Stent Graft Infection Research Articles

Endovascular treatment of ureteroarterial fistula using a covered stent, evaluated by intravascular ultrasound: a case report

BackgroundUreteroarterial fistula is a rare life-threatening complication of indwelling ureteral stents. The mechanism has not yet been fully evaluated using intravascular imaging.Case presentationAn-84-year-old female was referred to our unit because of large volume pulsatile bleeding from the left ureter during routine stent exchange in the urology department. The hematuria was initially managed by rapidly exchanging for a new stent; however, the patient went into hypovolemic shock due to acute blood loss. The patient underwent implantation of the bilateral ureteral stents due to urinary retention caused by retroperitoneal fibrosis 2 years ago. To prevent ureteral infection, occlusion of the stents and stone formation, the stents were exchanged every 6 months. Computed tomography revealed contact between the left ureter and the common iliac artery. Therefore, ureteroarterial fistula was suspected and endovascular therapy was performed. Although angiography did not show definite blood flow into the ureter, a soft guidewire was advanced from the subintima of the external iliac artery to the left ureter. The diagnosis of ureteroarterial fistula was confirmed. Intravascular ultrasound identified the stent in the ureter and its connection to the subintima of the external iliac artery. The ureter did not contact directly to the inner lumen of the iliac arteries according to the ultrasound findings; therefore, we considered that the risk of stent-graft infection might not be high. After coil embolization of the ipsilateral internal iliac artery, a covered stent was implanted in the external iliac artery to seal the subintimal entry. The patient had no further episodes of any gross hematuria on dual anti-platelet therapy, when the ureteral stent was exchanged three time during 1 year after the endovascular therapy.ConclusionsWe demonstrated a case of ureteroarterial fistula, in which intravascular ultrasound allowed to visualize the communication between the ureter and the subintimal lumen in the external iliac artery.

The GORE TAG conformable thoracic stent graft with the new ACTIVE CONTROL deployment system

ObjectiveThe aim of this study was to describe single-center intraoperative details and early outcome of the new GORE TAG conformable stent graft with ACTIVE CONTROL (C-TAG ACTIVE CONTROL; W. L. Gore & Associates, Flagstaff, Ariz). MethodsBetween September 2017 and June 2018, a consecutive 30 patients underwent thoracic endovascular aortic repair with C-TAG ACTIVE CONTROL. This new system provides an intermediate deployment step at 50% and optional angulation control of the proximal part of the stent graft. Indications for thoracic endovascular aortic repair varied widely, including chronic postdissection and degenerative aneurysms, complicated acute dissections, and intramural hematomas, among others, in an elective (63.3%), urgent (13.3%), or emergent (23.3%) setting. The proximal landing zone (LZ) was LZ 2 in 23.3%, LZ 3 in 43.3%, and LZ 4 in 33.3%. Data were collected retrospectively and analyzed for technical and clinical success. ResultsIn all patients, the stent graft was successfully introduced and deployed at the intended position, with complete exclusion of aortic disease and without intraoperative mortality (primary technical success, 100%). One emergent patient died at 2 days of ongoing septic shock (clinical success at 30 days, 96.6%). Median follow-up was 107 days (range, 33-271 days); late mortality was 3.4% (one patient died of stent graft infection at 40 days). Freedom from type I and type III endoleak at the early follow-up was 100%. No patients required other surgical or endovascular procedures for the primary treated aortic disease. ConclusionsOur reported initial experience in 30 patients with the C-TAG ACTIVE CONTROL showed excellent early results, with high deployment accuracy and conformability. The additional features of staged deployment and angulation control may be of great help in challenging aortic arch diseases, allowing precise positioning and preventing bird-beak effect.

