Stent-graft Repair Research Articles

Multiple aneurysm repair: hybrid approach to chronic dissection around visceral branches

The present case report details our experience with the hybrid approach for multiple aneurysms in the aortic arch, thoracoabdominal aorta, and around the aortic bifurcation. Total arch replacement for the arch aneurysm under hypothermic cardiopulmonary bypass with antegrade cerebral perfusion was the first stage of aneurysm repair. Five months later, bifurcated graft replacement with debranching of four abdominal branches was undertaken as the second stage of treatment. Finally, stent-graft repair for chronic dissection of the thoracoabdominal aorta was performed utilizing a Gore-Tex Tag endovascular prosthesis. Over 7 months of treatment, all aneurysms were excluded from the aortic blood flow and pressure without abdominal organ dysfunction except a transiently elevated total bilirubin level. Although the patient had an episode of minor gastrointestinal bleeding after discharge, he is currently leading a normal life without limitations at home 5 months after the stent-graft repair.

Two-dimensional versus three-dimensional CT angiography in analysis of anatomical suitability for stentgraft repair of abdominal aortic aneurysms

The morphological analysis prior to endovascular abdominal aneurysm repair (EVAR) plays an important role in long-term outcomes. Post-imaging analysis of computed tomographic angiography (CTA) by three-dimensional reconstruction with central lumen line detection (CLL 3D-CTA) enables measurements to be made in orthogonal slices. This might be more precise than equal post-imaging analysis in axial slices by two-dimensional computed tomographic angiography (2D-CTA). To evaluate the intra- and interobserver variability of CLL 3D-CTA and 2D-CTA post-imaging analysis methods and the agreement between them in pre-EVAR suitability analysis of patients with abdominal aortic aneurysm (AAA). Anonymized CTA data-sets from 70 patients with AAA were analyzed retrospectively. Length measurements included proximal and distal aortic neck lengths and total distance from the lower renal artery to the higher iliac bifurcation. Width measurements included proximal and distal neck diameters, maximum AAA diameter and common iliac diameters just above the iliac bifurcations. The measurements were performed in random order by two vascular surgeons, twice per method with 1-month interval between readings. In the CLL 3D-CTA method we used semi-automated CLL detection by software and manual measurements on CTA slices perpendicular to CLL. The equal measurements in 2D-CTA were performed manually on axial CTA slices using a DICOM viewer workstation. The intra- and interobserver variability, as well as the agreement between the two methods were assessed by Bland-Altman test and bivariate correlation analysis. The intraobserver variability was significantly higher in 2D-CTA measurements for both readers. The interobserver variability was significant in 2D-CTA measurements of proximal neck dimensions while the agreement in CLL 3D-CTA analysis between the two readers was excellent in all studied parameters. The agreement between the two suitability analysis techniques was poor for both readers, especially in measurements of proximal neck's dimensions and in total aortoiliac length (p = 0.001). In pre-EVAR morphological evaluation of AAAs the CLL-3D CTA post-imaging analysis has better intra- and interobserver correlation than 2D-CTA and might represent a useful tool for the proper selection of endograft's type and size.

Management of Blunt Traumatic Thoracic Aorta Injuries With Endovascular Stent-Grafts in a Tertiary Hospital in an Urban Asian City

Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed. All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months). Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.

Elephant trunk procedure 27 years after Borst: what remains and what is new?

The treatment of complex aortic pathology involving both the ascending and descending aortic segments at the same time represents a surgical challenge, with high postoperative morbidity and mortality rates reported. Over the past 27 years, different open surgical and endovascular techniques have been introduced and applied in various two-stage- or one-stage approaches to such cases. Thus, in 1983, Hans Borst significantly changed the traditional two-stage approach by introducing his elephant trunk technique. Leaving a segment of Dacron prosthesis reaching into the descending aorta during the first stage, the second-stage replacement of the residual dilated descending aorta was made far easier. The presence of interval mortality between the two stages, the unaffected need for two large operations to complete aortic repair, and the general failure of some patients to return for the second-stage repair set the scene for the development of one-stage procedures, both open surgical or hybrid surgical and endovascular, such as the frozen elephant trunk. However, the size of the operation, on the one hand, and the risk of spinal cord injury and need for surgical or endovascular completion during follow-up, on the other, have dampened enthusiasm. Recently, the introduction of supra-aortic debranching and endovascular aortic arch stent-graft repair has yet extended treatment to high-risk patients unsuitable to the more aggressive surgery, but mid- and long-term follow-up results are lacking. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. However, the technical revolution experienced over the past 27 years, along with the improvement in perioperative management, has produced outstanding morbidity and mortality results even in this challenging patient population, but the decision regarding which pathology correlates with what operation remains highly debated and dependent also on regional competence.

