Endovascular treatment with Viabahn stent-grafts for arterial injury and bleeding at the visceral arteries: initial and midterm results

Safety and efficacy of covered stent grafts in the treatment of emergent access related complications

BACKGROUND

Large bore percutaneous access is becoming increasingly common. Parallel to this, we observe an increase in vascular access site complications such as bleeding, dissection, thrombosis or pseudo-aneurysms. This study was aimed to evaluate safety and efficacy of covered stent grafts for fixing large bore vascular access injuries.

METHODS

A total of 147 Viabahn or Viabahn VBX (WL Gore) stent grafts which were placed across the inguinal ligament in emergent settings in 136 patients, were retrospectively analyzed. The two endpoints were the technical success rate, defined by complete arterial repair, and long-term stent graft patency. We also looked at the need for open conversion, wound infections, and in hospital and 30-day mortality. We followed the patients using duplex ultrasound and computed tomography angiogram to assess for arterial patency, freedom from intervention, stent kinking and clinical symptoms.

RESULTS

30 Viabahn and 117 Viabahn VBX (WL Gore) stent grafts were placed in the distal external iliac artery and into the proximal common femoral artery of 136 patients. Indications for intervention were bleeding in 92 patients (68 %), flow limiting dissection in 41 patients (30 %) and symptomatic AVF in 3 patients (2 %). Primary technical success rate was 100 %. Limited 3-year follow up (101/136 patients) showed 99 % patency with no evidence of stent fracture, stenosis or kinking except in one patient who needed target lesion revascularization due to neointimal hyperplasia.

CONCLUSIONS

Covered stent grafts can be placed safely, efficiently, and effectively in the distal external iliac and common femoral arteries across the inguinal ligament. These stent grafts can be used as an alternative therapeutic option to open surgery in patients with large bore vascular access injuries.

Right subclavian artery injury during catheter insertion into the right internal jugular vein treated with endovascular stent graft placement after balloon occlusion test: A case report

Subclavian artery injuries during internal jugular vein puncture when attempting central venous catheter insertion are rare. A 60-year-old man undergoing treatment for neuromyelitis optica with paralysis and sensory loss developed a complication during catheter placement into his right internal jugular vein for plasmapheresis. His previous physician felt resistance and discontinued the procedure. The patient later developed mild dyspnea and dysphagia. Computed tomography scans indicated thrombus formation and tracheal deviation. Contrast-enhanced computed tomography scans showed right subclavian artery injury with extravasation and a large pseudoaneurysm. Following transferal to our hospital, he was stable and asymptomatic; however, contrast-enhanced computed tomography scans showed a pseudoaneurysm located proximal to the right subclavian artery. Considering challenges with compression hemostasis and the invasiveness of open surgery, endovascular treatment was selected using a VIABAHN stent graft. A balloon occlusion test of the right vertebral artery was performed to assess stroke risk. Prophylactic embolization of the right vertebral artery, internal thoracic artery, and thyrocervical trunk were performed to prevent a type 2 endoleak. On hospital day 5, our patient showed no postoperative complications and was transferred to the referring hospital. Follow-up imaging showed the graft was intact with no pseudoaneurysm, confirming successful treatment. Endovascular treatment with a stent graft is highly effective for peripheral artery injuries. Using a balloon occlusion test to assess collateral blood flow and stroke risk is essential pretreatment, especially when a graft might occlude the vertebral artery. Balloon occlusion tests are recommended when planning treatment for iatrogenic and other types of subclavian artery injuries.

Three cases of recurrences after stent-graft placement for arterio-visceral/arterio-luminal fistulas in long-term follow-up

We report 3 patients with recurrences after stent-graft placement for arterio-visceral/arterio-luminal fistulas in long-term follow-up. Two patients had ureteroarterial fistulas and the other had a tracheo-innominate artery fistula. All 3 patients had hemorrhage on initial presentation and underwent a stent-graft placement for an arterio-visceral/arterio-luminal fistula. Recurrences occurred over a period of 8-26 months and were diagnosed by contrast-enhanced computed tomography; pseudoaneurysms were found in contrast-enhanced computed tomography images in all cases. Pseudoaneurysms may be noted on contrast-enhanced computed tomography as the only finding of recurrences during long-term follow-up after stent-graft placement for arterio-visceral/arterio-luminal fistulas.

Stent Graft Placement for Injured Visceral Artery

Injury of the visceral artery is a potentially fatal complication of iatrogenic procedures, trauma, and tumors. A stent graft can achieve rapid exclusion of the injured arterial portion and minimize the risk of ischemic complications by preserving arterial flow to organs. Although various types of stent grafts are available worldwide, Viabahn has only been approved for visceral arterial injury in Japan. The reported technical and clinical success rates, including cases with injured pelvic or thoracic arterial branches, are 80%-100% and 66.7%-100%, respectively. Severe ischemic complications are rare; however, fatal ischemia occurs when the stent graft is immediately occluded. The necessity of antiplatelet therapy is controversial, and a target artery diameter ≤ 4 mm is a significantly higher risk factor of stent-graft occlusion.