Late open conversion after thoracic endovascular aortic repair

ObjectiveWith the increasing use of endovascular aortic repair, open repair after aortic stent grafting is of increasing interest. We retrospectively reviewed cases of late open conversion for complications after thoracic endovascular aortic repair (TEVAR). MethodsTEVAR due to aortic aneurysm and dissection was performed in 538 patients between 1994 and 2017. A total of 33 patients, including 4 patients referred from other centers, required late conversion to open repair; 14 (42.4%) patients required circulatory arrest for aortic arch involvement. The mean interval to open conversion after TEVAR was 33.9 months (range, 1-123 months). Demographics of the patients, reason for conversion, surgical techniques, surgical outcomes, and survival were reviewed. ResultsIndications for late open conversion included type I endoleak (14), stent graft-induced new entry intimal tear (6), retrograde type A dissection (4), stent migration and fracture (3), stent graft infection (3), sac enlargement without endoleak (1), aortopulmonary fistula (1), and stent implantation failure (1). Hospital mortality was 9.1% (3/33). All occurred in the patients with arch involvement. The patients had several major morbidities; six patients (18.1%) had pulmonary complications, two (6.1%) suffered a stroke, one (3.0%) experienced paraplegia, and one (3.0%) had renal failure. Overall survival rates at 1 year, 5 years, and 10 years were 84.5% ± 6.4%, 74.5% ± 8.7%, and 67.1% ± 10.1%, respectively. The arch involvement group (48.1% ± 15.7%) had significantly worse 10-year survival than the no arch involvement group (86.1% ± 9.4%; P = .048). ConclusionsDespite the complexity of TEVAR, open conversion due to late complications can be performed successfully with acceptable results. However, cases involving the aortic arch have relatively worse outcomes. Lifelong surveillance is mandatory, and early decision-making about open conversion before the development of a complicated aortic arch lesion is suggested to achieve better outcomes.

Stent graft as a bridge to allograft to treat a septic thoracic aortic pseudoaneurysm after spinal fusion

A 29-year-old woman was admitted to our institution for severe septic syndrome. Her medical history included a T6-T8 posterior spinal fusion 7 years earlier for tuberculous spondylodiscitis. Contrast-enhanced computed tomography (CT) revealed a 70- × 58-mm pseudoaneurysm of the descending thoracic aorta extending from T6 to T8 level, surrounding the left T6 screw (A/Cover). A T6-T8 spondylodiscitis and bilateral paraspinal collections were also observed. Blood and T7 bone biopsy specimens grew Escherichia coli. To prevent an imminent pseudoaneurysm rupture and to allow cryopreserved aortic allograft (CAA) delivery, the patient first underwent conformable TAG 26- × 26- × 100-mm (W. L. Gore & Associates, Flagstaff, Ariz) thoracic aortic stent graft implantation under general anesthesia through a small left femoral incision. The procedure was uncomplicated. Exclusion of the pseudoaneurysm was assessed by final angiography and postoperative CT scan (B). Five days later, T2-T10 spinal fusion was conducted after infected hardware removal through a posterior approach along with drainage of the paraspinal collections. Aortic replacement using a 10-cm-long thoracic CAA was performed through a left posterolateral thoracotomy in the same operative course. A partial cardiopulmonary bypass at normothermia was established through a left femoral incision. An arterial perfusion cannula was positioned in the abdominal aorta and a venous cannula to the right atrium. During aortic replacement, a fistula was observed at the bottom of the aortic pseudoaneurysm communicating with the former location of the left T6 screw. The final step consisted of implantation in the vertebral defect of a titanium mesh cage containing autologous bone graft. Transdiaphragmatic epiploplasty was performed to isolate the CAA (C). The culture specimens of the removed orthopedic hardware and stent graft grew E. coli. Antibiotic treatment initially consisted of intravenous administration of cefotaxime and gentamycin switched postoperatively to intravenous administration of ceftriaxone for 12 weeks. Follow-up included visits at 1 month and 6 months postoperatively, and follow-up should be continued twice a year. Six months postoperatively, the patient was asymptomatic. The CT scan showed satisfactory coverage of the allograft by the omentum and the absence of allograft pseudoaneurysm or residual collection (D). Vascular injury after spinal instrumentation is a rare but life-threatening condition. Treatment of such injuries is not standardized. Previous studies have reported the use of stent grafts with good outcomes.1Zerati A.E. Leiderman D.B. Teixeira W.G. Narazaki D.K. Cristante A.F. Wolosker N. et al.Endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal: case report and literature review.Ann Vasc Surg. 2017; 39: 285.e17-285.e21Abstract Full Text Full Text PDF Scopus (5) Google Scholar In our case, we believed that simple endovascular treatment was not possible because of the high risk of stent graft infection. We believed that CAA represented the best option in a septic field, as is the case with aortic graft infections.2Corvera J.S. Blitzer D. Copeland H. Murphy D. Hess Jr., P.J. Pillai S.T. et al.Repair of thoracic and thoracoabdominal mycotic aneurysms and infected aortic grafts using allograft.Ann Thorac Surg. 2018; 106: 1129-1135Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Potential postoperative CAA pseudoaneurysm formation requires close and lifelong follow-up. The patient consented to the use of related medical history and images for educational purposes.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

