Successful Exclusion Research Articles

Mid-Term Outcomes of the Viabahn Balloon-Expandable Endoprosthesis as Bridging Stent Graft for Fenestrated and Branched Endovascular Aortic Repair.

Bridging stent grafts (BSG) implanted during fenestrated and branched endovascular aortic repair (F/B-EVAR) are crucial for the successful exclusion of thoracoabdominal and complex abdominal aortic aneurysms (AAA). The aim of this study was to analyze the outcomes of the Gore Viabahn VBX stent graft as BSG for renal and visceral target vessels during F/B-EVAR. All consecutive patients undergoing F/B-EVAR for thoracoabdominal or complex AAAs from January 2019 to May 2023 who were treated with at least 1 VBX stent graft as BSG were included. Procedural, radiological, and follow-up data of the included patients were retrospectively reviewed. Primary outcome of the study was technical success of VBX stent graft implantation. Secondary endpoints were VBX-related adverse events, target vessel instability, endoleaks, and overall survival. A total of 273 VBX stent grafts were implanted in 263 target vessels in 38 FEVAR, 46 BEVAR, and 3 F/B-EVAR (combined design) stent grafts in 87 patients (74.7% male; mean age, 73.6 ± 7.0 years). Technical success of VBX stent graft implantation was 97.5% with 273 successful implantations in 280 attempts. The VBX-related secondary endpoints were evaluated for 269 VBX stent grafts in 259 target vessels. Target vessel designs included 107 fenestrations (41.3%), 82 outer-branches (31.7%), and 70 inner-branches (27.0%). Freedom from VBX-related adverse events at 12 months postoperatively was 96.6% (95% CI: 92.9%-100%) for target vessels with a fenestration and 93.6% (95% CI: 89.4%-98.0%) for target vessels with a branch. Freedom from target vessel instability at 12 months postoperatively for fenestrations and branches was 98.1% (95% CI: 94.4%-100%) and 97.6% (95% CI: 94.9%-100%) respectively. A total of 9 (3.5%) VBX-related endoleaks were detected during follow-up. Overall survival of all treated patients was 86.7% (95% CI: 79.1%-94.9%) at a median follow-up of 14 months. The VBX stent graft shows an excellent performance as a BSG in F/B-EVAR. The VBX stent graft has a high technical implantation success and shows a high mid-term freedom from stent graft-related adverse events and target vessel instability for both target vessels with a fenestration and a branch. Long-term follow-up data of the performance of the VBX stent graft are to be awaited. This study evaluated the outcomes of the Gore Viabahn VBX stent graft as a bridging stent graft (BSG) for renal and visceral target vessels. It is important to evaluate the performance of such recently introduced stent grafts as these are essentially used in procedures outside of the Instructions for Use. This comprehensive analysis of the VBX stent graft as a BSG adds to the evidence of the performance of this stent graft as a BSG.

Percutaneous transcatheter closure of a large saphenous vein graft aneurysm with Amplatzer vascular plug

A saphenous vein graft (SVG) aneurysm is a rare complication seen in coronary artery bypass grafts (CABG). While the sternotomy for surgical correction is used in most of these patients, depending on the patient’s condition, an alternative method may be required. This case is a 64-year-old man who developed SVG aneurysm more than 10 years after CABG and underwent a successful percutaneous transcatheter exclusion of SVG aneurysm using 10 mm Amplatzer Vascular Plug 2, resulting in prevention of blood flow into the aneurysm and future rupturing. This case illustrates the potential of noninvasive treatment with flexible procedures based on the patient’s anatomy and risk for complicated surgery. Keywords: Amplatzer vascular plug, saphenous vein graft, saphenous vein graft aneurysm, coronary artery bypass graft

Fast Exclusion Candidate Identification Based on Sparse Estimation for ARAIM Fault Exclusion Process

