Stent-graft Repair Research Articles

Treatment of inadvertent cervical arterial catheterization: Single-center experience.

Inadvertent arterial catheterization can occur during transjugular central venous catheter insertion and should be promptly treated to prevent serious consequences. Although many treatment modalities are available, no exist guidelines regarding the selection of treatment. We aimed to describe our experience with the treatment of 11 patients who underwent inadvertent cervical arterial catheterization and propose an algorithm for the selection of treatment methods. We retrospectively identified all patients who were treated for inadvertent arterial catheterization at our center between January 2016 and March 2021. We reviewed patient profiles, images, treatment methods, and follow-up data. Eleven patients were included (eight men and three women, age: 36-73years). Ten catheter misplacements were in the right common carotid artery. The remaining catheter was inserted into the right subclavian artery after penetrating the right common carotid artery. Two catheters were 5-Fr and nine catheters were 11.5-Fr. Two patients underwent manual compressions, three underwent open surgery, three underwent stent-graft repairs, and four underwent Perclose Proglide closure. Clinical success was achieved in all 11 patients. Primary technical success was achieved in 10 patients. In one patient, unsuccessful manual compression was followed by successful stent-graft repair; the manual compression failed to prevent bleeding, possibly because of the long-term oral administration of aspirin for coronary heart disease. The mean follow-up was 5.4months (range, 1-12months). The overall mortality rate was zero, and no vascular or neurological events occurred. The existing data show that the current protocol for the treatment of inadvertent cervical arterial catheterization at our center is safe and effective. However, the data are insufficient and require further clinical validation.

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.

La revascularización de la arteria subclavia izquierda con un bypass axiloaxilar cruzado para la reparación híbrida de aneurismas de la aorta torácica

We present our subclavian artery revascularization experiences in the patients with thoracic aortic aneurysm who underwent hybrid repair. Between May 2015-December 2018,4 patients underwent TEVAR procedure following axilloaxillary bypass grafting.The mean age of the patients was 72.5 ± 3.01 years.One patient was female and 3 patients were male.Patients had thoracic aortic aneurysms including the left subclavian artery or aberrant right subclavian artery. All patients underwent endovascular stent graft repair following axilloaxillary bypass grafting in the same day.Mortality did not occur in the perioperative period.One patient had graft infection at 8th month of the operation and the graft was removed.He was lost due to pneumonia following the operation.The control computed tomographies of the other 3 patients revealed patent grafts together with successful endovascular interventions and they have been following uneventfully a mean of 27±6.2 months (range:24-32,median:29). The risk of stroke,spinal cord ischemia, and upper extremity ischemia are found higher in the patients who underwent coverage of the left subclavian artery without revascularization.The axilloaxillary bypass grafting may be performed in the patients with high risk to prevent carotid artery manipulation and clamping during carotid-subclavian bypass with long term promising patency rates.

Prediction of Adverse Events following Stent Graft Repair of Type B Aortic Dissection from Imaging Modalities

Prediction of Adverse Events following Stent Graft Repair of Type B Aortic Dissection from Imaging Modalities

The evolving role of endovascular therapy in the management of arterial thoracic outlet syndrome

ObjectiveOver the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. MethodsWe queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. ResultsOf 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively. ConclusionsThis study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared with open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.

Endovascular Management of an Aortacaval Fistula in Penetrating Trauma

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

Investigation of Three-dimensional Printing Materials for Printing Aorta Model Replicating Type B Aortic Dissection.