ObjectiveThe objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. MethodsThere were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. ResultsMean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. ConclusionsTotal endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.

Thoracoabdominal aortic aneurysm surgery: a different perspective on stent grafts failure

Endovascular repair of the descending and thoracoabdominal aortic aneurysm (TAAA), which is generally considered to be associated with lower morbidity and mortality than conventional open repair, appeals to both patients and clinicians. However, commonly this concept has been under continual evaluation and issues with long-term durability, disease progression and repair failure, including endoleak with all its types and not to forget aneurysm expansion, catastrophe of aortic rupture, and stent-graft infection are handing like ringing bells after every endovascular approach. In this literature review, we will review the current evidence of graft failure and delineate the actual and proposed theorems regarding the cause of failure of endovascular graft failure.

Surgical Treatment of Stent Graft Infection after TEVAR for Blunt Aortic Injury

Surgical Treatment of Stent Graft Infection after TEVAR for Blunt Aortic Injury

Risk factors and treatment outcomes for stent graft infection after endovascular aortic aneurysm repair

ObjectiveWe aimed to retrospectively analyze incidence, risk factors, and management of postoperative stent graft (SG) infection after endovascular aneurysm repair (EVAR). MethodsWe evaluated patients who underwent EVAR for infrarenal abdominal aortic aneurysm at our institution between July 2006 and December 2014. The primary end point was SG infection. We compared patients' demographics between the infection (group I) and noninfection (group NI) groups and reviewed management and outcomes in group I. A risk factor for SG infection was assessed by multivariable logistic regression. Patients without aortoenteric fistula (AEF) were treated with conservative therapy for SG infection. ResultsA total of 1202 patients underwent EVAR for infrarenal abdominal aortic aneurysm. During a mean follow-up of 43.9 ± 30.4 months, SG infection occurred in 15 cases (incidence, 3.5/1000 person-years). The median time between initial EVAR and detection of infection was 30 months (range, 14 days-86 months). Freedom from SG infection at 1 year, 3 years, and 5 years was 99.5%, 99.2%, and 98.2%, respectively. There were no differences in age, sex, comorbidities, and SG type between the groups. Coil embolization of the hypogastric artery was more frequent in group I (60% vs 31%). During follow-up before infection, type II endoleak (47% vs 24%), sac enlargement (40% vs 16%), and multiple reinterventions (13% vs 2%) were significantly higher in group I; however, after multivariate analysis, only coil embolization of the hypogastric artery (odds ratio, 3.22; 95% confidence interval, 1.12-9.24; P = .029) remained a significant predictor. Among the 15 patients, four had AEF and six bacteriologic species were detected in five patients (33%). Twelve patients (80%) were treated with conservative therapy; three underwent surgical therapy (two patients with SG resection, omentum patching, and extra-anatomic bypass with fistula closure or partial duodenectomy and one patient with graft preservation, irrigation, omentum patching, and aneurysmorrhaphy). In-hospital mortality occurred in three cases; two cases were due to sepsis after conservative therapy, and one case was due to aortic stump rupture after surgical therapy. Excluding in-hospital mortality cases, during a median follow-up of 31 (range, 2-76) months, five patients were lost because of cancer or senility. There was no aneurysm-related death or recurrence of SG infection. ConclusionsConcomitant coil embolization was a risk factor for SG infection. For patients with AEF, surgical therapy remains the first-line treatment of SG infection after EVAR; however, conservative therapy is a viable option for SG infection in patients without AEF, particularly considering patients' comorbidities and limited life expectancy.

