Low-profile Devices Research Articles

Tips About the Cordis INCRAFT Endograft

Recently, the new Cordis INCRAFT abdominal aortic aneurysm (AAA) Stent-Graft System ultra low-profile device has been introduced in the clinical practice of endovascular aortic repair (EVAR) for the treatment of infrarenal AAAs (iAAAs). In our operative unit, it has been used since November 2014. We report our initial experience with the use of this novel device. We further discuss some technical aspects about the use of the endograft. Data of all patients undergoing elective EVAR in our Division of Vascular Surgery using the Cordis INCRAFT AAA Stent-Graft System from November 2014 till now were retrospectively collected in a database and outcomes reviewed. Follow-up data were analyzed to evaluate primary success, survival, complications, and device-related events. Statistical analysis was performed using JMP(®) 5.1.2 (SAS Institute Inc., Cary, NC). Continuous variables are reported as mean ± standard deviation, and categorical variables are presented as n (%). From November 2014 till now in our institution, a total of 10 patients (7 male; mean age, 76.3 years old; range, 65-87 years) underwent elective exclusion of an iAAA with a challenge iliac anatomy (minimum access vessel, 6.7 mm) using Cordis INCRAFT endoprosthesis. There were 9 AAA and a left common iliac artery aneurysm 50 mm in diameter, involving the internal iliac artery. Primary success was achieved in 90% as 1 patient presented an immediate type Ia endoleak which was resolved by the placement of a proximal aortic cuff. There was 1 intraoperative acute leg ischemia requiring a left popliteal Fogarty thrombectomy. Three patients (30%) presented a postimplantation syndrome. No other complications occurred neither during in-hospital stay (mean, 3.4 days; range, 2-4 days) nor during follow-up. In our experience, the Cordis INCRAFT AAA System was a safe and effective device. Our reflections about technical aspects of the use of this device will probably find their answer when further studies will report shared experiences and results about using this type of endograft.

Perioperative Outcomes in Patients Requiring Direct Iliac Access With or Without Conduit for Endovascular Abdominal Aortic Aneurysm Repair

Objectives: Direct iliac access with or without conduit can be used in endovascular abdominal aortic aneurysm repair (EVAR) when anatomy is unfavorable for femoral access. The impact of this technical approach has not been adequately studied. We evaluated the perioperative outcomes in patients who required direct iliac access or conduit for EVAR and compared it with those who did not. Methods: Patients undergoing EVAR with and without iliac access/conduits were identified in the 2005 to 2012 National Surgical Quality Improvement Program data sets. Perioperative morbidity and mortality were assessed by 5:1 propensity matched (on age, gender, functional status, comorbidities, urgency, anesthesia use and relative operative duration) groups and multivariable analyses. Results: There were 15,082 patients undergoing infrarenal EVAR with 147 (1%) with (41) and without (107) conduit placement. Patients treated with iliac conduit/access were more likely to be female (25.9% vs 17.8%, P 1⁄4 .02) and have peripheral arterial disease (12.9% vs 5.5%, P < .01). There was no difference in age (74.5 6 8.4 conduit vs 74.9 6 8). On multivariate analysis the iliac conduits/access group had higher mortality (odds ratio [OR] 2.7; 95% confidence interval [CI], 1.4-5.4; P # .01), major complications, including cardiac arrest/ myocardial infarction (OR, 2.9; 95% CI, 1.3-6.3; P # .01) and pulmonary complications (OR, 2.1; 95% CI, 1.2-3.9; P 1⁄4 .01), and postoperative length of stay (means ratio, 1.3; 95% CI, 1.1-1.4; P # .01). No difference was noted for renal and wound complications. Matched analysis based on demographics, comorbidities, and operative time showed that iliac conduit/access patients had higher perioperative mortality (6.8% vs 2.3%, P < .01), cardiac (4.8% vs 1%, P < .01), pulmonary (8.8% vs 3.4%), and bleeding complications (10.2% vs 4.6%, P 1⁄4 .02). Conclusions: Our results demonstrate that the use of direct iliac access or conduits in EVAR is associated with increased mortality and major morbidity. In situations where anatomy mandates the use iliac access, surgeons should consider other options, including using lower profile devices or open aneurysm repair.