This study aims to determine a printing material that has both elastic property and radiology equivalence close to the real aorta for simulation of endovascular stent-graft repair of aortic dissection. With the rapid development of Three-Dimensional (3D) printing technology, a patient- specific 3D printed model is able to help surgeons to make a better treatment plan for Type B aortic dissection patients. However, the radiological properties of most 3D printing materials have not been well characterized. This study aims to investigate the appropriate materials for printing human aorta with mechanical and radiological properties similar to the real aortic Computed Tomography (CT) attenuation. Quantitative assessment of CT attenuation of different materials used in 3D printed models of aortic dissection for developing patient-specific 3D printed aorta models to simulate type B aortic dissection. A 25-mm length of aorta model was segmented from a patient's image dataset with a diagnosis of type B aortic dissection. Four different elastic commercial 3D printing materials, namely Agilus A40 and A50, Visijet CE-NT A30 and A70 were selected and printed with different hardness. Totally four models were printed out and CT scanned twice on a 192-slice CT scanner using the standard aortic CT angiography protocol, with and without contrast inside the lumen. Five reference points with the Region Of Interest (ROI) of 1.77 mm2 were selected at the aortic wall, and intimal flap and their Hounsfield units (HU) were measured and compared with the CT attenuation of original CT images. The comparison between the patient's aorta and models was performed through a paired-sample t-test to determine if there is any significant difference. The mean CT attenuation of the aortic wall of the original CT images was 80.7 HU. Analysis of images without using contrast medium showed that the material of Agilus A50 produced the mean CT attenuation of 82.6 HU, which is similar to that of original CT images. The CT attenuation measured at images acquired with the other three materials was significantly lower than that of the original images (p<0.05). After adding contrast medium, Visijet CE-NT A30 had an average CT attenuation of 90.6 HU, which is close to that of the original images without a statistically significant difference (p>0.05). In contrast, the CT attenuation measured at images acquired with other three materials (Agilus A40, A50 and Visiject CE-NT A70) was 129 HU, 135 HU and 129.6 HU, respectively, which is significantly higher than that of original CT images (p<0.05). Both Visijet CE-NT and Agilus have tensile strength and elongation close to actual patient's tissue properties producing similar CT attenuation. Visijet CE-NT A30 is considered the appropriate material for printing aorta to simulate contrast-enhanced CT imaging of type B aortic dissection. Due to the lack of body phantoms in the experiments, further research with the simulation of realistic anatomical body environment should be conducted.

Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application

PurposeTo test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices.MethodsA stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement.ResultsThe stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications.ConclusionThe novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis.Level of EvidenceNo level of evidence.

Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center.

BackgroundComplicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes.MethodsWe reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12–80 months).ResultsThe median interval from aortic dissection to TEVAR was 5.50 days (range, 0–32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%).ConclusionTEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.

One-year results of stent graft repair for carotid artery pseudo-aneurysm in patients with Behcet's disease.

Behcet's disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet's disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit. During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention. The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%). Stent graft repair for carotid artery pseudo-aneurysm in Behcet's disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.

Endovascular Stent Graft Repair for True and Post-Traumatic False Aneurysms of the Subclavian Artery

ObjectiveSubclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs. MethodsThe clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed. ResultsEighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak. ConclusionsEndovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms

ObjectiveTo review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA).DesignSystematic review and meta-analysisData...

The Evolving Role of Endovascular Therapy in the Management of Arterial Thoracic Outlet Syndrome

The Evolving Role of Endovascular Therapy in the Management of Arterial Thoracic Outlet Syndrome

Unibody design for aortic disease with a narrow aortic bifurcation: tips and tricks for success.

BackgroundSurgical management of patients with abdominal aortic diseases associated with distal narrowing is a challenging situation.ObjectivesTo evaluate outcomes of unibody bifurcated endovascular stent graft repair.MethodsThis is a retrospective, observational, multi-institutional database study of a cohort of consecutive cases, approved by the local Ethics Committee. Records were reviewed of patients diagnosed from 2010 to 2020 with “shaggy” aorta, saccular aneurysm, penetrating aortic ulcer, and isolated aortic dissection located in the infrarenal abdominal aorta. All patients were treated with a unibody bifurcated stent graft. Main outcomes were technical success, procedure complications, long-term patency, and mortality in the follow-up period up to 5 years. Data on demographics, comorbidities, surgical management, and outcomes were analyzed.ResultsTwenty-three patients were treated with unibody bifurcated stent graft repair, including 7 cases of “shaggy” aorta, 3 isolated dissections of the abdominal aorta, 4 penetrating aortic ulcers, and 9 saccular aneurysms. Immediate technical success was achieved in 100% of cases. At follow-up, all stent grafts remained patent and there were no limb occlusions. The patients were symptom-free and reported no complications related to the procedure. There were 5 deaths during the follow-up period (median= 4 years), but none were related to the procedure and there were no aorta-related deaths.ConclusionsThe present study shows that unibody bifurcated stent grafting is safe and effective in this group of patients with narrow distal abdominal aorta and complex aortic pathology. The results were similar for both infrarenal aortic aneurysms and aorto-iliac atherosclerotic disease.

