Successful Endovascular Repair Research Articles

Intraoperative iatrogenic type B aortic dissection. Temporary perfusion pause, immediate restoration and final solution.

We present the case of a 74-year-old female patient with a 50mm ascending aortic aneurysm who underwent ascending aorta replacement. During routine open heart surgery, suboptimal flow in the cardiopulmonary bypass circuit, led to the discovery of a type B aortic dissection with substantial flow in the false lumen. Conservative management was chosen, focusing on blood pressure control in the ICU. Despite an initial uneventful recovery the patient developed malperfusion syndrome prompting consideration of endovascular repair. Following a temporary improvement, malperfusion symptoms recurred, leading to a successful endovascular repair, with complete thrombosis of the false lumen.

Successful Thoracic Endovascular Aortic Repair of Kommerell Diverticulum to Relieve Refractory Chest Oppressions Caused by Secondary Esophageal Stricture.

Successful Thoracic Endovascular Aortic Repair of Kommerell Diverticulum to Relieve Refractory Chest Oppressions Caused by Secondary Esophageal Stricture.

Feasibility of endovascular aortic arch repair after hemiarch replacement for acute type A aortic dissection

ObjectiveWe assessed the treatment feasibility of 4 investigational arch endografts currently available in the United States, for patients who have undergone hemiarch replacement for an acute DeBakey I dissection. MethodsWe evaluated 71 consecutive patients for suitability for treatment with the Cook Medical Zenith Arch Branched Device, Gore TAG Thoracic Branch Endoprosthesis, Terumo Bolton Relay Dual Branch Device, and Endospan Nexus Aortic Arch Stent Graft System. Proximal landing zone anatomy was evaluated on postoperative computed tomography angiography using 3-dimensional imaging software and compared against each manufacturer recommended sizing criteria. ResultsTwenty-one patients (29.6%) were deemed unsuitable for branched endograft due to mechanical aortic valve, connective tissue disorder, and extension of dissection into the brachiocephalic trunk (BCT). Forty-one percent were excluded from all devices; 8.5% were candidates for only 1 device, 24% for 2, 4% for 3, and 23% for all 4 devices. Reasons for exclusion included ascending aortic/neck diameter being too large/small, insufficient ascending aorta length, insufficient BCT length, and BCT size being too large. Both patient-related factors (BCT diameter/length, dissection into BCT, and connective tissue disorder) and technical factors (mechanical aortic valve, ascending aorta graft length/diameter) influenced candidacy. ConclusionsDespite the availability of multiple branched endovascular devices, a significant number of patients may be unsuitable for subsequent endoarch repair. Awareness of anatomic inclusion criteria for arch endografts and modification of surgical technique for creation of a suitable landing zone at the initial operation may increase the likelihood of successful endovascular repair in the future.

Clinical outcomes of celiac artery coverage vs preservation during thoracic endovascular aortic repair