Carotid Occlusion Leads to Higher Annual Healthcare Costs than Carotid Stenosis

Objectives: Direct iliac access with or without conduit can be used in endovascular abdominal aortic aneurysm repair (EVAR) when anatomy is unfavorable for femoral access. The impact of this technical approach has not been adequately studied. We evaluated the perioperative outcomes in patients who required direct iliac access or conduit for EVAR and compared it with those who did not. Methods: Patients undergoing EVAR with and without iliac access/conduits were identified in the 2005 to 2012 National Surgical Quality Improvement Program data sets. Perioperative morbidity and mortality were assessed by 5:1 propensity matched (on age, gender, functional status, comorbidities, urgency, anesthesia use and relative operative duration) groups and multivariable analyses. Results: There were 15,082 patients undergoing infrarenal EVAR with 147 (1%) with (41) and without (107) conduit placement. Patients treated with iliac conduit/access were more likely to be female (25.9% vs 17.8%, P 1⁄4 .02) and have peripheral arterial disease (12.9% vs 5.5%, P < .01). There was no difference in age (74.5 6 8.4 conduit vs 74.9 6 8). On multivariate analysis the iliac conduits/access group had higher mortality (odds ratio [OR] 2.7; 95% confidence interval [CI], 1.4-5.4; P # .01), major complications, including cardiac arrest/ myocardial infarction (OR, 2.9; 95% CI, 1.3-6.3; P # .01) and pulmonary complications (OR, 2.1; 95% CI, 1.2-3.9; P 1⁄4 .01), and postoperative length of stay (means ratio, 1.3; 95% CI, 1.1-1.4; P # .01). No difference was noted for renal and wound complications. Matched analysis based on demographics, comorbidities, and operative time showed that iliac conduit/access patients had higher perioperative mortality (6.8% vs 2.3%, P < .01), cardiac (4.8% vs 1%, P < .01), pulmonary (8.8% vs 3.4%), and bleeding complications (10.2% vs 4.6%, P 1⁄4 .02). Conclusions: Our results demonstrate that the use of direct iliac access or conduits in EVAR is associated with increased mortality and major morbidity. In situations where anatomy mandates the use iliac access, surgeons should consider other options, including using lower profile devices or open aneurysm repair.

Hemodynamic support with percutaneous devices in patients with heart failure.

The use of surgically implanted durable mechanical circulatory support (MCS) in high-risk patients with heart failure is declining and short-term, nondurable MCS device use is growing. Percutaneously delivered MCS options for advanced heart failure include the intra-aortic balloon pump, Impella axial flow catheter, TandemHeart centrifugal pump, and venoarterial extracorporeal membrane oxygenation. Nondurable MCS devices have unique implantation characteristics and hemodynamic effects. Algorithms and guidelines for optimal nondurable MCS device selection do not exist. Emerging technologies and applications will address the need for improved left ventricular unloading using lower-profile devices, longer-term ambulatory support, and the potential for myocardial recovery.

Improved Business Driveway Channelizing Treatments in Work Zones

This paper documents the efforts and results of a human factors study of alternative business driveway channelizing treatments in work zones. The purpose of the research was to determine the effectiveness of alternative business driveway channelizing treatments over standard drum treatments. The alternative treatments included combinations of 18-in. low-profile longitudinal channelizing devices and 42-inch tall cones (i.e., grabber cones). Using paid participants who drove an instrumented vehicle, the researchers used driver eye-tracking equipment to compare differences in drivers' visual attention while approaching business driveways with the various channelization treatments deployed. Other measures of effectiveness considered were detection distance, percentage of missed driveways, driver perception and recall of treatments, and driver preferences. Although differences in the measures of effectiveness were less pronounced during the day, the alternative channelizing treatments generally performed better than the standard drum treatment at night.

Fontan fenestration closure with Amplatzer Duct Occluder II device.

