Rationale and design of the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE): interim analysis at 30 days of the first 180 patients enrolled

AIM

The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1200-patient multicenter prospective study initiated to augment the knowledge base (poolable and comparable) about endovascular aortic repair (EVAR) in a real-world population implanted with a single latest-generation stent graft system (Endurant). With enrollment ongoing at 80 high-volume sites, the registry has limited inclusion/exclusion criteria or procedural specification. Technical and clinical data will be reported through 5 years.

METHODS

An interim analysis was performed on investigator-reported data for the first 180 patients enrolled. These patients were asymptomatic elderly males (92.1%) with considerable comorbidities. For 47.3% of the patients, the American Society of Anesthesiologists risk class was either III or IV. The Endurant stent graft was successfully deployed in 99.4% of patients for elective treatment of abdominal aortic aneurysm.

RESULTS

Through 30 days, the rate of all-cause mortality was 1.7% (N=3), with all 3 deaths classified as procedure-related but not device-related. The rate of secondary endovascular procedures was 1.1%, and the rate of conversion to open repair was 0.6%. At postprocedure and at 30-day follow-up, there were no type I or type III endoleaks and no instances of stent graft kinking, thrombosis, or occlusion. ENGAGE represents the largest real-world registry for any single EVAR stent graft.

CONCLUSION

The interim results through 30 days of the first 180 patients enrolled are promising. Longer-term follow-up for more patients will be reported.

Multiple infected aortic aneurysms repaired by staged in situ graft replacement

The development of multiple infected aortic aneurysms is extremely rare, and treatment remains challenging. We report here a 72-year-old man with multiple infected aortic aneurysms in whom a staged in situ graft replacement for the aortic arch and pararenal abdominal aorta was successfully performed. A rifampicin-bonded graft seemed to be effective in preventing postoperative infection. Perioperative control of infection played a key role in the patient's surviving this critical condition.

Seven-year results of endovascular aneurysm repairs of abdominal aortic aneurysms with custom-made stent grafts

BACKGROUND

The purpose of this study was to determine the long-term results of a 7-year follow-up of endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs) using custom-made stent grafts (SGs).

METHODS AND RESULTS

We performed a retrospective review of 17 patients (14 males, 3 females; mean age: 74.3 +/- 7.9 years; range: 53-85) undergoing EVAR of infrarenal aortic aneurysms at our institution from April 2000 to August 2006. The primary and secondary clinical success rates were 82.4% (14/17) and 100% (17/17). The initial and short-term clinical success rates were 100%. During follow-up (mean: 38.8 +/- 35.9 months; range: 0.8-90 months), 4 patients died, but there was no aneurysm-related death. In 2 patients, additional surgery was performed. The long-term clinical success rate was 83.3% (5/6). In the Kaplan-Meier curve, the 1- and 5-year survival rates were 55.0% and 45.8%, respectively.

CONCLUSION

The initial and short-term clinical success rates were 100%; regarding the short-term, aneurysm-related death could be avoided. However, during long-term follow-up, aneurysm-related events did occur. Follow-up should be performed over a long period.

Totally percutaneous aortic aneurysm repair: methods and outcomes using the fully integrated IntuiTrak endovascular system

AIM

A totally percutaneous approach to endovascular abdominal aortic aneurysm repair (PEVAR) has been shown in multiple reports to be feasible, but carries attendant risks that appear to increase with increasing sheath size. We report our methods and sequential PEVAR case experience using a new delivery system having an integrated 19Fr introducer sheath for treatment of patients with aortic necks up to 32 mm in diameter.

METHODS

A single institution, prospective, controlled evaluation was conducted in 57 consecutive patients with abdominal aortic aneurysm who underwent PEVAR between December 2008 and April 2010. All patients have been followed for at least 30 days.