ObjectiveAdequate proximal and distal seal zones are necessary for successful thoracic endovascular aortic repair (TEVAR). Often, the achievement of an adequate distal seal zone requires celiac artery (CA) coverage by endograft with or without preservation of CA blood flow. The outcomes of CA coverage without its flow preservation were studied only in small case series. This study aims to determine the difference in outcomes between CA coverage with vs without preservation of CA blood flow during TEVAR using a multi-institutional national database. MethodsThe Vascular Quality Initiative database was reviewed for all TEVAR patients distally landing in zone 6. The cohort was divided into TEVAR with vs without CA flow preservation. Demographic, clinical, and perioperative characteristics, as well as postoperative mortality, morbidities, and complications, were compared between the groups. Univariate and multivariate regression analyses were performed. ResultsOf 25,549 reviewed patients, 772 had a distal landing in Zone 6, 212 of which (27.5%) had TEVAR without CA flow preservation, whereas 560 (72.5%) underwent TEVAR with CA flow preservation. Indications for TEVAR were aneurysm in 431 (55.8%), dissection in 247 (32.0%), or other in 94 (12.2%) cases. Patients who underwent TEVAR without CA flow preservation had statistically significantly higher rates of 30-day mortality (11.3% vs 5.9%; P = .010), 30-day disease/treatment-related mortality (8.0% vs 4.3%; P = .039), as well as a tendency of increased intestinal ischemia requiring intervention (1.9% vs 0.5%; P = .077). After adjusting for potential confounders, CA coverage without flow preservation was associated with more than a two-fold increase in the overall 30-day mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.35-5.92; P = .006) and 30-day disease/treatment-related mortality (OR, 2.72; 95% CI, 1.11-6.72; P = .029). In a sub-group analysis based on disease pathology, these results persisted only in the aneurysm group (30-day mortality [OR, 2.36; 95% CI, 1.01-5.48; P = .047]; 30-day disease/treatment-related mortality [OR, 2.88; 95% CI, 1.08-7.67; P = .034]), whereas there was no significant association between CA flow preservation status and the endpoints in the dissection subgroup (30-day mortality [OR, 1.16; 95% CI, 0.22-6.05; P = .856], 30-day disease/treatment-related mortality [OR, 0.90; 95% CI, 0.16-5.19; P = .911]). ConclusionsCA coverage during TEVAR without preservation of its blood flow is associated with significantly higher mortality in patients with aortic aneurysm, but not dissection. In patients with aortic aneurysm, CA flow should be preserved during TEVAR whenever feasible, whereas in patients with dissection, it may be safe to cover CA without preservation of its flow. Prospective studies should be done to confirm these findings and compare the open vs endovascular revascularization techniques on outcomes.

The Value of Aortic Volume and Intraluminal Thrombus Quantification for Predicting Aortic Events after Endovascular Thoracic Aneurysm Repair.

Objectives: To assess the ability of the aortic aneurysm volume (AAV), aneurysmal lumen volume (ALV), and aneurysmal thrombus volume (ATV) to predict the need for aortic reintervention when using the maximal aortic diameter as a reference. Methods: This monocentric retrospective study included 31 consecutive patients who underwent successful thoracic endovascular aortic repair (TEVAR) to treat an atheromatous thoracic aortic aneurysm. All patients underwent clinical and computed tomography angiography (CTA) for 3 years after TEVAR. The patients were categorized into group 0 if no aortic reintervention was required during the follow-up period and categorized into group 1 if they experienced a type I or III endoleak or aneurysm diameter increase requiring intervention. The maximum aneurysm sac diameter and the AAV, ALV, and ATV were calculated using CTA images obtained preoperatively (T0) and at 6-12 months (T1), 24 months (T2), and 36 months (T3) postoperatively, and their changes over time were analyzed. Correlations between diameter and changes in AAV, ALV, and ATV were assessed, and the association between diameter and volume changes and reintervetion was examined. The cutoff values for predicting the need for reintervention was determined using a receiver operating characteristic (ROC) curve. The accuracy of volume change versus diameter change for predicting the need for reintervention was analyzed. Results: There were no significant differences in terms of the mean aneurysm diameter or AAV, ALV or ATV between the groups at preoperative CTA or after one year of follow-up imaging. The mean ATV was higher in group 1 than in group 0 at 2 years (187.6 ± 86.3 mL vs. 114.7 ± 64.7 mL; p = 0.057) and after 3 years (195.0 ± 86.7 mL vs. 82.1 ± 39.9 mL; p = 0.013). The maximal diameter was greater in group 1 than in group 0 at 3 years (67.3 ± 9.5 mm vs. 55.3 ± 12.6 mm; p = 0.044). The rate of AAV change between T0 and T1 was significantly higher in group 1 (7 ± 4.5%) than in group 0 (-6 ± 6.8%; p < 0.001). The rate of ATV change between T1-T3 was significantly higher in group 1 than in group 0 (34 ± 40.9% vs. -13 ± 14.4% (p = 0.041)); similar results were observed for the rate of ATV change between T2 and T3 (27 ± 50.1% for group 1 vs. -8 ± 49.5% in group 0 (p < 0.001)). According to our multivariate analysis, the annual growth rate for AAV between T0 and T1 was the only independent factor that was significantly associated with aortic reintervention (area under the curve (AUC) = 0.84, OR = 1.57, p = 0.025; optimal cutoff +0.4%). An increase in the annual growth rate of the ATV between T0 and T3 was independently associated with the need for aortic reintervention (area under the curve (AUC) = 0.90, OR = 1.11, p = 0.0347; optimal cutoff +10.1%). Conclusions: Aortic volume analysis can predict the need for aortic reintervention more accurately and earlier than maximal aortic diameter.

