Monocentric Evaluation of Physician-Modified Fenestrations or Parallel Endografts for Complex Aortic Diseases

PURPOSE

This study aimed to investigate the demographic and anatomic characteristics, as well as perioperative and follow-up results of fenestration and parallel techniques for the endovascular repair of complex aortic diseases.

MATERIALS AND METHODS

A retrospective study was conducted on 67 consecutive patients underwent endovascular treatment for complex aortic diseases including abdominal aortic aneurysm (AAA), thoracoabdominal aneurysm (TAAA), aortic dissection, or prior endovascular repair with either fenestrated and parallel endovascular aortic repair (f-EVAR or ch-EVAR) at a single institute from 2013 to 2021. Choices of intervention were made by the disease' emergency, patients' general condition, the anatomic characteristics, as well as following the recommendation from the devices' guidelines. Patients' clinical demographics, aortic disease characteristics, perioperative details, and disease courses were discussed. Short- and mid-term follow-up results were obtained and analyzed. Endpoints were aneurysm-related and unrelated mortality, branch instability, and renal function deterioration.

RESULTS

Totally, 34 and 27 patients received f-EVAR and ch-EVAR, while 6 patients received a combination of both. Fenestrated endovascular aortic repair was conducted mainly in AAA affecting visceral branches and TAAA, whereas ch-EVAR was normally utilized for infrarenal AAA. Regarding the average number of reconstructed arteries per patient, there was a significant difference among f-EVAR, ch-EVAR, and the combination group (mean = 2.3 ± 0.9, 1.4 ± 0.6, 3.5 ± 0.5, p<0.001). Primary technical success was achieved in 28 (82.4%), 22 (81.5%), and 3 (50.0%) patients for each group. Besides operational time (5.77 ± 2.58, 4.47 ± 1.44, p=0.033), no significant difference was observed for blood transfusion, intensive care unit (ICU) or hospital stay, blood creatinine level, 30-day complications, or follow-up complications between patients undergoing f-EVAR or ch-EVAR. Patients receiving combination of both techniques had a higher rate of blood transfusion (p=0.044), longer operational time (p=0.008) or hospital stay (p=0.017), as well as more stent occlusion (p=0.001), endoleak (p=0.004) at short-term and a higher rate of endoleak (p=0.023) at mid-term follow-up.

CONCLUSION

In conclusion, this study demonstrated that f-EVAR and ch-EVAR techniques had acceptable perioperative and follow-up results and should be considered viable alternatives when encountering complex aortic diseases.

CLINICAL IMPACT

This study sought to investigate the baseline and pathological characteristics, as well as perioperative and follow-up results of f-EVAR and ch-EVAR at a single Chinese institution. F-EVAR (mostly physician-modified f-EVAR) was applied in patients with a wide range of etiologies and disease types, while ch-EVAR was preferred for AAA in older patients with an average higher ASA grade. Our experience suggested acceptable safety and efficacy both for techniques, and no significant difference was observed between the two groups regarding any short or mid-term adverse events.

Prolapse repair for aortic regurgitation in tricuspid aortic valves

OBJECTIVE

Cusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAVs) and can be caused by myxomatous degeneration or cusp fenestration. Long-term data for prolapse repair in TAVs are scarce. We analyzed the results of aortic valve repair in patients with TAV morphology and AR caused by prolapse and compared the results for cusp fenestration and myxomatous degeneration.

METHODS

Between October 2000 and December 2020, 237 patients (221 male; 15-83 years) underwent TAV repair for cusp prolapse. Prolapse was associated with fenestrations in 94 (group I) and myxomatous degeneration in 143 patients (group II). Fenestrations were closed using a pericardial patch (n = 75) or suture (n = 19). In myxomatous degeneration, prolapse was corrected by free margin plication (n = 132) or triangular resection (n = 11). Follow-up was 97% complete (cumulatively 1531, mean 6.5, median 5.8 years). Cardiac comorbidities were present in 111 patients (46.8%), and more frequent in group II (P = .003).

RESULTS

Ten-year survival was better in group I (I: 84.5%; II: 72.4%; P = .037), and patients without cardiac comorbidities (89.2% vs 67.0%; P = .002). Ten-year freedom from reoperation (P = .778), moderate or greater AR (P = .070), and valve-related complications (P = .977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (P = .042). The type of annuloplasty did not affect repair durability.

CONCLUSIONS

Repair of cusp prolapse in TAVs with preserved root dimensions can be performed with acceptable durability, even in the presence of fenestrations.