In Situ Graft Replacement for a Ruptured Abdominal Aortic Aneurysm Infected with Listeria monocytogenes after Endovascular Aneurysm Repair.

Listeria monocytogenes infection and rupture of the aneurysm sac, after endovascular aneurysm repair (EVAR), are both rare. We report the case of an 82-year-old man who presented with a ruptured aneurysm by infection with L. monocytogenes after EVAR. We successfully treated him by in situ reconstruction with a bifurcated expanded polytetrafluoroethylene (ePTFE) graft, with partial removal of the infected stent graft. At 30 months from the reoperation, the patient was in good health at home, with no symptoms of infection, and the gallium-67-citrate single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images confirmed no fluid accumulation.

A case study of nursing cooperation in axillobifemoral bypass surgery treating stent-graft infection after endovascular repair of abdominal aortic aneurysm

Objective To summarize the nursing cooperation of axillobifemoral bypass surgery treating stent graft infection after endovascular aortic repair of abdominal aortic aneurysm. Methods To review a case of stent graft infection after endovascular aortic repair of abdominal aortic aneurysm and summarize the nursing cooperation of this patient retrospectively. Results After the medical care tacit cooperation and the infection protection, the procedure was successfully completed. The artificial blood vessels of the patient were unobstructed after the operation, and the pulse of both dorsalis pedis arteries was strong. Conclusions Axillobifemoral bypass surgery poses the characteristicsof long duration and complex. Designation of appropriate nursing measures, such as multi-incision management, thrombosis preventing and prevention of ischemia based on potential complications, are essentials of successful operation. Key words: Axillary-bilateral femoral arterial bypass; Endo-graft infection; Nursing strategy; Operation cooperation

Spondylodiscitis following endovascular abdominal aortic aneurysm repair: imaging perspectives from a single centre\u2019s experience

ObjectiveVery few reports have previously described spondylodiscitis as a potential complication of endovascular aortic aneurysm repair (EVAR). We present to our knowledge the first case series of spondylodiscitis following EVAR based on our institution’s experience over an 11-year period. Particular attention is paid to the key imaging features and challenges encountered when performing spinal imaging in this complex patient group.Materials and MethodsOf 1,847 patients who underwent EVAR at our institution between January 2006 and January 2017, a total of 9 patients were identified with imaging features of spondylodiscitis (0.5%). All cross-sectional studies before and after EVAR were assessed by a Consultant Musculoskeletal Radiologist and a Musculoskeletal Radiology Fellow to evaluate for features of spondylodiscitis.ResultsAll 9 patients had single-level spondylodiscitis involving lumbosacral levels adjacent to the aortic/iliac stent graft. Eight out of nine patients had an extensive anterior paravertebral phlegmon/abscess that was contiguous with the infected stent graft and native aneurysm sac ± anterior vertebral body erosion. Epidural disease was present in only 3 out of 9 patients and was a minor feature. MRI was non-diagnostic in 3 out of 9 patients owing to susceptibility artefact. 18F-FDG PET/CT accurately depicted the spinal level involved and adjacent paravertebral disease in patients with non-diagnostic MRI and was adopted as the follow-up modality in 3 out of 5 surviving patients.ConclusionSpondylodiscitis is a rare complication post-EVAR. Imaging features of disproportionate anterior paravertebral disease and anterior vertebral body bony involvement suggest direct spread of infection posteriorly to the adjacent vertebral column. Use of MRI versus 18F-FDG PET/CT as the optimal imaging modality should be directed by the type of stent graft deployed.

