Treatment Of Complex Aneurysms Research Articles

French multicentric experience of the chimney technique to treat complex aneurysms of the abdominal aorta

French multicentric experience of the chimney technique to treat complex aneurysms of the abdominal aorta

Adenosine-assisted neurovascular surgery: initial case series and review of literature.

Cerebral aneurysms in complex anatomical locations and intraoperative rupture of aneurysms are challenging for neurosurgeons and anaesthetists alike. Mechanical and non-mechanical methods to reduce blood flow into aneurysms are well-recognised techniques to facilitate aneurysm exclusion from the circulation. Mechanical methods like temporary clipping of parent arteries, carotid artery ligation and endovascular balloon occlusion are commonly used in clinical practice. However, non-mechanical techniques such as rapid ventricular pacing and adenosine-induced cardiac standstill with hypotension are still emerging strategies. The aim of this study is to report our units' experience in the use of adenosine in aneurysm clipping and arteriovenous malformation (AVM) resection and review the literature. The records of all patients who had adenosine-assisted clipping of intracranial aneurysms and AVM resections in our institute between November 2015 and December 2016 were extracted from prospectively maintained database. The following data were collected: patient demographics, comorbidities, size and location of the aneurysms or AVM, number of boluses and total dose of adenosine administered, duration of cardiac standstill and hypotension (systolic blood pressure<60mmHg), intraoperative and postoperative complications and outcome scores at discharge. Literature search on Embase and PubMed for the terms "adenosine and clipping", "adenosine and aneurysm" and "adenosine and AVM" was performed. Eight aneurysms and two AVMs were identified. While both AVMs were elective procedures, half of the aneurysm clippings were on urgent basis. We used adenosine safely with spontaneous return of rhythm in all cases. Temporary clips to the parent artery were applied for brief periods in 2 patients who had pre-adenosine intraoperative rupture. We did not observe any immediate or late adverse events related to administration of adenosine. From our literature review, a total of ten case series and four case reports were identified. There were no reports on the use of adenosine in AVM resection. Transient adenosine-induced asystole is a safe and effective technique in facilitating surgical treatment of complex aneurysms and AVMs. In addition, adenosine use reduces the need, duration, and associated complications of temporary clip applications to parent arteries.

クリッピング困難な脳動脈瘤治療における術中運動誘発電位（MEP）の有用性

The utility of motor evoked potentials (MEPs) for intraoperative neurophysiological monitoring for unclippable complex aneurysms has not been established.The aim of this study was to evaluate and validate the usefulness of intraoperative MEP monitoring in the treatment of complex aneurysms with and without extracranial-intracranial (EC-IC) bypass.From among a group of patients who underwent intraoperative MEP monitoring during surgery for aneurysm, between 2007 and 2014, we retrospectively enrolled 17 consecutive patients with complex aneurysms.Aneurysms were located in the cavernous portion of the internal carotid artery (ICA) in 6, the intracranial portion of the ICA in 6, the anterior cerebral artery in 1, and the vertebral artery in 4 patients. They included 4 large, 7 thrombosed, and 6 dissecting aneurysms. All were treated with parent artery occlusion with or without EC-IC bypass, which included 7 high-flow bypass procedures with radial artery grafting, and 7 low-flow bypass procedures. Of the 17 patients, 6 showed transient or permanent MEP changes. Four of 6 patients showed MEP changes due to temporary occlusion of the recipient artery during bypass construction. However, these changes were reversed by substitution of the recipient artery, intentional hypertension, and shortening of occlusion time. Two patients demonstrated MEP changes when the parent artery was occluded. In one of those two patients, MEP completely disappeared after parent artery trapping, and this remained unchanged until the completion of the surgery without any modification in obliteration of the parent artery. This patient experienced permanent postoperative hemiparesis. The second patient showed significant changes in MEP during temporary ICA occlusion, which however improved after changing the site of occlusion to the common carotid artery (CCA).In conclusion, intraoperative MEP monitoring has a useful role in the treatment of complex aneurysms—in the selection of the safest and most appropriate recipient artery for EC-IC bypass, and choosing the most appropriate point for occlusion of the parent artery.

Off-Label Uses for Flow Diversion in Intracranial Aneurysm Management.