To evaluate Fontan fenestration closure using the Amplatzer Duct Occluder II device (ADO2). Fontan fenestration closure is a well established catheter intervention. A range of occlusion devices developed for other interventions have been utilized. Most of these devices, and especially the most commonly used Amplatzer Septal Occluder, are relatively bulky. The ADO2 is a low profile, flexible, and inexpensive device which seems well suited to the Fontan fenestration. This study details retrospective review of patients undergoing Fontan fenestration closure with an ADO2 device. Outcome measures included procedural success, pre- and post-procedural differences in oxygen saturation and mean pulmonary artery pressure and complications. Thirteen patients were eligible for inclusion during the 34 month study period. All procedures were technically successful. There was a significant increase in oxygen saturations (Mean=+12%, P<0.01) after fenestration closure but no significant change in mean pulmonary artery pressure (Mean=+0.5 mm Hg, P=0.08). There were no procedural complications. Fontan fenestration closure with the ADO2 device is a simple, short, and cost-effective procedure. The ADO2 characteristics recommend it to occlusion of varying sizes and morphologies of Fontan fenestration.

Miniaturization of Microstrip Antenna by CRLH-TL Technique

In this paper, an electrically small microstrip antenna has been presented by employing composite right/left-handed transmission line. The prototype antenna was designed by using Interdigital capacitor and spiral inductor. It is fabricated and printed on FR-4 low cost substrate with dielectric constant 4.4 and thickness 1.6 mm, Dimensions of antenna are $$15.5\,\hbox {mm}\times 12\,\hbox {mm}$$15.5mm×12mm. So, the size reduces about 69 % compared with conventional microstrip patch antennas at 1.8 GHz and more than 80 % for 1.1 GHz. Final model of the antenna has triple bands at 1,060, 1,800 and 2,500 MHz. Which two frequencies (1.8 and 2.5 GHz) are suitable for GMS and WLAN applications. The presented antenna is simulated in HFSS, Finally the simulated and experimental results are compared. The antenna has low gain so, it is suitable only for indoor and medical care applications which we need low power and low profile devices. The maximum gain of antenna at 2.4 GHz is around $$-$$-8 dBi that it is drawback of antenna, but it will sufficient for indoor and implant application such as health care. The antenna has an Omni directional pattern and a linear polarization.

Single‐Center Experience With 1‐Step Low‐Profile Percutaneous Endoscopic Gastrostomy in Children

The 1-step low-profile percutaneous endoscopic gastrostomy (1-step PEG) uses a single procedure that allows immediate use of a low-profile device. The aim of the present study was to provide our experience with this device and to analyze complications and outcomes after the initial placement. We performed a retrospective chart review of pediatric patients with 1-step PEG placement done by our pediatric gastroenterologists between 2006 and June 2011. Patients were studied for a minimum period of 6 months. A total of 121 patients were included in our study, with 23% infants. The most common indication for 1-step PEG placement was swallowing dysfunction in children with neurological impairment (49%). Postplacement complications included granulation tissue (52%), cellulitis (23%), leakage (21%), vomiting (17%), tissue breakdown (8%), failed placement (6%), embedded bolster (5%), perforation (0.8%), and bowel obstruction (0.8%). One-step PEG was maintained in 46 patients (38%). In the remaining 75 patients (62%), PEGs were changed to a balloon device in 66 patients and were completely removed in 9 patients. The most common indications for change were damaged PEG (19/75) and issues with size (11/75). The time to change ranged from <1 month to >4 years (14 ± 1.3 months). Sixty-eight percent of 1-step PEG changes/removal was performed with an obturator under brief inhalated anesthesia. The 1-step PEG has complication rates and outcomes comparable with standard PEGs.

Multishorting Pins PIFA Design for Multiband Communications

A novel PIFA model with multiple shorting pins is proposed for multiband, low profile wireless applications, which has the ability to work in adverse conditions. The proposed model has a planar radiating sheet, a ground plane, and sides covered with PEC boundaries. The substrate inside theantenna boxis tempered in order to improve the bandwidth and gain. The enhancements applied to the proposed PIFA model show improved characteristics for this PIFA model and make it a versatile candidate for handheld, low profile, and multiband resonant communication devices. Pertinent communication devices are those that work with GSM 850/900, UMTS 850/900/1700/1900/2100, LTE 2300/2500, and ISM 2400 bands used for Bluetooth and WLAN.