Successful chimney endovascular aortic repair with reconstruction of three visceral branches for huge saccular juxtarenal abdominal aortic aneurysm after trans-thoracoabdominal esophagectomy

BackgroundConventional graft replacement for a juxtarenal abdominal aortic aneurysm (JRAAA) remains challenging for high-risk patients since it often requires the reconstruction of some visceral arteries.Case PresentationA 76-year-old woman was diagnosed with an 87 × 48 mm saccular JRAAA. Open graft replacement was contraindicated because of frailty and a past history of trans-thoracoabdominal esophagectomy. Chimney endovascular aortic repair (ChEVAR) with three chimney endografts was successfully performed without any endoleaks, and each visceral circulation was kept intact. The patient was discharged uneventfully on postoperative day 8. Significant shrinkage of the aneurysmal sac and preservation of flow through each chimney graft were observed on computed tomography 6 months postoperatively, with no significant increase in serum creatinine levels on laboratory testing.ConclusionsChEVAR can be a useful surgical option instead of conventional operations, especially for high-risk cases.

Novel Strategies for the Hostile Iliac Artery during Endovascular Aortic Aneurysm Repair.

Successful endovascular aneurysm repair can be achieved with favorable aortic and iliac arterial anatomies. However, patients with challenging iliac anatomy, such as stenotic, calcified, tortuous arteries, or concomitant iliac artery aneurysms, are commonly encountered. Such a hostile iliac anatomy increases the risk of intraprocedural complications and worsens long-term outcomes. This review addresses various technical options for treating patients with a hostile iliac anatomy, including innovative endovascular solutions, physician-modified endografts, and hybrid procedures. These considerations demonstrate the wide scope of therapies that may be offered to patients with an unfavorable iliac anatomy.

Long term follow up after TEVAR for pediatric blunt thoracic aortic injury: Case report and review of literature

Previously, open surgical repair was the primary treatment for pediatric blunt thoracic aortic injury (BTAI). However, thoracic endovascular aortic repair (TEVAR) has recently become the most frequently used treatment option. Given the rarity of this pathology, long term complications and sizing difficulties of TEVAR in a growing aorta have not been well documented. Here we report two-year follow-up after successful endovascular repair of traumatic BTAI in a pediatric patient with concern for stent-graft-associated aortic stenosis similar to coarctation.

A successful endovascular aortic repair of aortoesophageal fistula following esophagectomy: a case report and literature review

BackgroundAortoesophageal fistula (AEF) is an extremely rare and highly fatal complication leading to a high risk of morbidity and mortality. Successful management of AEF after esophagectomy for esophageal carcinoma has rarely been reported in the literature.Case presentationHere we present a rare case of a 44-year-old female with complications of AEF after esophagectomy for esophageal carcinoma, mainly presented as vomiting of blood. Both computed tomographic and computed tomography angiography of the chest showed bilateral pleural effusion and atelectasis, while gastroscopy showed large gastrointestinal bleeding. Emergency surgery was performed that included the removal of the mediastinal abscess, left lower pulmonary wedge resection, and thoracic endovascular aortic repair (TEVAR), followed by supportive treatment. The surgery went successful, and the patient was followed up for 1 year after discharge and showed good recovery. We also reviewed previous literature on the history, causes, pathophysiology, clinical presentation, diagnosis, and treatment of AEF after esophagectomy for esophageal adenocarcinoma.ConclusionsIn our case, thoracotomy combined with TEVAR was effective in treating AEF after esophagectomy for esophageal adenocarcinoma. This case provides successful experiences for clinical diagnosis and treatment of AEF after esophagectomy for esophageal carcinoma.

External iliac vein injury and acute iliofemoral deep venous thrombosis after total hip arthroplasty: a rare iatrogenic complication and its successful endovascular repair.

External iliac vein injury and acute iliofemoral deep venous thrombosis after total hip arthroplasty: a rare iatrogenic complication and its successful endovascular repair.

