Successful Exclusion Research Articles

Urgent endovascular repair for ruptured aortic aneurysm using computed tomography image fusion

Abdominal aortic aneurysm rupture remains a cardiovascular catastrophe with strikingly high morbidity and mortality rates. Endovascular aneurysm repair management has recently emerged as a valuable treatment modality for ruptured abdominal aortic aneurysm, but better outcomes have to be reached. Image fusion may potentially improve perioperative outcomes in selected patients, guiding navigation and device implantation and limiting contrast dosage during interventions. We report an 83-year-old man presenting with an 80-mm infrarenal aortic aneurysm rupture suitable for endovascular aneurysm repair. Endovascular navigation and stent graft deployment were achieved using computed tomography image fusion for the first reported case in English.

Successful 36 Months Result of Debranching TEVAR for Kommerell?s Diverticulm with the Aberrant Left Subclavian Artery

A case of successful endovascular repair of right aortic arch with the aberrant left subclavian artery (ALSA) arising from Kommerell’s diverticulum (KD). Our strategy consisted of coil embolization for the orifice of the ALSA, put the bypass between left common carotid artery and left subclavian artery and exclusion of KD by stent graft insertion. Enhanced computed tomography scan 36 months after the operation showed successful exclusion of KD, patency of the bypass graft, and no evidence of endoleak. Endovascular repair can be a safe and effective treatment for aortic disease with challenging anatomy in the midterm, avoiding the need for a complex open surgery procedure. It is very rare in this successful case with midterm result we presented.

Endovascular Rescue of a Narrowed Aorto-Aortic Bypass Graft in a Patient with Takayasu’s Arteritis

We report a case of successful endovascular treatment of a pseudoaneurysm and the obstruction of an aorto-aortic bypass graft, which had been performed to treat Takayasu’s arteritis fifteen years prior, at the thoracic aorta. Along with the immediate relief of proximal hypertension that had caused severe heart failure, the successful exclusion of the pseudoaneurysm and the patency of the stem graft were maintained three years after the procedure.

Left Atrial Appendage Thrombus After Successful Surgical Exclusion on Anticoagulation: A Need for Closer Postintervention Monitoring

A 59-year-old man with long-standing persistent atrial fibrillation underwent the first stage of a hybrid Maze by bilateral video-assisted thoracoscopy. Preoperative transesophageal echocardiogram (TEE) showed no atrial clot or mitral regurgitation. The left atrial appendage (LAA) was excluded with Endoloops (Ethicon, Somerville, NJ). He was discharged in sinus rhythm with prescriptions and instructions for continuing antiarrhythmic medications and warfarin. After 2 months, TEE demonstrated a 0.7-cm appendage stump (dotted arrow, Fig 1A) with thrombus (arrow, Figs 1A and 1B) despite adequate anticoagulation (INR 3.2). Six weeks later, TEE showed persistent, though smaller, thrombus (Fig 1C). Expert consensus on atrial fibrillation recommends complete LAA occlusion. Surgical literature defines remnant LAA as a stump or pouch longer than 1 cm [1Kanderian A.S. Gillinov A.M. Pettersson G.B. et al.Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography.J Am Coll Cardiol. 2008; 52: 924-929Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar]. After exclusion, late neurologic events occur at 0.2% with excision and 1.13% with nonexcisional techniques (median occurrence, 3.6 years) [2Lee R. Jivan A. Kruse J. et al.Late neurologic events after surgery for atrial fibrillation: rare but relevant.Ann Thorac Surg. 2013; 95: 126-132Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. This case demonstrates continued risk despite conventionally defined exclusion success. Similarly, reported endocardial thrombus after LARIAT (SentreHeart, Redwood City, CA) [3Giedrimas E. Lin A.C. Knight B.P. Left atrial thrombus after appendage closure using LARIAT.Circ Arrhythm Electrophysiol. 2013; 6: e52-e53Crossref PubMed Scopus (23) Google Scholar] implantation raises concerns with percutaneous techniques. These cases call for consideration of routine TEE monitoring, redefinition of successful exclusion, and improvement of current techniques.