Advanced receiver autonomous integrity monitoring (ARAIM) is an integrity technique for a global navigation satellite system (GNSS), centered on the multiple hypothesis solution separation (MHSS) test, which assesses the consistency between a subset and the all-in-view solution. Successful fault exclusion (FE) in ARAIM relies on identifying exclusion candidates that ensure no faults among the remaining satellites, a process requiring computationally expensive MHSS tests. The existing methods guide exclusion candidate searches based on the size of the normalized solution separation statistics, i.e., the normalized absolute difference between the subset solution and the all-in-view solution. However, in scenarios involving more than one satellite fault, these statistics can become unreliable due to fault diversity and interactions, perhaps misleading the FE process and causing its failure. To overcome this issue, our study proposes employing sparse estimation to simply identify satellite faults in one go, leveraging the sparsity of faulty satellites compared to the total number of observations in civil aviation GNSSs. Unlike the existing methods, which infer the fault likelihood indirectly through solution separation statistics, our approach represents an improvement that directly indicates potential exclusion candidates. Our experiments demonstrate that this method is fast and accurate. As a fundamentally different approach, it serves as a valuable complement or an alternative to the existing methods, enhancing the success and efficiency of the ARAIM FE process.

Facilitators and barriers to implementing successful exclusion among children with shiga toxin-producing Escherichia coli: a qualitative analysis of public health case management records

BackgroundShiga toxin-producing Escherichia coli (STEC) infections are a significant public health concern as they can cause serious illness and outbreaks. In England, STEC incidence is highest among children and guidance recommends that children under six diagnosed with STEC are excluded from childcare until two consecutive stool cultures are negative. We aimed to describe the barriers and facilitators to implementing exclusion and the impact of exclusion policies on young children and their families.MethodsIndividual level data was obtained from a wider study focusing on shedding duration among STEC cases aged < 6 years between March 2018 – March 2022. Data was extracted from England’s public health case management system. The case management system includes notes on telephone conversations, email correspondence and meeting minutes relating to the case. Collected data consisted of free text in three forms: (1) quotes from parents, either direct or indirect, (2) direct quotes from the case record by health protection practitioners or environmental health officers, and (3) summaries by the data collector after reviewing the entire case record. We analysed free text comments linked to 136 cases using thematic analysis with a framework approach.ResultsThe median age of included cases was 3 years (IQR 1.5-5), with males accounting for 49%. Nine key themes were identified. Five themes focused on barriers to managing exclusion, including (i) financial losses, (ii) challenges with communication, engagement and collaboration, (iii) issues with sampling, processing, and results, (iv) adverse impact on children and their families and (v) conflicting exclusion advice. Four themes related to facilitators to exclusion, including (i) good communication with parents and childcare settings, (ii) support with childcare, (iii) improvements to sampling, testing, and reporting of results, and (iv) provision of supervised control measures.ConclusionsQualitative analysis of public health case records can provide evidence-based insights around complex health protection issues to inform public health guidelines. Our analysis highlights the importance of considering wider social and economic consequences of exclusion when developing policies and practices for the management of STEC in children.

Attentional set and explicit expectations of perceptual load determine flanker interference.

Task-irrelevant stimuli often capture our attention despite our best efforts to ignore them. It has been noted that tasks involving perceptually complex displays can lead to reduced interference from distractors. The mechanism behind this effect is debated, with some accounts emphasizing the "perceptual load" of the stimuli themselves and others emphasizing the role of proactive control. Here, in three experiments, we investigated the roles of perceptual load, proactive control, and reward motivation in determining distractor interference. Participants performed a visual search task of high, low, or intermediate load, with flanking task-irrelevant distractors. Each trial was preceded by a cue indicating the level of perceptual load (Experiments 1-3) as well as the potential reward that could be earned (Experiments 2 and 3). In all three experiments, the attentional set induced by the preceding trial and cued proactive expectation of perceptual load interacted to determine flanker interference, which was significant for all trial types except trials cued as high load which were also preceded by high load. These effects were not modulated by reward motivation, although in the final experiment reward did significantly improve performance overall. Thus, successful distractor exclusion does not depend upon motivation or load per se but does require an expectation of high load. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Endovascular repair of bilateral isolated common iliac artery aneurysms with unsuitable anatomy utilizing an aortic bifurcated unibody endograft and modified sandwich technique to preserve pelvic blood flow: a case series