Physician-Modified Endograft with the TREO Stent Graft System

PURPOSE

Description of physician-modified endograft technique and its advantages using the TREO stent graft system.

TECHNIQUE

After partial back-table deployment of the TREO endograft, fenestrations are created using a scalpel and reinforced with a double snare loop and running suture. The distance between the Z-shaped stents of the TREO main body of almost 20 mm allows for more flexible placement of multiple fenestrations and easier and faster re-sheathing. The technique is illustrated with physician modification of a TREO aortic cuff and bifurcated endograft in three patients with juxtarenal aortic aneurysms or type Ia endoleak after previous endovascular aortic aneurysm repair.

CONCLUSION

Physician modification of the TREO stent graft system can be safely performed, making it an excellent additional option to treat juxtarenal aneurysms.

CLINICAL IMPACT

The TREO stent graft system offers various sizing options including different main body lengths and diameters, thus increasing applicability. Larger distance between the main body's stents facilitates placement of multiple physician-modified fenestrations. Re-sheathing is easier and faster due to the low number of main body stents which have to be re-sheathed. Therefore, the TREO stent graft system is an excellent platform for the physician-modified technique.

Early Experience With Fenestration Modification of Castor Branched Stent-Graft for Aortic Arch Diseases

PURPOSE

This study aimed to assess the safety and viability of combining branched stent graft with fenestrated thoracic endovascular aortic repair (TEVAR) in treating aortic arch lesions.

MATERIALS AND METHODS

The cohort included patients presenting with aortic arch lesions who underwent treatment with a combination of branched stent graft and fenestrated TEVAR between July 2020 and November 2022. Technical success was defined as the precise deployment of the stent graft, maintenance of branch vessel patency, and the absence of type I endoleak. The secondary outcomes examined were complications and all-cause mortality.

RESULTS

The study cohort comprised 21 patients (average age: 61.0±14.8 years) with aortic arch lesions from 3 tertiary care hospitals. The aortic arch lesions encompassed aortic dissection (N=8), aortic aneurysm (N=8), pseudoaneurysm (N=1), intramural hematoma (N=1), and penetrating aortic ulcer (N=3). The technical success rate achieved was 95.2% (20/21). Failure in one case was due to an intraoperative type I endoleak, which was rectified with an additional stent graft placement. The 30-day mortality rate was 4.8% (1/21). One patient suffered a stroke but responded well to medical intervention. The median hospital stay was 10.9±5.4 days. During the follow-up period, one death (4.8%) was associated with aortic complications. A type II endoleak was observed and managed with close monitoring. Two patients underwent re-interventions for retrograde type A dissection and stent migration, respectively. No occlusions were observed in the target branch arteries.

CONCLUSIONS

The combination of branched stent graft with fenestrated TEVAR emerges as a viable strategy for addressing specific lesions in the aortic arch.

CLINICAL IMPACT

This study demonstrates the feasibility of using branched stent grafts with fenestrated TEVAR for treating aortic arch lesions, achieving a technical success rate of 95.2%. Compared to traditional open surgery, this innovative, minimally invasive approach reduces perioperative mortality and complications, such as stroke and spinal cord ischemia. For clinicians, it offers a viable alternative for patients unfit for open repair, particularly in complex aortic arch cases. While the initial outcomes are promising, further research is needed to assess long-term durability and risks, including stent graft migration and late endoleak, ensuring the technique's safety and efficacy over time.

Effectiveness of Percutaneous Needle Tenotomy for Tendinopathies: A Systematic Review

CONTEXT

Tendinopathy is a disease state characterized by tendon disorder with pain or decreased function that can cause significant disability. Multiple treatment modalities exist; however, no single treatment is superior. Ultrasound-guided percutaneous needle tenotomy (PNT) and TENEX are emerging as promising treatment options for tendinopathy.

OBJECTIVE

To review the current literature of reported outcomes for PNT, TENEX, and TENJET, for the treatment of tendinopathy, including pain relief, change in function, and patient-reported outcomes.

DATA SOURCES

A comprehensive search was conducted from database inception to September 2023 in Ovid Medline, Ovid Embase, and Cochrane Library.

STUDY SELECTION

Keywords and index terms related to tendon injury, ultrasound, and tenotomy were used in combination to identify relevant literature that included ultrasound-guidance, treatment of tendinopathy, and treatment with PNT, TENEX, or TENJET. Covidence Systematic Review Software used to screen for relevant studies. Only English-language studies were included.