Impact of left atrial appendage exclusion using an epicardial ligation system (LARIAT) on atrial fibrillation burden in patients with cardiac implantable electronic devices.

The left atrial appendage (LAA) is a well-known source of atrial arrhythmia and atrial fibrillation (AF). The purpose of this study was to determine whether LAA exclusion using the LARIAT device would decrease AF burden. A total of 50 patients with AF and cardiac implantable electronic devices who underwent successful LAA exclusion were enrolled in this prospective observational study. AF burden before LAA exclusion (baseline) and 3 and 12 months after exclusion was assessed by device interrogation. AF burden at 3-month follow-up (42% ± 34%) was significantly lower compared to baseline (76% ± 33%, P < .0001). The reduction in AF burden was sustained at 12 months (59% ± 26%, P < .001). Subgroup analysis revealed that AF burden at 3-month follow-up was similarly reduced in both paroxysmal AF (n = 19) and nonparoxysmal AF (n = 31). However, there was no reduction in AF burden in patients with paroxysmal AF at 12 months. AF burden in patients with known AF triggers in the LAA (n = 9) was significantly reduced at 3 months (52% ± 35%) and 12 months (42% ± 19%) compared to respective baseline (84 ± 31%, P < .0001). LAA exclusion appears to reduce AF burden. The presence of AF triggers in the LAA appears to be the strongest predictor of AF reduction. The study underscores the role of the LAA in arrhythmogenesis for AF and highlights the complementary role of LAA exclusion in restoration of normal sinus rhythm.

Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal Artery Aneurysm Repair

The aim was to evaluate long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). This study was a retrospective review of all EVPAR cases between 1999 and 2012. Sac volume shrinkage, long-term patency, limb salvage, and survival were evaluated using Kaplan-Meier estimates. The association of anatomical and clinical characteristics with patency was evaluated using multivariate analysis. Forty-six EVPAR were carried out in 42 patients (mean age 78 years, 86% male; mean sac volume 45.5 ± 3.5 mL). In 93% of cases (n = 43) the procedure was elective, while in 7% of cases it was for rupture (n = 2) or acute thrombosis (n = 1). Of the 43 patients who underwent elective repair, 58% were asymptomatic and 42% symptomatic (14 claudication, 3 rest pain, and 1 compression symptoms). Technical success was 98%. Mean duration of follow-up was 56 ± 21 months. Primary patency at 1, 3, and 5 years was 82% (SE 2), 79% (SE 4), and 76% (SE 4), while secondary patency was 90% (SE 5), 85% (SE 4), and 82% (SE 1) respectively; at 5 years there was 98% limb salvage and an 84% survival rate. During follow-up 11 limbs had stent graft failure: six required conversion, one underwent amputation, and four continued with mild claudication. Of those with graft failure, 63% (7/11) occurred within the first year of follow-up. The mean aneurysm sac volume shrinkage between preoperative and 5-year post-procedure measurement was significant (45.5 ± 3.5 mL vs. 23.0 ± 5.0 mL; p < .001). Segment coverage >20 cm was a negative predictor for patency (HR 2.76; 95% CI 0.23; p = .032). EVPAR provides successful aneurysm exclusion with good long-term patency, excellent limb salvage, and survival rates. Close surveillance is nevertheless required, particularly during the first postoperative year. Patients requiring long segment coverage (>20 cm) may be at increased risk for failure.