Bilateral isolated common iliac artery aneurysms (CIAAs) are rare, and endovascular repair of CIAAs has emerged as an alternative to traditional open surgical repair. The primary goal of therapy is to exclude the aneurysm sac while maintaining perfusion of at least one internal iliac artery (IIA) to prevent pelvic ischemia. Although the iliac branch device (IBD) has improved the feasibility of preserving the IIA, its applicability is limited to a specific subset of aneurysm anatomy. We present a case series of three patients with bilateral isolated CIAAs in whom preoperative CT scans revealed an absence of a landing zone, the diameter of proximal CIA diameter was less than 13.0 mm, and normal diameter of the nonaneurysmal infrarenal aorta, making it challenging to use an IBD alone or a standard bifurcated aortic endograft to provide a proximal landing zone for iliac artery stenting. To overcome the small diameter of the infrarenal aorta, we implanted an aortic bifurcated unibody endograft. Then, we utilized a balloon-expandable covered stent-graft with overdilation as a modified sandwich technique to create an “eye of the tiger” configuration to prevent gutter leakage. The final angiography performed during the procedure revealed successful exclusion of the aneurysms, with blood flow to the right IIA and no type III endoleak. During the postoperative follow-up period, no patients exhibited symptoms associated with pelvic ischemia. There were no endoleaks or sac expansions on the two-year follow-up CT scans, and all external and internal iliac graft limbs were patent. This study demonstrated that a combination of an aortic bifurcated unibody endograft and a modified sandwich technique can effectively treat bilateral isolated CIAAs with certain anatomical constraints.

Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations.

To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy. In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM. Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5months (range 2-10), all stents remained patent, and AVMs were excluded without other complications. Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.

The Role of Aortic Volume in the Natural History of Abdominal Aortic Aneurysms and Post-Endovascular Aortic Aneurysm Repair Surveillance.

There has been a debate about whether maximum diameter can be solely used to assess the natural history of abdominal aortic aneurysm. The aim of the present review is to collect all the available evidence on the role of abdominal aortic aneurysm (AAA) volume in the natural history of AAAs, including small untreated AAAs and AAAs treated by EVAR. The current literature appears to reinforce the role of volume as a supplementary measure for evaluating the natural history of AAA, in both intact AAAs and after EVAR. The clinical impact of AAA volume measurements remains unclear. Several studies show that volumetric analysis can assess changes in AAAs and predict successful endoluminal exclusion after EVAR more accurately than diameter. However, most studies lack strict standardized measurement criteria and well-defined outcome definitions. It remains unclear whether volumetry could replace diameter assessment in defining the risk of rupture of AAAs and identifying clinically relevant sac growth.

Application of hybrid operating room in the surgical treatment for intracranial aneurysm

BackgroundIntracranial aneurysms are associated with a high mortality rate in the event of a rupture and significant morbidity during subsequent treatment. Hybrid treatment approaches for vascular diseases have been incorporated into modern operating rooms as guides for surgical interventions now. The current study evaluates the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment of intracranial aneurysms. AimsTo evaluate the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment for aneurysms. Methods76 patients with 84 intracranial aneurysms were surgically treated in Hybrid operating room with intraoperative angiography between March 2018 and March 2021. Aneurysm clipping was performed in 76 (94.7 %) cases; Aneurysm trapping with extracranial-intracranial (EC-IC) bypass in 4 (5.3 %) cases. Patient demographics, aneurysm size, location, Hunt and Hess score, were recorded. 69 (90.8 %) patients were followed up 6–12 months post operation. ResultsIntraoperative angiography demonstrated 5 (6.9%) unexpected aneurysm neck residuals leading to adjustment; 6 (8.3%) parent vessel stenosis in which 5 returned to normal after adjustment. Four giant paraclinoid aneurysms trapping with EC-IC bypass showed total successful vessel reconstruction and complete aneurysm exclusion (100%). The postoperative outcome was evaluated with the modified Rankin Scale (mRS). 53 (76.8%) patients showed good outcome (mRS 0), 11 (15.9%) showed mild neurological defect (mRS 1–2), 3 (4.3%) showed poor outcome (mRS 5), and 2 (2.9%) patients died (mRS 6, Hunt-Hess grade V before surgery). Conclusion: Hybrid operating room provides new concepts in the surgically treatment of intracranial aneurysms, especially valuable for the complex aneurysms. The combination of intraoperative imaging of angiography and clipping surgery may offer the opportunity of radical clipping and reduced complications for aneurysm patients.