STUDY DESIGN

Systematic Review using PICO framework as defined and registered with the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42022321307).

LEVEL OF EVIDENCE

Level 4 (evidence from a systematic review graded to the lowest level of study included).

DATA EXTRACTION

Articles meeting the inclusion criteria were reviewed. Type and region of tendinopathy studied, outcome measures, and complications were recorded. Clinical and self-reported outcomes data were compared across studies.

RESULTS

A total of 10 studies, representing 11 tendon sites, were included. The studies overall report improvements in pain, function, and quality of life after undergoing PNT or TENEX, with minimal adverse effects. Mean risk of bias assessment scores were 8.35 out of 10 assessing internal and external validity for included studies.

CONCLUSION

PNT and TENEX are safe, beneficial, and minimally invasive treatment option for patients, especially for conditions refractory to more conservative treatments options.

Severe radiographic artifact created by a large fenestration of the skin and labial mucosa following placement of a plate piercing: a case report

The presence of facial jewelry and medical devices within a radiographic field of view may promote the formation of artifacts that challenge diagnostic interpretation. The objective of this article is to describe a previously unreported radiographic anomaly produced by an oral piercing site below the lower lip. This unusual artifact masqueraded as a severe resorptive defect, dental caries, or cervical abfraction and occurred following removal of an extremely large labret below the lower lip and subsequent acquisition of a radiographic image. The radiolucency was ultimately attributed to an extensive aperture below the lower lip created by a series of sequentially larger soft tissue expanders. Clinicians should seek correlation of atypical radiographic presentations with soft tissue defects secondary to injury or intentional oral piercing.

Giant symptomatic splenic cyst treated with laparoscopic fenestration using single-incision plus one-port laparoscopic surgery: A case report

Laparoscopic fenestration is the preferred treatment for symptomatic splenic cysts because it is curative and spleen-sparing. We report a case of a 25-year-old female who underwent laparoscopic fenestration for a giant splenic cyst using a single-incision plus one-port approach. She presented to our hospital with repeated vomiting. Imaging showed a 23 × 18 cm splenic cyst with no solid components, strongly compressing the stomach to the right side. Laparoscopic fenestration was initiated through a 2.5-cm umbilical incision, and a 5-mm port was added in the left abdomen intraoperatively. The drain placement was deemed necessary to prevent abscess formation and post-operative bleeding because of a thick cyst component and unexpectedly thick wall. Splenic cysts are typically benign and commonly develop in young people, hence, organ preservation and cosmetic results are crucial. Laparoscopic fenestration using single-incision plus one-port is considered to be an appropriate procedure for giant splenic cysts with non-serous contents.

Endoscopic endonasal resection of Rathke cleft cysts: a single-institution analysis of 148 consecutive patients

OBJECTIVE

The traditional treatment of sellar Rathke cleft cysts (RCCs) generally involves transsellar drainage; however, suprasellar RCCs present unique challenges to appropriate management and technical complexity. Reports on overall outcomes for the endoscopic endonasal approach (EEA) for this pathology are limited. The EEA for RCCs allows three surgical techniques: marsupialization, fenestration, and fenestration with cyst wall resection.

METHODS

The authors performed a retrospective review of consecutive patients with RCCs that had been treated via an EEA at a single institution between January 2004 and May 2021. Marsupialization entailed the removal of cyst contents while maintaining a drainage pathway into the sphenoid sinus. Fenestration involved the removal of cyst contents, followed by separation from the sphenoid sinus, often with a free mucosal graft or vascularized nasoseptal flap. Cyst wall resection, either partial or complete, was added to select cases.

RESULTS

A total of 148 patients underwent an EEA for RCC. Marsupialization or fenestration was performed in 88 cases (59.5%) and cyst wall resection in 60 (40.5%). Cysts were classified as having a purely sellar origin (43.2%), sellar origin with suprasellar extension (37.8%), and purely suprasellar origin (18.9%). Radiological recurrence was demonstrated in 22 cases (14.9%) at an average 39.7 months' follow-up (median 45 months, range 0.5-99 months), including 13 symptomatic cases (8.8%). Cases with cyst wall resection had no significantly different rate of recurrence (11.7% vs 15.9%, p = 0.48) or postoperative permanent anterior pituitary dysfunction (21.6% vs 12.5%, p = 0.29) compared to those of fenestrated and marsupialized cases. There was no significant difference in postoperative permanent posterior pituitary dysfunction based on technique, although such dysfunction tended to worsen with cyst wall resection (13.6% vs 4.0%, p = 0.09). Based on cyst location, purely suprasellar cysts were more likely to have a radiological recurrence (28.6%) than sellar cysts with suprasellar extension (12.5%) and purely sellar cysts (9.4%; p = 0.008). Most notably, of the 28 purely suprasellar cysts, selective cyst wall resection significantly improved the long-term (10-year) recurrence risk compared to fenestration alone (17.4% vs 80.0%, p = 0.0005) without any significant added risk of endocrinopathy.