Parallel Endografts in the Treatment of Distal Aortic and Common Iliac Aneurysms

Endovascular treatment of distal abdominal aortic aneurysms (D-AAA) and bilateral common iliac artery aneurysms (BCIAA) may present technical challenges for standard EVAR. Parallel iliac leg endografts (ILEs) of standard aortic devices and covered stents have been successfully employed to treat patients with D-AAA and BCIAA. The perioperative and long-term results of this straightforward endovascular technique are presented. Beginning in 2009, patients deemed unfit for open surgery underwent parallel endografts D-AAA and BCIAA exclusion. Avoiding the use of a main body, ILEs are simultaneously delivered from both femoral arteries, landing parallel into the aortic neck (parallel grafts: PG). Distal landing zones including external iliac arteries (EIAs) are reached using appropriate ILEs. A third parallel covered stent graft (Viabahn, Gore) is delivered from a left brachial approach to maintain prograde blood flow to one internal iliac artery (IIA) when needed. Eighteen patients were successfully treated using parallel endografts, nine for BCIAA and nine for D-AAA. All D-AAA presented an irregular saccular shape, including three penetrating aortic ulcers and two pseudoaneurysms of previous aortic grafts. Prograde flow to one IIA was successfully maintained using a Viabahn graft in five patients with BCIAA. Mean aneurysm size was 50 mm in D-AAA and 43 mm in BCIAA. One patient required a perioperative ILE extension to treat a type Ib endoleak. One patient suffered a minor stroke 24 hours after the procedure. Two type II endoleaks were observed postoperatively. Five patients died of non-aneurysm related causes during follow-up. No new endoleaks, graft displacements or occlusions were observed during follow-up (median: 26 months, range 12-42 months). Successful exclusion of D-AAA and BCIAA was achieved in high-risk patients using parallel endografts, allowing antegrade blood flow to one IIA when needed. Commercially available endografts were used in a simple and effective approach, with excellent follow-up results.

Aiming at one-stage corrective surgery for extended thoracic aortic dilatation.

Definitive treatment of extended thoracic aortic dilatation is a major surgical challenge. Histopathology of resected thoracic aortic wall may reveal undiagnosed aortitis affecting outcome. We sought to investigate the benefit of thorough histopathology after one-stage corrective surgery for the treatment of extended thoracic aortic dilatation. Five patients underwent one-stage corrective surgery using the hybrid open arch repair by the frozen elephant trunk together with endovascular aortic grafting. A representative sample of the resected aortic arch was procured for histology. T- and B-lymphocytes, plasma cells, macrophages, and immunoglobulin G4 (IgG4) positivity were evaluated by immunohistochemistry. The mean preoperative maximum aortic diameter was 54 mm (range, 41-79 mm). The mean follow-up was 18 months (range, 1-24 months). As confirmed by computed tomography (CT) upon follow-up, complete thrombosis of the false lumen at the level of the frozen elephant trunk was achieved in all patients with dissection. One patient was operated due to atherosclerotic dilatation of the thoracic aorta, and postoperative CT showed successful exclusion of the atherosclerotic dilatation; this 75-year-old man was diagnosed with IgG4-positive aortitis and experienced unexpected blindness after surgery without evidence of emboli or long-term neurological impairment upon repeated brain CT. The hybrid open arch repair by the frozen elephant trunk and simultaneous endovascular repair is a feasible choice for one-stage surgery through sternotomy aiming at definitive treatment of extended thoracic aortic pathology. However, systematic evaluation of inflammation may reveal concealed aortitis affecting postoperative outcome and need for long-term surveillance.

Hybrid endovascular treatment of an aberrant right subclavian artery with Kommerell aneurysm

Aberrant right subclavian artery is a rare anatomical finding of abnormal embryologic development of the dorsal aorta and right subclavian artery. An associated aortic outpouching, or Kommerell diverticulum, may develop at the origin of the aberrant right subclavian artery. Given historically high rates of aneurysm rupture and mortality, early repair is indicated. Successful aneurysm exclusion can be accomplished with thoracic endovascular stent grafting following open carotid-subclavian bypass, maintaining upper extremities perfusion. Such hybrid techniques offer a decrease in mortality and complication rates. Herein, we describe a successful repair of a symptomatic (dysphagia, weight loss) aberrant right subclavian artery with Kommerell diverticulum using this hybrid open-endovascular approach.

