Computational study of fenestration and parallel grafts used in TEVAR of aortic arch aneurysms

To explore the differences between fenestration technique and parallel grafts technique of thoracic endovascular aortic repair, and evaluate the risk of complications after interventional treatment of aortic arch aneurysms. A three-dimensional aortic model was established from the follow-up imaging data of patient who reconstructed the superior arch vessel by the chimney technique, which was called the chimney model. Based on the chimney model, the geometric of the reconstructed vessel was modified by virtual surgery, and the normal model, fenestration model and periscope model were established. The blood flow waveforms measured by 2D phase contrast magnetic resonance imaging were processed as the boundary conditions of the ascending aorta inlet and the superior arch vessels outlets of the normal model. The pressure waveform of descending aorta was obtained using three-element Windkessel model, and specific pressure boundary conditions were imposed at reconstructed branches for the postoperative models. Through computational fluid dynamics simulations, the hemodynamic parameters of each model were obtained. The reconstructed vessel flow rate of the periscope model and the fenestration model are 33% and 50% of that of the normal model, respectively. The pressure difference between the inner and outer walls of the fenestration stent and periscope stent is 3.15 times and 7.56 times that of the chimney stent. The velocity in the fenestration stent and periscope stent is uneven. The high relative residence time is concentrated in the region around the branch stents, which is prone to thrombosis. The "gutter" part of the chimney model may become larger due to the effect of the stent-graft DF, increasing the risk of endoleak. For patients with incomplete circle of Willis, the periscope technique to reconstruct the supra-arch vessels may affect blood perfusion. It is recommended to use balloon-expandable stent for fenestration stent and periscope stent, and self-expanding stent for chimney stent. For patients with aortic arch aneurysms, the fenestration technique may be superior to the parallel grafts technique.

Efficacy of biomaterials for lateral bone augmentation performed with guided bone regeneration. A network meta-analysis

Bone regeneration is often required concomitant with implant placement to treat a bone fenestration, a dehiscence, and for contouring. This systematic review assessed the impact of different biomaterials employed for guided bone regeneration (GBR) simultaneous to implant placement on the stability of radiographic peri-implant bone levels at ≥12 months of follow-up (focused question 1), as well as on bone defect dimension (width/height) changes at re-assessment after ≥4 months (focused question 2). Only randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared different biomaterials for GBR were considered. A Bayesian network meta-analysis (NMA) was performed using a random-effects model. A ranking probability between treatments was obtained, as well as an estimation of the surface under the cumulative ranking value (SUCRA). Overall, whenever the biological principle of GBR was followed, regeneration occurred in a predictable way, irrespective of the type of biomaterial used. A lower efficacy of GBR treatments was suggested for initially large defects, despite the trend did not reach statistical significance. Regardless of the biomaterial employed, a certain resorption of the augmented bone was observed overtime. While GBR was shown to be a safe and predictable treatment, several complications (including exposure, infection, and soft tissue dehiscence) were reported, which tend to be higher when using cross-linked collagen membranes.

Physician-Modified Stent-Grafts Created in the Three-Dimensionally Aortic Template Have Better Reliability and Greater Alignment With the Target Vessels Than Stent-Grafts Modified Based on Measurements From Computed Tomography

PURPOSE

Physician-modified stent-grafts (PMSG) are widely used, especially when a patient's condition precludes waiting for a custom-made device. In recent years, the modification process has been upgraded using 3-dimensional (3D) aortic templates. Nonetheless, the reliability of PMSG and accuracy of fenestration alignment with the target vessel are not known. Thus, the study is aimed to fulfill the gap in current knowledge.