Treatment of abdominal aortic aneurysm with a new type of polymer-filled low profile device

Purpose of the studyTo evaluate the mid-term safety and effectiveness of a novel stent graft for treatment of abdominal aortic aneurysm (AAA). MethodsThirty-three patients with AAA (20 males and 13 females; mean age: 71.3 y) were treated with the Ovation™ Abdominal Stent Graft System (TriVascular, Inc., Santa Rosa, CA, USA). Indications for endovascular aneurysm repair: AAA ⩾5.5 cm, neck ⩾7 mm, angulation ⩾60° and with an inner wall diameter of no less than 16 mm and no greater than 30 mm; the presence of neck calcification and thrombosis is not much of a problem in this device because aortic seal is achieved with 2 polymer-filled sealing rings and the fixation by means of a suprarenal stent with 8 pairs of anchors. Patients were followed through discharge and returned for follow-up visits. The follow-up protocol included a CT-A exam at 1 and 12 months after the intervention; the mid-term follow up was performed at 3 and 6 months with contrast-enhanced ultrasound (CEUS). Mean follow-up duration was 18.6 months (range: 3–25 months). Main findingsTechnical success was 100%. Mean implantation procedure time was 31.1 minutes, and median hospital stay was 4.6 days. None of the patients required conversion to open surgery, and no aneurysm enlargement, rupture, fracture, or migration were observed. No type I, III or IV endoleaks were observed. Hospitalization death rate was 0%. Death rate at 30 days was 0%. No major complications were observed. ConclusionsThe first results from this 3-center study with the Ovation stent graft are promising with high technical success and excellent safety and effectiveness.

Treatment of congenital non‐ductal shunt lesions with the amplatzer duct occluder II

To evaluate feasibility of use of ADO II in non-ductal positions, incidence of complete heart block (CHB), advantages and disadvantages. Out of 79 defects closed with ADO II, 61 had perimembranous, 12 apical/mid-muscular ventricular septal defects (VSD), 4 Gerbode defects, one each of coronary arterio-venous fistula and aorto-right ventricular tunnel. Age ranged from 8 months to 21 years (mean 8.9 ± 4.02 years, median 9 years). The mean fluoroscopy time was 5.2 ± 1.1 min with range 4.2-9.2 min. Complete closure was achieved in all. Three cases developed transient junctional bradycardia, treated with steroids. One patient who developed CHB (1.3%) needed temporary pacing. ADO II is a low profile device. It can be easily delivered through a 5F guiding catheter and needs very short fluoroscopic time as arteriovenous loop is not needed. The cost is 1/3 of regular ventricular septal occluders. The CHB that is a major challenge for closure of VSDs is less common with soft, specially designed ADO II, which does not compress the conducting system. Use of the ADO II in non-ductal positions can be achieved with high success and low complication rates, especially CHB; its use is also associated with significantly reduced procedure time and device cost. Device size availability restricts use of the ADO II to defects up to 6 mm in diameter. © 2013 Wiley Periodicals, Inc.

Biomechanics of an integrated interbody device versus ACDF anterior locking plate in a single-level cervical spine fusion construct

Background contextNo profile, integrated interbody cages are designed to act as implants for cervical spine fusion, which obviates the need for additional internal fixation, combining the functionality of an interbody device and the stabilizing benefits of an anterior cervical plate. Biomechanical data are needed to determine if integrated interbody constructs afford similar stability to anterior plating in single-level cervical spine fusion constructs. PurposeThe purpose of this study was to biomechanically quantify the acute stabilizing effect conferred by a single low-profile device design with three integrated screws (“anchored cage”), and compare the range of motion reductions to those conferred by a standard four-hole rigid anterior plate following instrumentation at the C5–C6 level. We hypothesized that the anchored cage would confer comparable postoperative segmental rigidity to the cage and anterior plate construct. Study designBiomechanical laboratory study of human cadaveric spines. MethodsSeven human cadaveric cervical spines (C3–C7) were biomechanically evaluated using a nondestructive, nonconstraining, pure-moment loading protocol with loads applied in flexion, extension, lateral bending (right+left), and axial rotation (left+right) for the intact and instrumented conditions. Range of motion (ROM) at the instrumented level was the primary biomechanical outcome. Spines were loaded quasi-statically up to 1.5 N-m in 0.5 N-m increments and ROM at the C5–C6 index level was recorded. Each specimen was tested in the following conditions:1. Intact2. Discectomy+anchored cage (STA)3. Anchored cage (screws removed)+anterior locking plate (ALP)4. Anchored cage only, without screws or plates (CO) ResultsROM at the C5–C6 level was not statistically different in any motion plane between the STA and ALP treatment conditions (p>.407). STA demonstrated significant reductions in flexion/extension, lateral bending, and axial rotation ROM when compared with the CO condition (p<.022). ConclusionsIn this in vitro biomechanical study, the anchored cage with three integrated screws afforded biomechanical stability comparable to that of the standard interbody cage+anterior plate cervical spine fusion approach. Due to its low profile design, this anchored cage device may avoid morbidities associated with standard anterior plating, such as dysphagia.