Selective Endovascular-First Approach for Critical Limb Ischemia Carries Minimal Cost of Worsening Long-Term Outcomes

was embolized with Interlock Fibered IDC (Boston Scientific) 3 mm coils. Postembolization common hepatic angiogram revealed successful exclusion of the sac, flush occlusion of the GDA, and patent hepatic arteries. Selective celiac and SMA angiogram revealed patent vessels with no retrograde flow into the VAPA. The patient had an unremarkable postoperative course without any further bleeding. He was discharged on postoperative day 5. A follow-up computed tomographic angiography confirmed continued exclusion of VAPA. Conclusions: VAPA should be included in the differential diagnosis of patients presenting with GI bleeding. Coil embolization using microcatheter techniques is a suitable treatment option for this challenging clinical condition. Advanced embolization techniques should be included in the training and practice of modern vascular surgeons.

Exclusion of an Internal Iliac Artery Aneurysm Using Stacked Aorto-uni-iliac Converters over a Femoro-femoral Pullthrough Wire

An endovascular solution for treating internal iliac artery aneurysms (IIAAs) with tortuous iliac anatomy and intraprocedural complications is presented. An 85-year-old male presented with a 7-cm left IIAA causing hydronephrosis. Following inability to deploy a standard aorto-uni-iliac converter and subsequent iliac dissection, two low-profile aorto-uni-iliac converters were deployed from the external to common iliac artery over a femoro-femoral pullthrough wire, achieving a stacked configuration and successful aneurysm exclusion. Iliac artery tortuosity may preclude successful iliac coverage and predispose to dissection. A pullthrough wire allows arterial straightening; use of flexible low profile devices facilitates procedural success.

Endovascular Exclusion of Complex Postsurgical Aortic Arch Pseudoaneurysm Using Vascular Plug Devices and a Review of Vascular Plugs

We report the management of a patient presenting with haemoptysis due to aortobronchial fistula. He had previously undergone emergency exclusion bypass of a ruptured pseudoaneurysm developing post-aortic coarctation repair. Computed tomography scan showed persistent filling of pseudoaneurysm sac from proximal and distal aortic ligature sites tied during previous exclusion bypass surgery. Successful exclusion of aneurysm was achieved by using 3 vascular plug devices (1 Amplatzer plug II and 2 Amender patent ductus arteriosus occluder devices). We also review types of Amplatzer vascular plugs and their use in peripheral vascular interventions.

The “Periscope” Technique Successfully Lengthens the Distal Landing Zone During TEVAR

We describe our early experience with the “periscope” technique to extend the distal landing zone and successfully treat distal thoracic pathology in patients with inadequate distal seal zones near the mesenteric vessels. Four consecutive patients with planned endovascular repair of complex TAA extending near mesenteric and renal arteries were reviewed. In the periscope configuration, which is similar to an upside-down snorkel/chimney approach, parallel stent grafts adjacent to the TEVAR device were placed into the mesenteric and renal vessels from the contralateral femoral approach. Six periscope grafts (4 SMA, 2 in solitary renal arteries) were utilized in four patients (mean age, 72 years). Mean aneurysm diameter was 69.5 mm (range, 59-85 mm), and the “periscope” configuration improved the distal seal zone from a diameter of 45 mm and length of 0 mm to a more appropriate landing zone of 33 mm diameter and 28 mm length. Technical success was 100% and all patients are alive at latest followup (mean, 15.1 months; range, 9-23). The only morbidity was reoperation for femoral access occlusion. Postoperative follow-up imaging revealed all six periscopes to be patent. One small type Ib and one type II endoleak have been observed without aneurysm sac enlargement. All aneurysms have regressed with mean sac change of -4.7 mm. In select high-risk patients opting for an all-endovascular approach of distal thoracic pathology, the “periscope” technique is successful in extending the landing zone into juxtamesenteric and juxtarenal anatomies to provide successful aneurysm exclusion. Long-term follow-up is obviously necessary to assess for continued protection from aneurysm rupture, but at this point it appears to be safe and effective until fenestrated/branched grafts become more widely available.

Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling.