MATERIALS AND METHODS

Ten computed tomographic (CT) scans of aortic aneurysm previously treated with the fenestrated endovascular repair were selected to 3D-print aortic templates and elastic vessel phantoms. Two vascular surgeons performed fenestrations using the 3D template and modification plan based on CT measurements. Two operators each performed 10 fenestrated stent-grafts in the aortic template and 10 using CT measurements, for a total of 40 fenestrated stent-grafts. Then, stent-grafts were implanted in elastic vessel phantoms, which served to evaluate fenestration alignment with the target vessel. The alignment was judged in a 5-point scale: 0%, 1% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%. The distances between fenestrations served to calculate interobserver variability for both methods. The measurements were processed as interclass correlation coefficient (ICC), Pearson and Spearman correlation, and Bland-Altman plots.

RESULTS

PMSG created with a 3D template had higher interclass correlation coefficient values and Pearson/Spearman correlation than fenestrations created from CT measurements. The rate of fenestration alignment with the target vessel was higher for PMSG created with a 3D template (p=0.007).

CONCLUSIONS

PMSGs created with a 3D template are more reliable and have better fenestration alignment with the target vessel than PMSGs created based on CT measurements.

Conservative Management of a Rare Presentation of Mucosal Fenestration in a Four-Year-Old Child

Mucosal fenestration refers to a window-like defect in the alveolar bone where the root of a tooth is denuded of its bony covering. Various causes ranging from trauma to chronic periapical or periodontal inflammation can produce such defects. This condition usually manifests either in adolescents or in extreme age group patients. The present case report is of a four-year-old boy who showed the presence of mucosal fenestration in the anterior maxillary gingivae in relation to teeth 51 and 61 (primary maxillary right and left central incisors as per the Fédération Dentaire Internationale (FDI) System) and was treated in a conservative and least invasive manner. Mucosal fenestration in the primary dentition phase can be treated in a conservative manner as opposed to any invasive treatment approaches, likely to instill fear or anxiety in a pediatric patient.

Bone regeneration in implant dentistry: Which are the factors affecting the clinical outcome?

The key factors that are needed for bone regeneration to take place include cells (osteoprogenitor and immune-inflammatory cells), a scaffold (blood clot) that facilitates the deposition of the bone matrix, signaling molecules, blood supply, and mechanical stability. However, even when these principles are met, the overall amount of regenerated bone, its stability over time and the incidence of complications may significantly vary. This manuscript provides a critical review on the main local and systemic factors that may have an impact on bone regeneration, trying to focus, whenever possible, on bone regeneration simultaneous to implant placement to treat bone dehiscence/fenestration defects or for bone contouring. In the future, it is likely that bone tissue engineering will change our approach to bone regeneration in implant dentistry by replacing the current biomaterials with osteoinductive scaffolds combined with cells and mechanical/soluble factors and by employing immunomodulatory materials that can both modulate the immune response and control other bone regeneration processes such as osteogenesis, osteoclastogenesis, or inflammation. However, there are currently important knowledge gaps on the biology of osseous formation and on the factors that can influence it that require further investigation. It is recommended that future studies should combine traditional clinical and radiographic assessments with non-invasive imaging and with patient-reported outcome measures. We also envisage that the integration of multi-omics approaches will help uncover the mechanisms responsible for the variability in regenerative outcomes observed in clinical practice.

Regeneration of Buccal Wall Defects after Tooth Extraction with Biphasic Calcium Phosphate in Injectable Form vs. Bovine Xenograft: A Randomized Controlled Clinical Trial

Bone healing after tooth extraction may be affected by defects of the alveolus buccal wall, such as fenestrations and dehiscences. Therefore, to minimize dimensional changes it is advisable to perform alveolar ridge preservation after tooth extractions. Different biomaterials are used for this purpose. The aim of this study was to investigate the qualitative and quantitative histological changes in human biopsies taken after 6 months of healing of extraction sockets with buccal wall defects. For this purpose, the defects of 36 patients (18 per group) were treated with injectable biphasic calcium phosphate (I-BCP) or bovine xenograft (BX) after extraction. After six months of healing, biopsies were taken and proceeded to the histology laboratory. No evidence of an inflammatory response of the tissue was observed in the biopsies of either group, and the newly formed bone (NB) was in close contact with the remaining biomaterial (BM). The histomorphometric results showed that there was no statistically significant difference between the groups in the mean percentage of NB (p = 0.854), BM (p = 0.129), and soft tissue (p = 0.094). To conclude, both biomaterials exhibited osteoconductivity and biocompatibility and achieved satisfactory bone regeneration of buccal wall defects after tooth extraction.