RESULTS

Patients presented at a mean age of 74 years with median AAA diameter of 5.4 cm preprocedurally. Calcified/tortuous access vessels were identified in 98% of patients. All PEVAR procedures with adjunctive "pre-close" use of the Prostar XL closure device were performed in a hybrid endovascular suite with patients maintained under conscious sedation and local anesthesia. The anatomically-fixed bifurcated stent graft and aortic/limb extensions as needed were implanted via the 19 Fr indwelling introducer sheath with minimal blood loss (79 mL). Technical success was 98%, with one conversion to open repair attributable to very small diameter (4 mm) access vessels. Cumulatively, major access-related complications were observed in five patients (8.8%) within 30 days.

CONCLUSION

PEVAR using the IntuiTrak System with 19Fr introducer sheath with vessel closure facilitated by the Prostar XL device is feasible, even in patients with challenging access anatomy. Further evaluation in a prospective, multicenter, randomized trial is warranted.

Prevention and treatment of in-stent restenosis

In-stent restenosis has always been an important issue, since the launch of the first stents on the market. The occurrence of in-stent restenosis (ISR) is due to two main reasons. First, the presence of stent fractures significantly influences restenosis rates. Second, the continuous interaction between the permanently implanted artificial material and the vessel tissue, leads to physical irritation, long-term endothelial dysfunction, or chronic inflammatory reactions. In the Literature only very limited data on ISR treatment in the peripheral arteries are available. There are no peer-reviewed publications or studies with in-depth follow-up on this specific indication. The underlying reason for this probably being that currently available treatments do not yield satisfactory results. However, the continuing search for better solutions and the technological evolution lead to the introduction of the Viabahn with PROPATEN coating, DES and DCB, which may result in the first promising treatment options for ISR.

New results with the Zenith graft in the treatment of aortic aneurysms

Aneurysmal disease of the arterial vasculature has been reported since ancient times. Regarding aneurysms of the aorta, a steady progress has been made ranging from making such pathology amenable to surgical treatment to making the procedure much less invasive. There have been a number of stent grafts, introduced by different companies, used to exclude different segments of the aneurysmal aorta and the Zenith devices are one of them. The safety and efficacy of these devices to exclude infrarenal and descending thoracic aortic aneurysms has been well documented. The early and late complications associated with these procedures and the methods used to manage such complications have also been elucidated in different publications. In dealing with pararenal and thoracoabdominal aneurysms, the need to ensure patency of the visceral vessels while still repairing the aorta to healthy tissue must be considered. Strategies involving fenestrations and side-arm branches have evolved extending the ability to treat the entire aorta with an endovascular approach. Challenges exist including the inherent tortuosity and mobility of the aortic arch, close approximation of the supra-aortic vessels, small or multiple renal vessels, the commonly noted arcuate ligament compression of the celiac artery, but great strides have been made and virtually all pathologies have been addressed. The desire for smaller delivery systems has spurred interest in low-profile devices. This manuscript is intended to address the latest developments and clinical results for endovascular grafting of the aorta.

Current knowledge on E-vita abdominal endograft

The field of endovascular abdominal aortic repair has changed remarkably compared to what it was prior to 1993, the year of the first commercial endograft deployment in the United States. Over the years of endovascular aneurysm repair experience, various companies have attempted to construct an ideal stent-graft for exclusion of an abdominal aortic aneurysm (AAA). However, it has become evident that not all abdominal aortic anatomies are amenable to endovascular treatment and that the rationale "one device fits all AAAs" can lead to disastrous results. Different endografts have dissimilar properties and characteristics. Type of graft material, configuration and type of stent structural support, modularity, type of transrenal fixation, are potentially influential factors of endograft behavior. The self-expanding E-vita abdominal stent-graft (JOTEC, Hechingen, Germany) is a relatively new infrarenal, modular stent-graft with suprarenal fixation designed for AAA reconstruction. The present paper analyzes the technical characteristics and properties of this device. We also analyze our experience with the endoprosthesis and review the current literature.

New results with 100 Excluder cases

AIM

The purpose of this study was to report the outcome of EVAR using EXCLUDER endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz.) with low-porosity polytetrafluoroethylene (PTFE) in the medium term. We reviewed a 10-year-experience with this device to document the outcome of 100 consecutive elective EVARs with Excluder-Device performed at a single centre.