CONCLUSIONS

Endoscopic endonasal marsupialization or fenestration of sellar RCCs may be the ideal treatment strategy, whereas purely suprasellar cysts benefit from partial cyst wall resection to prevent recurrence. Selective cyst wall resection reduced long-term recurrence rates without significantly increasing rates of hypopituitarism.

Anatomical Feasibility of the "Canaud Technique" for Physician-Modified Thoracic Endovascular Grafts for the Treatment of Aortic Arch Disease

PURPOSE

Thoracic endovascular aortic repair (TEVAR), originally conceived for deployment distal to the left subclavian artery (LSA), has been recently extended to more proximal landing zones. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The aim of this study is to report the proportion of patients with zone 0, 1, and 2 aortic arch lesions that could theoretically be treated with a C-PMEG.

MATERIALS AND METHODS

Computed tomography angiography (CTA) of all consecutive patient candidates to open, hybrid, or endovascular arch repair from January 2009 to July 2023 at our Institution were analyzed. The assessment of feasibility of C-PEMG was conducted following previously extensively described anatomical criteria.

RESULTS

During the study period, 209 consecutive patients were candidates for an open, hybrid, or endovascular aortic arch repair. Of them, 164 patients had a preoperative CTA scan eligible for analysis. One hundred twenty-six patients were male (76.8 %), with a mean age of 67 ± 10.8 years. Ninety-four patients (57.3%) were affected by atherosclerotic aneurysms, 48 post-dissecting aneurysms (29.3%) and 22 penetrating aortic ulcers (PAUs) (13.4%). Twenty patients (12.2%) were suitable for double-fenestrated C-PMEG, and 34 patients (20.7%) for single-fenestrated C-PMEG, totaling 32.9% of the entire cohort. The combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, would extend the C-PMEGs feasibility to 69 patients (42.1%). The use of an iliac graft conduit in 3 (1.8%) patients with inadequate ileo-femoral accesses would increase the C-PMEG suitability to 72 patients (43.9%). The main reason for exclusion was excessive ascending aortic diameter in 78 patients (47.6%).

CONCLUSIONS

The use of C-PMEG was shown to be theoretically feasible in a percentage of patients ranging from 32.9 to 43.9% affected by aortic arch aneurysms, dissections, and PAU. The main reason for exclusion was the dimension of the ascending aorta. The C-PMEG technique is a viable option in aortic arch lesions endovascular treatment. An off-the-shelf device with similar characteristics could also be used in emergency, avoiding the limitations of physician modifications (such as time for back-table procedure, sterility, off-label use).

CLINICAL IMPACT

Thoracic endovascular aortic repair (TEVAR) has been extended to more proximal landing zones for the treatment of aortic arch aneurysm, dissections, penetrating aortic ulcers. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The anatomical feasibility in 164 consecutive patients was 69 patients (42.1%), with the combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, showing that the C-PMEG technique is a viable option in aortic arch lesions endovascular treatment.

Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note

PURPOSE

The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD).

TECHNIQUE

We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks.

CONCLUSIONS

Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable.

CLINICAL IMPACT

The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.

Investigating the effects of buccal bone fenestration on maxillary anterior implants: A 1- to 6-year retrospective study

PURPOSE

To examine the effects of buccal bone fenestration on maxillary anterior implants.

MATERIALS AND METHODS

Patients who underwent implant placement in the maxillary anterior region between January 2017 and December 2021 and had received final restorations 1 to 6 years prior were screened for inclusion in the present study. Propensity score matching was used to match the two-group sample size and reduce the influence of potential confounding factors. Generalised linear mixed models were employed to evaluate the correlation between buccal bone fenestration and peri-implant marginal bone loss.

