PCI in severely degenerated saphenous vein graft using a novel mesh-covered stent together with a conventional embolic protection system

Although the protection with filter-based devices during percutaneous coronary intervention (PCI) in a saphenous vein graft (SVG) reduces major adverse cardiac events, a large number of patients undergoing SVG PCI still experience these events. New methods must be used in order to reduce this incidence. Novel local plaque-trapping stents have been developed and show promise in pilot human testing. We present 2 cases of patients with degenerated SVGs and a large amount of plaque volume, who underwent coronary angioplasty in our department. Considering the high risk of distal embolization, we used a standard distal embolic protection system and a recently developed mesh-covered stent. This combination approach has not yet been studied very well.

Endovascular thoracoabdominal aortic aneurysm repair: a literature review of early and mid-term results

Successful endovascular repair of abdominal aortic aneurysms (AAA) requires undilated proximal (infrarenal neck) and distal landing zones (common or external iliac arteries). A range of approved endografts are available to exclude such aneurysms. Recent multicentric prospective randomized trials have demonstrated a short and midterm decrease in aneurysm-related deaths of the endovascular technique compared to open surgery. These results have induced an overall increase in the rate of endovascular repair of AAA. Patients with more complex aortic aneurysms, involving the visceral vessels (juxta, para and thoraco-abdominal aneurysms (TAAA), have increased perioperative morbidity and mortality after open repair compared to AAA. These patients could potentially benefit from an endovascular approach. Branched and fenestrated endografts have been developed to address this endovascular challenge. This review was carried out on the current literature evaluating these new endovascular complex procedures. Spinal cord ischemia, 30-day mortality and branch patency rates after endovascular exclusion of TAAA ranged from 2.7% to 20%, 0% to 9.1% and 96% to 100% respectively. Mid-term results of endovascular complex aortic repairs are favourable compared to open surgery in high risk patients. Long-term results will be necessary to evaluate specific complications such as migration, material fatigue and component separation that can result in loss of visceral branches.

Imaging of the endoleak after endovascular aneurysm repair procedure by using multidetector computer tomography angiography

Abdominal aortic aneurysms (AAA) are an important cause of death in elderly men. Most used treatment options are endovascular aneurysm repair (EVAR) and open surgical repair. After the endovascular stent graft placement, however, several complications may occur and an important complication of EVAR is endoleak formation which occurs in approximately one-fourth of patients. Endoleak represents a blood flow outside the stent graft lumen but within the aneurysm sac. For these reasons, unlike the minimal imaging follow-up that is typically performed after surgical repair, patients undergoing EVAR require a life-long postoperative surveillance imaging. In the last years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (multidetector CT angiography, MDCTA), CT imaging became the most commonly used examination for endoleak detection. Moreover, the volume data obtained can be further rendered to generate high quality two-dimensional (2D) and three-dimensional (3D) images, that allow a better distinction between Endoleak type II, III and IV. Purpose of this study was to review and describe MDCTA potentialities in the detection of endoleak after EVAR procedures.

Palliative stent-graft insertion followed by an allograft replacement for an infected and ruptured aortic aneurysm

We report a surgical case of infected thoracic aortic aneurysm. Before arrival of the cryopreserved aortic allograft, the patient had hemoptysis resulting from aneurysm rupture. Therefore endovascular stent grafting was urgently performed three days prior to in situ allograft implantation. Palliative stent grafting prevented circulatory collapse and stabilized the patient until successful allograft implantation.

The applicability of chimney grafts in the aortic arch

AIM

Proximal fixation is often limiting for thoracic endovascular aortic repair (TEVAR) and the stent graft may need to cover the origin of the arch branch vessels. Chimney grafts have been proposed to preserve flow into over stented branches during urgent TEVAR. The aim of this report is to share our initial experience of this technique.

METHOD

Eleven patients underwent urgent TEVAR combined with a chimney graft between January 2004 and April 2009. The indications included acute complicated type B dissection (N. = 2), ruptured aneurysms of the aortic arch (1) and descending aorta (2), traumatic aortic transaction (1), aortoesophageal fistula (1) and accidental over stenting of the left carotid artery during TEVAR (4). Chimney grafts were implanted into the innominate (N. = 3), left carotid (7) and left subclavian (1) arteries. Mean length of follow up was 20 months.