Staged hybrid open and endovascular exclusion of a symptomatic thoracoabdominal aortic aneurysm in a high-risk patient

Thoracoabdominal aortic aneurysms have a higher prevalence in the elderly, who are often poor surgical candidates. These extensive aneurysms may be lethal if left untreated. Conventional open repair has proven to be a major task, involving cardiopulmonary bypass, aortic cross-clamping and expeditious repair of an inaccessible structure involving two body cavities. Endovascular repair has become a viable option to treat isolated descending thoracic aneurysms and infrarenal abdominal aortic aneurysms. However, endovascular techniques alone have been less applicable for treating complex aortic aneurysms, including those involving visceral vessels. Therefore, a hybrid open and endovascular approach with visceral debranching has become an increasingly favorable alternative for patients with these complex conditions. We report a case in which a staged hybrid approach was used for successful exclusion of an extensive thoracoabdominal aortic aneurysm in a symptomatic, high-risk patient who would not have been an appropriate candidate for open surgical repair.

Long Term Outcomes and Sac Volume Shrinkage After Endovascular Popliteal Artery Aneurysm Repair

To evaluate long term outcomes and sac volume (SV) shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). A retrospective review of EVPAR cases performed between January 1999 and December 2012. SV shrinkage, long term patency, limb salvage (LS), and survival (S) were evaluated with K-M estimates. Anatomical characteristics and clinical presentation were evaluated for their association with patency using multiple logistic regression. 46 EVPAR procedures in 42 patients. Mean age was 68 yr, 86% were male; mean SV 42 ± 12 cm3. Elective repair in 91% of cases, while 9% treated for rupture or thrombosis; 56% were asymptomatic, 35% had claudication and 9% rest pain. Technical success was 98%. At mean follow-up of 84 months (range, 6 to 138 months) primary, assisted primary, and secondary patency was 63%, 68%, and 68%; LS was 96% and S 81%. Of the 13 limbs with stent graft failure, seven required conversion, two underwent amputation, while four remained with mild claudication. Of those with graft occlusion, 61% (8 out of 13) of cases occurred within the first year of follow-up. The overall mean difference in aneurysm SV shrinkage at 7 years was significant (42 ± 12 cm3 vs 21 ± 8 cm3; P = .02). The association of covering a length >20 cm and distal landing zone between 1 and 1.5 cm from the take off of the anterior tibial artery (ATA) was a negative predictor for improved patency (OR, 3.05; 95% CI, 1.9 to 2.3; P = .005). EVPAR provides successful aneurysm exclusion with acceptable long term patency, excellent LS and S. However, close surveillance is required, particularly within the first postoperative year. Patients requiring coverage >20 cm and a distal landing zone between 1 and 1.5 cm from the ATA may be at increased risk for failure.

The Chimney Technique in Endovascular Aortic Aneurysm Repair: Late Ruptures After Successful Single Renal Chimney Stent Grafts

The chimney graft technique has been proposed as an alternative endovascular treatment of juxtarenal aortic aneurysms, extending the landing zone and enabling successful exclusion of the aneurysm with standard endograft devices. A prospective observational study assigning patients with juxtarenal aortic aneurysm treated with single renal chimney grafts in a tertiary vascular center in the United Kingdom was conducted. Primary outcome endpoints were defined as technical success, perioperative morbidity and mortality, and freedom from any type of endoleak, reintervention, and aneurysm-related death. Nine patients were enrolled. Successful aortic and chimney graft implantation was achieved in all patients. A proximal type I endoleak noticed on completion angiogram was treated with an aortic extension cuff. None of the patients died within 30 days of treatment. Two patients developed a type IA endoleak during follow-up, resulting in aneurysm rupture and death. Both patients had had uneventful chimney procedures, and no endoleak was evident on previous surveillance computed tomographic scans. All chimney grafts remained patent, and none of the patients developed renal impairment during the follow-up period. Proximal type I endoleak constitutes a weak point of chimney graft interventions. Increased vigilance in surveillance of such patients to prevent late aneurysm-related complications is required. Additional research to identify potential poor prognostic morphologic indicators is expected.