Fenestration: Integrating Wings Into the Atrial Septal Occluder for Navigating a Challenging Terrain

Background Atrial septal defect (ASD) closure with significant left-to-right shunt and concurrent comorbidities poses challenges for intervention. A fenestrated atrial septal defect (FASD) device is a viable option for patients who cannot undergo complete occlusion due to hemodynamic and medical reasons. This study explores the use of FASD occluders in patients with secundum ASD and associated comorbidities where complete occlusion is difficult. Methodology This retrospective study collected the details of patients recommended for FASD closure diagnosed with significant secundum ASD and who had additional comorbidities between July 2015 and July 2023 in a tertiary cardiac center in eastern India. Among this cohort, patients who underwent FASD device placement were subjected to a comprehensive analysis. Results In total, 16 patients diagnosed with secundum ASD, characterized by significant left-to-right shunt and concurrent comorbidities, were considered for FASD closure during the study period. Ultimately, 13 patients (first group) underwent fenestrated atrial septal occluder implantation. The average age was 45.07 years, with the majority being females (n = 9). Comorbidities among this cohort included substantial left ventricular diastolic dysfunction (n = 7), left ventricular diastolic dysfunction coupled with moderate pulmonary hypertension (n = 1), severe pulmonary hypertension (n = 1), severe pulmonary valvular stenosis with right ventricular diastolic dysfunction (n = 2), and systemic lupus erythematosus (SLE) (n = 2). From this cohort, three patients did not undergo the intervention. The second group consisted of an elderly patient with severe left ventricular diastolic dysfunction, a young adult with a history of left atrial arrhythmia, and a child with Duchenne muscular dystrophy (DMD). The average ASD size among patients who underwent the intervention was 26.38 mm, with a thick-to-thick dimension measuring 31.15 mm. The procedure was successful in all 13 patients, with the most frequently used device being a 34 mm occluder (range = 28-40 mm). All devices, excluding the initial one, were custom-made atrial septal occluders (Lifetech Scientific). Among the patients, 12 exhibited left-to-right fenestration flow, while one patient experienced fenestration constriction, likely due to occluder overcrowding. The first patient had a handmade 5 mm fenestration in a 40 mm Amplatzer septal occluder, which got closed off at the one-year follow-up. The procedure was well-tolerated hemodynamically in all patients, with no major complications during the peri-procedural period. Short-term follow-up indicated favorable patient progress. Conclusions FASD closure emerges as a pivotal alternative for intricate scenarios involving secundum ASD coupled with concurrent comorbidities, offering individualized tailored solutions. Alongside the conventional associated comorbidities, such as left ventricular diastolic dysfunction and pulmonary hypertension, FASD devices hold the potential to extend their benefits to patients grappling with other complexities, including severe pulmonary valvular stenosis, SLE, predisposition to left atrial arrhythmia, and conditions like DMD. Ensuring meticulous evaluation of patient suitability and providing ongoing vigilant care becomes paramount for achieving optimal outcomes. The validation of these findings and the broadening of the comprehension of this approach necessitate further comprehensive investigations.