Management of Isolated Abdominal Aortic Dissection: Indications and Strategies for Treatment

The aim of this paper was to report our experience in the management of isolated abdominal aortic dissection with endovascular aortic repair and conservative treatment. A cohort of 22 consecutive patients with isolated abdominal aortic dissection was treated between January 2016 and December 2021. We reviewed the demographics, clinical features, therapeutic modalities and follow-up results. Retrospective data analysis from patient charts was performed. Twenty-two patients were enrolled in this study from 2 centers. The mean age was 66.2±13.3 years. Hypertension was the primary risk factor. Seventeen (72.7%) patients were asymptomatic, and 18 patients were subrenal artery type (type II). A total of 12 patients had successful endovascular repair (EVAR), and 10 patients underwent conservative treatment. In the group receiving conservative treatment, no patients required EVAR during follow-up, and 4 patients died. However, none of them had aortic causes: 2 patients had cardiac causes, the other 2 had cancer, and the others remained symptom-free. The latest computed tomographic angiography images showed that abdominal aortic dissection still existed, and the extent of the false lumen did not increase significantly. Both conservative treatment and EVAR are effective treatment options. Appropriate treatment needs to be performed according to different patients' clinical manifestations and doctors' experience.

Successful endovascular repair of challenging abdominal aortic aneurysm with anaconda LoPro 90 stent graft system: Case report

Successful endovascular repair of challenging abdominal aortic aneurysm with anaconda LoPro 90 stent graft system: Case report

Rare complication: refractory hypertension and intermittent claudication caused by elephant trunk entrapped in a new entry after total arch replacement for type A aortic dissection

BackgroundTotal arch replacement using elephant trunk (ET) has been accepted as a standard technique for thoracic aortic dissection. However, there are few complications related to the ET, such as kinking of the ET, paraplegia, splitting of the anastomosis, and thromboembolic complications. We report a successful thoracic endovascular aortic repair (TEVAR) in a patient with ET entrapment in a new isolated dissecting aortic aneurysm.Case presentationA 50-year-old woman who underwent total arch replacement (TAR) with the ET technique 6 years ago was admitted with refractory hypertension and heart failure. Magnetic resonance angiography revealed that the ET was entrapped in an isolated dissecting aortic aneurysm, which obstructed blood flow, thus causing ischemia. She underwent TEVAR to reset the entrapment of the ET. After TEVAR, ischemic symptoms were immediately relieved.ConclusionWe present a case of new entry after the repair of a type A acute aortic dissection using ET, which rapidly progressed to a distal arch dissecting aneurysm and dislocation of the ET.

Solving Intraoperative Complications During Endovascular Repair of Late Contained Ruptured Aortic Pseudoaneurysm After Surgical De-coarctation: Case Report and Systematic Review of Literature.

We present a case of successful endovascular repair of late ruptured aortic anastomotic pseudoaneurysm following previous left subclavian artery-descending thoracic aorta bypass and concomitant emergency thoracic endovascular aortic repair (TEVAR) of complicated endovascular aortic de-coarctation never previously described is also presented. A review of the intraoperative, 30-day, and follow-up morbidity, mortality, and complications of TEVAR as endovascular treatment of late aneurysm/pseudoaneurysms after surgical aortic de-coarctation was also performed. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and following PICO model. A literature search was conducted on MEDLINE, PubMed, EMBASE, Cochrane Library, Google Scholar, Science Direct, and Web of Science using the words "tevar of late complication of aortic coarctation surgical repair" and "endovascular repair of anastomotic pseudoaneurysm in coarctation" up to June 17, 2022. Data were extracted from study documents about study design, patient's demographics and comorbidities, details about primary surgical repair, type of late complication, time between open surgery and occurrence of complications, details of the secondary endovascular procedure with technical success, early, and follow-up mortality and morbidity. A total of 18 papers were included with 78 patients (48 men, 69.5%). The most frequent type of primary open surgical repair was patch aortoplasty (46, 58.9%). Focusing on aneurysm and pseudoaneurysm as late complications, most of the patients were asymptomatic (45, 57.7%). All patients underwent TEVAR, 14 of them (17.9%) in urgent/emergent setting. The technical success was 98.7%, with 1 intraoperative death due to rupture of the aorta. In total, 31 patients out of 78 (39.7%) showed different complications in the immediate postoperative time, with type II endoleak being the most observed (8/31, 25.8%). The mean follow-up time was about 2 years (26.5 months, range 3-92). Overall, 30-day mortality was 2.6%. Complications occurred in 30 patients (39.4%), 23 of them resolved during the follow-up period. With the limit of low-quality data, TEVAR can be considered a safe and effective option for the treatment of late complications after open surgery for aortic coarctation, even in urgent settings. Different specialists have to face the technical complexities and risks related to treatment of late complications after surgical de-coartaction, which can be either surgical or endovascular, and depend on patient's ages. Although covered stents appear to have some protection from the development of stent fractures, doesn't provide complete protection from late aneurysm formation. In this setting, TEVAR may represent a valuable option, combining the advantages of the covered stent with those of a device that can cover a wider range of aortic length, especially in adult patients. This study shows thoracic endovascular repair can be considered a safe and effective option in clincal practice for the treatment of late complications after open surgery for AC, even in urgent settings.