Abstract No. 363: Branched stent-graft repair: Which bridging stent-grafts should be used?

Abstract No. 363: Branched stent-graft repair: Which bridging stent-grafts should be used?

Penetrating Aortic Ulcer in the Infrarenal Stent-Graft Landing Zone:Treatment With Coils and the Ethylene Vinyl Alcohol Copolymer Onyx

To describe a technique to enable endovascular aneurysm repair in patients with penetrating aortic ulcer (PAU) in the infrarenal neck of an abdominal aortic aneurysm (AAA). The technique is illustrated in a 76-year-old man with a 5.7-cm infrarenal AAA and a 2.3 × 1.8-cm PAU situated immediately distal to the right renal artery and covering 20% of the 28-mm-diameter proximal aortic neck. During the stent-graft repair, the PAU was successfully excluded by embolization with coils and the ethylene vinyl alcohol copolymer Onyx. The AAA and PAU were completely excluded without complications. At 6 months, there were no signs of endoleak, the AAA remained excluded, and there was no reperfusion of the Onyx cast in the PAU. This technique for treatment of a PAU in the proximal neck of an AAA is a reasonable alternative in cases involving severely diseased infrarenal necks that would otherwise require open surgery. The liquid embolic agent Onyx performed well, with fast embolization and excellent control of the growing cast maintained by the interventionist.

Coil embolization of persistent false lumen after stent graft repair of type B aortic dissection

Patent false lumen after endovascular stent graft treatment of type B aortic dissection is a predictor for late death and retreatment. Between June 2008 and March 2010, five men with patent false lumen, due to a type B dissection previously treated with thoracic stent graft, underwent endovascular coiling treatment. Within a 30-day period, there were no deaths or major complications. The follow-up duration ranged from 1 to 22 months (mean 10.6 ± 8.5). Endovascular coiling of patent false lumen after endovascular stent graft treatment for type B aortic dissection avoided the risk of rupture or death due to secondary aneurysm formation.

Serious complications following endovascular treatment of thoracic aortic disease -10 years experience

Introduction: With growing experience in aortic endovascular stent-graft repair more and more complications are reported. We describe serious complications following endovascular treatment of thoracic aortic disease.

Pectoralis Major Musculocutaneous Flaps—An Effective Tool in the Cardiothoracic Surgeon's Armamentarium

