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Hüttl A, Nguyen TD, Borzsák S, Süvegh A, Szentiványi A, Szilvácsku I, Kovács D, Dobránszky J, Sótonyi P, Csobay-Novák C. Comparison of the Snare Loop Technique and the Hungaroring Reinforcement for Physician-Modified Endograft Fenestrations-An In Vitro Study. J Cardiovasc Dev Dis 2024; 11:134. [PMID: 38786956 PMCID: PMC11122024 DOI: 10.3390/jcdd11050134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation. MATERIALS AND METHODS The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration. RESULTS Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010-1090) compared to 760 s (IQR:685-784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8-27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3-20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm. CONCLUSION Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.
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Affiliation(s)
- Artúr Hüttl
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - Tin Dat Nguyen
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - Sarolta Borzsák
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
- Semmelweis Aortic Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - András Süvegh
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - András Szentiványi
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - István Szilvácsku
- Department of Materials Science and Engineering, Budapest University of Technology and Economics, Műegyetem rkp. 3-9, 1111 Budapest, Hungary
| | - Dóra Kovács
- Department of Materials Science and Engineering, Budapest University of Technology and Economics, Műegyetem rkp. 3-9, 1111 Budapest, Hungary
| | - János Dobránszky
- ELKH-BME Research Group for Composite Science and Technology, Műegyetem rkp. 3-9, 1111 Budapest, Hungary
| | - Péter Sótonyi
- Semmelweis Aortic Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
| | - Csaba Csobay-Novák
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
- Semmelweis Aortic Center, Semmelweis University, Városmajor u. 68., 1122 Budapest, Hungary
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Behrendt CA, Kolh P, Loftus I, Hinchliffe RJ. The Key Role of the European Society for Vascular Surgery in Improving the Surveillance of High Risk Medical Devices. Eur J Vasc Endovasc Surg 2024; 67:365-366. [PMID: 37640251 DOI: 10.1016/j.ejvs.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Medical School Brandenburg, Theodor Fontane, Neuruppin, Germany. https://twitter.com/VASCevidence
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liège, Liège, Belgium; GIGA Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - Ian Loftus
- St George's Vascular Institute, St George's University Hospital, London, United Kingdom
| | - Robert J Hinchliffe
- Department of Vascular Surgery, University of Bristol, Bristol, United Kingdom
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Luo ZR, Li SL, Chen LW, Huang RD. Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch. Sci Rep 2024; 14:4051. [PMID: 38374192 PMCID: PMC10876643 DOI: 10.1038/s41598-024-54781-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/16/2024] [Indexed: 02/21/2024] Open
Abstract
The study aimed to provide physician modified fenestration (PMF) on a single-branched stent for the aortic arch (Castor) to protect the isolated left vertebral artery (ILVA) during thoracic endovascular aortic repair (TEVAR). Patients who underwent TEVAR involving ILVA reconstruction through PMF performing on the Castor branched stent were included in a retrospective, multi-centre study from June 2018 to December 2022. In these patients, all proximal landing zones of "Castor" were positioned in Ishimaru zone 2a. A total of twenty-five patients met the inclusion criteria and the achievement rate showed 25/25 (100%) success in them. The twenty-five patients had a median follow-up length of 28.5 ± 14.6 months. One patient (4.0%) suffered from postoperative ischemic stroke before discharge. One patient (4.0%) died from a hemodialysis-related brain hemorrhage before discharge on the 29th day after the procedure. One patient died of advanced liver cancer in the 33th month after discharge. Aortic rupture, stroke or spinal cord injury did not occur throughout the follow-up period after discharge. Two patients (8.0%) experienced endoleak at the fenestration, however, resulting in only one's necessity for reintervention. Notably, the procedure effectively maintained ILVAs patency for all patients during follow up. According to our preliminary findings, performing a TEVAR under local anaesthesia using PMF on a Castor branched stent for ILVA preservation appeared practical, secure, and effective.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fuzhou, Fujian Province, China
| | - Sai-Lan Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fuzhou, Fujian Province, China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fuzhou, Fujian Province, China
| | - Rong-Da Huang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fuzhou, Fujian Province, China.