The use of human cadavers and virtual reality simulation in endovascular training: A questionnaire of patient and professional opinion

s / International Journal of Surgery 11 (2013) 686e745 737 ABSTRACTS 0544: THE USE OF HUMAN CADAVERS AND VIRTUAL REALITY SIMULATION IN ENDOVASCULAR TRAINING: A QUESTIONNAIRE OF PATIENT AND PROFESSIONAL OPINION Stuart Maitland , Craig Nesbitt , Roger Searle , Gerard Stansby . 1 Freeman Hospital, NUT, Newcastle Upon Tyne, UK; Newcastle University, NUT, Newcastle Upon Tyne, UK. Aim: To establish the opinion of patients and clinicians on the use of virtual reality simulators (VRS) and human cadavers (HC) for endovascular training. Methods: Experts in interventional cardiology, radiology and vascular surgery rated their agreement to statements regarding endovascular simulation (HC and VRS) through an online questionnaire. Patients' views on endovascular simulation training were also sought. Results: 100 professionals completed questionnaires. < 25% were aware of endovascular HC training, none had first hand experience, five (5.6%) disagreed with its use. All candidates were aware of VRS, 80.9% had first hand experience. Many expressed interest in HC stating concerns regarding the realism of VRS. 107 patients (50 non-vascular, 57 vascular*) responded. All patients agreed with HC training. Patients declared greater confidence in doctors trained on HC versus VRS (p1⁄40.000). Conclusion: These are the first recorded opinions of professionals and patients regarding endovascular simulation training. Endovascular professionals question the suitability, appropriateness and feasibility of endovascular HC training, yet few are wholly satisfied with VRS. Patients appreciate the need for adjunctive simulation training, but harbor mistrust in computer technology. Enhanced patient education is required to maintain confidence and trust. * non-vascular patients have no history of vascular disease 0547: TYPE II ENDOLEAKS: LOW RISK OF RUPTURE AND HIGH RISK OF TREATMENT FAILURE David Sidloff, Philip Stather, Eddie Choke, Matt Bown, Robert Sayers. University of Leicester, Leicester, UK. Aim: To assess the risk of rupture and determine the benefits of intervention for the treatment of type II endoleaks after endovascular abdominal aortic aneurysm repair. Method: A systematic review was performed according to PRISMA guidelines. Outcome data including incidence, spontaneous resolution, sac expansion, interventions, success, and complications were recorded. Results: 32 non-randomised retrospective studies were included, totalling 21,728 patients, 1515 type II endoleaks and 392 interventions. This analysis reveals type II endoleaks have an incidence of 10% with 32.3% spontaneously resolving. 14 ruptures were reported (incidence 0.9%), from which 43% did not have concurrent sac expansion. Analysing interventions, 28% were unsuccessful. Translumbar embolization had a higher success rate compared to transarterial embolization (TL81% v TA62.5% P1⁄40.024) with fewer persistent endoleaks (TA36% Vs TL19% P1⁄40.0396). Transarterial embolizations had a higher associated number of complications (TA10% Vs TL0% P1⁄40.0426). Conclusion: This review has revealed that rupture secondary to an isolated type II endoleak is rare (<1%) and that over a third occur in the absence of sac expansion. Nearly a third of all interventions for the treatment of type II endoleaks fail, however a translumbar intervention has a higher success rate with a lower risk of complications. 0555: AN EVALUATION OF OUR EARLY EXPERIENCE OF PERCUTANEOUS EVAR USING THE PROSTAR XL DEVICE David Ormesher, Jenna Godfrey, Andrew Schiro, David Murray, Ferdinand Serracino-Inglott. Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Manchester, UK. Introduction: There is a trend towards less invasive procedures in all areas of surgery. It is suggested that the use of percutaneous closure devices for endovascular procedures that require larger seat sizes may have a positive impact on patient outcomes. Methods: A retrospective review of our endovascular logbook was undertaken from which all patients who received a Prostar XL device were identified and data collected. Results: 96 Prostar XL devices were deployed. Mean skin to common femoral artery (CFA) depth was 31.3mm, all but 5 patients had some degree of CFA calcification. The median length of stay was 4 days. 4 patients went on to develop groin haematomas postoperatively; all of these were treated conservatively. The Prostar XL cut through the CFA in one patient and this required repair. 80% of complications were in the first 15 cases. Conclusion: No long-term complications in our series can be attributed to the percutaneous approach for EVAR. We believe that US-guided puncture can overcome problems associated with CFA calcification and that the depth from skin to CFA has no impact on morbidity. The use of low profile devices ( 16F) and operator experience have a positive impact on outcomes with the Prostar XL device. 0564: TEMPORAL ARTERY BIOPSY e TOO MANY TOO LATE? Ruth Graham, Lourdusamy Selvam. West Wales General Hospital,