RESULTS

All chimney grafts were successfully implanted. Two patients developed a primary proximal type I endoleak: one leak was successfully coil embolized, the other awaits treatment. One paraplegia was reversed by spinal drainage but two months later, this patient presented with a contained rupture and underwent successful conversion to open repair. No other postoperative aneurysm expansion has occurred and the chimney grafts remain patent. The only aneurysm related death occurred in a patient with an unrecognized chronic occlusion of his right carotid artery who received a left carotid chimney graft and suffered from a lethal stroke.

CONCLUSION

Chimney grafts in the supra-aortic branches seem feasible and may facilitate urgent TEVAR in patients with an inadequate proximal neck.

Different types of thoracic endografts

The emerging role of stent-graft strategies for the management of thoracic aortic diseases has attracted growing acceptance, especially in considering the sobering results of open repair in thoracic high-risk settings (e.g., acute dissection, trauma, rupture). Aortic endograft technology for thoracic diseases has rapidly improved after the early use of first generation devices, and the new models show very promising early and mid-term success rates. To date there is no evidence of the superiority of any single device model over the others. Indeed, each device has some peculiarities that makes it more useful in specific settings. Current limitations in thoracic stent-grafts will hopefully be addressed with new designs of highly-individualized low-profile devices in order to extend the applicability of stent-graft technology in the thoracic aorta. Despite progress in configuration and flexibility and the greater availability of different devices compared to a decade ago, shortcomings of specific endovascular grafts including collapse, migration, or dislodgment have not been fully resolved. Nowadays the selection of patients on the basis of favourable anatomy and pathology is the key for the success of the procedure. Not all patients have lesions amenable to stent-graft repair (contraindications for endovascular treatment of thoracic aorta are still not marginal and mainly defined by anatomical constraints) and thoracic endografting is technically challenging, requiring dedicated facilities and experienced specialists. This paper discusses the different configurations and models of stent-graft for thoracic aortic disease as well as the still existing shortcomings.

Endovascular repair of thoracoabdominal aneurysms: design options, device construct, patient selection and complications

The aim of this paper was to describe the current status of endovascular thoracoabdominal aortic aneurysm (TAAA) repair. This is a comparative review of current device designs and implantation techniques. A literature review of all reported results of endovascular TAAA repair has also been carried out, together with a comparison of clinical outcomes achieved with endovascular TAAA repair and those achieved in current series of standard open TAAA repair. Endovascular TAAA repair has been performed with both unibody and modular devices, but modular devices currently predominate. In modular devices the aortic component provides access to the target visceral artery either through a fenestration or a cuff. Cuffs increase device profile and the length of aorta that is covered, but easily accommodate variations in deployment position and provide a good seal zone. Fenestrations do not affect device profile or add length to the device, but deployment position tolerates little deviation and the seal zone is tenuous. A covered stent is used to bridge the gap between the fenestration or cuff in the aortic component and the target visceral artery. Balloon-expandable covered stent branch extensions are delivered from the femoral approach when fenestrations are used. Self-expanding covered stents are delivered from either the brachial or femoral approach when cuffs are used, depending on the orientation of the cuff. Some groups reinforce the self-expanding covered stent with an uncovered self-expanding stent to enhance flexibility and stability. The majority of endovascular TAAA repairs have been performed in three centers, accounting for 84% of all reported cases. The treated TAAAs were Type 1 31.8%, Type 2 14.2%, Type 3 14.2% and Type 4 37.5%. Perioperative mortality is 6.9% (N. = 20), late mortality 13.6% (N. = 38), spinal cord ischemia (SCI) 14.9% (N. = 29) permanent in 6.7% (N. = 6), transient in 10.0% (N. = 9). Deterioration of renal function was reported in 9.8% (N. = 8), and required initiation of dialysis in 5.1% (N. = 5). Reintervention was required in 18 patients (20.0%) early in 8.9% and late in 11.1%. Branch occlusion developed in 3.5% (N. = 9) and stenosis in 0.85% (N. = 2). Current single-center series of open surgical TAAA repair report mortality rates of 5-16%, spinal cord ischemia rates of 3.8-15.5% and new onset dialysis between 2-16.2%. Population-based series of open surgical TAAA repair report mortality rates between 19.2-26.9%, spinal cord ischemia rates between 7.3-16.0% and new onset dialysis rates of 14.2-18.2%. Final status of SCI neurologic deficit, reintervention rates and branch occlusion or stenosis rates for open TAAA repair are inconsistently available, if at all. In conclusion, endovascular TAAA repair is an evolving technique that is developing increasing consistency in device design and implantation technique. It is effective in eliminating aneurysm flow and in preserving visceral branch perfusion. These early outcomes are better than the results achieved with open TAAA repair in population-based studies and are at least equal to the results of open TAAA repair reported from centers of focused expertise. These results support expanding the indications for endovascular TAAA repair to include standard risk patients.

