LSA without revascularization during the endovascular treatment of traumatic thoracic aorta injuries. MethodsA retrospectively collected data set from two trauma centers in Saudi Arabia was reviewed between April 2007 and January 2018 to analyze the safety of LSA coverage during TEVAR performed for traumatic thoracic aorta transection. In this data set, 69 patients presented with descending thoracic aortic injuries. All were treated urgently with TEVAR with intentional LSA occlusion without revascularization during aortic injury endovascular repair. Those who underwent thoracotomy and pre-TEVAR patients who died were excluded from this study. ResultsA total of 69 patients underwent intentional left subclavian artery (LSA) coverage without revascularization during the procedure; the primary technical success reached 94.2% for patients who underwent TEVAR for traumatic aortic transection. The clinical success rate was 98.6%. Only 1 of 69 patients with LSA coverage developed a localized ischemic stroke (1.4%). The 30-day mortality rate was 4.3% due to multiple organ failure. ConclusionRevascularization of LSA is not mandatory with TEVAR for treating traumatic thoracic aortic injury with an inadequate proximal landing zone. Extending the landing zone to zone 2 and coverage of LSA is considered safe and non-time-consuming, especially in urgent situations. It provides better fixation and a good sealing zone.

Social Equity in Public Administration: A Call to Action

Abstract This article presents a “Call to Action” Social Equity Manifesto developed at the Minnowbrook at 50 conference. The Social Equity Manifesto identifies several critical areas of emphasis that can help move toward the achievement of social equity in the research, teaching, and practice of public administration. Regarding research, we discuss the presence of social equity manuscripts in PAR, JPART, and ATP. Interestingly, the coverage of class inequality is low across all three journals. However, a clear research strength is the plurality of methodological and theoretical approaches. In terms of teaching, all of the NASPAA social equity award winning public affairs programs in the United States offer multiple courses that provide intentional coverage of social equity. With respect to practice in the United States, inequities exist across multiple policy areas. Programs and policies ranging from nondiscrimination to diversity management are discussed. In essence, exposing students to social equity perspectives within the context of public administration curricula can make PA graduates more responsive to the needs of all people.

GORE TAG Thoracic Endograft with Active Control System: Landing Accuracy and Wall Apposition in an Initial Clinical Experience

The aim was to describe a single-center experience with the Conformable GORE TAG Thoracic Endoprosthesis (C-TAG) with active control system, specifically designed to evaluate the accuracy of proximal and distal deployment and its capability to adapt to the aortic wall. This is a single-center prospective study including all patients treated with the C-TAG with active control system for thoracic aorta pathologies from September 2017 to May 2018. Proximal and distal accuracy of deployment was measured as the distance between "intended" and "actual landing" zone measured on the digital subtraction angiography images. Mean lack of wall apposition was measured at postoperative computed tomography (CT) angiogram images as the distance between the proximal or distal graft radiopaque ring marker and the point of graft aortic complete apposition, using parasagittal multiplanar reconstructions. Eleven cases were treated: 6 atherosclerotic aneurysms (5 descending and 1 arch), 1 dissecting aneurysm, 2 type B acute dissections, 1 thoracic pseudoaneurysm, and 1 Kommerell diverticulum. The proximal deployment was in landing zone 3 in 6 cases (54%), 2 in 2 cases (18%), 1 in 1 case (9%), and 0 in 2 (18%). The distal landing was in zone 4 in 1 case (9%), zone 5 in 9 cases (81%), and in 1 case (9%), it was in zone 6 with intentional coverage of the celiac trunk. Rapid pacing was used only in 2 cases. Mean accuracy of deployment was 1.8±1.3mm for the proximal and 0.7±1mm for the distal landing zones. Mean lack of wall apposition was 1.1±1.9mm at the proximal landing zone and 0.6±1.8mm at the distal landing zone. The C-TAG with active control system offers accurate deployment both at the proximal and at the distal levels. The conformability, staged deployment, and angulation control allow good adaptation to aortic arch and precise deployment.