Exclusion of an Internal Iliac Artery Aneurysm Using Stacked Aorto-uni-iliac Converters over a Femoro-femoral Pullthrough Wire

An endovascular solution for treating internal iliac artery aneurysms (IIAAs) with tortuous iliac anatomy and intraprocedural complications is presented. An 85-year-old male presented with a 7-cm left IIAA causing hydronephrosis. Following inability to deploy a standard aorto-uni-iliac converter and subsequent iliac dissection, two low-profile aorto-uni-iliac converters were deployed from the external to common iliac artery over a femoro-femoral pullthrough wire, achieving a stacked configuration and successful aneurysm exclusion. Iliac artery tortuosity may preclude successful iliac coverage and predispose to dissection. A pullthrough wire allows arterial straightening; use of flexible low profile devices facilitates procedural success.

A simplified fixation of the new thin cochlear implant receiver-stimulators in children: Long term results with the “back-pocket” technique

ObjectiveTo describe a simple technique for pediatric cochlear implant receiver-stimulators (R/S) fixation and long term results with it. MethodsClinical sample include thirty-two children with severe-to-profound or profound hearing loss candidate for cochlear implantation. Low-profile devices were used (Med El Concerto© and Nucleus CI512©). The R/S was housed into a tight subperiosteal pocket carefully dissected behind the mastoidectomy. The pocket was closed with a single periosteal to bone suture around the posterior edge of mastoidectomy. No skull drilling was required for housing the device. ResultsNo intraoperative complications have been observed. 20% of operating time was saved. No migration of R/S over time was apparent at follow up. ConclusionsThe back-pocket technique seems effective in retaining the CI package and in optimizing surgical time and safety in pediatric cochlear implantation. It seems particularly suitable with new generation low profile CI devices.

Assessing the anatomic applicability of the multibranched endovascular repair of thoracoabdominal aortic aneurysm technique

Multibranched endovascular aneurysm repair (MBEVAR) has the potential to lower the morbidity and mortality rates of thoracoabdominal aneurysm repair, but the applicability of the technique is unknown. Our aim was to estimate the prevalence of anatomic suitability for MBEVAR. Retrospective review of patients referred for a prospective trial of MBEVAR between November 2005 and July 2012. Anatomic suitability was assessed on three-dimensional computed tomography scan reconstructions according to the current criteria for a custom-made stent graft or a fixed, off-the-shelf stent graft in both standard (22F) and low-profile (18F) delivery systems. A total of 250 contrast-enhanced computed tomography scans were reviewed, 49 of which were excluded due to inadequate aneurysm size. Of 201 candidates for repair, 149 (74%) were men and 86 (43%) had Crawford classification type IV/paravisceral aneurysms; 109 (58%) were anatomically suitable for a single-stage repair with a custom-made, low-profile stent graft. Another 58 (29%) could have been made suitable for MBEVAR with an adjunct procedure, including angiogram with visceral or renal artery stenting (n= 23), carotid-subclavian bypass (n= 5), or iliac bypass for device insertion (n= 17), or to preserve internal iliac artery flow because of an iliac aneurysm (n= 9), or dissection (n= 8). There was no association between suitability and gender, aneurysm diameter, or type. However, women were significantly more likely to need a conduit or low-profile device (P= .003). Patients with type B aortic dissections were significantly less likely to have anatomy suitable for repair (P= .035) and more likely to require a multistage repair. Thirty-four patients would have been unsuitable for repair because of renal artery anatomy (n= 14), visceral artery anatomy (n= 4), lack of a proximal landing zone due to an arch aneurysm (n= 7), or inadequate access arteries (n= 9). The low-profile device increased the number of patients who would have been suitable for a single-stage repair by 16. The off-the-shelf graft has the advantage of a faster assessment-to-treatment time, but only 64 patients would have been suitable for a single-stage repair and another 30 could have been made suitable with an adjunct procedure. Most patients would have been suitable or could have been made suitable for a thoracoabdominal stent graft using current anatomic criteria. The applicability of MBEVAR will continue to change as the experience with the technique grows and devices evolve, as evidenced by the potential reduction in iliac bypasses after the introduction of a low-profile device and the ability to treat symptomatic or urgent patients with the off-the-shelf device.