Long-Term Recurrent Intramedullary Arachnoid Cyst: Case Report and Literature Review

Objectives  This article reports the management of a case of a 32-year-old male who presented with progressive weakness in the lower limbs and spastic paraparesis secondary to an intramedullary arachnoid cyst (IMAC). For literature review, the authors used the phrase "intramedullary arachnoid cyst" in PubMed search engine. 23 articles describing cases with IMAC were included in this review, with a total of 26 patients. Materials and Methods  We report a case with long term recurrant intramedullary arachnoid cyst and present a review on spinal intramedullary arachnoid cyst. Result  IMAC is showing bimodal incidence and trending to occur below 10 years and after 30 years. However, rarely, it should be considered in the differential diagnosis of intramedullary cystic lesions. Authors suggest doing laminoplasty or fusion for the pediatric patients to prevent kyphoscoliosis deformity in the long run, but doing early surgery to gain better outcome. Resection of the cyst wall should be done as much as possible; if it could not be achieved, then marsupialization or cysto-subarachnoid shunt should be considered. Aspiration alone or fenestration is not enough to eradicate the cyst. Long-term and prospective studies are recommended to achieve the best treatment options. Conclusion  Review supports early surgical treatment of symptomatic IMACs with resection of the cyst wall as much as possible.

Pediatric intraspinal arachnoid cyst: successful endoscopic fenestration. Illustrative case

BACKGROUND

Intradural spinal arachnoid cysts (SACs) are a rare cause of spinal cord compression. Treatment is centered on decompression of the spinal cord via laminectomy or laminoplasty followed by resection or fenestration of the cyst. Although laminectomy or laminoplasty access may be needed to achieve the desired result, either procedure can be associated with more extensive surgical dissections and long-term spinal stability concerns, including postsurgical kyphosis.

OBSERVATIONS

The authors present a case of a cervical intradural SAC in a 4-month-old girl presenting with symptomatic compression. The patient was treated by laminotomy and endoscopic fenestration of the SAC with resolution of symptoms and no disease progression 10 months postoperatively, when the patient was 14 months old.

LESSONS

Microsurgical endoscopic fenestration of an intradural SAC can provide a less invasive means of treatment while avoiding the risks associated with more invasive approaches.

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms

BACKGROUND

There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required.

METHODS

Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency.

RESULTS

Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality.

CONCLUSION

Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.

Gingival Biotypes and its Relation to Biologic Width, Alveolar Bone Thickness, Dehiscence and Fenestration in Mandibular Anterior Region: A CBCT Analysis Study

Background

Gingival biotype and its relationship to biologic width and alveolar bone thickness may affect surgical periodontal therapy outcomes. Hence, it is vital to assess the gingival biotype prior to any of these treatments for its success.

Aim

The study aims to compare the thick and thin gingival biotype in the mandibular anterior region concerning biologic width, buccal bone thickness, prevalence and distribution of dehiscence, and fenestration in lower anterior teeth.

Materials and Methods

A total of 30 patients were selected for the study based on the inclusion and exclusion criteria. The Cone Beam Computed Tomography analysis was performed in the mandibular anterior area to assess gingival thickness (biotype), biologic width, buccal bone thickness, dehiscence, and fenestrations. The data were analyzed using SPSS version 26. An independent t-test was used to assess the relationship between the variables.

Results

Our study identified an increased biologic width in the thick gingival biotype, a higher frequency of dehiscence in the thin gingival biotype than in the thick biotype, and a greater mean alveolar bone thickness in the thick biotype group.

Conclusion

A statistical difference was not observed between the groups; however, the thick biotype showed better results than the thinner biotype for the periodontal parameters examined.

Toward Overcoming Pyrethroid Resistance in Mosquito Control: The Role of Sodium Channel Blocker Insecticides