METHODS

From 01.2006 to 01.2009 all elective abdominal aortic aneurysm (AAA) cases (N=100) with an abdominal aortic aneurysm (AAA; mean diameter 5.61 cm; range 4.2-7.3 cm) that were treated electively with the EXCLUDER Bifurcated Endoprosthesis were entered in an index. Anatomical and clinical evaluations and radiological results have been analyzed. Mean aortic neck length was 12.24 mm, mean proximal aortic diameter was 24.39 mm. Primary outcome that has been examined, include operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency have also been determined. Finally, the need for reinterventions and success of such secondary procedures were evaluated. Endoleaks were diagnosed from contrast-enhanced computed tomography, the rate of type II endoleaks was analyzed after 1, 3 and 12 months.

RESULTS

Mean patient age was 74.1 years (range 44-91 years); 91% were male. Mean follow-up was 20 months; 78 % of the patients had 2 or more major comorbidities, and 32 % were categorized as inappropriate for open repair. On an intent-to-treat basis, device deployment was successful in 100%. Thirty-day mortality was 0%; freedom from AAA rupture was 100%. Type II endoleak appeared directly after the procedure in 24%, after 3 months in 15% and after 12 months in 7%. The initial technical success defined as endovascular aneurysm exclusion and absence of type I endoleak was 99%. Proximal type I early endoleak occurred (detected by intraoperative DSA) in 3 patients, in 2 cases intraoperative proximal aortic cuffs were needed to seal proximal type I endoleaks. In one case we performed a proximal bending via a retroperitoneal access and sealed the endoprosthesis. Postoperatively, the size of the AAA decreased or remained unchanged in 93% after 12 months. Freedom from reinterventions was 94% after 2 years.

CONCLUSION

EVAR using the EXCLUDER-Device is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application within a wide spectrum of patients.

Ring-stents supported infrarenal aortic endograft fits well in abdominal aortic aneurysms with tortuous anatomy

AIM

Abdominal aortic aneurysms (AAA) with severe angulation of the neck or of the iliac arteries are often unsuitable for endovascular repair with conventional endografts. We evaluated the performance of a ring-stent abdominal endograft (AnacondaTM Vascutek, Terumo, Scotland) in a consecutive series of infrarenal AAA.

METHODS

Preoperative, procedural and follow-up data of patients treated with AnacondaTM endograft between September 2005 and September 2009 were prospectively enrolled. Patients were divided in Group A (proximal neck angle > or =60 degrees or iliac arteries angle > or =90 degrees ) and Group B (all others). Main endpoints were technical and clinical success (primary and assisted) and late outcome in the two groups. Results were compared by Kaplan-Meier life table analysis with log-rank test (Mantel-Cox).

RESULTS

One hundred twenty-seven patients, with a mean age of 73.5+/-6.9 years, have been included in this series. Mean aneurysm size was 56.7+/-10.4 mm. A severe angulation of the proximal aortic neck or/and of the iliac arteries was present in 44 cases (Group A), absent in 83 cases (Group B). The mean follow-up was 18.2+/-16.3 months. Overall primary technical success was achieved in 100% of the patients. At twenty-four months survival, primary and assisted clinical success were 94.2%, 88.2% and 91.3% in Group A and 80.3%, 83.7% and 95.2% in Group B respectively. No significant differences were found between the two groups. The only factor significantly associated with decreased survival was preoperative renal insufficiency. Iliac limb patency 24 months after EVAR in severely and non-severely angulated iliac axis was 96.7% and 98.1% respectively, with no significant difference between the groups. Only one proximal type I endoleak was detected in a patient with severe angulation of proximal aortic neck. No significant correlation between proximal type I endoleak and severe neck angulation was found.

CONCLUSION

Aneurysms with severe neck or iliac arteries angulation can be treated by a ring-stent endograft with results similar to those of AAA with more favourable anatomy.