Treatment of complex aneurysms using microsurgical and other conventional neuroendovascular techniques remains challenging. As a result, stent- and balloon-assisted coiling are instead performed to treat morphologically complex aneurysms, which include giant, wide-necked, and fusiform aneurysms. While these techniques have had success in treating these complex aneurysms, recanalization rates associated with these techniques are still problematic. In the constant effort to improve the outcome of complex aneurysm treatment, flow-diverting stents (FDSs) have emerged in recent years as the preferred treatment. Instead of directly obstructing the flow of blood into the aneurysmal sac, as is the case for stent- and balloon-assisted coiling, FDSs are placed in the parent blood vessel to divert blood flow away from the aneurysm itself. Subsequent to the diverting away of blood from the aneurysm, a thrombotic cascade ensues that ultimately results in the closure of the aneurysm while the parent vessel's perforators are preserved. Current known risks for this procedure include vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural or delayed hemorrhages, and perianeurysmal edema. In this review, we will evaluate the mechanisms of actions, clinical applications, complications, and ongoing studies for FDSs.

Technique for treating complex aneurysms with Hercules stent graft modified by the surgeon

Endovascular treatment of thoracoabdominal aneurysms with fenestrated stent grafts expands its applicability because of good technical results. However, stent graft customization requires an average of 6 to 12 weeks, which makes this technique ineligible for symptomatic or ruptured aneurysms. Authors advocate perioperative fenestration by the surgeon, allowing this technique to be used for emergency cases with good results and favorable prognosis. This article describes a technique for intraoperative changes of the Hercules stent graft (MicroPort Scientific Corporation, Shanghai, China) to include the ostia of visceral arteries by making fenestrations and scallops, with a temporary diameter-reducing wire as a further modification to facilitate positioning and catheterization of fenestrations with guidewires.

Experimental Model for Sutureless Proximal Anastomosis by the ViaBahn Open Revascularization Technique (VORTEC)

IntroductionIn the treatment of complex aneurysms, debranching is an extra-anatomical revascularization of visceral arteries followed by endograft coverage of the thoracoabdominal aorta. It eliminates the need for a thoracotomy and aortic clamping, but requires the performance of several technically demanding visceral anastomosis. In 2008, Lachat described visceral revascularization with the use of a sutureless distal anastomosis, performed by the telescoping of an endograft in the visceral branch, named VORTEC (Viabahn Open Revascularization TEChnique).ObjectiveAn experimental model was created to test the feasibility and short term results of performing a telescoped proximal anastomosis to the abdominal aorta.MethodsSwine model. The abdominal aorta was dissected and ligated between the renal arteries and the iliac vessels. Three centimeters bellow the renal arteries a Viabahn endograft was telescoped for 2 cm into the proximal aorta. The other extremity was conventionally anastomosed to the distal aorta. Patency, sealing and tensile strength of the anastomosis were tested.ResultsTime for performing the telescoped anastomosis was shorter (5.4±2.8 min versus 10.3±3.4 min, P<0.05). All grafts were patent and both types of anastomosis presented no bleeding. Immediate tensile strength showed a higher strength of the conventional suture (22.7 x 14.3 N, P<0.09). After 30 days there was no pseudo-aneurysms and the strength of the conventional and VORTEC anastomosis were similar (37.3 x 40.8 N, respectively, P=0.17).ConclusionTelescoped proximal anastomosis by the technique of VORTEC is feasible. After 30 days the tensile strength of the both anastomosis were similar.

Endovascular reconstruction of aneurysms with a complex geometry.

Conventional endovascular coiling remains the mainstay of treatment for most aneurysms; however, it may not be suitable for aneurysms with a complex geometry and there remains the risk of recanalization. Aneurysms with an unfavorable morphology are difficult to treat through both endovascular and surgical means. Progress in endovascular technology has allowed for the emergence of newer strategies to treat aneurysms with a complex geometry. Better packing density in wide-necked and large aneurysms can be achieved through the balloon remodeling technique. Similarly, a self-expanding stent cannot only act as a scaffold that helps to retain coils but also aids in diverting the blood flow away from the aneurysm sac. Lately, focus has shifted from endosaccular occlusion to endoluminal reconstruction; flow diverters are being increasingly used to treat aneurysms with an unfavorable geometry. However, there is no clear consensus on the best endovascular management strategy in certain subset of aneurysms - large and giant internal carotid aneurysms, blister aneurysms, and fusiform/dissecting aneurysms of the vertebrobasilar artery. We present a review of literature and discuss the current evidence for the various endovascular strategies to treat complex aneurysms.