Comparison of Open and Endovascular Aneurysm Repair in Native Arteriovenous Fistulas

Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF). A retrospective review of all upper extremity primary AVFs over 12years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined. Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1±2 (mean±standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P=0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2±3 vs. 2±2weeks, mean±SD; endovascular open repair versus open repair; P=0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P=0.04). Median functional dialysis durations were superior in the open repair (48±6%, mean + standard error) compared to the endovascular repair at 5years. (26±7%; P=0.03). Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.

Incorporation of internal iliac arteries as target vessels during physician-modified fenestrated branched endovascular repair of pararenal abdominal aortic aneurysm with concomitant bilateral short common iliac artery aneurysms

This report describes an alternative endovascular approach to iliac branch devices for treatment of an abdominal aortic aneurysm with concomitant bilateral short common iliac aneurysms. The short distance between the renal arteries and internal iliac artery origins made the addition of distal iliac branch devices to the proximal fenestrated stent graft challenging. We elected to perform physician-modified fenestrated branched endovascular repair, using four fenestrations for the visceral and renal arteries and an additional two directional branches for the bilateral internal iliac arteries. The patient recovered uneventfully, and the 24-month follow-up imaging shows successful aneurysm exclusion with patent internal iliac artery branches.

Endovascular Popliteal Artery Aneurysm Repair Using an "Off-Label" Abdominal Endograft Limb-Module with Nitinol-Ring Structure: A Single Centre Experience.

To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure. Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6cm (range 2.1-5.3cm). Stent-graft diameters and lengths used were 10-15 and 60-140mm, respectively. The median covered stented length was 218mm (range 160-270mm) and median duration of follow-up was 3.7years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival. All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30days. Primary stent-graft patency at 1, 3 and 4years was 93%, 75%, and 64%. By 8years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5years was 93%/84% and 93%/67%, respectively. The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

Endovascular repair for arterio-venous fistula treatment: a case report

BackgroundArterio-venous fistula is a rare clinical entity that occurs as a result of a ruptured abdominal aortic aneurysm into the inferior vena cava or iliac vein. Open surgery has been considered the treatment of choice for this condition; however, endovascular repair has become an evolving therapeutic option over the past 20 years. The endovascular treatment has contributed to a decrease in the perioperative mortality; nevertheless, some endovascular repair specific concern for residual fistula still remains.Case presentationA 70-year-old man was referred to our department for an enlarged inferior vena cava without any complaint. Contrast-enhanced computed tomography demonstrated a 40-mm AAA and a 42-mm right saccular CIAA, with a fistula between the CIAA and left CIV. Endovascular aneurysm repair which focused on the exclusion of the right CIAA and prevention of endoleak formation was performed. To prevent type 2 endoleaks, which cause residual arterio-venous shunt flow, right internal iliac artery was embolized with a vascular plug prior to stent graft procedure. Successful aneurysm exclusion without residual arterio-venous shunt flow was confirmed with a final angiographic examination. The patient had an uneventful recovery, and computed tomography 1 month later showed no sign of persistent fistula.ConclusionsAlthough endovascular treatment for AVF has a negative possibility of residual shunt, stent graft with a focus on type 2 endoleak prevention can be an attractive treatment option, reducing the incidence of residual AVF.

Kommerell's Diverticulum in a Right-Sided Aortic Arch With an Aberrant Left Subclavian Artery Hybrid Repair.

Kommerell's diverticulum (KD) with a right aortic arch (RAA) and aberrant left subclavian artery (aLSCA) is a rare congenital anomaly of the aortic arch. Treatment is not well defined due to its uncommon presentation, with rupture and dissection risk rates of up to 53%. A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred. We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.

Mesenteric arteries aneurysms rupture secondary to paradoxical hypertension after aortic coarctation stenting.