Immediate evidence of the benefit of distal protection in vein graft intervention

Percutaneous intervention carries a higher risk of distal embolization and fatal outcome in saphenous vein grafts (SVG) than in native coronary vessels. Most of these adverse clinical events, predominantly myocardial infarction and reduced antegrade flow (no reflow phenomenon), are due to distal embolization of atherothrombotic debris and distal microvascular occlusion. For this reason, in current interventional practice, the use of distal protection devices is mandatory. Our case report provides direct and dramatic evidence of the usefulness of a low-profile filter device in the setting of massively thrombotic SVG.

Demonstration of enhanced broadband unidirectional electromagnetic radiation enabled by a subwavelength profile leaky anisotropic zero-index metamaterial coating

In this paper, we report a technique for creating broadband unidirectional electromagnetic radiation with a grounded nonmagnetic anisotropic zero-index metamaterial coating. We demonstrate that the leaky modes supported by the finite sized coating structure can be exploited to create a unidirectional radiation device with a subwavelength thickness of only 0.12\ensuremath{\lambda}. Numerical simulations and experimental characterization of the metamaterial-enabled radiator confirm the physical mechanisms governing its performance, showing a stable directive beam with an over fivefold radiation power enhancement at broadside. Due to the resulting nonmagnetic material properties, this approach provides a new path to highly efficient, small footprint, low profile, and broadband directive radiation devices for microwave and potentially even optical wavelength applications.

Conversion of the Gastric LAP-BAND Port to Low-Profile Access: An Adjunctive Technique during Abdominoplasty in the Bariatric Patient

As body-contouring procedures are aimed at producing thebestpossibleaestheticandfunctionaloutcomes,thereis no reason for the plastic surgeon to limit the results of the procedure by leaving a residual deformity and possible source of pain on the abdominal wall fascia. We report a simple technique of port exchange for a low-profile device with preservation of band volume in combination with the routinepanniculectomyorabdominoplastyinthemassiveweightloss patient.

Catheterization of the Lumbar Artery via the Superior Mesenteric Artery During Type 2 Endoleak Treatment.

A 72-year-old man with an infrarenal aortic aneurysm was successfully treated with a Talent stent graft 39 months ago. The aneurysm sac size increased approximately 2 mm on a computed tomography (CT) angiogram recently, and type 2 endoleak was diagnosed. A CT angiogram demonstrated lumbar artery and inferior mesenteric artery (IMA) involvement. We planned to treat the type 2 endoleak via the superior mesenteric artery (SMA) to the IMA approach. A 6-F Ansel sheath and a 5-F Berenstein catheter were placed at the origin of the SMA. Then, an Echelon microcatheter was advanced at the origin of the 3rd lumbar artery via the arc of Riolan, IMA, and aneurysm sac, and the type 2 endoleak was identified. Embolization of the lumbar artery origin and the aneurysm sac was performed with eight Concerto detachable coils with sizes between 3–6 mm. Then, embolization of the aneurysm sac and at the origin of the IMA was performed with four Cosmos detachable coils with sizes between 6–10 mm. Follow-up SMA angiograms after the completion of the procedure and after a month demonstrated successful embolization without any complications. We are presenting this case because type 2 endoleak treatments with IMA embolization via the SMA are rare but not new, and it is not a simple procedure [1]. In particular, passing the Riolan arc with the microcatheter is hard because of its angled nature. Recently available low-profile devices are allowing further progress with lumbar artery access and successful embolization.