Endovascular management of iliac rupture during endovascular aneurysm repair

Snare-Dragging Technique to Target the Hypogastric Artery in an Iliac Bifurcation Dissection

PURPOSE

To describe snare-assisted vessel targeting to selectively overcome a dissection in the iliac bifurcation and gain antegrade access to the hypogastric artery (HA).

TECHNIQUE

The technique is demonstrated in a 64-year-old woman with an asymptomatic Crawford type III thoracoabdominal aneurysm. A 2-stage endovascular repair, consisting of a thoracic endovascular aortic repair (TEVAR) and a branched endovascular aortic repair was planned. In the control angiography after TEVAR, a disrupted plaque with consequent dissection in the right iliac bifurcation was detected. The perfusion of the common iliac artery and external iliac artery resulted impaired. The targeting of the right HA through a contralateral antegrade approach failed, whereas an ipsilateral retrograde approach was possible but unsuitable for therapeutic purposes. Using the catheter of the retrograde ipsilateral access, a snare from a contralateral crossover was cached and dragged into the HA, allowing the targeting of the vessels and further endovascular therapy with angioplasty and stenting. Follow-up 8 months postoperatively demonstrated the patency of the stents and well-preserved perfusion in the right iliac bifurcation.

CONCLUSION

The snare-dragging technique can be used to gain access to vessels presenting challenging conformations or dissections. This application may be a valuable support for complex endovascular treatment in a variety of patients.

CLINICAL IMPACT

The snare-dragging technique can be used to gain access to vessels presenting challenging conformations or dissections. It allows the catheterization to be establish from the easiest and safest approach and then "transferred" from one access to the other. It avoids the risk of repeated loss of catheterization due to unstable and unfavorable working angles, and it saves time and radiation. It permits different material combinations, adapting to the available resources and materials. We believe that the current technique may increase the strategy spectrum available for endovascular therapy and complex endovascular procedures.

Optimizing Femoral Access in Emergency EVAR with a Decision-Making Algorithm

Endovascular aneurysm repair (EVAR) has become the preferred approach over open repair for abdominal aortic aneurysms (AAAs) due to its minimally invasive nature. The common femoral artery (CFA) is the main access vessel for EVAR, with both surgical exposure and percutaneous access being utilized. However, in emergent cases, percutaneous access can be challenging and may result in complications such as bleeding or dissection thrombosis, leading to the need for surgical conversion. This study aimed to share experiences in implementing a decision-making algorithm to reduce surgical conversions due to percutaneous access failures. A total of 74 aortic patients treated with EVAR in emergency settings were included in this retrospective study. This study focused on various outcomes such as perioperative mortality, morbidity, procedure time, surgical exposure time, and surgical conversion rate. After the implementation of the decision-making algorithm, decreases in surgical conversions and operating time were observed. Percutaneous access was found to be more challenging in cases with specific anatomical characteristics of the CFA, such as severe atherosclerosis or smaller vessel diameter. This study highlighted the importance of carefully assessing patient anatomical features and utilizing a decision-making algorithm to optimize outcomes in EVAR procedures. Further research is needed to continue improving practices for managing aortic aneurysms and reducing complications in femoral artery access approaches.

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage.

METHODS

This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up.

RESULTS

A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38).

CONCLUSION

In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Hybrid management of iliac injury during thoracic endovascular aortic repair: A case report

Thoracic endovascular aortic repair is nowadays the preferred option to manage descending thoracic aorta diseases. However, despite feasibility and safety of the procedures, several complications may occur. We report the case of an 83-year-old female patient with inadvertent iliac rupture occurred during thoracic endovascular aortic repair. To limit massive bleeding, considering the patient's comorbidities contraindicating open surgical repair and the morphology of the arterial injury (circumferential rupture of the artery from its origin), we chose to perform a homolateral hypogastric and common iliac artery embolization and an aorto-uniliac balloon expandable stent graft deployment from the distal aorta to the contralateral common iliac artery. A femoro-femoral crossover bypass graft was performed to restore both lower limbs perfusion. Final angiography documented correct positioning and regular patency of the implanted grafts and bypass with no blood loss from the right iliac vessels. Despite careful preoperative assessment, iliac artery injury can represent a challenging complication of thoracic endovascular aortic repair, particularly in the setting of inadequate iliac diameter, calcification and vessel tortuosity, or when large-caliber introducers are required. The hybrid approach we describe is a valid and effective solution to minimize blood loss and avoid major consequences in the management of iatrogenic iliac artery rupture during endovascular procedures.