Late open conversion after endovascular abdominal aortic repair: a 20-year experience

With the increasing use of endovascular aortic repair, secondary interventions after aortic stent grafting remain a concern. We retrospectively reviewed open conversion cases with complications following endovascular abdominal aortic repair (EVAR). EVAR due to infra-renal abdominal aortic aneurysm (AAA) was performed in 566 patients between January 1994 and May 2015. A retrospective review of EVAR requiring late open conversion (>1 month after implant) was conducted. Patient demographics, reasons for conversion, operative techniques, operative outcomes, and late survival were reviewed. Thirty of these patients (5.3%) required late conversion to open repair. The median interval to open conversion after EVAR was 48.6 months (range: 2-190 months). Indications of open conversion included type I endoleak (N.=10), stent fracture (N.=4), type V endoleak (N.=4), stent graft infection (N.=4), stent limb obstruction (N.=3), stent migration (N.=3), and type II endoleak (N.=2). Twenty-four operations were elective, and six operations (20%) were emergent due to aneurysm rupture. Compete endograft removal was performed in 14 patients (46.6%) and 16 endografts were partially left in situ. The hospital mortality rate was 10% (3/30) overall, 33.3% in the emergency group and 0% the elective group (P=0.03). Overall survival rate at a mean follow-up of 35 months was 80.7%, with a tendency towards lower survival rate after emergency compared with elective open conversion (89.3% vs. 44.4%; P=0.06). Open conversion due to late complications after EVAR seems to be a lifesaving procedure with acceptable initial and mid-term outcomes. Elective conversion has better outcomes compared to those in an emergency setting. Therefore, lifelong surveillance is warranted, and an early decision for open conversion, if indicated, is necessary to achieve the best outcomes.

Thoracoabdominal aortic replacement replacement with a bovine pericardial tube graft for aorto-bronchial fistulation 10 years after TEVAR

Aortobronchial fistula after thoracic endovascular aortic repair is usually a late complication. It is associated with high mortality and its surgical management is technically challenging. This tutorial illustrates the steps involved in removing an infected stent graft andreplacing it with a bovine pericardial tube graft.

Management of Endograft Infection After EVAR and TEVAR - a Case Series and Literature Review

Introduction Endograft infection after EVAR (Endovascular aortic repair) or TEVAR (Thoracic endovascular aortic repair) is a rare but severe complication with high mortality. As the number of patients with endovascular aneurysm repair has increased over the last decade, the number of patients with endograft infection might also have increased. However, no guideline defines the treatment of endograft infection. Diagnosis is difficult and depends on clinical symptoms, radiological imaging and blood cultures. Surgery with graft excision, debridement and revascularisation should be proposed. Several techniques and graft materials are used. Additionally long term antibiotic therapy under close control of inflammation markers is always required. Methods We conducted a retrospective analysis of all patients treated for infected aortic endografts in our hospital between January 2008 and May 2017. Study endpoints were freedom from reinfection, survival and primary patency. An extensive electronic health database search was performed to identify articles reporting endograft infection after EVAR and TEVAR. Results We detected aortic endograft infection in three patients (100% male, median age 77 years). In all cases, infrarenal endovascular aortic aneurysm repair had been performed. The infected stent grafts were removed and anatomical revascularisation performed. One homograft and two xenografts were used as graft material. No patient was treated conservatively. A causative organism was found in 2 of the 3 cases. The patients received antibiotics for 12 weeks. Thirty day mortality was 0%. During follow-up, one patient died from bowel perforation after 2 months and another from lung cancer after 92 months. There were no reinfections. Primary patency of the reconstructions was 100%. Publications report high mortality after conservative therapy of endograft infection. There is evidence for lower mortality in patients who underwent surgery. Conclusions Removal of the infected graft, anatomical revascularisation and antibiotic therapy are important for long term survival after aortic endograft infection. Conservative therapy is only warranted in patients unsuitable for surgical treatment.