Risk factors for neurological worsening and symptomatic watershed infarction in internal carotid artery aneurysm treated by extracranial-intracranial bypass using radial artery graft.

OBJECT The revascularization technique, including bypass created using the external carotid artery (ECA), radial artery (RA), and M2 portion of middle cerebral artery (MCA), has remained indispensable for treatment of complex aneurysms. To date, it remains unknown whether diameters of the RA, superficial temporal artery (STA), and C2 portion of the internal carotid artery (ICA) and intraoperative MCA blood pressure have influences on the outcome and the symptomatic watershed infarction (WI). The aim of the present study was to evaluate the factors for the symptomatic WI and neurological worsening in patients treated by ECA-RA-M2 bypass for complex ICA aneurysm with therapeutic ICA occlusion. METHODS The authors measured the sizes of vessels (RA, C2, M2, and STA) and intraoperative MCA blood pressure (initial, after ICA occlusion, and after releasing the RA graft bypass) in 37 patients. Symptomatic WI was defined as presence of the following: postoperative new neurological deficits, WI on postoperative diffusion-weighted imaging, and ipsilateral cerebral blood flow reduction on SPECT. Neurological worsening was defined as the increase in 1 or more modified Rankin Scale scores. First, the authors performed receiver operating characteristic curve analysis for continuous variables and the binary end point of the symptomatic WI. The clinical, radiological, and physiological characteristics of patients with and without the symptomatic WI were compared using the log-rank test. Then, the authors compared the variables between patients with and without neurological worsening at discharge and at the 12-month follow-up examination or last hospital visit. RESULTS Symptomatic WI was observed in 2 (5.4%) patients. The mean MCA pressure after releasing the RA graft (< 55 mm Hg; p = 0.017), mean (MCA pressure after releasing the RA graft)/(initial MCA pressure) (< 0.70 mm Hg; p = 0.032), and mean cross-sectional area ratio ([RA/C2 diameter](2) < 0.40 mm [p < 0.0001] and [STA/C2 diameter](2) < 0.044 mm [p < 0.0001]) were related to the symptomatic WI. All preoperatively independent patients remained independent (modified Rankin Scale score < 3). After adjusting for age and sex, left operative side (p = 0.0090 and 0.038) and perforating artery ischemia (p = 0.0050 and 0.022) were related to neurological worsening at discharge (11 [29%] patients) and at the 12-month follow-up or last hospital visit (8 [22%] patients). CONCLUSIONS Results of the present study showed that the vessel diameter and intraoperative MCA pressure had impacts on the symptomatic WI and that operative side and perforating artery ischemia were related to neurological worsening in patients with complex ICA aneurysms treated by ECA-RA-M2 bypass.

Adenosine-induced transient asystole during intracranial aneurysm surgery: indications, dosing, efficacy, and risks.

Several flow-arrest techniques have been introduced for the treatment of complex aneurysms that cannot be treated with conventional clipping or endovascular coil embolization. Adenosine-induced transient asystole is an alternative method of flow arrest. However, given the limited number of studies that have reported on this topic, there is no consensus regarding the dose, regimen, efficacy, and potential risks of adenosine. A total of 22 aneurysms in 22 different patients that underwent adenosine-induced transient asystole during aneurismal neck clipping within the past 4 years were retrospectively reviewed. Adenosine was administrated intravenously in a test-incremental manner (starting with 6-12 mg and then giving additional doses as needed) in 11 patients and in an estimated manner (pre-calculated as 0.3-0.4 mg/kg) in 11 patients. Overall, the study consisted of 18 unruptured saccular aneurysms, three ruptured saccular aneurysms, and a ruptured pseudoaneurysm. Adenosine-induced transient asystole was used in cases of temporary clipping inability, wide necked aneurysm, deep-seated aneurysm, or a thin aneurysm wall. The number of administrations, dose (mg/kg in ideal body weight) and duration of asystole were 1-4 (mean, 2.3) times, 0.08-1.27 (mean, 0.36) mg/kg and 0-30 (mean 13) seconds in the test-incremental manner and 1-2 (mean, 1.09) times, 0.24-0.42 (mean, 0.34) mg/kg and 13-41 (mean, 24) seconds in the estimated manner, respectively. There was a linear relationship between the dose and the duration of asystole. Twenty out of 22 aneurysms were clipped successfully with adenosine-induced transient asystole. However, in the other two cases, additional suction decompression was required for the final clipping. Adenosine-related cardiologic complications occurred in two cases of self-limited atrial fibrillation during restoration of the cardiac rhythm. In our experience, adenosine-induced transient asystole was safe and helpful for satisfactory clipping of a complicated aneurysm. An estimated dose injection of adenosine was more convenient than the test-incremental method and did not result in serious cardiologic problems.

Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms.

Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms. All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. "Complex aneurysm" was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed. Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent (n = 42, 3 ruptured) or balloon (n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6-72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% (n = 50) (mean, 21 months; range, 6-65 months). There were 4 minor and 3 major recurrences (14.0%). In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.

Long-term occlusion results with SILK flow diversion in 28 aneurysms: Do recanalizations occur during follow-up?

The purpose of this article is to report on the long-term success rates of Silk flow-diverter (FD) treatment in a multicenter prospective study for the treatment of complex aneurysms. Between May 2008 and January 2011, all consecutive patients featuring complex intracranial aneurysms eligible for FD treatment with the Silk in three neurovascular centers were included. Clinical and imaging data were assessed during hospitalization and follow-up. Five patients were initially asymptomatic, 20 patients showed various neurological symptoms. Twenty-eight FDs were implanted in 25 patients treating 28 aneurysms. The immediate procedure-related morbidity was 8% (two of 25), mortality 0%. One procedure-related death was observed during follow-up (in-stent thrombosis). Compared to the immediate result nearly two of three aneurysms improved during follow-up; all angiographically confirmed inflow changes took place within six months after treatment. Final anatomic outcome in 24 aneurysms of 22 patients comprised 14 (59%) with complete occlusion, seven (29%) with a neck remnant, two (8%) with residual filling <50%, none with residual filling >50% and one (4%) unchanged in comparison to its pretreatment status. Postinterventional recanalizations were seen in three of 13 (23%) aneurysms treated with FD alone; none were observed in 15 aneurysms treated with adjunctive coiling. Anatomic presentation and location are key for successful FD treatment. The rate of successful occlusion increases during follow-up. Postinterventional monitoring for at least six months is paramount, as anatomic outcome is not reliably predictable and recanalizations may occur in initially completely occluded aneurysms.

Commentary: Occlusion of Parallel/Bridging Stent-Grafts in the Treatment of Complex Aneurysms

Commentary: Occlusion of Parallel/Bridging Stent-Grafts in the Treatment of Complex Aneurysms

Neurovascular reconstruction with flow diverter stents for the treatment of 87 intracranial aneurysms: Clinical results

Flow diverter stents represent a new endovascular tool to treat complex aneurysms, such as giant, large, wide-necked and fusiform. The highly dense mash of these stents reduces inflow and outflow inside the aneurysm, resulting in intra aneurysmal thrombosis and stent endothelialization. To present the results of treatment of intracranial aneurysms with flow diverter stents in a single center. Retrospective review of 77 patients with 87 aneurysms treated using two different types of flow diverter stent, the Pipeline Embolization Device and SILK stent, between October 2010 and September 2013 in an interventional neuroradiology center. Flow diverter stent placement was successful in 98% of the lesions and resulted in an immediate major stasis within most of the treated aneurysms. The overall aneurysm occlusion rate at six months and 18 months was 80% and 84% respectively. Symptomatic complications occurred in 11 patients (14.3%) with morbidity in eight (10.4%) and mortality in three patients (3.9%). Flow diversion is a promising technique for treatment of challenging intracranial aneurysms with acceptable morbidity. A high rate of complete occlusion for small large necked aneurysms, a low morbidity and mortality rate and no recanalization encourage their use in these aneurysms. Further studies accessing long-term aneurysm occlusion and recanalization are required.

Pre-protection re-haemorrhage following aneurysmal subarachnoid haemorrhage: Where are we now?