Endovascular aneurysm repair: state-of-art imaging techniques for preoperative planning and surveillance

Endovascular aneurysm repair (EVAR) represents one of the greatest advances in vascular surgery over the past 50 years. In contrast to conventional aneurysm repair, EVAR requires accurate preoperative imaging and stringent postoperative surveillance. Duplex ultrasound (DUS), transesophageal echocardiography, intravascular ultrasound, computed tomography (CT) and magnetic resonance (MR), each provide useful information for patient selection, choice of endograft type and surveillance. Today most interventionists and surgeons will rely on CT or MR to assess aortic morphology, evaluate access artery patency and locate side branch orifices. However, recent developments in cross-sectional imaging, including advanced image postprocessing, multi-modality image fusion and new contrast agents have resulted in improved spatial resolution for preoperative planning. Advanced reconstruction algorithms, like dynamic CTA and MRA, provide valuable information on dynamic changes in aneurysm morphology that might have an important impact on endograft selection. During follow-up, imaging of the graft and aneurysm is of utmost importance to identify patients in need of secondary intervention. This has led to rigorous follow-up protocols including duplex ultrasound and regular CT examinations. The use of these intense follow-up protocols has recently been questioned because of high radiation dose and the frequent use of nephrotoxic contrast agents. New imaging modalities like contrast enhanced DUS, dynamic MR and dual-source CT could reduce radiation dose and obviate the need for nephrotoxic contrast. Up-to-date knowledge of non-invasive vascular imaging and image processing is crucial for EVAR planning and is essential for the development of follow-up programs involving reduced risk of harmful side effects.

Retrograde recanalization of left main from saphenous vein graft supported by percutaneous Impella Recover LP 2.5 assist device

Percutaneous coronary interventions (PCI) in patients with severely depressed left ventricular (LV) function and in those with chronic total occlusions are technically challenging and at high risk of complications. Here we report a case of successful retrograde transradial recanalization and stenting of a chronically occluded left main coronary artery (LMCA) from a saphenous vein graft supported by the Impella Recover LP 2.5 assist device.

Hybrid approach for arch and thoracoabdominal pathologies

The endovascular era began about 20 years ago and subsequently revolutionized vascular surgery as a less invasive treatment option, especially for high risk patients. In the late 1990s, a new hybrid approach for arch and thoracoabdominal pathologies was developed. Debranching and rerouting supra-aortic and visceral aortic branches with extra-anatomic bypass grafting was performed in order to achieve sufficient landing zones demanding for subsequent stent grafting. The initial single-center results of small series up to 20 patients were encouraging with acceptable complication rates. Hybrid arch procedures are feasible but seem to carry risks. However, the latest reports for thoracoabdominal hybrid procedures demand a word of caution due to high morbidity rates. The hybrid approach may be reserved for a selected comorbid patient cohort, which is regarded unfit for open reconstruction.

Novel approach to a type I endoleak following a hybrid repair of an arch aortic aneurysm

Hybrid surgical and endovascular approaches such as open visceral vessel debranching and subsequent endovascular exclusion of thoracic abdominal aortic aneurysms (TAAA) represents a significant development in treatment of TAAAs. As compared to traditional endovascular aneurysm repair, hybrid repairs commonly have a higher rate of endoleak and other endograft-related complications. In this report, we present a 71 year-old man with significant comorbidities including chronic obstructive pulmonary disease, hypertension and prostate cancer. The patient after undergoing debranching of the thoracic arch followed by endograft repair of an arch aneurysm developed a proximal type I and type II endoleak fed by the previously ligated left subclavian artery. Despite coiling of the left subclavian artery and proximal extension of the endograft, a type I endoleak persisted. Several months after the left subclavian artery was coiled, a catheter was advanced through the coils and beyond the site of ligation directly into the aneurysmal sac. Once in the aneurysmal sac, multiple coils were deployed resulting in successful treatment of the type I endoleak. This report highlights the unique challenges in treating proximal descending thoracic aneurysms and represents the first report of the treatment of a type I endoleak with reaccess through a previously coiled vessel for deployment of embolics directly into the aneurysmal sac.

Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

BACKGROUND

An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery.

CASE DESCRIPTION

We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day.

CONCLUSIONS

Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.

Drug‐eluting stents for the treatment of in‐stent restenosis – ‘real world’ double centre experience in consecutive patients

OBJECTIVES

We evaluated clinical outcome of consecutive patients with in stent restenosis (ISR) treated with drug-eluting stents (DES) at two intervention centres from April 2002 to April 2004, reflecting 'real world' practice.

BACKGROUND

ISR is the major limitation to successful long-term outcome after implantation of bare metal stents during percutaneous coronary intervention (PCI). The optimal strategy for the treatment of ISR has yet to be determined.

METHODS

121 consecutive patients with significant ISR were treated with DES. Sirolimus DES were used in 60 patients and paclitaxel DES in the remainder. All patients were followed up to evaluate the incidence of major adverse cardiac events (MACE), angina class and clinically driven angiography. Data were collected between 7 and 27 months after the procedure (mean follow up of 16.5 months).

RESULTS

Overall MACE rate at 16.5 months was 13.2% (16 patients) including 4 deaths (3%). Fifteen (12.3%) patients underwent clinically driven angiography. Eight patients (6.6%) developed ISR within the treated segment, of whom, four underwent further PCI and 4 CABG. Mean Canadian angina class decreased from 2.46+/-0.7 pre-procedure to 0.69+/-0.6 at follow up. All patients achieved an improvement in angina, with 59% being rendered angina free and 87% free of MACE. There were no differences in clinical outcome in those who received a paclitaxel and sirolimus DES.

CONCLUSIONS

The use of DES implantation for the treatment of ISR is safe, effective and associated with low recurrence rates in a 'real world' large cohort of patients with a complex mix of anatomical and clinical factors.

Drug‐eluting versus third‐generation bare metal stents: The US strategy

Drug-eluting stents have rapidly come to dominate the field of coronary intervention, constituting 85% of the US market just one year after introduction. The current utilization of bare metal stents in coronary intervention in the US is quite limited. This article will review technological advances in third-generation bare metal stents, which optimize procedural performance by means of improved flexibility, lower crossing profile, and thinner struts while maintaining fluoroscopic visibility and may portend a continued role for bare metal stents in some settings. This article will review data pertaining to outcomes with new generation bare metal stents and discuss current options for utilization of drug eluting stents versus bare metal stents in the US.

Secondary Prevention of Cardioembolic Stroke: Oldest and Newest Promises

Atrial fibrillation (AF) is the most common cause of cardioembolism. An update on secondary prevention strategies used to protect from the risk of stroke AF patients is presented. The main line of actions of stroke prevention in AF are antithrombotics (anticoagulant or antiplatelet), antiarrhythmics (for rate control and sinus rhythm restore), mechanical means (for occlusion of the left atrial appendage or protection of the internal carotid artery from emboli). Classic pharmacological prevention with K vitamin Kantagonists such as warfarin may be overcome by direct thrombin inhibitors like ximelagatran and melagatran. New ablation technologies promise to cure, at least a part of Nonvalvolae AF in the community, restoring sinus rhythm. Recent achievements on endovascular procedures deploying carotid artery implants provide an opportunity to divert emboli to nonhazardous locations, whereas cardiac devices can seal left atrial appendages and avoid risk of clot migration in the blood stream. In the next decade, the challenge will be to understand competitiveness between old and new drugs with endovascular implants.

Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm

The authors present a case report of a 79-year-old man with insufficient cardiac contractile function who underwent endovascular stent-grafting for an abdominal aortic aneurysm. Thirty months later, the aneurysm ruptured into the inferior vena cava and subsequently formed an aortocaval fistula caused by migration of the stent-graft. Urgent secondary endovascular stent-grafting successfully excluded the blood flow into the vena cava. Endovascular stent-grafting is deemed suitable for treating this serious disorder, especially in severely debilitated or compromised patients who might not withstand a standard surgical intervention. Furthermore, in patients with previous stent-grafting, since the primary stent-graft makes repair by open surgery more difficult, a secondary endovascular intervention is recommended if feasible.