A novel technique of coronary reconstruction during complex aortic root replacement

Many modifications of the Bentall technique have been described since its introduction in 1968. The crucial phases of the operation include the re-establishment of coronary flow and control of intraoperative hemorrhage. Based on their experience with Blalock-Taussig shunts, the proximal take-off of which is at the innominate/right subclavian artery junction, the present authors have developed a novel technique of coronary reconstruction. The details of a new technique of coronary reconstruction to minimize the duration of cardiopulmonary bypass, myocardial ischemia and bleeding, are reported.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: open repair and endovascular techniques

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

Fenestrated stent-grafting after previous endovascular abdominal aortic aneurysm repair

AIM

The aim of this study was to present their experience and highlight the technical difficulties associated with the use of fenestrated stent-grafts to treat juxta and pararenal abdominal aortic aneurysms (AAA) in patients having undergone a previous infrarenal endovascular aneurysm repair (EVAR).

METHODS

A prospectively held database maintained at the University Medical Center of Groningen including 162 patients who have undergone branched and fenestrated stent-grafting for AAA, was queried for patients treated with this technology after previous EVAR. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality and morbidity were evaluated.

RESULTS

A total of 9 patients underwent repair with a fenestrated endograft after previous EVAR. All patients had aneurysmal degeneration of the juxta- and pararenal aorta not suitable to standard endovascular techniques. We encountered various intraoperative complications including iliac and renal artery access problems, intraoperative previous graft migration, and dislocation of previous graft limb. In one patient, immediate conversion was needed because a twisted graft limb prevented retrieval of the top cap of the fenestrated graft. The remaining eight patients were successfully treated by endovascular means. For these patients, target vessel success rate was 100% (20/20) and mean hospital stay 6.0 days (range 3-12 days). Thirty-day and one-year mortality were 0%. Mean follow up was 31 months (range 1-76 months). No aneurysm related death occurred during follow-up.

CONCLUSION

Fenestrated endovascular stent-grafts can be used to repair juxta- and pararenal AAA after previous EVAR. However, several technical challenges have to be overcome due to the presence of a previous stent-graft.

Improved patency and reduced intimal hyperplasia in PTFE grafts with luminal immobilized heparin compared with standard PTFE grafts at six months in a sheep model

AIM

The aim of this study was to compare the performance of polytetrafluoroethylene (PTFE) grafts with luminal coating of immobilized heparin to that of standard PTFE grafts at six months.

METHODS

Twenty-eight common carotid arteries in fourteen sheep were bypassed with heparin-coated PTFE grafts (6 mm diameter, 6 cm length) on one side and standard PTFE grafts on the other. The grafts were explanted after six months. The thickness of intimal hyperplasia (IH) in open grafts was measured with histomorphometrical methods.

RESULTS

Two of 14 heparinized PTFE grafts and nine of 14 grafts in the control PTFE-group were occluded at explantation (P=0.006). Six-month patency rates for heparinized PTFE grafts and for standard PTFE grafts were 86% and 36%, respectively. Mean graft anastomotic IH thickness in open grafts were 0.074 mm for heparinized PTFE grafts and 0.259 mm for PTFE-grafts (P=0.006).

CONCLUSION

PTFE grafts with luminal coating containing immobilized heparin had significantly better patency and recruited less intimal hyperplasia than standard PTFE grafts at six months.

Endovascular approach for acute aortic syndrome

Acute aortic syndrome (AAS) refers to the spectrum of aortic emergencies that include aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. These aortic pathologies may lead to aortic rupture and a timely treatment is crucial to obtain clinical success and benefit on survival. Endovascular strategies have gained wide acceptance in the management of AAS and currently represent the new minimally invasive alternative to traditional surgery. In particular in acute complicated aortic dissection endovascular therapy demonstrated a better survival and limited complications with respect to open surgery. Aim of the present study was to provide an overview of AAS and to assess the current role of endovascular aortic repair in its treatment.

Simultaneous endovascular stent-graft repair of descending thoracic and abdominal aortic pathologies. Report of four cases

Four patients suffering from concomitant descending thoracic pathology and abdominal aortic aneurysms were treated with endovascular stent-grafts simultaneously. Graft deployment was successful and uneventful in all patients. Paraplegia was not observed. One patient developed an abdominal type Ib endoleak at 12 months which was repaired endovascularly. One patient died from multiorgan failure 3 days after the deployment of the grafts. After 18, 36 and 42 months follow up all the other patients are well without any graft related complication. Simultaneous endovascular repair for coexisting descending thoracic and abdominal aortic pathologies might be an acceptable alternative to open surgery or hybrid operations, at least for the high risk patients.