Endovascular repair of a common iliac artery aneurysm with an iliac branch device in a patient with vascular Ehlers-Danlos syndrome due to a null COL3A1 variant

Endovascular repair is avoided in patients with connective tissues disorders due to concerns for stent graft migration and endoleaks. We describe a successful endovascular repair of a common iliac artery aneurysm with a bifurcated aortoiliac stent graft and iliac branch endoprosthesis in a patient with Vascular Ehlers-Danlos syndrome (VEDS) due to a null COL3A1 variant. This case demonstrates that the VEDS genotype is associated with tissue integrity, specifically, individuals with VEDS due to null/haploinsufficiency variants, and adds to our understanding of endovascular repair in this population.

Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma

BackgroundThe current treatment for retrograde ascending aortic intramural hematoma (RAIMH) remains challenging. This study aims to summarize the short-term results of endovascular repair in the treatment of retrograde ascending aortic intramural hematoma.MethodsBetween June 2019 and June 2021, 21 patients (16 males and 5 females) with a retrograde ascending aortic intramural hematoma, aged 53 ± 14years, received an endovascular repair in our hospital. All cases involved an ascending aortic or aortic arch intramural hematoma. 15 patients had an ulcer on the descending aorta combined with an intramural hematoma in the ascending aorta and 6 patients had typical dissection changes on the descending aorta combined with an intramural hematoma in the ascending aorta. All patients had a successful endovascular stent-graft repair, with 10 cases operated on in the acute phase (<14 days) and 11 cases in the chronic phase (14–35 days).ResultsA single-branched aortic stent graft system was implanted in 10 cases, a straight stent in 2 cases, and a fenestrated stent in 9 cases. All surgeries were technically successful. One of the patients developed a new rupture 2 weeks after surgery and was converted to a total arch replacement. No perioperative stroke, paraplegia, stent fracture or displacement, limb or abdominal organ ischemia occurred. The intramural hematomas started being absorbed on CT angiography images before discharge. There was no incidence of postoperative 30-day mortality, and the intramural hematomas in the ascending aorta and aortic arch were fully or partly absorbed.ConclusionEndovascular repair of retrograde ascending aortic intramural hematoma was shown to be safe and effective, and correlated with favorable short-term results.

Long-term outcomes of thoracic endovascular repair with quick fenestrater assisted in situ fenestration for type B aortic dissection.

To report the long-term outcomes of patients with type B aortic dissection (TBAD) treated with thoracic endovascular aortic repair (TEVAR) and quick fenestrated (QF)-assisted in situ fenestration (ISF). Between October 2017 and December 2018, 15 patients with TBAD requiring revascularization of the supra-aortic trunks underwent TEVAR with QF-assisted ISF at our institution. Thirteen of the 15 patients were male, and the mean age was 52.87 ± 11.26. The technical success rate was 100%. Thirty-day mortality rate was 0. The median follow-up period was 41months (range, 35-49). During follow-up, one non-aortic-related death was recorded, no fenestration lost its alignment, and no stroke or stent graft migration was observed. Two patients underwent another successful endovascular repair. One case of type Ib endoleak occurred 19months postoperatively. This was caused by aortic progression distal to the stent graft. Another stent graft with a larger diameter was implanted in the descending aorta. One case of type Ic endoleak was observed 35months postoperatively. The patient was diagnosed during the annual follow-up without any symptoms. Another bridging stent graft was implanted into the left subclavian artery distal to the already existing one, and the type Ic endoleak was successfully treated. TEVAR with QF-assisted ISF may be an effective treatment for ISF in type B aortic dissection.