BackgroundRe-haemorrhage is a negative, prognostic predictor of outcome in aneurysmal subarachnoid haemorrhage (aSAH). The process of aSAH care has changed however, and most reports on re-haemorrhage are from a time when aneurysms were treated predominantly by open microneurosurgery. The current frequency and impact of re-haemorrhage on outcome in the ‘post-ISAT’ era is therefore unknown. The aim of this study was to review current outcome, risk factors and causes for inpatient re-haemorrhage in aSAH patients. MethodThe departmental aSAH database was reviewed between Jan 2008 and March 2014 (N=1008) to identify cases of re-haemorrhage. Re-haemorrhage was defined as inhospital deterioration in neurological status with CT confirmation of rebleeding. Binary logistic regression was used to (a) determine the impact of re-haemorrhage on outcome adjusted for age and injury severity and (b) to identify any independent predictors of its occurrence. ResultsRe-haemorrhage occurred in 55 (5.4%) of patients and most cases had occurred within 24h of ictus (32, 58.1%). Re-haemorrhage was an independent predictor of death (AOR 10.0, p<0.0005, 95%CI 4.9, 20.2) and unfavourable outcome (AOR 5.8 p<0.0005, 95%CI 2.4, 14.0). Only WFNS grade on admission was an independent predictor (AOR 1.7, p<0.0005, 95%CI 1.4, 1.9) of re-haemorrhage. Of the patients who re-bled, in 20 there was no intention to treat due to severe brain injury and in the remainder, the majority occurred early (<24h) (19/35, 54%), or had complicated aneurysm morphology (10/35, 31%) which necessitated a delayed treatment strategy. ConclusionsRe-haemorrhage remains a poor prognostic predictor in aSAH and the grade of SAH is an independent risk factor. Earlier treatment of complex aneurysms could offer the most immediate improvements in its incidence.

Endovascular Revascularization of a Renal Branch Occlusion in a Monorenal Patient after a 3-Branched Stent Graft Procedure of the Abdominal Aorta

Branched aortic endograft placement is increasingly used to treat complex aneurysms of the abdominal aorta involving visceral and renal arteries. Occlusion of one or more branches can occur due to mechanical forces between the branch and the stent graft. The present report describes a case of acute renal failure secondary to a left renal artery branch occlusion in a monorenal patient 4 months after a 3-branched stent graft procedure. The authors emphasize the successful recanalization and technical details of the procedure.

Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable.

ObjectiveThe treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established.MethodsCases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study.ResultsAmong a total of 16 cases, there were 7 giant aneurysms (≥25 mm diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities.ConclusionSurgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

Bypasses and Reconstruction for Complex Brain Aneurysms

Microsurgery for brain aneurysms is a current relevant technique, as advances in endovascular and stent-assisted coiling have not solved many of the difficulties inherent in the management of complex brain aneurysms. The following review highlights the importance of microsurgical bypass techniques for the management of complex cerebrovascular aneurysms and emphasizes, through two clinical cases, the technical difficulties and indications for bypass surgery. These cases demonstrate that in selected scenarios, bypass microsurgery still offers the only viable treatment for complex aneurysms.