Pathology of graft and stent-graft infections: Lessons learned from examination of explant materials

Due to the aging population, the number of patients treated with aortic grafts or endografts continues to increase. Although infection after these procedures is uncommon, aortic graft infection is a life-threatening condition, and refinement of management guidelines based on implant pathophysiology is appropriate. In the early 1990s, our European collaborative retrieval program, European Group for Research on Prostheses Applied for Vascular Surgery (GEPROVAS) was commissioned to analyze the degenerative phenomenon occurring on explanted grafts or endografts. In this review, our observations from the examination of explanted aortic grafts and endografts found that both fabric and structural degradation is present and is greater in the setting of inflammation produced by infection.

Management of the infected aortic endograft

Although the incidence of abdominal and thoracic aortic endograft infection is infrequent, ranging between 0.2% and 5%, stent-graft infection carries significant morbidity and mortality and exemplifies a formidable therapeutic challenge. The treatment goal is to eradicate the infectious process by endograft explantation, regional tissue debridement, and arterial reconstruction by either an extra-anatomic or in situ grafting procedure using autologous vein, cryopreserved allograft, or antibiotic-soaked prosthetic grafts. Successful treatment should maintain normal arterial perfusion to the visceral arteries and lower extremities. Important treatment adjuncts included antibiotic therapy based on cultures, specific bacterial isolates, and coverage of the repair or aortic stump using an omental wrap. Nonoperative treatment in patients with severe comorbidities that preclude endograft explantation may be appropriate in the setting of low-grade biofilm infection. Percutaneous drainage of the perigraft abscess followed by continuous antibacterial irrigation of the cavity can be utilized, but is associated with a high clinical failure rate.

Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience

To report experience with open conversion (OC) after previous failed EVAR and to compare outcomes of patients undergoing elective OC with those operated on in an urgent setting. Patients undergoing OC after EVAR between August 2008 and September 2016 were included in this retrospective and observational single institution study. Indications, demographic, anatomical, intra-operative and post-operative data were collected prospectively. Primary endpoints were 30 day and in hospital mortality. Secondary endpoints included moderate to severe complications, secondary interventions, length of intensive care unit, and hospital stay. OC was performed in 31 patients over the study period: 19 elective and 12 emergency OC, including six ruptures. Median time from index EVAR to delayed OC was 35 months (0-228 months). The most common indications for OC were endoleaks (n=24, 77%), followed by stent graft infection (n=3, 10%), thrombosis (n=3, 10%) and kinking (n=1, 3%). Eight of the removed stent grafts were Endurant, two were Talent, five Excluder, six Nellix, two AFX, five Zenith, one Vanguard, one Anaconda, and one Seta. Overall in hospital mortality was 10%, with significantly increased in hospital mortality in the emergency group compared with the elective group (25% vs. 0%, p=.049). Renal and pulmonary complications were significantly higher in the emergency group (42% vs. 5%, p=.02 and 42% vs. 0%, p=.005, respectively). No late complication or death was recorded after a mean follow-up of 18±13 months. Emergency OC is associated with significantly increased in hospital mortality and morbidity compared with elective OC. Elective OC appears to be safer and effective, and should be considered as the best option in cases of EVAR failure to avoid further emergency OC procedures.