Acute aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in type B acute aortic dissection

We describe a patient with aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in acute type B aortic dissection. A 70-year-old man presented to a nearby hospital with severe lower back pain, and was subsequently referred to our hospital with a diagnosis of abdominal aortic rupture. Computed tomography scanning on admission revealed type B aortic dissection with concomitant false-lumen rupture at the level of pre-existing infrarenal abdominal aortic aneurysm. The patient underwent abdominal aortic replacement with the true lumen reconstructed using a bifurcated knitted Dacron graft. On postoperative day 2, the patient developed severe lower body ischemia. Computed tomography scanning revealed complete true-lumen occlusion at the renal artery level because of false-lumen expansion. The patient underwent open fenestration by opening the bulging flap with a transverse graftotomy distal to the proximal graft anastomosis. After fenestration, the patient developed severe metabolic complications (i.e., myonephropathic-metabolic syndrome) and died a day later of cardiac arrest resulting from hyperkalemia. Abdominal aortic replacement with true-lumen reconstruction in patients with abdominal aortic rupture in type B acute aortic dissection could also lead to acute aortic occlusion due to re-dissection or true-lumen compromise accompanying retrograde propagation of false-lumen thrombosis. This lethal sequela after true-lumen reconstruction might be prevented by an adjuvant procedure such as concomitant fenestration.

Off-label use of stretchable polytetrafluoroethylene: overexpansion of synthetic shunts

PURPOSE

To describe our experience with balloon dilatation and stenting of modified systemic-to-pulmonary artery (PA) shunts in relation to an assessment and interpretation of the mechanical properties of thin-walled expandable polytetrafluoroethylene (ePTFE) stretch vascular grafts.

METHODS

Our pediatric cardiology/cardiac surgery database was reviewed to identify all infants and children with a modified systemic-to-PA shunt who underwent cardiac catheterization. Reports and images were reviewed. Thin-walled stretchable and regular Gore-Tex vascular grafts were mechanically compared using tensiometry.

RESULTS

11 patients underwent dilatation or stenting procedures of a systemic-to-PA shunt. No major complications occurred and none of our patients died during or due to this intervention. High pressures in balloons and stents with diameters larger than the graft were used. Shunt diameters and oxygen saturation levels increased from 2.05 +/- 1.25 mm to 4.75 +/- 0.88 mm and with 12 +/- 6.8%, respectively. In 6 patients re-catheterizations were performed. Four patients died, all with patent shunts. The fail-stress and the fail-strain in the circumferential direction of the stretchable graft were significantly higher than in the non-stretchable graft.

CONCLUSIONS

Dilatation and stenting of stenosed modified systemic-to-PA shunts is feasible and safe. Dilatation and stenting of these shunts to calibers larger than those provided by the manufacturer is possible. Results of our technical study posit a great advantage for the use of the thin-walled stretch configuration of ePTFE.

New technique for the preservation of the left common carotid artery in zone 2a endovascular repair of thoracic aortic aneurysm

To describe a technique for the preservation of the left common carotid artery (CCA) in zone 2 endovascular repair of thoracic aortic aneurysm. This technique involves the placement of a guide wire into the left CCA via the right brachial artery before stent graft deployment to enable precise visualization and protection of the left CCA during the whole procedure. Of the 107 patients with thoracic endovascular aortic repair in our study, 32 (30%) had the left subclavian artery intentionally covered (landing zone 2). Eight (25%) of those 32 had landing zone 2a-the segment distally the origin of the left CCA, halfway between the origin of the left CCA and the left subclavian artery. In all patients, a guide wire was positioned into the left CCA via the right brachial artery before stent graft deployment. It is a retrospective study in design. In seven patients, stent grafts were positioned precisely. In the remaining patient, the positioning was imprecise; the origin of the left CCA was partially covered by the graft. A stent was implanted into the left CCA to restore the flow into the vessel. All procedures were performed successfully. The technique of placing a guide wire into the left CCA via the right brachial artery before stent graft deployment is a safe and effective method that enables the precise visualization of the left CCA during the whole procedure. Moreover, in case of inadvertent complete or partial coverage of the origin of the left CCA, it supplies safe and quick access to the artery for stent implantation.

