Thoracic Aortic Stent-graft Placement Research Articles

Endovascular Treatment of a Symptomatic Mural Thrombus of the Descending Thoracic Aorta: A Case Report

Aortic mural thrombus is an uncommon source of peripheral embolization. We present a case of a patient with a symptomatic mobile mural thrombus in the proximal descending thoracic aorta who presented with left hand ischemia. The patient was treated with anticoagulation and radial artery thrombectomy followed by thoracic aortic stent graft placement.

Biomechanical and histologic analysis in aortic endoprosthesis using fibrin glue

The absence of incorporation between endoprosthesis (EP) and the arterial wall may lead to device migration and endoleaks around the stent graft. Alternatives have been tested aiming to improve this incorporation. Fibrin glue is used in many operating procedures promoting adhesion and tissue regeneration; however, its use to improve EP incorporation by arteries is unknown. The objective of this study was to analyze dislodgement forces needed to extract the EPs implanted in pig aorta, compare different oversizing and fibrin glue injections, and to analyze histologic changes among groups. Straight EPs were implanted in the thoracic aorta of pigs using 10% oversizing plus fibrin glue in the interface between the EP and the artery (group 1), using 20% oversizing (group 2), and 10% oversizing (group 3). Fourteen days after the implant, the animals were killed to enable biomechanical analysis of the EP and to verify histologic changes of the aortic wall and its interface with the EP. Group 1 showed a dislodgement force of 21.9 ± 5.3 Newton (N) being higher than the other groups and statistically significant when compared to group 3 (15.6 ± 3.6N), P = .003%. Group 2 had a higher dislodgement force and statistically more significant than group 3 (19.5 ± 7.8N). Histologic analysis showed tissue reaction with inflammatory cells and fibroblasts higher in group 1 and group 2 compared to group 3. This study reports a large animal survival model of thoracic aortic stent graft placement by testing the impact of fibrin glue on EP incorporation. Compared to oversizing alone, fibrin glue placed between the stent graft and the arterial wall increases EP incorporation. Additional studies are needed to determine the potential utility of fibrin glue in the setting of human arterial endografts.

Spinal Cord Protection with a Cerebrospinal Fluid Drain in a Patient Undergoing Thoracic Endovascular Aortic Repair

Paralysis and paraparesis are dreaded complications of thoracic endovascular aortic repair (TEVAR) that occur with an incidence of 2%-6%. Risks factors include the type of thoracic aortic pathology treated, coverage of the left subclavian artery origin without revascularization, concomitant infrarenal abdominal aortic aneurysm repair, extent of stent graft coverage of the thoracic aorta, and renal failure. Cerebral spinal fluid (CSF) drains have been advocated as one of several protective strategies to prevent spinal cord ischemia. This case discussion briefly addresses the evidence supporting the use of CSF drains in patients undergoing TEVAR and offers an algorithm for managing CSF drains.

Letter by Canaud et al Regarding Article, “Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement: Insight From the European Registry on Endovascular Aortic Repair Complications”

To the Editor: We read with great interest the article by Eggebrecht and coworkers.1 They concluded that the majority of retrograde ascending aortic dissection cases were associated with the use of proximal bare spring stent grafts. The authors report that this decision is strengthened by evidence of stent graft–induced injury at surgery or necropsy in half of the patients. However, we have several comments. First, it is difficult to draw conclusions from …

Response to Letter Regarding Article, “Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement: Insight from the European Registry on Endovascular Aortic Repair Complications”

To the Editor: We thank Canaud et al for their interest in our article1 and for raising some concerns. They suggested that the findings of our study should be interpreted with caution, particularly with respect to factors that may be predisposing toward the occurrence of retrograde ascending aortic dissection (rAAD) after thoracic endovascular aortic repair (TEVAR). We fully agree with Canaud and coworkers that it is difficult to draw conclusions from a retrospective registry. We have clearly acknowledged the lack of a control group of patients who did not develop rAAD as the major limitation of …

Endovascular Treatment of Massive Thoracic Aortic Thrombus and Associated Ruptured Atheroma

Atheroembolic disease typically presents with isolated lower extremity digital ischemia. Treatment traditionally includes optimization of medical management, with open surgery reserved for complicated or recurrent embolic events. We present a novel endovascular approach for treatment of complicated thoracic aortic atherosclerotic disease incidentally discovered in a 63-year-old female. The patient demonstrated visceral artery embolization from a mobile 2.6 cm atherosclerotic plaque despite maximal medical therapy. Thoracic aortic stent graft placement successfully excluded the atheroma and prevented further embolization. This case demonstrates a unique treatment option for complicated thoracic aortic atheroembolic disease utilizing a minimally invasive endovascular approach.

Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement

Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients.

Aortoesophageal Fistula After Thoracic Aortic Stent-Graft Placement: A Rare but Catastrophic Complication of a Novel Emerging Technique

Our goal was to report characteristics and outcomes of 6 patients with aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR). Neurologic events are severe complications of TEVAR. With growing experience of TEVAR, other yet unexpected devastating complications have emerged. Between July 1999 and August 2008, 268 patients underwent TEVAR for various thoracic aortic diseases at our institution. Six of 268 patients (age 49 to 77 years, 50% female patients) developed AEF (incidence 1.9%) within 1 to 16 months after the procedure. Indications for TEVAR were acute aortic dissection (n = 3), chronic aortic dissection (n = 1), and thoracic aortic aneurysm (n = 2). Four patients presented with sudden massive hematemesis whereas 2 patients were readmitted for new-onset fever and elevated markers of inflammation that preceded hematemesis. Esophago-gastro-duodenoscopy identified deep esophageal ulcerations at the level of the implanted aortic stent-graft in 4 patients, but only mild erosive lesions within the proximal esophagus without signs of active bleeding in the remaining 2 patients. Surgical repair was performed in only 1 patient and declined in the remaining because of comorbidities and multiorgan system failure. Despite this, all patients died due to fatal rebleeding (n = 4) or mediastinitis (n = 2). AEF is a rare and unusual complication of TEVAR that occurs relatively early after the procedure and is almost invariably fatal. New-onset fever with elevated inflammatory markers or hematemesis should heighten clinical suspicion of AEF in TEVAR patients and prompt computed tomography or esophago-gastro-duodenoscopy in the hope of detecting, triaging, and treating this early to improve the otherwise dismal outcomes of these patients.

Abstract 4274: Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent-Graft Placement- Insights from the European Registry on EVAR Complications (EUREC)

Background: Thoracic endovascular aortic repair (TEVAR) is increasingly applied in the treatment of aortic dissections and aneurysms. Single center reports have addressed retrograde ascending aortic dissection (rAAD) as a potentially lethal complication unique to TEVAR. We used data from a European multi-center registry to determine possible etiological factors and outcomes of this dreadful complication. Methods: So far 15 European sites and 1 Chinese center are contributing to the European Registry on EVAR Complications (EUREC) which is an open, independent, ongoing multi-center registry. Between 01/1998 and 05/2008 these centers performed a total of 3074 TEVAR procedures. Results: 33 rAAD cases (56.3±11.6 yrs, 20 males) were reported (incidence 1.1%). Indications for TEVAR were: acute type B dissection (n=17), chronic dissection (n=10), thoracic aneurysm (n=4), and aortic ulcer (n=1). 20 procedures were performed as emergency TEVAR. Stent-grafts with proximal bare springs were used in 26/33 (79%) cases. Additional balloon inflations were performed in 6 (18%) cases. rAAD occurred intraoperatively (n=5, 15%), during the index hospitalization (n=7, 21%), and during follow-up (n=21, 64%). 9 (27%) patients were asymptomatic, the remaining patients presented with acute chest pain (n=11, 33%), syncope (n=10, 30%), or sudden death (n=5, 15%). Emergency or elective surgical repair was performed in 19 and 4 patients, respectively. Conservative therapy was chosen in the remaining 10 patients. Outcome was fatal in 14/33 (42%) patients. The most probable cause of rAAD as reported by the investigators was stent-graft induced in 58%, procedure related in 9%, and underlying undiagnosed aortic disease in 15% of patients. In 16/33 patients direct evidence of stent-graft induced rAAD was obtained by surgery or necropsy. Conclusion: Although the incidence of rAAD was low (1.1%) in the present EUREC analysis, it was associated with significant mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone rAAD. As suspected, the majority of rAAD cases was associated with the use of proximal bare spring stent-grafts and in almost half of the patients direct evidence of stent-graft induced injury was obtained from surgery or necropsy.

Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol

Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair. From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05. Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement. Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.

Use of the Abdominal Aorta as an Alternative Access Site for Thoracic Aortic Stent Graft Placement

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.

Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement

To quantify inflammatory markers in a large cohort of patients undergoing thoracic endovascular aortic repair (TEVAR) and investigate if profound biomarker elevations may be predictors of postprocedural death. We analyzed data from 103 patients (70 men; mean age 64.5+/-11.2 years, range 22-83) undergoing TEVAR between July 1999 and December 2006. Baseline as well as at least 3 serial measurements of C-reactive protein (CRP), fibrinogen, white blood cell (WBC) count, and D-dimers were performed within the first 20 days after TEVAR. Compared with baseline, all inflammatory biomarker levels rose significantly. WBC peaked 2 days after the procedure, whereas CRP, fibrinogen, and D-dimers showed a sustained elevation up to 20 days after TEVAR. Inflammatory responses were more pronounced in patients with acute aortic pathology compared with chronic aortic diseases. There was evidence of greater increase in biomarkers with an increasing number of stent-grafts implanted. Kaplan-Meier analysis suggested that increasing maximum D-dimer values postoperatively were associated with decreased survival after TEVAR (p=0.036) in a subset of patients; however, multivariate analysis failed to identify postinterventional biomarker elevation as independent predictor of in-hospital death. Postprocedural inflammatory responses characterized by elevations of CRP, fibrinogen, D-dimers, and WBC are observed in all patients undergoing TEVAR. Our data indicate that this response is more pronounced in patients with acute aortic pathology and those receiving >1 stent-graft.

Abstract No. 41: Midterm Survival Following Endovascular Repair of the Thoracic Aorta in the Post-FDA Approval Era

Following FDA approval of the Gore TAG® (W. L. Gore & Associates, Flagstaff, AZ), off-label indications rapidly expanded to include additional thoracic aortic pathologies. The purpose of this study was to examine whether the outcomes with this device changed after the strict anatomical and pathological inclusion and exclusion criteria of FDA-controlled clinical trials no longer governed patient selection for thoracic aortic stent-graft placement.

Thoracic aorta endografts: Variations in practice among medical specialists

Endovascular stent-graft placement is emerging as a novel treatment option for patients with diseases of the descending thoracic aorta. However, currently no consensus guidelines exist to direct uniformity in stent-graft procedures as well as for pre- and postprocedural patient management, unlike that for the management of other cardiovascular disorder. Accordingly, the aim of the present survey was to assess variations in thoracic aortic stent-graft practice among different subspecialties in Germany. An interdisciplinary questionnaire survey was conducted among 206 departments of vascular surgery, radiology, cardiology, and cardiothoracic surgery in Germany that actively performed aortic stent-graft placement. Data on preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized, self-administered questionnaire comprising 29 items. Responses were tabulated for analysis. Of a total of 206 questionnaires, 184 (89.3%) were returned with 71 (38.5%) centers reporting to have performed thoracic aortic stent-graft placement (total number of procedures 2,267) through 1997 and 2003. The average number of stent-graft procedures per year was 7.4 (25-75% percentile, 2.05-10.75) at participating sites, with 49% of the respondents reporting <5 procedures per year. Treatment of thoracic aortic aneurysms was the predominant indication for stent-graft placement, followed by type B-dissection. As anticipated, marked variability existed among the different medical specialties performing stent-graft procedures with respect to all aspects of the procedures including indication for treatment, choice of preoperative and intraoperative imaging modalities, technical equipment and perioperative management. The only consistent agreement was on the need for lifelong follow-up after stent-graft placement, with CT being the preferred imaging technique (90% of centers). The present survey documents an increasing adoption of endovascular stent-graft placement for patients with diseases of the descending thoracic aorta in Germany. Despite this, there is a lack of consensus among the different medical specialties performing stent-graft placement with respect to indications and technical execution of stent-grafting. Our data supports the need for consensus practice guidelines endorsed by medical professional societies for stent-graft procedure to standardize the growing number of thoracic stent graft procedures.