RESULTS

A total of 42 patients with 50 implants were included in the study, 16 of whom had buccal bone fenestration (group 1) and 26 of whom did not (group 2). No implant failures occurred, resulting in a cumulative implant survival rate of 100.0%. There was no statistically significant difference between the pink aesthetic scores for the two groups. The mean marginal bone loss was 0.44 ± 0.46 mm for group 1 and 0.33 ± 0.32 mm for group 2 (P > 0.05). Buccal bone fenestration was not the influencing factor of marginal bone loss (P > 0.05). Marginal bone loss was greater around implants used to replace canines than those inserted to replace central incisors (P < 0.05). Far less marginal bone loss occurred around immediately loaded implants than delayed implants with cover screws (P < 0.05). When there is sufficient keratinised mucosa around the implant, marginal bone loss will decrease significantly (P < 0.05).

CONCLUSIONS

Within the limitations of this study, buccal bone fenestration defects around dental implants cannot influence peri-implant bone loss.

CONFLICT-OF-INTEREST STATEMENT

The authors report no conflicts of interest relating to this study.

TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review

OBJECTIVES

Blunt thoracic aortic injuries (BTAIs) involving the aortic arch are a challenging condition. Thoracic endovascular aortic repair (TEVAR) with fenestration, which expands the proximal landing zone, is able to exclude the injury while preserving blood flow in supra-aortic branches.

METHODS

Here we report a case of TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm and perform a systematic review.

RESULTS

A 24-year-old man suffering a blunt thoracic injury and a left femoral fracture was sent to our hospital. A pseudoaneurysm was found in the aortic arch between the brachiocephalic artery and the left common carotid artery. The patient underwent emergent TEVAR with fenestrations of all supra-aortic branches, which excluded the pseudoaneurysm and preserved the patency of all branches. The orthopedic team then treated the femoral fracture. The patient's recovery was unremarkable. We performed a systematic review on TEVAR with fenestrations for BTAI. Six patients (75%) received TEVAR with single fenestration, 1 patient (12.5%) received TEVAR with two fenestrations, and 1 patient (12.5%) had fenestrations of all supra-aortic branches. Except one patient died in the perioperative, other patients survived without stent-related complications in the short-term follow-up.

CONCLUSIONS

TEVAR with fenestration is feasible for treating BTAI involving the aortic arch in selected patients.

The long-term effects of the fenestration in patients with extracardiac Fontan circulation-a multicenter Korean cohort study based on national Fontan registry

Introduction

The long-term effects of fenestration in patients with Fontan circulation remain unclear. We aim to evaluate the fenestration impact on early and late outcomes in patients with extracardiac Fontan (ECF) using a propensity score matching analysis.

Methods

We performed an extensive retrospective multicenter clinical data review of the Korean Fontan registry and included 1,233 patients with surgical ECF (779 fenestrated, 454 non-fenestrated). Demographics, baseline, and follow-up data were collected and comprehensively analyzed. Patients were divided into two groups according to the baseline presence or absence of surgical fenestration. Subsequently, patients were sub-divided according to the fenestration status at the last follow-up. Propensity-score matching was performed to account for collected data between the 2 groups using a multistep approach. The primary outcomes were survival and freedom from Fontan failure (FFF). We also looked at postoperative hemodynamics, cardiopulmonary exercise test results, oxygen saturations, and functional status.

Results

After propensity-score matching (454 matched pairs), there was no difference in survival or FFF between the 2 groups. However, ECF patients with baseline fenestration had significantly lower oxygen saturation (p = 0.001) and lower functional status (p < 0.001). Patients with fenestration had significantly longer bypass times, higher postoperative central venous pressure, higher postoperative left atrial pressure, and less prolonged pleural effusion in the early postoperative period. The propensity score matching according to the fenestration status at the last follow-up (148 matched pairs) showed that patients with a persistent fenestration had significantly lower oxygen saturation levels (p < 0.001). However there were no intergroup differences in the functional status, survival and FFF.

Conclusions

Our results showed no long-term benefits of the Fenestration in terms of survival and FFF. Patients with persistent fenestration showed oxygen desaturation but no difference in exercise intolerance was shown between the 2 groups.

Comparison of the Snare Loop Technique and the Hungaroring Reinforcement for Physician-Modified Endograft Fenestrations-An In Vitro Study

BACKGROUND

We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation.

MATERIALS AND METHODS

The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration.

RESULTS

Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010-1090) compared to 760 s (IQR:685-784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8-27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3-20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm.

CONCLUSION

Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.