Diseases spread by mosquitoes lead to the death of 700,000 people each year. The main way to reduce transmission is vector control by biting prevention with chemicals. However, the most commonly used insecticides lose efficacy due to the growing resistance. Voltage-gated sodium channels (VGSCs), membrane proteins responsible for the depolarizing phase of an action potential, are targeted by a broad range of neurotoxins, including pyrethroids and sodium channel blocker insecticides (SCBIs). Reduced sensitivity of the target protein due to the point mutations threatened malaria control with pyrethroids. Although SCBIs-indoxacarb (a pre-insecticide bioactivated to DCJW in insects) and metaflumizone-are used in agriculture only, they emerge as promising candidates in mosquito control. Therefore, a thorough understanding of molecular mechanisms of SCBIs action is urgently needed to break the resistance and stop disease transmission. In this study, by performing an extensive combination of equilibrium and enhanced sampling molecular dynamics simulations (3.2 μs in total), we found the DIII-DIV fenestration to be the most probable entry route of DCJW to the central cavity of mosquito VGSC. Our study revealed that F1852 is crucial in limiting SCBI access to their binding site. Our results explain the role of the F1852T mutation found in resistant insects and the increased toxicity of DCJW compared to its bulkier parent compound, indoxacarb. We also delineated residues that contribute to both SCBIs and non-ester pyrethroid etofenprox binding and thus could be involved in the target site cross-resistance.

Prolapse Repair for Aortic Regurgitation in Tricuspid Aortic Valves

OBJECTIVE

Cusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAV), 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 (AVr) in patients with TAV morphology and AR caused by prolapse, and compared the results for cusp fenestration and myxomatous degeneration.

METHODS

Between 10/2000 and 12/2020, 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=0.003).

RESULTS

Ten-year survival was better in group I (I:84.5%; II:72.4%; p=0.037), and patients without cardiac comorbidities (89.2% vs. 67.0%; p=0.002). Ten-year freedom from reoperation (p=0.778), ≥moderate AR (p=0.070), and valve-related complications (p=0.977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (p=0.042). 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.

Common Designs of Custom-Made Fenestrated Arch Devices and Applicability of an Off-the-Shelf Design

OBJECTIVES

To analyze device designs, similarities and overlaps of custom-made fenestrated arch endografts intended for mid/distal arch thoracic endovascular aortic repair.

MATERIALS AND METHODS

A multicenter cross-sectional study analyzing custom-made anonymized graft plans was performed. Graft plans were included from a cohort of mid/distal aortic arch repairs using custom-made fenestrated aortic endografts treated at 8 centers. Grafts targeting >2 arteries were excluded. No patient/clinical data were analyzed. A descriptive analysis was performed followed by an analysis of overlap of the designs to reach a common design in which the greatest number of grafts would overlap.

RESULTS

One hundred thirty-one graft plans were included. All grafts were custom-made grafts from the COOK Medical Fenestrated arch platform. Ninety-four (71.8%) had a scallop-and-single-fenestration design, 33 (25.2%) had a single fenestration and 4 (4.3%) a single scallop. For analysis purposes, these latter 4 grafts were excluded. Two main graft plans (Plans 1 and 2) were proposed after analysis with similar configuration (1 scallop with 30 mm width, 20 mm height, 12:00 position; 1 preloaded fenestration with 8 mm diameter, 26 mm from the top of the graft and 12:00 position; tapered, with a 193 mm length and 32 mm distal diameter) but with 2 different proximal diameters of 38 mm (Plan 1) and 44 mm (Plan 2), reaching an overall feasibility of 85.8% (n=109), being 47.2% (n=60) and 38.6% (n=49) for each design, respectively.

CONCLUSION

The degree of overlap between the studied fenestrated and/or scalloped thoracic endovascular aneurysm repair (TEVAR) graft designs was high. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.

CLINICAL IMPACT

In a multicenter study analyzing 127 fenestrated aortic arch endograft plans from 9 aortic centers, we found that the degree of overlap between the studied fenestrated and/or scalloped arch graft designs was high and that 2 proposed graft designs would be theoretically applicable in 85.8% of cases. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.