Total endovascular treatment for extent type 1 and 5 thoracoabdominal aortic aneurysms

ObjectiveThe study objective was to describe the results of thoracic endovascular aortic repair with the intentional coverage of the celiac artery and distal supramesenteric landing zone for extent type 1 and type 5 thoracoabdominal aortic aneurysms. MethodsInclusion criteria were thoracic endovascular aortic repair with celiac artery coverage to treat elective or urgent extent type 1 and 5 thoracoabdominal aortic aneurysms. Primary end points were in-hospital and follow-up survival, freedom from aortic-related mortality, and freedom from reintervention. ResultsThoracoabdominal disease extent was type 1 in 12 patients (71%) and type 5 in 5 patients (29%). Urgent repair was performed in 4 patients (23.5%). Primary technical success was 100%. Early mortality and visceral ischemia did not occur. Permanent spinal cord ischemia rate was 6% (n = 1). Follow-up ranged from 3 to 120 months (interquartile range, 12-36.5). Survival estimate was 85% ± 9% (95% confidence interval, 67-94) at 1 year and 49% ± 17% (95% confidence interval, 21-78) at 5 years. Cumulative freedom from aortic-related mortality was 94%, and estimated freedom from reintervention at 1 and 5 years was 93% ± 7% (95% confidence interval, 68-99). Neither type 1 endoleaks nor distal stent-graft migration causing superior mesenteric artery occlusion was detected. ConclusionsThoracic endovascular aortic repair with intentional coverage of celiac artery for extent 1 and 5 thoracoabdominal aortic aneurysms had satisfactory results in selected patients at high risk for open repair. Visceral ischemia did not occur, but spinal cord ischemia is still high at 6%. At midterm follow-up, neither endoleak development nor aortic reintervention was related to the inadequate distal landing zone. Follow-up survival is satisfactory and comparable to open repair.

Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm

ObjectiveThe aim of this study was to evaluate the impact of intercostal and lumbar segmental arteries (SAs) detectable on computed tomography angiography (CTA) on the risk of spinal cord ischemia (SCI) in patients undergoing single-step or two-staged branched endovascular aneurysm repair (BEVAR). MethodsA retrospective analysis of patients treated with branched stent grafts for thoracoabdominal aortic aneurysm at a single institution from January 2009 to June 2015 was performed. Data including preoperative comorbidities, perioperative and aneurysm-related parameters, presence and type of endoleak, and rate of severe SCI at discharge or 30 days after the procedure were collected. Preoperative and postoperative contrast-enhanced CTA images were semiquantitatively analyzed by two independent investigators, and the number of visible SAs in the stented aorta before and after BEVAR was evaluated to find a possible correlation with severe SCI. ResultsSeventy-seven patients were treated for thoracoabdominal aortic aneurysm with BEVAR (47 men; mean age, 71.0 years), 40 (51.9%) of them with temporary aneurysm sac perfusion (TASP; open branch/TASP group) and 37 without (single-step group). The groups were comparable regarding parameters related to the patient, aneurysm type, and endovascular procedure. Severe SCI or paraplegia was observed in 10 patients (12.3%), and SCI was lower in the open branch/TASP group (2/40) compared with the single-step group (8/37; P = .032). The number of visible SAs in the intentionally overstented aortic segment was significantly reduced on postoperative CTA (10.0 vs 15.57 SAs; P < .001) in comparison to preoperative CTA imaging, with similar results in the open branch/TASP group (9.48 vs 15.83 SAs) and the single-step group (10.57 vs 15.30 SAs; P < .001 for both groups). Within the open branch/TASP group, more visible SAs were detected during the TASP interval in comparison to postoperative CTA after side branch completion (12.93 vs 9.48 SAs; P < .001). Receiver operating characteristic curve analysis in the single-step group revealed a cutoff point of 15 SAs on preoperative CTA with correlation to severe SCI (P = .006). In the high-risk subgroup of patients with 15 or more overstented SAs during BEVAR, staged open branch/TASP procedures again reduced the risk of SCI in comparison to the single-step patients (1/20 vs 8/22; P = .008). ConclusionsMore spinal arteries are visible during the TASP interval, supporting the open branch and TASP concept with a reduction of severe SCI during BEVAR. An intentional coverage of more than 15 SAs is related to an increased risk of SCI, and the rate of paraplegia was reduced after staged BEVAR with open branch/TASP in these high-risk patients.