Multivariate analysis of alveolar bone dehiscence and fenestration in anterior teeth after orthodontic treatment: A retrospective study

OBJECTIVE

To compare the prevalence of fenestration and dehiscence between pre- and post-orthodontic treatment and to explore the factors related to fenestration and dehiscence in the anterior teeth after treatment.

METHODS

This study included 1000 cone-beam computed tomography (CBCT) scans of 500 patients before (T1) and after (T2) orthodontic treatment. These images were imported into Dolphin 11.9 software to detect alveolar fenestration and dehiscence in the anterior teeth area. The chi-square test and Fisher's exact test were performed to compare the prevalence of alveolar bone defects between time points T1 and T2. A total of 499 patients were selected for logistic regression analysis to examine the correlation among age, sex, crowding, sagittal facial type, extraction, miniscrew use and fenestration or dehiscence post-treatment.

RESULTS

Except for the maxillary lingual fenestration and labial fenestration of mandibular canines, a significant change in the prevalence of fenestration and dehiscence was noted between time points T1 and T2 (P < .025). Multinomial logistic regression showed that age, miniscrew use and extraction highly influenced the prevalence of anterior lingual dehiscence (P < .05). Dehiscence of the mandibular labial side (skeletal Class III vs. I, OR = 2.368, P = .000) and fenestration of the mandibular lingual side (skeletal Class II vs. I, OR = 2.344, P = .044) were strongly correlated with the sagittal facial type. Dehiscence of the maxillary labial side (moderate vs. mild, OR = 1.468, P = .017) was significantly associated with crowding.

CONCLUSIONS

Older age, maxillary moderate crowding, skeletal Class III, extraction and miniscrew potentially significantly affect the prevalence of anterior teeth dehiscence. Adult females, skeletal Class III patients on the mandibular labial side and skeletal Class II patients on the mandibular lingual side should be monitored for anterior teeth fenestration.

Surgical and radiological perspectives for the spinal accessory nerve passing through a fenestrated internal jugular vein: case series and literature review

The preservation of the spinal accessory nerve represents a key goal in head and neck oncologic surgery during selective neck dissection. This study aims to illustrate the anatomical variants of the XI cranial nerve, delving into the relationship between the spinal nerve and the internal jugular vein, as well as the surgical implications. Two cases of patients who underwent oncologic surgery with neck dissection are described. Both cases found the spinal accessory nerve passing through the fenestration of the internal jugular vein. Alongside this case series, an independent literature review was conducted using the Medline and PubMed databases. In the majority of cases (67% - 96%), the spinal accessory nerve traces a lateral course to the internal jugular vein. Less frequently, the XI cranial nerve courses medial to the internal jugular vein. More rarely, as described in this case series, the nerve crosses through the fenestration of the vein (0.48% - 3.3%).

A case of left testicular artery with high origin passing through a left renal vein fenestration

BACKGROUND

Fenestrations of are extremely rare in the venous system, especially renal veins. This paper aims to present a case of left renal vein fenestration where a high origin testicular artery passes through it. Materials and Methods The variation was observed incidentally in a 74-year-old Caucasian male cadaver during routine retroperitoneal dissections for second year medical students.

RESULTS

A fenestration in the mid portion of the left renal vein was observed. The length and height of the fenestration was 23 and 3.6 millimeters, respectively. The left testicular artery passed through the fenestration and followed a normal course distal to the fenestration. Posterior to the left renal vein, the testicular artery originated from the lateral aspect of abdominal aorta, just caudal to the left renal artery. On the right side, the testicular artery had a similar high origin, and two renal arteries were present. No venous variations were observed on the right side.

CONCLUSIONS

The long course of the left renal vein is a factor of preference for donor kidney selection. Uncommon variations of the left renal veins, such as fenestrations, might result in a change in surgical technique and would put the left donor kidney at risk of prolonged anastomosis time and lower survival rates.

Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report

RATIONALE

Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft.

PATIENT CONCERNS

A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours.

DIAGNOSES

Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA.

INTERVENTIONS

Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery.

OUTCOMES

The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery.

LESSONS

This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

Use of a modified microvascular plug to modify fenestration flow in a rapidly failing Fontan

We report a case of an alternative transcatheter use of the modified Medtronic microvascular plug to modify fenestration stent flow in a patient with a rapidly deteriorating clinical condition. This four-year-old boy developed severe cyanosis following fenestration stent insertion, initially placed due to prolonged drainage post-Fontan with extra-cardiac conduit. In April 2023, he underwent urgent cardiac catheterisation and had partial occlusion of fenestration stent with a modified 9Q microvascular plug. His oxygen saturations improved from 50 to 89% in room air with no re-emergence of raised cavopulmonary pressures.