Influence of Occlusal Hypofunction on Alveolar Bone Healing in Rats

The aim of this in vivo study was to investigate the effect of occlusal hypofunction on alveolar bone healing in the absence or presence of an enamel matrix derivative (EMD). A standardized fenestration defect over the root of the mandibular first molar in 15 Wistar rats was created. Occlusal hypofunction was induced by extraction of the antagonist. Regenerative therapy was performed by applying EMD to the fenestration defect. The following three groups were established: (a) normal occlusion without EMD treatment, (b) occlusal hypofunction without EMD treatment, and (c) occlusal hypofunction with EMD treatment. After four weeks, all animals were sacrificed, and histological (hematoxylin and eosin, tartrate-resistant acid phosphatase) as well as immunohistochemical analyses (periostin, osteopontin, osteocalcin) were performed. The occlusal hypofunction group showed delayed bone regeneration compared to the group with normal occlusion. The application of EMD could partially, but not completely, compensate for the inhibitory effects of occlusal hypofunction on bone healing, as evidenced by hematoxylin and eosin and immunohistochemistry for the aforementioned molecules. Our results suggest that normal occlusal loading, but not occlusal hypofunction, is beneficial to alveolar bone healing. Adequate occlusal loading appears to be as advantageous for alveolar bone healing as the regenerative potential of EMD.

Stenting-assisted embolization of a saccular aneurysm of the azygos anterior cerebral artery associated with fenestration at its beginning

Aneurysms of the azygos anterior cerebral artery (AACA) associated with fenestration are exceptional. We reported such a case. A 61-year-old woman presented with subarachnoid hemorrhage. Computed tomography angiography and digital subtraction angiography showed an aneurysm at the distal end of the AACA with a fenestration at its beginning. Stenting-assisted coiling of the aneurysm was performed. The postoperative recovery was uneventful. Follow-up DSA showed complete coiling of the aneurysm. By this case report and review of the literature, we found that the coexistence of the aneurysm and fenestration on the AACA was exceptional. Endovascular treatment of saccular AACA aneurysms is an appealing option.

Unilateral Fenestration of Internal Jugular Vein With a Radiological Clue: A Rare Case Report and Literature Review

The intricacies of human anatomy continue to astound, as underscored by this unusual case of a 45-year-old female patient who presented to our esteemed otolaryngology department with T3N1MO squamous cell carcinoma of the lip. The preoperative diagnostic imaging of this patient divulged an enigmatic venous anomaly involving the internal jugular vein (IJV). Our team meticulously orchestrated a wide local excision of the primary tumor and modified radical neck dissection with Abbe Estlander flap reconstruction. Identification of the anomaly during the preoperative phase helped in meticulous planning and preparation. Thus, the surgical team was well-prepared for neck dissection and successfully navigated the rare IJV fenestration without incurring nerve or vascular injuries. This remarkable case accentuates the importance of maintaining a profound understanding of potential anatomical aberrations while performing intricate surgical procedures such as neck dissections. Heightened awareness can circumvent inadvertent damage to critical structures, ultimately safeguarding patient well-being. In this captivating report, we explain the preoperative suspicion, intraoperative identification, and subsequent outcome of a rare fenestration of the IJV encountered during a challenging neck dissection.

Homemade fenestration and chimney techniques for the left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair

Background

To investigate the safety and efficacy of homemade fenestration and chimney techniques for the left subclavian artery (LSA) revascularization during zone 2 thoracic endovascular aortic repair (TEVAR).

Methods

From February 2017 to February 2021, 41 patients undergoing fenestration technique (group A) and 42 patients undergoing chimney technique (group B) to preserve the LSA during zone 2 TEVAR were enrolled in the present study. The procedure was indicated for dissections with unsuitable proximal landing zone with refractory pain and hypertension, rupture and malperfusion, and high-risk radiographic features. The baseline characteristics, peri-procedure, and follow-up clinical and radiographic data were recorded and analyzed. The primary endpoint was clinical success, and the secondary endpoints were rupture-free survival, LSA patency, and complications. Aortic remodeling, defined as patency, partial and complete thrombosis of the false lumen, was also analyzed.