Prophylactic accessory renal artery coil embolization for prevention of type II endoleak following endovascular aneurysm repair: a case report

BackgroundPrior reports indicate that intentional coverage of the accessory renal arteries (ARAs) with a diameter larger than 3 mm during endovascular aneurysm repair (EVAR) increases risk of additional treatment for type II endoleak. Here, we report a case of prophylactic coil embolization for a 4 mm ARA originating from an abdominal aortic aneurysm.Case presentationA 76-year-old woman was admitted to our hospital after noticing an abdominal pulsatile mass. Computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 mm. Preoperative CT scan showed a right ARA, 4 mm in diameter, which was considered likely to lead to type II endoleak following EVAR. ARA coil embolization was performed at the time of EVAR. We observed no endoleaks and no infarct of the inferior pole of the right kidney on completion angiography. The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative level (56.7 ml/min). After EVAR, blood pressure was under control, and no additional anti-hypertensive medicines were required. Postoperative enhanced CT image showed that the distal portion of the ARA was well perfused without type II endoleak from ARA.ConclusionsProphylactic coil embolization for a large ARA originating from an abdominal aortic aneurysm appears to be safe and effective in preventing type II endoleak following EVAR.

Mid- and long-term result of celiac artery coverage in TEVAR treatment for aortic dissection

To observe the mid- and long-term result of intentional coverage of celiac artery in thoracic endovascular aortic repair (TEVAR) surgery for aortic dissection. Methods: We retrospectively analyzed 21 cases who received TEVAR with celiac artery coverage during the operation. The existence of collaterals between celiac artery (CA) and superior mesenteric artery (SMA) was confirmed by preoperative CT angiography (CTA) or digital substract angiography (DSA) for each patient. We used the stent-graft precisely above the orifice of SMA. Follow-ups were carried out at 2 weeks, 1 month, 3 months, 6 months, 1 year after the operation, and once per year thereafter. Results: No signs of visceral artery ischemic syptoms such as liver dysfunction, abdominal pain or distention were observed after the operation. There was no signs of spinal cord ischemia (SCI). Seven cases showed type II endoleak upon completion DSA but stopped automatically within 3 months. CTA in follow-ups showed thrombosis formation in false lumen. Conclusion: The intentional coverage of CA during the TEVAR for aortic dissection is safe and effective. The incidence of post-operative SCI or visceral artery ischemia is low. Type II endoleak is a major complication but it can be ceased automatically after medication.

252 * SPINAL CORD INJURY AFTER ENDOVASCULAR TREATMENT FOR THORACO-ABDOMINAL ANEURYSM OR DISSECTION

OBJECTIVES: Postoperative spinal cord injury (SCI) is a devastating complication of surgical repair for thoracoabdominal aortic aneurysm or dissection (TAAD), despite the complex reconstruction of inter-costal or lumbar arteries involved in the surgery. As an alternative technique, endovascular thoracoabdominal aneurysm repair (EVTAR) with visceral artery reconstruction has been accepted as a treatment option for severe comorbid patients of TAAD, because there is a permissible frequency of SCI after EVTAR in spite of no reconstruction of inter-costal or lumbar arteries. We report the results of EVTAR at our hospital with a focus on spinal cord injury. METHODS: We analyzed data from 54 consecutive patients with TAAD (mean age, 74 ± 9.6 years; 42 men) who underwent EVTAR at our hospital between February 2007 and February 2014. Three types of EVTAR technique were used: fenestrated and/or branched stent graft implantation in 39 patients, a hybrid technique (bypass grafts to visceral arteries and straight stent graft implantation) in 10 patients, and intentional coverage of the coeliac artery and straight stent graft implantation in 5 patients. In all patients, mean systemic blood pressure was maintained at ≥80 mmHg. Opioid use was avoided in the perioperative period. RESULTS: According to the Crawford classification, the graft coverage extent was 9% (5/54) in type I, 11% (6/54) in type II, 39% (21/54) in type III, 22%(12/54) in type IV and 19% (10/54) in type V. In most patients (74%, 40/54), cerebrospinal fluid drainage was done intraoperatively and 1 day postoperatively. Hospital mortality was 5.6% (3/54). No patient developed SCI in the perioperative period. However, in the follow-up period 2 patients developed paraplegia as a consequence of shock caused by an aortic event. CONCLUSIONS: With close attention to spinal cord protection, EVTAR may be associated with only a low incidence of SCI in the perioperative period. Therefore, EVTAR is expected to become a promising treatment option for appropriately selected patients with TAAD.