Endovascular Rescue Aortic Fenestration After Accidental False Lumen TEVAR in Type B Dissection

PURPOSE

Unintended false-lumen thoracic endovascular aortic repair (TEVAR) is under-reported and often fatal. We present percutaneous endovascular rescue techniques for true-lumen reperfusion with strategies to address the peripheral artery perfusion needs unique to each case.

CASE REPORT

Two patients deteriorated 24 hours after uncomplicated and complicated acute aortic type-B dissection TEVAR treatment at a tertiary community hospital. Reevaluation of index and repeated imaging studies revealed inadvertent false-lumen TEVAR with severe visceral and peripheral ischemia. Stepwise subtraction angiography was used to confirm continuous true-lumen catheterization from femoral puncture into the thoracic aorta. Retrograde fenestration distal to the misplaced TEVAR from the true- into the false-lumen allowed for snorkeling by distal stent-extension across the dissection membrane. In one case, TEVAR stent graft extension resulted in true-lumen re-expansion and in the other case, bare-metal stent-extension for stabilization of the dissection membrane resulted in true-lumen re-expansion in addition to preservation of visceral and peripheral perfusion via the false-lumen. Despite excellent acute hemodynamic results and initial signs of recovery, both patients eventually died (multiorgan failure; cerebral hemorrhagic infarction).

CONCLUSION

Correct indication and prompt recognition of potential inadvertent false-lumen stenting is critical to avoid disastrous sequelae, for example, malperfusion. Endovascular salvage is feasible for restoration of correct perfusion and must be performed in a timely manner.

CLINICAL IMPACT

Clinically apparent, complicated type-B dissection necessitates instantaneous treatment. Prerequisite for an endovascular approach is a true-lumen guidewire continuously from access to the ascending aorta. DSA after TEVAR and prompt clinical re-evaluation are to verify effective visceral and peripheral restoration of blood flow. Despite these measures, inadvertent false-lumen TEVAR may occur rarely. Immediate recognition may allow for timely true-lumen re-expansion using percutaneous endovascular salvage techniques e.g. retrograde fenestration from the true- into the false-lumen for distal snorkeling of the misplaced TEVAR across the dissection membrane. However, morbidity and mortality are very high, if erroneous stent graft placement is not identified early.

In Situ Laser Fenestration Technique: Bench-Testing of Aortic Endograft to Guide Clinical Practice

PURPOSE

In situ laser fenestration (ISLF) is a recently introduced technology that offers the potential to perform total endovascular treatment of aortic arch and thoracoabdominal aortic pathologies in the acute setting. This experiment's aim was to assess ISLF in some currently common aortic endografts and bridging stent-grafts.

MATERIALS AND METHODS

Three different aortic endografts were evaluated: (1) Zenith Alpha, (2) Zenith TX2, and (3) Conformable GORE TAG. Each endograft was submerged in 37°C saline to create fenestrations using the 308 nm CVX-300 Excimer Laser System fitted with a 2.3 mm diameter Turbo-Elite laser atherectomy catheter compatible with a 0.018″ guidewire. Three different 8 mm bridging stent-grafts were evaluated: (1) BeGraft peripheral, (2) BeGraft peripheral plus, and (3) GORE VIABAHN VBX Balloon Expandable. All bridging stent-grafts were deployed and exposed to different balloon sizes and pressures. The ISLFs and bridging stent-grafts were then evaluated for any tears, stenoses, and seal.

RESULTS

A laser fenestration was consistently rapidly obtained in the Zenith Alpha and the Zenith TX2 endografts while it proved difficult to achieve a timely fenestration in the C-TAG. No fabric tears were noted in the Zenith Alpha and Zenith TX2 when inflating Armada (Abbott) 8 mm balloon in the fenestrations with pressures up to 15 atmospheres (rated burst pressure) nor when flaring bridging stent-grafts with balloons up to 12 mm in diameter at 10 atmospheres, while major tears were frequently noted in the C-TAG when the Armada 8 mm balloons were inflated. BeGraft Peripheral and BeGraft Peripheral Plus were all firmly attached to the fenestrations showing good seal on manual testing, while every sixth VBX bridging stent-graft displayed poorer attachment to the fenestration before dilatation at high pressure. Commonly, significant stenoses remained in the bridging stent-grafts after dilatation at nominal pressure, which could only be eradicated with high-pressure balloons.