Results

Technical success was achieved in 38 and 41 patients in groups A and B, respectively. Four intervention-related deaths were confirmed, two in each group. Immediate post-procedural endoleaks were detected in two and three patients in group A and B, respectively. No other major complications were found in either group, except for one retrograde type A dissection in group A. During follow-up, the initial clinical success rates were 90.24% and 92.86% in groups A and B, respectively. The primary and secondary mid-term clinical success rates were 87.5% and 90% in group A, and both of them were 92.68% in group B. Rupture-free survival and LSA patency were not significantly different between the two groups. The incidence of complete thrombosis in the aorta distal to the stent graft was 67.65% and 61.11% in groups A and B, respectively.

Conclusions

Apart from the lower clinical success rate of fenestration technique, both physician-modified techniques are available for LSA revascularization during zone 2 TEVAR and significantly promote favorable aortic remodeling.

Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair

PURPOSE

Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure.

MATERIALS

A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected.

METHODS

Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels.

RESULTS

Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure.

CONCLUSIONS

The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term.

CLINICAL IMPACT

With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.

Novel Surgeon-Modified Fenestrated Iliac Stent Graft

PURPOSE

We describe the feasibility and early results of a novel endovascular approach with a surgeon-modified fenestrated iliac stent graft to preserve pelvic perfusion in patients with iliac aneurysms not suitable for iliac branch devices (IBDs).

TECHNIQUE

Seven high-risk patients, median age 76 years (range 63-83), with a complex aortoiliac anatomy with contraindications for commercially available IBDs were treated with a novel surgeon-modified fenestrated iliac stent graft between August 2020 and November 2021. The modified device was built using an iliac limb stent graft (Endurant II Stent Graft; Medtronic), which was partially deployed, surgically fenestrated with a scalpel, reinforced, re-sheathed, and inserted via femoral access. The internal iliac artery was cannulated and bridged with a covered stent. Technical success rate was 100%. After a median follow-up period of 10 months, there was 1 type II endoleak and no migrations, stent fractures, or loss of device integrity. One iliac limb occlusion occurred after 7 months, which needed a secondary endovascular intervention, restoring patency.

CONCLUSION

Surgeon-modified fenestrated iliac stent graft is feasible and might be used as an alternative in patients with a complex iliac anatomy not suitable to commercially available IBDs. Long-term follow-up is needed to evaluate stent graft patency and potential complications.

CLINICAL IMPACT

Surgeon modified fenetrated iliac stent grafts might be a promising alternative to iliac branch devices, extending endovascular solutions to a broader patient population with complex aorto-iliac anatomies preserving antegrade internal iliac artery perfusion. It is possible to treat small iliac bifurcations and large angulations of the iliac bifurcation safely and there is no need for a contralateral or upper-extremity access.

Anatomical Variations of the External Jugular Vein: A Pictorial and Critical Review

(1) Background: The external jugular vein (EJV) descends on the sternocleidomastoid muscle to drain deep into the subclavian vein. Anatomical variations of the EJV are relevant for identification of the greater auricular nerve, flap design and preparation, or EJV cannulation. (2) Methods: Different publications were comprehensively reviewed. Dissections and three-dimensional volume renderings of peculiar cases were used to sample the review. (3) Results: Different anatomical possibilities of the EJV were critically reviewed and documented: fenestrations and double fenestrations, true or false duplications, triplication, absence, aberrant origin or course, or bifurcation. Tributaries of the EJV, such as the facial and posterior external jugular veins, are discussed. The internal jugular vein termination of the EJV is also presented. (4) Conclusions: Care should be taken when different morphological features of the EJV are encountered or reported.

Fenestration and dehiscence defects in maxillary anterior teeth using two classification systems

BACKGROUND

The primary objective of the study was to assess the buccal bone thickness (BT), evaluate and compare the prevalence of bone fenestration and dehiscence in anterior maxillary teeth using cone-beam computed tomography (CBCT).

METHODS

Images of 300 maxillary anterior teeth were investigated. The BT was measured at the bone crest, 3, 6 and 9 mm from the bone crest, and apical. Fenestration and dehiscence were recorded according to Yang and Pan's classification. Student's t-test and one-way ANOVA were performed for statistical analysis.