deployment and so open thoraco-abdominal graft repair should be considered. doi:10.1016/j.hlc.2010.10.046 Pectoralis Major Musculocutaneous Flaps—An Effective Tool in the Cardiothoracic Surgeon’s Armamentarium Diana Tam ∗, John Tan Gold Coast Cardiac Surgery, Gold Coast, Australia Introduction: Median sternotomy continues to be the standard approach formost cardiac operations. Deep sternal wound infection is a significant cause ofmorbidity and mortality. The incidence reportedly ranges from0.5 to 5.9% [1]. Jurkiewitz pioneered the concept of vascular flap closure of the infected median sternotomy wound in 1980 [1]. Techniques using omentum, pectoralis major, rectus abdominis, external oblique and latissimus dorsi have been described. The use of pectoralis major musculocutaneous flaps to treat refractory sternal wound infections has gained popularity in recent years. Traditionally, these reconstructions have been referred to specialist reconstructive surgeons. The purpose of this research is to evaluate the outcome of sternal reconstruction carried out by the cardiothoracic surgeon. Methods: A review of the 25 cases of sternal wound [ Endovascular Stent Graft Repair for Penetrating Ulcers of Descending Thoracic Aorta—Cases Series and Review Deepak Mehrotra, Ms, Mch Fiacs ∗, Mark Webster, Fracp, Indran Ramanathan, Phd, Fracs, Parma Nand, Fracs Auckland City Hospital (Greenlane unit), Auckland, New Zealand Penetration aortic ulcers (PAU) are defined as breach in aortic initima secondary to ulceration of varied depth (including media) and severity. Optimal treatment for penetrating aortic ulcers has yet to be determined. On one side where definite surgical treatment is proposed for ascending aorta PAU, at other side PAUof descending thoracic aorta (DTA) is controversial. With the emergence of endoluminal stenting,which is less invasive and confers less morbidity and mortality, open surgical repair is for this particular entity is fading in current times. Although surgical treatment is very effective option, its invasive nature is critical in high risk group. We reviewed our experience atGreenlaneCardiothoracic unit with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta. Between July 2005 and August 2009,10 patients underwent thoracic endovascular stenting for this entity. The indications of stenting included PAU with or without dissection. Details of patients characteristics and outcome will be discussed. infections over a 10 yearperiod (2000–2009)wasperformed with the data extracted and analysed. One cardiothoracic surgeon performed all the operations. Results: There were 2 cases of failure in the sternal reconstructionsutilisingpectoralmyocutaneousflapsduring this ten-year period. In the first case, the sternal reconstruction failed because the patient continued to smoke cigarettes. When the sternal reconstruction broke down, his wound was subsequently treated with a rectus abdominis musculocutaneous flap and VAC dressings. In the second case, the patient was seen 4 years after a median sternotomy and coronary artery bypasswhichwas complicated by mediastinitis. He initially had a bilateral pectoralis major myocutaneous flap and a greater omentumflat reconstruction.At followup, thepatientwasnoted to have a herniation occurring through the mid part of his sternum where the pectoralis major flap has totally disrupted. The defect was repaired with Marlex mesh. Discussion: Muscle flap closure for refractory sternotomy infection should be considered as a part of the cardiothoracic surgeon’s armamentarium.

Endovascular Stent Graft Repair for Penetrating Ulcers of Descending Thoracic Aorta—Cases Series and Review

Endovascular Stent Graft Repair for Penetrating Ulcers of Descending Thoracic Aorta—Cases Series and Review

Stent thrombosis in aortic aneurysm: evaluation by multidetector CT

ObjectiveTo evaluate the demographic characteristics and imaging findings of thrombosis in a series of patients submitted to endovascular stent-graft repair of abdominal aortic aneurysm (ESGAAA). MethodsWe evaluated the imaging features, which allowed the diagnosis of endoluminal thrombosis in a series of 30 patients undergoing ESGAAA and followed from 5 to 29 months, using 64-channel multidetector computed tomography (MDCT). ResultsThrombosis was diagnosed in 10 patients (33.3%), and in 3 of those patients, total thrombosis was observed in an iliac branch. ConclusionMDCT allowed the diagnosis of different types of endoluminal thrombosis in patients submitted to ESGAAA. The use of this minimally invasive diagnostic technique should be encouraged in clinical practice.

Endovascular Treatment of an Innominate Artery Iatrogenic Pseudoaneurysm Following Subclavian Vein Catheterization

Central venous catheterization is routinely required in a wide range of clinical situations such as hemodynamic monitoring, delivery of blood products and drugs, hemodialysis, total parental nutrition, and management of perioperative fluids. Pseudoaneurysms account for 4% of all innominate artery aneurysms. Clinical presentation may include airway and neurological compression, chest pain, mediastinal syndrome, upper limb ischemia, and hemodynamic instability. We report what we believe is the first documented case of a successful endovascular stent-graft repair of an innominate artery iatrogenic pseudoaneurysm.

The Suitability of Thoraco-abdominal Aortic Aneurysms for Branched or Fenestrated Stent Grafts – And the Development of a New Scoring Method to Aid Case Assessment