A 51-year-old female with long-term poorly controlled hypertension was found to have a systolic murmur on physical examination. A transthoracic echocardiogram showed a bicuspid aortic valve with left ventricular hypertrophy and normal ejection fraction. Computed tomography (CT) detected a critical coarctation of the aorta (Panel A). The invasive gradient through the coarctation was 80 mmHg. It was decided to treat with stent implantation (Panels B and C). A covered cheatham-platinum stent of 39 mm mounted on a balloon-in-balloon balloon of 16 × 40 mm was successfully implanted. Immediately after stent deployment, the systolic blood pressure reached 210 mmHg, despite pharmacological treatment. The day after the procedure, the patient started with abdominal pain and an emergency CT scan was performed (Panel D). Computed tomography showed a large mesenteric haematoma (with no active bleeding at that moment), a large aneurysm of the proximal ileocolic artery, and a small aneurysm of the middle colic artery. Angiography confirmed these findings (Panel E) and it was decided to embolize both aneurysms using Micro Vascular Plugs and coils, which resulted in a successful exclusion of the aneurysms but also in a lack of vascularization of the distal ileum and ascending colon (Panel F), that eventually required resection (right hemicolectomy). The possibility of aneurysms and other alterations in the vessels of patients with aortic coarctation should be considered. Whether these anomalies should be treated before stenting is still unknown. Paradoxical hypertension after stent implantation and its severe complications could be prevented by pharmacological treatment days before the intervention.

Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report.

Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients. A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup. Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length. After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD. The stent grafts were patent without endoleak at the 6-month follow-up. In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Giant True Inferior Pancreaticoduodenal Artery Aneurysm Associated with Celiac Axis Occlusion

Giant visceral artery aneurysms are uncommon. Branch vessel aneurysms, particularly of the pancreaticoduodenal territory are challenging to treat due to their location, anatomy, and access to an aneurysm. While open surgical resection is associated with significant morbidity, endovascular treatment is becoming increasingly mainstream. The utilization of coil embolization, particularly in the setting of rupture has been well described. Access and platform in these settings often involve the celiac axis. We describe unusual care of a large inferior pancreaticoduodenal aneurysm and associated retroperitoneal bleed, being fed through an ectatic superior mesenteric artery. This was associated with an occluded celiac axis. Due to the unusually large proximal and distal landing zones, a covered balloon-expandable stent was deployable with the successful exclusion of the aneurysm. This is the first reported case report of successful management of retroperitoneal rupture and associated pancreaticoduodenal aneurysm treated with a covered stent graft. This technique allowed for rapid access and exclusion of the aneurysm. In addition, it allowed the preservation of foregut flow through the collateral pathway and successfully excluded the large aneurysm.

A Giant Coeliac Trunk Aneurysm

A 66 year old man with hypertension as the only cardiovascular risk factor had an incidental ultrasound diagnosis of an abdominal aortic aneurysm > 90 mm in diameter. In contrast, computed tomography angiography (CTA) detected an isolated dissection of the coeliac trunk (A, asterisk) with large pseudoaneurysm 11 cm in diameter, with a contained rupture. Through a right femoral percutaneous access, a balloon expandable 8 × 59 mm VBX covered stent (Gore & Associates, Flagstaff, AZ, USA) was deployed in the coeliac trunk. Post-operative CTA showed successful exclusion of the aneurysm and a patent coeliac trunk (B, arrows).Image 1

Aortic Valve Replacement and Exclusion of Sinus of Valsalva Aneurysm With Balloon-Expandable Transcatheter Aortic Valve

An 85-year-old female with severe aortic valve stenosis presented with heart failure complicated with cardiogenic shock and was found to have a right coronary cusp sinus of Valsalva aneurysm. We report the first case of successful exclusion of a sinus of Valsalva aneurysm during transcatheter aortic valve replacement using a balloon-expandable valve. (Level of Difficulty: Intermediate.)

Stent Graft Induced Thoracic Aortic Rupture After 10 Years

A 72 year old male underwent thoracic endovascular aortic repair and left carotid subclavian bypass for a saccular aneurysm in arch zone 3. Post-operatively, annual computed tomography angiography (CTA) follow up showed patency of the bypass and successful exclusion of the saccular aneurysm with shrinkage and no evidence of migration, fracture, or endoleaks (A, arrows). At 10 years, the patient was asymptomatic, but CTA detected a stent graft induced contained aortic rupture at the distal landing zone (B, asterisk). Distal endograft extension was performed successfully using the through and through technique to seal the rupture. No complications occurred and post-operative CTA confirmed exclusion of the aneurysm.Image 1