CONCLUSION

In this limited bench-test, Dacron endografts responded well to the ISLF technology. Satisfactory deployment of the bridging stent was noted only after inflation and/or flaring with high-pressure balloons. Further work with different types of commercially-available bridging stent-grafts and endografts to assess the durability of in situ fenestration (ISF) and bridging stents in ISF is recommended.

CLINICAL IMPACT

This report on experimental in situ laser fenestration provide important insights for clinicians considering using in situ laser fenestration of aortic stentgrafts in vivo. In particular, different laser settings were tested together with a selection of aortic stentgrafts. Also, the target pressure needed in PTA balloons to dilate the fenestrations and any subsequent tears in the fabric were noted. This was followed by deployment of assorted balloon-expandable stentgrafts with estimation of residual stenosis and seal.

Comparison of three methods for nucleus pulposus volume measurement in rabbit lumbar spines: a preclinical model for measurement of the effectiveness of prophylactic intervertebral disk fenestration in dogs

OBJECTIVE

Compare 3 methods of nucleus pulposus (NP) volume measurement using the rabbit lumbar spines as a preclinical model to determine the effectiveness of prophylactic intervertebral disk fenestration in dogs.

ANIMALS

Twelve 9-month-old, skeletally mature female entire New Zealand White rabbits weighing between 3.5 to 4.5 kg.

METHODS

NP volume measurements of dissected rabbit lumber spines between L1 and L6 were made and compared using gross measurements, reconstructed MRI images, and water volumetry based on Archimedes' principle. Water volumetry was used as the true gold standard volume measurement in this study.

RESULTS

The true volume (mean ± SD) of the nucleus pulposus NP as measured by water volumetry increased caudally from L1/L2 (16.26 ± 3.32 mm3) to L5/L6 (22.73 ± 6.09 mm3). Volume estimates made by MRI were significantly higher than those made using water volumetry at all sites (L1/L2 [P = .044], L2/L3 [P = .012], L3/L4 [P = .015], L4/L5 [P < .001], and L5/L6 [P < .001]). Gross measurements also significantly overestimated volume when compared to water volumetry at all sites; L1/L2 (P = .021), L2/L3 (P = .025), L3/L4 (P = .001), L4/L5 (P < .001), and L5/L6 (P < .001). MRI and gross volume estimates were significantly different at L4/L5 (P = .035) and L5/L6 (P = .030).

CLINICAL RELEVANCE

The findings of this preclinical model might be relevant to veterinary surgeons who perform prophylactic fenestration for which there is no reliable method to determine the amount of NP to be removed. Preclinical ex vivo and in vivo fenestration studies with pre- and postoperative NP volume assessment are required.

Tranexamic Acid in Reducing Intraoperative Bleeding in Dogs Undergoing Thoracolumbar and Lumbar Hemilaminectomy and Intervertebral Disc Fenestration

Hemilaminectomy associated with intervertebral disc fenestration (HF) is the most used spinal decompression surgical technique for the treatment of intervertebral disc extrusion (IVDE). The surgical procedure can be hampered by excessive bleeding from the venous sinuses; however, tranexamic acid intravenously (IV) is a possible adjunct to hemostasis in these patients. This study aimed to verify the effectiveness of tranexamic acid in reducing intraoperative bleeding in dogs with thoracolumbar and lumbar IVDE submitted to HF. Sixteen dogs with IVDE undergoing HF were included. These were distributed into a TXA group (tranexamic acid 20 mg/kg IV bolus, followed by 2 mg/kg/h IV continuous infusion) (n = 8) and a control group, with saline solution (n = 8). Blood loss was measured using the gravimetric method. The difficulty of operative visualization due to bleeding was classified by the surgeon. Median blood loss (%) in patients in the TXA group was lower than those in the control group (2.75 ± 1.23 and 4.99 ± 4.44, respectively) (P = .028). Intraoperative visualization difficulty due to bleeding occurred in 10 patients in the control group, and in no patients in the TXA group. A severe arterial thromboembolic complication was recorded, potentially due to tranexamic acid. The use of intraoperative tranexamic acid was effective in reducing bleeding and facilitating operative visualization in dogs with IVDE undergoing hemilaminectomy and intervertebral disc fenestration.