Objective To determine the proportion of TAAAs which might be suitable for pure endovascular repair based on aneurysm morphology and to develop an MDCTA based scoring system to grade case complexity. Design 70 consecutive MDCTA of patients with TAAAs were analysed in relation to specific morphological characteristics. Methods The characteristics included potential stent landing zone lengths, arch angulation, thoraco-abdominal aorta angulation, branch vessel origin stenosis, access tortuosity/diameter and aortic dissection. Results 60% of TAAAs would be suitable for branched/fenestrated stent grafting but 40% are unsuitable due to adverse anatomy. 27% had an aortic arch angulation of ≤110° and 24% had descending thoracic aorta angulation of ≤90°. Significant ostial stenosis was identified in 31% of celiac arteries, 7% superior mesenteric arteries, 24% left renal artery and 19% right renal arteries. 11% of left common iliac and 7% right common iliac arteries had angulation of ≤70°. There were 26 cases with aortic dissection and 54% of these had a true lumen of ≤26 mm. Conclusion Successful fenestrated/branched stent graft repair of TAAAs requires adequate landing zones, cannulation of visceral arteries and suitable diameter access vessels. 60% of TAAAs studied were suitable for branched/fenestrated stent graft repair but 40% of TAAAs were unsuitable; aortic angulation, visceral vessel ostial stenosis and dissection true lumen diameter were the principle issues. Development in stent technology may address these anatomical challenges.

Current Management of Traumatic Thoracic Aortic Injury

Traumatic aortic rupture is a devastating injury that is difficult to manage because of the need to approach aortic repair, often in concert with management of complex associated injuries to nonvascular organ systems. Traditional open repair, while effective in the long-term, is associated with a periprocedural mortality between 10% and 20%, along with a 5% risk of stroke and up to a 5% risk of spinal chord ischemia. The advent of endovascular stent graft repair has allowed single centers to cut periprocedural mortality in half and decrease the risk of major neurologic events to <2%. It is unlikely that a multicenter prospective randomized trial will ever be performed to evaluate these two procedures. However, several large meta-analyses have been published recently, along with a clinical practice guideline from the Society for Vascular Surgery. The purpose of this article is to review the trends and current concepts in the management of traumatic rupture of the thoracic aorta.

Prophylactic Antibiotic Guidelines in Modern Interventional Radiology Practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Endovascular interventions for descending thoracic aortic aneurysms: The pivotal role of the clinical nurse in postoperative care

Descending thoracic aortic aneurysms (dTAA) comprise 40% of all aneurysms arising from the thoracic aorta. Because rupture of thoracic aneurysms is associated with a 94% mortality rate, timely detection, surveillance and treatment is imperative. Endovascular stent-graft repair of thoracic aneurysms was first performed in 1992 and has become an accepted treatment option for this condition in select candidates. There is an abundance of information for the care of patients after open surgical repair of dTAA. However, still relatively few written guidelines exist in the nursing literature for postoperative care and complications associated with endovascular stent-graft repair. The prevalence of aortic endografting, however, now makes it necessary for nurses to have a solid knowledge base in the operative procedure, complications and postoperative care for this patient population. Ideal candidates for aortic endografting undergo CTA or MRI preoperatively and fit a set of strict anatomic criteria to ensure proper delivery and fixation of the device. The early postoperative care focuses on minimizing pulmonary complications, paraplegia, renal failure and embolic complications such as stroke and limb ischemia through skilled nursing assessment and interventions. Late complications such as stent-graft migration, kinking, stent fracture and endoleak are often without symptoms, making it necessary for patients to be educated about these potential complications and to be encouraged to comply with lifelong follow up. This overview provides a sound cognitive framework for nurses practicing in a vascular surgery milieu.

Hybrid Repair of the Aortic Arch in Patients with Extensive Aortic Disease

Objective To evaluate the outcome of hybrid treatment of the aortic arch with supra-aortic debranching and endovascular stent-graft repair in a selected group of patients with complex disease. Design Case series study with retrospective analysis of prospectively collected non-randomised data. Methods Patients with hybrid repair of complex arch disease at a single centre over a 6-year period were enrolled in the study. Only patients with extensive arch pathologies requiring debranching of at least the left carotid artery were considered. Patients were divided into those who underwent complete and partial supra-aortic revascularisation. The χ 2 test was used to evaluate differences in outcomes. Logistic regression analyses were applied to identify predictors of poor outcome. Results A total of 33 patients were included in the study. Complete and partial arch repair was performed in nine and 24 patients, respectively. The aortic disease extended to the thoracic and abdominal aorta in 39% and 52% of the patients, respectively. One-third of the patients (30%) were treated on an urgent/emergency basis. Elective 30-day mortality and morbidity rates were 13% and 35%, respectively. Early mortality was significantly higher in the complete arch repair group ( p = 0.046). Pre-existing renal impairment was identified as a poor prognostic factor. All extra-anatomic bypasses remained patent and no aortic disease-related deaths occurred during a mean follow-up period of 23 months (range, 1.5–58 months). Complete arch repair was associated with an increased incidence of late endoleak ( p = 0.018). Conclusions Hybrid treatment of the aortic arch provides a feasible alternative treatment in patients who are high risk for conventional open surgical repair. Careful selection of patients is required to achieve satisfactory results.