Frequency and Outcomes of Acute Renal Failure Following Thoracic Aortic Stent-Graft Placement

We assessed the incidence, correlates, and outcomes of acute renal failure (ARF) after thoracic aortic stent-graft placement. Postprocedural ARF is an inherent complication of catheter-based interventional procedures that use intra-arterial contrast agents and has adverse effects on short- and long-term outcomes. However, few data exist on the incidence, predictors, and outcomes of ARF after thoracic aortic stent-graft placement. We analyzed data of 97 patients (64.4 +/- 11.6 years of age; 73% men) who underwent thoracic aortic stent-graft placement from July 1999 to October 2005. Postprocedural ARF was defined as an increase > or = 25% and/or > or = 0.5 mg/dl in preprocedural serum creatinine at 48 hours after the procedure. Baseline estimated glomerular filtration rate was 65 +/- 24 ml/min/1.73 m2. Chronic kidney disease (glomerular filtration rate < or = 60 ml/min/1.73 m2) at baseline was present in 45% of patients. During the stent-graft procedure, patients received 307 +/- 188 ml of nonionic contrast medium. Postprocedural ARF occurred in 33 patients (34%), and 3 required dialysis. Multivariable analysis identified American Society of Anesthesiologists class > 3 (odds ratio 5.53, 95% confidence interval 1.71 to 17.85, p = 0.004) and duration of the stent-graft procedure (odds ratio 1.01, 95% confidence interval 1.001 to 1.014, p = 0.022) as independent predictors of postprocedural ARF. Compared with patients without ARF, those with ARF had markedly higher 30-day (18.2 +/- 6.7% vs 1.6 +/- 1.6%, p = 0.0022) and 1-year (35.2 +/- 8.6% vs 10.1 +/- 3.9%, p = 0.001) mortality. In conclusion, postprocedural ARF is a frequent complication of thoracic aortic stent-graft placement and has a significant adverse effect on 30-day and 1-year survival. Baseline factors identified in our study as associated with increased risk of ARF may facilitate a comprehensive informed consent process by way of patient education. In addition, identification of an at-risk subset may allow modification of reversible periprocedural factors that may help decrease postprocedural ARF.

Thorakale Aorten-Stentgraftimplantation

Endovascular stent-graft placement is emerging as a novel therapeutic option in patients with disease of the descending thoracic aorta. Quality standards for performing stent-graft procedures as well as for pre- and postoperative patient management are lacking, so far. It was the aim of this present survey to assess the current therapeutic standard of thoracic aortic stent-graft placement in Germany. In a nationwide survey, a total of 206 vascular surgical, radiologic, cardiologic, and cardiothoracic surgical departments were contacted. Data concerning preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized questionnaire comprising 29 items. Data analysis was performed using univariate analysis. 184 (89.3 %) of the 206 departments participated in the survey. Of these, 71 centers reported intending to perform or having performed thoracic aortic stent-graft placement. The survey overall represents 2267 endovascular stent-graft procedures performed in Germany between 1997/98 and 2003. On average, 7.4 stent-graft procedures/year were performed by each center, with half the centers performing fewer than 5 procedures/year. Thoracic aortic aneurysms was the main indication for endovascular stent-graft placement, followed by aortic dissection. There were significant differences between the different medical specialties which perform stent-graft procedures with respect to indications, choice of preoperative and intraoperative imaging methods, and technical equipment. There was strong agreement between the different centers concerning the necessity of a life-long follow-up after stent-graft placement, with computed tomography being the preferred imaging technique (90 % of centers). The present survey documents an increasing use of endovascular stent-graft placement in patients with disease of the descending thoracic aorta. There were differences regarding the technical execution of this procedures between specialties with respect to indication, procedure planning, and practical-technical aspects of stent-graft placement.

Induced arterial hypotension for interventional thoracic aortic stent-graft placement: impact on intracranial haemodynamics and cognitive function.