The impact of increased dispersal in response to disease control in patchy environments

This paper uses a mathematical framework to investigate the impact of increased movement in response to disturbance caused by disease control strategies. Implementation of invasive disease control strategies such as culling may cause species to disperse beyond their natural range, thus aiding the spread of infection to otherwise infection free areas. Both linear and non-linear dispersal functions are compared with constant per capita dispersal in a coupled two patch SI model. For highly virulent or infrequently transmitted pathogens, it is found that an increase of dispersal due to control requires a higher level of disease control than in the constant dispersal model. Patches which may be sources or reservoirs of infection are investigated and it is found that if dispersal increases in response to control, then all patches, reservoir or not, must be targeted. The single host two patch model is then extended to a two host wildlife/livestock system with one species ‘wildlife’ free to move between patches and the other ‘livestock’ confined. In the two host case, control of one species alone will only achieve successful pathogen exclusion if that species is a reservoir for infection.

CT Angiography at 24 Months Demonstrates Durability of EVAR With the Use of Chimney Grafts for Pararenal Aortic Pathologies

To present the 24-month radiological follow-up data for patients with pararenal aortic pathologies treated with chimney and periscope grafts during endovascular repair. Between January 2008 and December 2011, 124 high-risk patients with complex pararenal aortic pathologies were treated using the chimney technique at 2 European vascular and cardiovascular centers with advanced experience of the described technique. In particular, 50 patients were treated at Site 1 and 74 at Site 2. Forty (32.2%) patients (32 men; mean age 79.2±4.9 years) completed computed tomographic angiography follow-up at 24 months postoperatively. The overall technical success was 100%, and the early- and midterm procedure-related mortality was 0%. Three (2.4%) patients had a perioperative type Ia endoleak that persisted; two were treated by transbrachial perigraft embolization and cuff implantation. The last patient is under radiological surveillance due to a "low-flow" type Ia endoleak and stable sac size. A type II endoleak was detected in 7 (5.6%) patients. During the 2-year follow-up, significant shrinkage (>5 mm; n=22) or stable aneurysm diameter (n=14) was seen in 36 (90%) of the cases. Overall, mean aneurysm sac shrinkage was 12% (p=0.002) and 10% (p=0.014) for the 2 centers, respectively (overall p=0.008). The causes for sac progression in the 4 (10%) patients were a type Ia endoleak, 2 type II endoleaks, and endotension. The present study demonstrates that the use of chimney and/or periscope endografts for pararenal aortic pathologies achieves and maintains successful exclusion of the aneurysm in 90% of the cases at 24 months of radiological follow-up. In centers experienced with this approach, the chimney technique may represent a reliable therapeutic modality in selected patients.

Initial Experience With a Novel Percutaneous Left Atrial Appendage Exclusion Device in Patients With Atrial Fibrillation, Increased Stroke Risk, and Contraindications to Anticoagulation

Atrial fibrillation (AF) increases by fivefold a patient's risk for thromboembolic stroke. The main source of emboli in AF is the left atrial appendage (LAA). Therefore, LAA closure could reduce the risk for thromboembolic events in AF. The investigators report the first United States experience with a novel percutaneous LAA closure device, the Lariat snare device, and its outcomes in 21 patients with AF, CHADS2 scores ≥2, and contraindications to anticoagulation. The LAA was closed with a snare containing suture from within the pericardial space. The intraoperative success of the procedure was confirmed by left atrial angiography and transesophageal echocardiographic color Doppler flow. The effectiveness of the procedure was evaluated by follow-up transesophageal echocardiography. The incidence of periprocedural and short-term complications was assessed by reviewing medical records. Twenty patients (100%) had successful LAA exclusion that was preserved at 96 ± 77 days. No patient had a stroke during an average of 352 ± 143 days of follow-up. One patient had right ventricular perforation and tamponade that required surgical exploration and repair. Two patients required prolonged hospitalization: 1 because of pericardial effusion that required repeat pericardiocentesis and 1 because of noncardiac co-morbidities. Three patients developed pericarditis <1 month after the procedure, of whom 1had associated pericardial effusion that required drainage. In conclusion, percutaneous LAA exclusion can be achieved successfully and with an acceptable incidence of periprocedural and short-term complications. Further studies are needed to determine whether LAA exclusion lowers the long-term risk for thromboembolic events in patients with AF and contraindications to anticoagulation.