Acute Type B Aortic Intramural Hematoma: Treatment Strategy and the Role of Endovascular Repair

To report a prospective study that explored the therapeutic strategies in the treatment of type B aortic intramural hematoma (IMH) and evaluated the role of endovascular repair. Between January 2001 and December 2009, 56 consecutive patients were enrolled in a prospective study to evaluate stent-graft repair versus medical therapy for acute type B IMH (patients with type A IMH excluded). Patients who had penetrating atherosclerotic ulcers, maximum aortic diameter >45 mm, hematoma thickness >10 mm, or sustained chest or back pain despite maximal medical therapy received endovascular stent-grafts (n=33; mean age 60 years, range 33-86), while other patients (n=23; mean age 56 years, range 29-83) received conservative therapy. Stent-grafts were implanted successfully as scheduled in 33 patients as elective procedures; there were no complications related to the procedure. The mean follow-up up was 28±15 months (range 3-108). In the medically treated patients, there were 6 (26%) cases of IMH progression (4 treated with stent-grafts) and 2 (9%) deaths versus no IMH progression or death in the stent-graft patients. The thickness of the hematoma was reduced in all 37 patients receiving stent-grafts, and the maximum aortic diameter decreased in 19 of these patients. The 17 surviving patients in the medical group also showed regression of the hematoma in follow-up. Type B IMH is a potentially lethal disease, and the application of endovascular stent-grafts achieved an encouraging result in this study. Therefore, a more optimistic strategy, including endovascular repair, should be considered and evaluated in the future.

Is Endovascular Stent-Graft Treatment of Primary Aortoesophageal Fistula Worthwhile?

Aortoesophageal fistula (AEF) as a result of prolonged nasogastric intubation is rare and certainly fatal, without prompt surgical intervention. We report the case of a 41-year-old man with morbid obesity who was admitted after suffering 55% of total body surface area burns. After several skin graft operations over the course of 12 weeks, he was rushed into surgery because of the acute onset of severe upper gastrointestinal bleeding. Exploratory laparotomy and esophagogastroduodenoscopy (EGD) suggested an AEF, which was then quickly confirmed by a diagnostic angiogram. An endovascular aortic stent graft repair was performed that successfully stopped the bleeding. We include a review of the literature pertaining to cases of AEF treated by endovascular surgery, which appears to be a promising alternative to open surgery in the unfit patient.

Endovascular Repair of Infrarenal Penetrating Aortic Ulcers: A Single-Center Experience in 20 Patients

To present the early and midterm results of endovascular stent-graft repair in patients with infrarenal penetrating aortic ulcers (PAU). Between January 1997 and December 2009, 20 patients (17 men; median age 72 years, range 48-85) with PAU of the infrarenal aorta underwent endovascular repair. In this cohort, 2 (10%) patients had a concomitant PAU in the descending thoracic aorta. Indications for treatment were aortic rupture in 2 patients, persistent or recurrent pain in 3 patients, and progression of PAU size or morphological aspects (e.g., thin wall) in the 15 asymptomatic patients. Follow-up included serial aortic imaging at predefined intervals. The technical success rate was 100%. In-hospital mortality was 10%, with 2 patients dying of myocardial infarction (MI). Postoperative complications were observed in 5 of 20 patients (4 MIs, 1 case of pneumonia, 1 acute on chronic renal failure, and a lymphatic complication at the access site). Primary endoleaks were observed in 4 (20%) patients and a secondary endoleak in 1 patient. The median follow-up was 22.3 months (range 0.4-104). The actuarial survival estimates at 1, 3, and 5 years were 77%, 69%, and 69%, respectively, with no aorta-related death during follow-up. The reintervention rate during follow-up was 10%, including 1 conversion at 11 months for type III endoleak. Patients with PAU have a significant number of cardiovascular comorbidities. The endovascular repair of infrarenal penetrating aortic ulcers thus is accompanied by mortality and morbidity caused predominantly by cardiac complications.