Management of endo-graft infection following endovascular repair of abdominal aortic aneurysm

To summarize our experience in the management of stent-graft infection after endo-vascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA). Data of patients who were diagnosed as endo-graft infection following EVAR and admitted in our center between January 2000 and December 2015 were reviewed. Clinical records including causes of infection, medical history, re-operative procedures, and prognostic data were analysed. A total of 10 male patients, aged 45-72 years (averaged 62.5 years), were enrolled. Two patients received previous EVAR in our center, accounting for 0.23% of all the 885 EVAR procedures we conducted during the same period. The symptoms related to stent infection, including recurrent fever (100%) and persistent back pain (40%), occured 0 to 27 months (averaged 6.9 months) after EVAR procedure. Eight patients were found to have apparent causes (80%), including 1 case with upper respiratory infection and sepsis, 4 cases with aorto-enteric fistula (AEF) and 3 cases with inflammatory AAA. Except one DNR, other 9 patients received re-operation, including 1 procedure of open debridement and drainage, 1 procedure of endo-graft excision and bilateral axillary-femoral bypass, 7 procedures of endograft excision and axillary-bifemoral bypass. During the follow-up period(2-60 months, averaged 24.1 months), 1 patient was lost, 1 patient died from aortic stump rupture (12.5%) and other 7 patients survived. Bypass occlusion was observed in 1 patient (12.5%) without severe limb ischemia. AEF and inflammatory AAA are two leading causes of endo-graft infection following EVAR in our patients. Graft excision and axillofemoral bypass is an acceptable management for this life-threatening morbidity.

Late single-center outcome of the Talent Abdominal Stent Graft after a decade of follow-up

Lifelong yearly surveillance is advised after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms. This follow-up requires a substantial amount of health care resources. The aim of this paper was to assess the occurrence of stentgraft-related complications and secondary interventions during a minimum 10-year follow-up after elective EVAR. Patients who were treated in a high-volume endovascular center in The Netherlands with the Talent infrarenal stent graft (Medtronic Vascular, Santa Rosa, Calif) between June 1999 and February 2005 were included. Patients with previous aortic surgery or emergency interventions were excluded. Our primary outcome was clinical success up to 10years. Secondary end points were technical success and survival. A total of 149 patients were included; 91.9% were male. The mean age was 70.2± 7.8years. A stent graft was implanted in 98% of patients; technical success was achieved in 89.9%. Clinical success after 30days, 1year, 5years, and 10years was 81.1%, 74.3%, 70.3%, and 65.5%, respectively. In 30 patients (20.7%), a secondary intervention was required; 80.0% of first secondary interventions occurred within the first 5years. Six late conversions were necessary because of stent graft infection (2), migration (2), or persisting endoleak (2). The 5- and 10-year overall survival rates were 55.2% and 38.6%, respectively. The risk of EVAR-related complication is highest in the first 5years. Consequently, the main focus should beon that period; further follow-up must not be neglected, as complications occur up to 10years after treatment.

Hybrid Treatment of Large Brachial Artery Pseudoaneurysms

Conventional surgical treatment of brachial artery pseudoaneurysms (BAPs) includes aneurysm excision/opening and subsequent arterial reconstruction with different options depending on the extent of the arterial deficit. Endovascular repair of BAPs with stent grafting has also been reported but published experience remains limited. In this report, we present our experience with a novel hybrid approach consisting of primary endovascular aneurysm exclusion with a stent graft and subsequent open surgical evacuation of pseudoaneurysm content for decompression of adjacent structures. This study included all patients who underwent hybrid repair of a BAP within the period 2005-2014 in our institution. Data were collected retrospectively. During the study period a total of 5 patients with iatrogenic BAPs were treated. Mean BAP diameter was 58 ± 4.9 mm. Technical success was 100%. Thirty-day mortality was null. No major perioperative complications were noted. Hand ischemia and neurological symptoms were reversed in all patients after the procedure. During follow-up (median 24 months, range 6-60 months) all stent grafts remained patent and no aneurysm relapse was noticed. No signs of stent-graft infection were noticed in any of the patients and no reintervention was needed. Primary endovascular exclusion of BAPs with a stent graft followed by surgical evacuation of pseudoaneurysm sac content is associated with good early and mid-term results in this limited experience. Larger patient cohorts are required for further evaluation of this technique.