Study of correlation of MDCT angiography in diagnosis of type of Stanford aortic dissection with surgical or endovascular stent graft repair findings

Study of correlation of MDCT angiography in diagnosis of type of Stanford aortic dissection with surgical or endovascular stent graft repair findings

Commentary on "Outcomes of Endovascular Stent Graft Repair for Penetrating Aortic Ulcers with or without Intramural Hematoma"

Penetrating Aortic Ulcer (PAU) is a kind of Acute Aortic Syndrome (AAS). Compared with PAUs without IMH, PAUs with Intramural Hematoma (IMH) presented significant differences in history of acute coronary syndrome, pleural effusion, emergency admitted, aortic diameter at the PAU level, and the occurrence of Stent-Induced New Entry (SINE). The cumulative survival rates of patients undergoing endovascular repair during the first hospitalization were significantly higher than those having delayed repair during the follow-up.

Pre-fenestration endovascular repair of aortic diseases in patients with zone 2 segment: A single-center experience

The present study aims to analyze the outcomes of three cases of pre-fenestration and branch stent-graft endovascular repair of aortic disease with zone 2 aortic lesions. From August 2017 to June 2018, three patients with zone 2 aortic lesions underwent thoracic endovascular repair with innominate artery, left common carotid artery, and left subclavian artery recannulation using pre-fenestration and branched stent-grafts to preserve the patency of the aortic arch branches. The technical success rate was 100%. One patient had a proximal type I endoleak with no need for additional treatment. The overall mortality was 0%. All branches were patent. The follow-up period lasted for 2-15 months, with one patient lost to follow-up. There were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde type A aortic dissection. The use of a pre-fenestration and branch stent-graft for the thoracic endovascular repair of zone 2 aortic lesions is a feasible and effective method for aortic arch branch revascularization. The risk of this surgical procedure is high, requiring significant expertise. The procedure should be conducted only in experienced centers. Durability concerns should be assessed in future studies with long-term follow-up.

Mohankumar Adiseshiah

Born in Chennai, the son of the renowned UNESCO educationalist, Malcolm Adiseshiah, Mo graduated from Westminster Hospital Medical School with the surgery prize Mo trained in the heyday of invasive...

Outcomes of endovascular stent graft repair for penetrating aortic ulcers with or without intramural hematoma

ObjectiveWe investigated the outcomes of endovascular repair for penetrating aortic ulcers (PAUs) with and without intramural hematoma (IMH). MethodsPatients with PAUs who had undergone thoracic endovascular aortic repair (TEVAR) or endovascular abdominal aortic repair (EVAR) at our center were enrolled. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed to investigate the TEVAR/EVAR indications, perioperative complications, and mortality. ResultsWe identified 138 patients with PAU. Of the 138 patients, 58 (42.0%) had also had IMH. Compared with the patients without IMH, the patients with IMH had had significantly greater emergency admission rates (P < .01), a larger aortic diameter (P = .03), and a greater incidence of stent-induced new entry development (P = .02). No significant differences were found in mortality or freedom from reintervention between patients with PAUs with and without IMH during follow-up. However, the cumulative survival rates calculated using Kaplan-Meier analysis for patients who had undergone TEVAR/EVAR during their first hospitalization were significantly greater than those who had undergone delayed TEVAR/EVAR during follow-up. ConclusionsTEVAR/EVAR was safe and effective, with encouraging outcomes for patients with PAUs with or without IMH, and can be used more aggressively for symptomatic patients. The presence of PAUs with IMH did not seem to adversely affect long-term mortality. However, but stent-induced new entry was more likely to develop.

Preoperative Planning for EndoAnchor Use During Thoracic Endovascular Aortic Repair in the Distal Aortic Arch

Purpose: To describe steps related to intraoperative C-arm orientations that can be taken during preoperative planning of thoracic stent-graft repair to facilitate the deployment of EndoAnchors in the distal aortic arch. Technique: Previous experience from transcatheter aortic valve implantation (TAVI) may be helpful in addressing issues with C-arm orientation. In TAVI, preoperative computed tomography (CT) images are routinely obtained to generate a patient-specific curve that represents a virtually complete rotation of the C-arm perpendicular to the annulus. The curve clearly demonstrates that each adjustment in cranial or caudal view needs parallax correction in the left or right anterior oblique direction to remain perpendicular, and vice versa. This experience can be translated to the preoperative planning of EndoAnchor use in the aortic arch. By placing markers along the circumference of the proximal landing zone of the preoperative CT scan, the required C-arm orientations can be determined for each marker. Conclusion: Determining the optimal C-arm orientation during preoperative planning will facilitate successful EndoAnchor deployment and may contribute to improved durability of endovascular repair in hostile necks in the aortic arch.