- Department of Cardiovascular Surgery and Cardiac Disease Center, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
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Jónsson GG, Shehab M, Wanhainen A, Mani K, Kuzniar M, Lindström D. Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm. J Endovasc Ther 2023:15266028231215976. [PMID: 38049945 DOI: 10.1177/15266028231215976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. METHODS Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. RESULTS (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. CONCLUSIONS Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. CLINICAL IMPACT Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Maysam Shehab
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Marek Kuzniar
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - David Lindström
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
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Jiang X, Xiang G, Du G, Li X, Wu P, Du X. A hemodynamic analysis of fenestrated physician-modified endograft repair for complicated aortic dissections involving the visceral arteries. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107785. [PMID: 37678097 DOI: 10.1016/j.cmpb.2023.107785] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/12/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The aim of this study is to perform patient-specific hemodynamic simulations of the patients with complicated aortic dissection underwent Physician-modified endograft (PMEG) and evaluate the treatment outcome. METHOD 12 patient-specific models were reconstructed from computed tomography angiography (CTA) data of 6 patients with complicated aortic dissection before and after the PMEG. Hemodynamic simulations were conducted with the same time-varying volumetric flow rate extracted from the literature and 3-element Windkessel model (3 EWM) boundary conditions were applied at the aortic outlet. Hemodynamic indicators such as time-averaged wall shear stress (TAWSS), relative residence time (RRT) and endothelial cell activation potential (ECAP) were obtained to evaluate the postoperative effect of PMEG. RESULTS Comparing with the preoperative models, the flow rates of most visceral arteries were increased in the postoperative models (PSMA = 0.012, PRRA = 0.013, and PLRA = 0.005). Pressure and TAWSS in visceral regions were significantly reduced (PP = 0.003 and PTAWSS = 0.017). With the false lumens (FL) covered by the stent grafts, the average TAWSS level increased in the regions of postoperative abdominal aorta (P = 0.002), and the average RRT and ECAP values decreased significantly (PRRT = 0.02 and PECAP = 0.003). CONCLUSION This study shows that PMEG, as a new technique for the treatment of complicated aortic dissection involving the distal tears in the visceral region, can effectively restore the abnormal blood supply of the visceral arteries, reduce the risk of aortic rupture, the formation of aortic dissection aneurysm (ADA), and thrombosis. This corresponds well with clinical retrospective studies and 1-year follow-up outcomes. The findings of this study are of great significance for the development of PMEG.
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Affiliation(s)
- Xudong Jiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, China; Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China
| | - Guangyuan Xiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China
| | - Guanting Du
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, 8 Jixue Road, Suzhou, Jiangsu 21513, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, China; Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China.
| | - Peng Wu
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, 8 Jixue Road, Suzhou, Jiangsu 21513, China.
| | - Xiaolong Du
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China.
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Jayet J, Canonge J, Heim F, Coggia M, Chakfé N, Coscas R. Mechanical Comparison between Fenestrated Endograft and Physician-Made Fenestrations. J Clin Med 2023; 12:4911. [PMID: 37568314 PMCID: PMC10420147 DOI: 10.3390/jcm12154911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION A fenestrated endograft (FE) is the first-line endovascular option for juxta and pararenal abdominal aortic aneurysms. A physician-modified stent-graft (PMSG) and laser in situ fenestration (LISF) have emerged to circumvent manufacturing delays, anatomic standards, and the procedure's cost raised by FE. The objective was to compare different fenestrations from a mechanical point of view. METHODS In total, five Zenith Cook fenestrations (Cook Medical, Bloomington, IN, USA) and five Anaconda fenestrations (Terumo Company, Inchinnan, Scotland, UK) were included in this study. Laser ISF and PMSG were created on a Cook TX2 polyethylene terephthalate (PET) cover material (Cook Medical, Bloomington, IN, USA). In total, five LISFs and fifty-five PMSG were created. All fenestrations included reached an 8 mm diameter. Radial extension tests were then performed to identify differences in the mechanical behavior between the fenestration designs. The branch pull-out force was measured to test the stability of assembling with a calibrated 8 mm branch. Fatigue tests were performed on the devices to assess the long-term outcomes of the endograft with an oversized 9 mm branch. RESULTS The results revealed that at over 2 mm of oversizing, the highest average radial strength was 33.4 ± 6.9 N for the Zenith Cook fenestration. The radial strength was higher with the custom-made fenestrations, including both Zenith Cook and Anaconda fenestrations (9.5 ± 4.7 N and 4.49 ± 0.28 N). The comparison between LISF and double loop PMSG highlighted a higher strength value compared with LISF (3.96 N ± 1.86 vs. 2.7 N ± 0.82; p= 0.018). The diameter of the fenestrations varied between 8 and 9 mm. As the pin caliber inserted in the fenestration was 9 mm, one could consider that all fenestrations underwent an "elastic recoil" after cycling. The largest elastic recoil was observed in the non-reinforced/OC fenestrations (40%). A 10% elastic recoil was observed with LISF. CONCLUSION In terms of mechanical behavior, the custom-made fenestration produced the highest results in terms of radial and branch pull-out strength. Both PMSG and LISF could be improved with the standardization of the fenestration creation protocol.
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Affiliation(s)
- Jérémie Jayet
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Laboratoire de Physique et Mécanique Textiles (LPMT), ENSISA, 68093 Mulhouse, France
- UMR 1018, Inserm-Paris11—CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94800 Villejuif, France
| | - Jennifer Canonge
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Department of Vascular Surgery, Henri Mondor University Hospital, 94010 Créteil, France
| | - Frédéric Heim
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Laboratoire de Physique et Mécanique Textiles (LPMT), ENSISA, 68093 Mulhouse, France
| | - Marc Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
| | - Nabil Chakfé
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Department of Vascular Surgery and Kidney Transplantation, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67084 Strasbourg, France
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- UMR 1018, Inserm-Paris11—CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94800 Villejuif, France
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