RESULTS

Fenestration and dehiscence rates were 35.66% and 20%, respectively. Type III fenestration was higher in group 3 (>65 years) (P = 0.028). Type I and IV fenestration and CII DII dehiscence were more common in canines (P > 0.05). Fenestration involving two-thirds (46.76%) and one-third (44.84%) of the root length was more common. Fenestrations involving the entire root were 8.4%. Most of the dehiscence (63.3%) involved one-third of the root length. Dehiscence involving two-thirds of the root length and the entire root was 5% and 9.95%, respectively. The coexistence of fenestration and dehiscence was 8.3%. Dehiscence on the palatal aspect was detected in 1.65% of the anterior maxilla.

CONCLUSIONS

The rate of BT ≤1 mm was 80.08%, and ≥2 mm was 3.66%. Fenestration was most common in canines. Fenestration was mostly located in the apical third, while dehiscence was mostly located in the coronal third. © 2022 Australian Dental Association.

Optic nerve sheath fenestration for treating papilloedema in the era of cerebral venous sinus stenting

BACKGROUND

Pseudotumour cerebri (PTC) is the syndrome of intracranial hypertension without intracranial mass or hydrocephalus and is the commonest cause of papilloedema seen in many eye clinics. In the last 10 years, we have increasingly used TSS in patients whose papilloedema was not well controlled with medical treatment and have done fewer ONSFs. Here, we review our experience at Royal Prince Alfred Hospital Sydney with ONSF in 35 patients over the period 2002-2021.

METHODS

Retrospective case series of 35 patients, 30 of whom had primary PTC [i.e., idiopathic intracranial hypertension (IIH)] and 5 with secondary PTC.

RESULTS

Eighteen patients had bilateral ONSF and 17 patients unilateral ONSF, in each case of the worse eye. Thirteen patients then underwent transverse sinus stenting (TSS), in each case following ONSF. The primary outcome measures were visual acuity (VA) and mean deviation (MD) on visual field (VF) testing. MD improved by 5 dB or more in 34 of 70 total eyes (48.6%); VA improved by 0.2 logMAR (two lines on Snellen chart) or more in 21 eyes (30%), and by both in 15 eyes (21.4%). Final MD was -10 dB or better in 38 eyes (54.3%); final VA was 0.3 (6/12) or better in 54 eyes (77.1%), and both in 39 eyes (55.7%).

CONCLUSIONS

The results confirm that ONSF can relieve papilloedoema in both eyes and improve both VF and VA, even in cases of fulminant PTC with severe acute visual impairment.

Reverse Cheese-Wire Septotomy to Create a Distal Landing Zone for Thoracic Endovascular Aortic Repair

PURPOSE

The objective of this study is to describe a novel method for creating a distal landing zone for thoracic endovascular aortic repair (TEVAR) in chronic aortic dissection. The technique is described in a patient with prior total arch and descending aortic replacement, with false lumen expansion.

TECHNIQUE

A cheese-wire endovascular septotomy was desired to create a single lumen above the celiac axis. To avoid dividing the septum caudally across the visceral segment, we performed a modified septotomy in a cephalad direction. Stiff wires were passed into the prior surgical graft, through true lumen on the right and false lumen on the left. An additional wire was passed across an existing fenestration at the level of the celiac axis, and snared and externalized. 7F Ansel sheaths were advanced and positioned tip-to-tip at the fenestration. Using the stiff wires as tracks, the through-wire was pushed cephalad to endovascularly cut the septum. Angiogram demonstrated successful septotomy, and TEVAR was performed to just above the celiac with successful aneurysm exclusion and no endoleak or retrograde false lumen perfusion. Follow-up computed tomography angiogram (CTA) showed continued exclusion without false lumen perfusion.

CONCLUSIONS

This novel modification in a reverse direction provides an alternative method for endovascular septotomy, when traditional septotomy may threaten the visceral vessels.