Unruptured, isolated giant aneurysm of the sinus of valsalva resulting from medial mucoid degeneration

We report a quite rare case of unruptured, isolated giant aneurysm of the sinus of Valsalva resulting from medial mucoid degeneration in a young adult woman. A 29-year-old Japanese female diagnosed as having an aneurysm of the sinus of Valsalva and severe aortic regurgitation with no clinical findings of Marfan's syndrome or Ehlers-Danlos syndrome. A modified Bentall's operation was performed successfully, and she was discharged with no complications. A pathological examination revealed marked medial mucoid degeneration of the aneurismal wall. In the literature, most giant aneurysms resulting from mucoid degeneration were found in African young adult females. In this case, there was much mucoid degeneration in the media with no focal destruction of elastic fibers, which was distinct from cystic medial necrosis in Marfan's syndrome. A careful follow-up will be required to detect any other aneurysmal formation in the future.

Results from the monitoring use programme for endovascular repair of abdominal aortic aneurysms in Spain

AIM

The aim of this study was to present the results from the Monitoring Use Programme (MUP) for endovascular repair (ER) of abdominal aortic aneurysms (AAA) using stent grafts in Spain, carried out to determine the procedure's effectiveness and safety.

METHODS

This was a follow-up study carried out through a multicentric-case registry between 2001-2003. Variables were grouped into: 1) general information, 2) postoperative period and 3) follow-up period.

RESULTS

The study enrolled 740 cases (97% males), from 32 hospitals. Mean age of patients was 72.7+/-7.3 years. Mean AAA diameter was 59.5+/-13.7 mm. Forty-seven percent of patients required additional intervention procedures; 19% patients presented intervention complications (53% were endoleaks). The endovascular intervention could not be completed in 6 patients, and in 2 patients the operation was changed to conventional surgery; 24% patients suffered, mostly minor, postoperative complications. Between 4-24 months, follow-up was normal in 81-85% cases with the most common complication being endoleaks (7%). After 24 months, and especially after 37, reinterventions and complications, in particular angulation and stent migration, increased, mainly associated to the Vanguard device. After 37 months, an increase in AAA size was observed. Among patients with preoperative AAA<50 mm, there was a greater proportion of individuals requiring additional procedures (60% vs 41%, P<0.01), suffering postoperative complications (26% vs 24%), and presenting more leaks (71% vs 52%), than among patients with AAA >or= 50 mm.

CONCLUSIONS

ER of AAA shows favourable results in the short/medium term with regards to procedure safety and effectiveness. The appearance of some complications and increase in AAA size 2-3 years after ER raises the need for caution. Care should be taken when considering ER of small AAA.

Clinical comparison of two different types of bifurcated graft for postoperative baPWV and ABI

AIM

A newly-designed bifurcated graft with the distal end larger than the conventional type has been developed. The purpose of this study was to evaluate the early results of graft replacement using this new graft, and to compare whether the new graft is more advantageous than the conventional graft in terms of peripheral blood flow and arterial stiffness.

METHODS

Records of 36 patients who underwent bifurcated graft replacement for infrarenal abdominal aortic aneurysm (AAA), from May 2003 to September 2006 were reviewed after excluding peripheral arterial disease (ABI > 0.9). Subjects were divided into two groups: group C (N.=20), with implantation of the conventional type and group N (N.=16), with implantation of the new type. We investigated changes in brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI), measurements being performed preoperatively and postoperatively.

RESULTS

baPWV in the postoperative group as a whole was significantly higher than in the preoperative group (P<0.05), while ABI in the postoperative group was lower than in the preoperative group (P<0.05). In group C, baPWV increased (P<0.05) and ABI decreased (P<0.05) after bifurcated graft replacement, whereas in group N, there were no significant differences in changes of baPWV and ABI.

CONCLUSIONS

This study shows that the new graft reduces the development of arterial stiffness postoperatively compared with the conventional type. These results may predict the new type graft decrease in the risk of morbidity and mortality caused by atherosclerotic disease.