The study investigated the impact of induced arterial hypotension for the facilitation of endovascular stent-graft placement in patients with thoracic aortic aneurysm on cerebral blood flow velocity and neurological/neurocognitive outcome. In 27 ASA III patients, cerebral blood flow velocity was recorded during induced arterial hypotension for endovascular stent-graft placement using transcranial Doppler sonography and the Folstein Mini Mental State Examination and the National Institute of Health Stroke Scale were performed before and after the intervention. Mean arterial pressure was decreased <50 mmHg, and in 22 patients it was <40 mmHg. Diastolic cerebral blood flow velocity decreased by 59%. Postoperatively, six of 21 patients exhibited changes in the Folstein Mini Mental State Examination and four of these six patients in the National Institute of Health Stroke Scale as indices of new-found neurocognitive dysfunction, but there were no signs of stroke. Loss of the diastolic blood flow profile was detected in two of six patients with new-found neurocognitive dysfunctions and in 18 of 21 patients with no new-found neurocognitive dysfunction. Changes in the Folstein Mini Mental State Examination on postoperative day 1 were correlated to the pre-procedural Folstein Mini Mental State Examination, but not to the time spent with a mean arterial pressure <50 mmHg, <40 mmHg or with a loss of diastolic blood flow profile. Transcranial Doppler sonography visualizes the individual effect of induced hypotension and the period of intracranial circulatory arrest during aortic stent-graft placement. However, transient new-found neurocognitive dysfunctions occur independently of the transcranial Doppler data, and are in close correlation to the neurocognitive state before the procedure. The results suggest that induced arterial hypotension is not the major factor for postoperative new-found neurocognitive dysfunction.

Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta.

To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. A retrospective review was conducted of patients treated at our facility between July 1999 and June 2003. During this interval, 60 patients (46 men; average age 66+/-10 years) underwent thoracic aortic stent-graft placement for a variety of pathologies. AEF occurred in 3 (5%) patients. One 62-year-old man presented with recurrent back pain and fever and died suddenly due to fatal exsanguination; the AEF was revealed at necropsy. The other 2 patients (both women) presented with hematemesis after endovascular repair of thoracic aortic aneurysms. AEF was detected by esophagogastroduodenoscopy. Both patients were treated conservatively, as open surgical repair was refused because of their general condition. Both patients developed severe mediastinitis and died after 5 weeks and 10 months, respectively. Aortoesophageal fistula is, in our experience, a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Outcome under conservative management is, however, almost invariably fatal.

Induced arterial hypotension for interventional thoracic aortic stent-graft placement: impact on intracranial haemodynamics and cognitive function

Background and objective: The study investigated the impact of induced arterial hypotension for the facilitation of endovascular stent-graft placement in patients with thoracic aortic aneurysm on cerebral blood flow velocity and neurological/neurocognitive outcome. Methods: In 27 ASA III patients, cerebral blood flow velocity was recorded during induced arterial hypotension for endovascular stent-graft placement using transcranial Doppler sonography and the Folstein Mini Mental State Examination and the National Institute of Health Stroke Scale were performed before and after the intervention. Results: Mean arterial pressure was decreased <50 mmHg, and in 22 patients it was <40 mmHg. Diastolic cerebral blood flow velocity decreased by 59%. Postoperatively, six of 21 patients exhibited changes in the Folstein Mini Mental State Examination and four of these six patients in the National Institute of Health Stroke Scale as indices of new-found neurocognitive dysfunction, but there were no signs of stroke. Loss of the diastolic blood flow profile was detected in two of six patients with new-found neurocognitive dysfunctions and in 18 of 21 patients with no new-found neurocognitive dysfunction. Changes in the Folstein Mini Mental State Examination on postoperative day 1 were correlated to the pre-procedural Folstein Mini Mental State Examination, but not to the time spent with a mean arterial pressure <50 mmHg, <40 mmHg or with a loss of diastolic blood flow profile. Conclusions: Transcranial Doppler sonography visualizes the individual effect of induced hypotension and the period of intracranial circulatory arrest during aortic stent-graft placement. However, transient new-found neurocognitive dysfunctions occur independently of the transcranial Doppler data, and are in close correlation to the neurocognitive state before the procedure. The results suggest that induced arterial hypotension is not the major factor for postoperative new-found neurocognitive dysfunction.

Percutaneous Treatment of Bronchial Artery Aneurysm with Use of Transcatheter Coil Embolization and Thoracic Aortic Stent-Graft Placement

Percutaneous Treatment of Bronchial Artery Aneurysm with Use of Transcatheter Coil Embolization and Thoracic Aortic Stent-Graft Placement