Coronary covered stents in the management of late-onset arterial complications post-hepato-pancreato-biliary surgery

PURPOSE

To retrospectively evaluate the safety, efficacy, and late clinical outcome of coronary covered stent placement for the treatment of late-onset arterial complications after hepato-pancreato-biliary surgery.

MATERIALS AND METHODS

Consecutive patients presenting with post-hepato-pancreato-biliary surgery-related arterial lesions and subsequently treated with a covered coronary stent in the authors institution between January 2012 and November 2021 were included. Primary endpoints were technical and clinical success; secondary endpoints were covered stent patency and end-organ perfusion of the affected artery.

RESULTS

The study included 22 patients (13 men and 9 women) with a mean age of 67 years ± 9.6 years. Initial surgery included pancreaticoduodenectomy (n = 15; 68%), liver transplantation (n = 2; 9%), left hepatectomy (n = 1; 5%), bile duct resection (n = 1; 5%), hepatogastrostomy (n = 1; 5%), and segmental enterectomy (n = 1; 5%). Technically, coronary covered stents were successfully placed in n = 22 patients (100%) without immediate complication. Definitive bleeding control was observed in n = 18 patients (81.1%) with recurrent bleeding within 30 days postintervention in n = 5 patients (23%). No ischemic liver or biliary complications occurred during the follow-up period. The 30-day mortality rate was 0%.

CONCLUSION

Coronary covered stents are a safe and efficient treatment option in most of the patients presenting with late-onset postoperative arterial injuries following hepato-pancreato-biliary surgery and are associated with an acceptable recurrent bleeding rate and no late, ischemic, parenchymal complications.

Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes

PURPOSE

To evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries.

MATERIALS AND METHODS

Patients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency.

RESULTS

Thirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter-related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77-98). The median primary patency was 87 days (95% CI, 73-293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14-0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09-0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients.

CONCLUSIONS

Stent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.

Emergency endovascular treatment using a Viabahn stent graft for upper and lower extremity arterial bleeding: a retrospective study

BACKGROUND

A Viabahn stent graft (SG) is a heparin-coated self-expandable SG for lower extremity arterial disease that exhibits high flexibility and accuracy in the delivery system. This study aimed to evaluate the short-term efficacy and safety of emergency endovascular treatment (EVT) using a Viabahn SG for upper and lower extremity arterial bleeding (ULEAB).

METHODS

Consecutive patients with ULEAB who underwent emergency EVT using the Viabahn SG between January 2017 and August 2021 were retrospectively reviewed. The indications for EVT, location of artery, technical success, clinical success, limb ischemia, periprocedural complications, bleeding-related mortality, 30-day mortality, diameter of the target artery, diameter of the SG, neck length, rebleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated.

RESULTS

EVT using the Viabahn SG was performed in 22 patients (mean age, 72.0 ± 13.0 years; 11 men) and 23 arteries (upper, 6; lower, 17). The indications for EVT were pseudoaneurysm (n = 13, 59.1%), extravasation (n = 9, 39.1%), and inadvertent arterial cannulation (n = 1, 4.3%). The anatomical locations of the 23 ULEAB injuries were the brachiocephalic (1 [4.3%]), subclavian (3 [13.0%]), axillary (1 [4.3%]), brachial (1 [4.3%]), common iliac (4 [17.4%]), external iliac (8 [34.8%]), common femoral (2 [8.7%]), superficial femoral (2 [8.7%]), and popliteal (1 [4.3%]) arteries. The technical and clinical success rates were 100%. The rates of limb ischemia, periprocedural complications, and bleeding-related mortality were 0%, whereas the 30-day mortality rate was 22.7%. The mean diameters of the arteries and SGs were 7.7 ± 2.2 and 8.9 ± 2.3 mm, respectively. The mean neck length was 20.4 ± 11.3 mm. No endoleaks or rebleeding occurred during the follow-up period (mean, 169 ± 177 days). Two SG occlusions without limb ischemia occurred in the external iliac and brachial arteries after 1 and 4 months, respectively. Subsequently, cumulative SG patency was confirmed after 1, 3, 6, and 12 months in 91.7%, 91.7%, 81.5%, and 81.5% of patients, respectively.

CONCLUSIONS

Emergency EVT using the Viabahn SG for ULEAB was effective and safe according to short-term outcomes. Appropriate size selection and neck length are important for successful treatment. SG patency was good after 1, 3, 6, and 12 months.