Mid-Term Results of Treating Kommerell's Diverticulum and Aberrant Subclavian Artery Anomalies Using a Patient-Centered Team Approach.

The management of Kommerell's Diverticulum (KD) has evolved from open surgical resection and graft replacement of the aorta, to endovascular repair in asymptomatic patients due to its recognized possible sequelae - aortic rupture and dissection. Despite these technical advances, standard indications for intervention and treatment algorithms remain unclear. We will present our single-center experience in the treatment of KD, supporting a multidisciplinary endovascular-first approach. All patients who underwent thoracic endovascular aortic repair (TEVAR) for KD between 2017 and 2020 were retrospectively identified from a prospectively maintained institutional surgery database. Chart review was used to characterize presenting symptoms, interventions, technical results, and complications. Revascularization was performed using carotid-axillary bypass. Routine endovascular subclavian artery occlusion was employed to eliminate retrograde diverticulum perfusion and avoid open ligation. 8 patients were identified, including 6 females and 2 males between the ages of 44-76. Patients presented with dysphagia (n = 3), acute embolic stroke (n = 1), transient ischemic attack (TIA) (n = 1), upper extremity embolization (n = 1), and acute type B aortic dissection (n = 1). One patient had a prior incomplete open repair that was successfully treated endovascularly. Another patient had a mediastinal neoplasm infiltrating an incidental aberrant subclavian artery and KD. All cases had symptomatic improvement and successful endovascular repair as demonstrated on post-operative imaging. Perioperative complications included percutaneous access site pseudoaneurysm (n = 2), stroke (n = 1), and subclavian artery rupture immediately recognized and treated (n = 1). There was no perioperative mortality. Endovascular techniques have resulted in technical success and symptomatic improvement for KD without open thoracotomy or sternotomy. Significant rates of endovascular complications and paucity of long-term durability data should be considered. Until formal criteria for repair are established, early application of TEVAR using a consistent multi-specialty approach may mitigate the risk of unpredictable aortic complications in these patients while avoiding the accepted morbidity and mortality of open surgery.

Giant thoracic aorta aneurysm below an endovascular stent - An unexpected finding during linear endoscopic ultrasound.

A 50-year-old woman with a history of bicuspid aortic valve (BAV) and ascending aorta dissection was referred for endoscopic ultrasound (EUS) for suspected choledocholithiasis. Twelve years earlier she had undergone a Bentall-de Bone procedure and 7 years earlier a thoracic aorta aneurysm (TAA) was repaired with an endovascular prosthesis. EUS confirmed choledocholithiasis, however a large aneurysm (60 mm of diameter), was incidentally detected at the distal end of the aortic endoprosthesis. Computed tomography (CT) later confirmed the aneurysm, extending 4.5 cm above the renal arteries. The patient underwent a successful new endovascular repair. This rare incidental finding underscores the usefulness of a systematic approach when performing EUS, enabling the detection of significant abnormalities beyond the initial indication and allowing for early intervention in TTA patients.

A Case of Gigantic Unruptured Abdominal Aneurysm Successfully Treated With Endovascular Repair (EVAR)

Aortic aneurysms are focal dilations of more than 50% the normal aortic diameter; giant abdominal aortic aneurysms (AAAs) have diameters greater than or equal to 10 cm and are rare clinical entities. We present a case of an elderly man with an AAA with a 14.6-cm diameter, treated successfully with endovascular repair (EVAR). AAAs pose anatomical challenges for EVAR because of their narrow necks, extreme angulation, and dislocation of intra-abdominal organs. A literature review shows only 5 EVARs have been attempted for the repair of giant AAAs; 4 were successful. With the technical advancement and careful patient selection, successful EVAR of giant AAAs is possible.