Invited commentary

The report by Dr Cochennec highlights some very significant issues related to the practice and dissemination of complex aortic procedures. The authors present 113 cases performed during a period of 7 years, which equates to fewer than 20 cases per annum divided among four operators using three endovascular devices. Previous studies have shown a link between surgeon as well as center volumes and outcomes.1Thompson M. Holt P. Loftus I. Forbes T.L. Debate: whether abdominal aortic aneurysm surgery should be centralized at higher-volume centers.J Vasc Surg. 2011; 54: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Complex aneurysms represent a small proportion of all aneurysms treated, and it is difficult, even in large vascular centers, to achieve volumes large enough to reap the benefits of truly high volumes. In contrast to “simpler” aortic procedures, treatment of complex aneurysms is not only a question of individual operator experience and skill, but it places significant demands on the supporting structure of the center. Preoperative planning of complex cases is paramount for success. Detailed anatomic analysis as well as extensive specific device knowledge is needed. The learning curve is significantly longer than for infrarenal endovascular aneurysm repair. This indicates that it is better to use a single device and to learn it well rather than to stray between different devices, trying to take advantage of individual stent graft benefits. Certain morphologic features need to be specifically addressed. (1) A “shaggy” aorta is a risk factor for embolic events and poor outcome.2Patel S.D. Constantinou J. Hamilton H. Davis M. Ivancev K. A shaggy aorta is associated with mesenteric embolisation in patients undergoing fenestrated endografts to treat paravisceral aortic aneurysms.Eur J Vasc Endovasc Surg. 2014; 47: 374-379Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar (2) Poor access can lead to difficulties in orienting the device, leading to target vessel loss, resulting in end-organ dysfunction. Very long procedures can lead to compartment syndrome as well as a systemic reperfusion injury causing severe physiologic instability and multiorgan failure in the immediate postoperative phase.3Kristmundsson T. Sonesson B. Malina M. Bjorses K. Dias N. Resch T. Fenestrated endovascular repair for juxtarenal aortic pathology.J Vasc Surg. 2009; 49 (discussion: 754-5): 568-574Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Patients with complex aneurysmal disease often carry significant comorbidities and generally have a much lower tolerance for perioperative and postoperative complications, which is clearly seen in the current study with significant morbidity and mortality. This furthermore emphasizes the need for appropriate patient selection, workup, and optimization before surgery as well as extensive involvement of anesthetic and intensive care expertise in the preoperative, perioperative, and postoperative period. This can most likely be achieved only in very select high-volume centers dedicated to treatment of complex aortic disease. I thank the authors for their honest reporting and for highlighting the issues in dealing with complex endovascular aortic procedures. Impact of intraoperative adverse events during branched and fenestrated aortic stent grafting on postoperative outcomeJournal of Vascular SurgeryVol. 60Issue 3PreviewFenestrated and branched endovascular devices are increasingly used for complex aortic diseases, and despite the challenging nature of these procedures, early experiences from pioneering centers have been encouraging. The objectives of this retrospective study were to report our experience of intraoperative adverse events (IOAEs) during fenestrated and branched stent grafting and to analyze the impact on clinical outcomes. Full-Text PDF Open Archive

E-vita open plus for treating complex aneurysms and dissections of the thoracic aorta: a NICE medical technology guidance.

The E-vita open plus is a one-stage endoluminal stent graft system used for treating complex aneurysms and dissections of the thoracic aorta. The National Institute for Health and Care Excellence (NICE), as a part of its Medical Technologies Evaluation Programme (MTEP), selected this device for evaluation and invited the manufacturer, JOTEC GmbH, to submit clinical and economic evidence. King’s Technology Evaluation Centre (KiTEC), an External Assessment Centre (EAC) commissioned by the NICE, independently critiqued the manufacturer’s submissions. The EAC considered that the manufacturer had included most of the relevant evidence for the E-vita open plus, based on international E-vita open registry data for 274 patients, but had provided only limited evidence for the comparators. The EAC therefore conducted a systematic review and meta-analysis of all comparators to supplement the information, and found ten additional studies providing outcome data for the three two-stage comparators. The EAC noted that the cost model submitted by the manufacturer did not include key complications during the procedures. The EAC developed a new economic model incorporating data on complications along with their long-term costs. The revised model indicated that the E-vita open plus might not provide cost savings when compared with some of the comparators in the short-term (1 year), but would have high cost savings in the long-term, from the second year onwards. The NICE Medical Technologies Guidance MTG 16, issued in December 2013, recommended the adoption of the E-vita open plus in selected patients within the National Health Service in England.

A Case of Endovascular Treatment for Followed by Side to Side Bypass for Vertebral Artery Dissecting Aneurysms Involved Posterior Inferior Cerebellar Artery

Treatment of complex aneurysms usually entails not only direct clipping but also alternative treatment modality. We recently experienced a case of vertebral artery dissecting aneurysm and obtained good treatment outcomes. Our case suggests that the endovascular segmental occlusion with posterior inferior cerebellar artery (PICA) to PICA side anastomosis might be a good treatment option in patients with complex vertebral artery dissecting aneurysms. A 45-year-old woman has a left vertebral dissecting aneurysm with dizziness. Based on the aneurysmal morphology and the involvement of PICA, the patient underwent side to side anastomosis of the PICA. This was followed by the endovascular segmental coil occlusion. The aneurysmal sac was completely obliterated. At a 2-year follow-up, the patient achieved a good patency of both PICA. In conclusion our case suggests that the endovascular segmental occlusion of the parent artery followed by PICA to PICA bypass surgery through a midline suboccipital approach is a reasonable multimodal treatment option in patients with complex vertebral artery dissecting aneurysms.