Right retroperitoneal approach for repair of an abdominal aortic aneurysm involving bilateral iliac arteries in a patient with a left-side stoma after abdominoperineal resection

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Novel sutureless telescoping anastomosis revascularization technique of supra-aortic vessels to simplify combined open endovascular procedures in the treatment of aortic arch pathologies

BACKGROUND

We report our clinical experience with the use of a sutureless telescoping anastomosis, initially described as the VORTEC (Viabahn Open Rebranching TEChnique) revascularization technique, for debranching of supra-aortic vessels.

METHODS

Between May 2005 and December 2008, 20 patients (15 men) with an aortic arch lesion underwent trans-sternal debranching with sutureless telescoping anastomosis performed with a Viabahn (diameter, 5-8 mm; length, 5-15 cm) or Hemobahn (diameter, 9-13 mm; length, 10-15 cm), followed by endovascular aneurysm repair. Initially, the Viabahn/Hemobahn was sutured to a feeding graft after deployment. Since 2008, the Viabahn/Hemobahn has been deployed within an interposition graft, rendering unnecessary the anastomosis. The underlying aortic pathology was (1) isolated aortic arch aneurysm in 10, (2) aortic arch aneurysm extending to the ascending or descending aorta in 6, (3) floating thrombus within the aortic arch in 1, (4) acute aortic arch dissection in 1, and (5) Crawford II thoracoabdominal aortic aneurysm extending into the aortic arch in 2. Postprocedural duplex ultrasound imaging showed normal flow profiles in all patients. Follow-up included computed tomography angiography at 1, 3, and 6 months postoperatively, and then annually.

RESULTS

Overall, 56 supra-aortic vessels in the 20 patients were debranched by sutureless telescoping anastomosis, including the carotid artery in 18, subclavian artery in 13, and left vertebral artery in 1. Technical success was 100%. The mean ischemia time was 3 minutes (range, 1-9 minutes) for the debranching procedure vs 6 minutes (range, 5-16 minutes) for a conventional suture anastomosis. The 30-day mortality rate was 15% (3 if 20); 28.5% (2 of 7) in urgent cases and 7.6% (1 of 12) in elective patients. Three patients (15%) had neurologic deficits after debranching in the conventionally-sutured anastomosis territories. No early (<30 days) occlusion occurred. During a mean follow-up of 14 +/- 9 months (range, 1-39 months), one patient with Takayasu disease showed asymptomatic occlusion of a Viabahn implanted into the left common carotid artery. Stenosis in the aortic anastomosis of the bypass graft in another patient was successfully treated by angioplasty and stent placement through the right brachial artery.

CONCLUSIONS

Sutureless telescoping anastomosis with a Viabahn or a Hemobahn in supra-aortic debranching seems to be a safe and reliable alternative to sutured anastomosis. It enables safe and fast-track revascularizations, especially in anatomically challenging situations, and requires a very short ischemia time. Questions about long-term results and the technique reproducibility must be addressed.

Aortoesophageal fistula secondary to placement of an esophageal stent: emergent treatment with cyanoacrylate and endovascular stent graft

We report on N-butyl 2-cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of an aortoesophageal fistula secondary to placement of an esophageal stent. A 53-year-old man with lung cancer was admitted with massive hematemesis due to the formation of an aortoesophageal fistula 20 days after esophageal stent placement. Injection of N-butyl 2-cyanoacrylate into the aortoesophageal fistula was performed as emergent treatment for this hemodynamically unstable condition, and an endovascular stent graft was subsequently placed via the right femoral artery. The patient was well without hematemesis until he died of pneumonia 45 days later. Cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of massive hemorrhage caused by an aortoesophageal fistula is a prompt, effective method and can be an alternative to surgical repair.