Intentional coverage gaps reduce cost of mating disruption for Phyllocnistis citrella (Lepidoptera: Gracillariidae) in citrus.

The leafminer, Phyllocnistis citrella Stainton (Lepidoptera: Gracillariidae), is a global pest of citrus and contributes to the incidence and severity of citrus bacterial canker. SPLAT CLM (ISCA Technologies, Riverside, CA) is an emulsified wax that provides sustained release of (Z,Z,E)-7,11,13-hexadecatrienal, the major component of P. citrella sex pheromone. Trials in commercial orchards demonstrated that SPLAT CLM applied to plots of varying width resulted in disruption of trap catch of male P. citrella within treated rows and across untreated rows adjacent to treated rows. SPLAT CLM applied to plots of constant width (10 rows) disrupted trap catch across an untreated gap as the square of the width of the gap. Similarly, the ability of the pheromone source in treated rows to disrupt trap catch across untreated gaps of constant size declined as the square of the width of adjacent treated areas. A coverage pattern of 4 rows skipped for every 10 treated rows resulted in a 4% reduction of trap shutdown, and reduced the product and application costs by 29%. Mining incidence by P. citrella in treated rows was reduced by 53% compared with untreated areas. Intentional coverage gaps can significantly reduce the cost of mating disruption. Commercial lures for P. citrella used in this study were highly potent with respect to attracting males. Each lure was approximately 10(3) times as attractive as an individual P. citrella female. Disruption of trap catch using commercial lures may underestimate actual mating disruption achieved in the field.

A case-control study of intentional occlusion of accessory renal arteries during endovascular aortic aneurysm repair

The purpose of this study was to evaluate outcomes of patients treated by intentional coverage of accessory renal artery (ARA) during endovascular abdominal aneurysm repair (EVAR). The clinical data of 119 patients (110 male and nine female; mean age, 75years) from a cohort of 811 patients treated by EVAR from 1998 to 2009 was reviewed. Patients who had intentional coverage of at least one ARA (group A) were compared with two control groups, which included patients with no ARA (group B) and those who had ARA preserved during EVAR (group C). All three groups of patients were matched for age, gender, hypertension, and preoperative estimated glomerular filtration rate (eGFR). Paired pre- and postoperative computed tomography angiography was analyzed for the presence and volume of kidney infarction. End points were changes in eGFR, chronic kidney disease (CKD) stage, blood pressure measurements, presence and volume of kidney infarction, freedom from reintervention, and endoleak. There were 42 patients in group A, 42 in group B, and 35 in group C. Demographics, cardiovascular risk factors, and CKD classification were similar in all three groups. Among patients in group A, 44 ARAs were intentionally covered with ARAs originating from the proximal neck in 22 patients, the aneurysm sac in 20, and the iliac arteries in two. There was one (1%) early death in the entire study. Early morbidity was similar in all three groups, including four patients (9%) in group A, four (9%) in group B, and four (11%) in group C (P= .9). Six (5%) patients had >25% decrease in eGFR, including two who had ARA coverage. None of the patients required dialysis. After a mean follow-up of 37months, there were no differences in late renal function deterioration, changes in eGFR, CKD stage, or blood pressure measurements among the three groups. Three of the 18 patients (17%) with ARA >3mm arising from the aneurysm sac developed a type II endoleak requiring coil embolization. Kidney infarction was noted in 28 patients (67%) in group A. Freedom from reintervention at 2years was similar in groups A (64%), B (80%), and C (96%; P= .09). Intentional ARA occlusion during EVAR was not associated with changes in renal function or blood pressure measurements, even when performed in patients with more advanced renal dysfunction. Type II endoleak may result from persistent outflow into large (>3mm) ARAs that arise from the aneurysm sac.