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting

Purpose

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Stent placement for AIOD demonstrated excellent outcomes in terms of long-term patency. However, iliac artery rupture is the most fearful complication during the aortoiliac stenting (AIS). This study aimed to evaluate the incidence and risk factors of iliac artery rupture during AIS.

Materials and Methods

A retrospective review of consecutive patients with AIOD treated with AIS from 2009 to 2021 was completed. We excluded patients with instent restenosis. All types of stents, including self-expanding stent (SES), balloon-expandable stent (BES), or balloon-expandable covered stent (CS), were used. Angiographic characteristics and procedural outcomes were analyzed. Procedural success was defined as the residual stenosis <30%.

Results

A total of 242 patients (86.8% male; mean age 68.8±10.0 years) with de novo AIOD were treated with AIS. The procedural success rate was 100%. Rupture occurred in six patients (2.5%) and all ruptures were occurred in the external iliac artery (EIA). Stenting of the EIA and less calcified lesion were risk factors for iliac rupture (P=0.028). All cases of iliac artery rupture were successfully treated with the CSs. Overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. Primary patency rates of SES, BES, and CS were 87.7%, 88.4%, and 100% at 36 months, respectively.

Conclusion

The incidence of iliac artery rupture during AIS was 2.5%. Stent placement in the less calcified lesion and EIA was a risk factor for rupture during AIS. Placement of the CS can be the straightforward solution in case of iliac artery rupture during AIS.

Outcomes of iliofemoral conduits during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

OBJECTIVE

To describe the technical pitfalls and outcomes of iliofemoral conduits during fenestrated-branched endovascular repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

We retrospectively reviewed the clinical data of 466 consecutive patients enrolled in a previous prospective nonrandomized study to investigate FB-EVAR for CAAAs/TAAAs (2013-2021). Iliofemoral conduits were performed through open surgical technique (temporary or permanent) in patients with patent internal iliac arteries or endovascular technique among those with occluded internal iliac arteries. End points were assessed in patients who had any iliac conduit or no conduits, and in patients who had conduits performed prior or during the index FB-EVAR, including procedural metrics, technical success, and major adverse events (MAE).

RESULTS

There were 138 CAAAs, 141 extent IV, and 187 extent I-III TAAAs treated by FB-EVAR with an average of 3.89 ± 0.52 vessels incorporated per patient. Any iliac conduit was required in 35 patients (7.5%), including 24 patients (10.4%) treated between 2013 and 2017 and 11 (4.7%) who had procedures between 2018 and 2021 (P = .019). Nineteen patients had permanent conduits using iliofemoral bypass, 11 had temporary iliac conduits, and 5 had endoconduits. Iliofemoral conduits were necessary in 12% of patients with extent I to III TAAA, in 6% with extent IV TAAA, and in 3% with CAAA (P = .009). The use of iliofemoral conduit was more frequent among women (74% vs 27%; P < .001) and in patients with chronic obstructive pulmonary disease (49% vs 28%; P = .013), peripheral artery disease (31% vs 15%; P = .009), and American Society of Anesthesiologists classification of III or higher (74% vs 51%; P = .009). There were no inadvertent iliac artery disruptions in the entire study. The 30-day mortality and MAE were 1% and 19%, respectively, for all patients. An iliofemoral conduit using retroperitoneal exposure during the index FB-EVAR was associated with longer operative time (322 ± 97 minutes vs 323 ± 110 minutes vs 215 ± 90 minutes; P < .001), higher estimated blood loss (425 ± 620 mL vs 580 ± 1050 mL vs 250 ± 400 mL; P < .001), and rate of red blood transfusion (92% vs 78% vs 32%; P < .001) and lower technical success (83% vs 87% vs 98%; P < .001), but no difference in intraoperative access complications and MAEs, compared with iliofemoral conduits without retroperitoneal exposure during the index FB-EVAR and control patients who had FB-EVAR without iliofemoral conduits, respectively. There were no differences in mortality or in other specific MAE among the three groups.

CONCLUSIONS

FB-EVAR with selective use of iliofemoral conduits was safe with low mortality and no occurrence of inadvertent iliac artery disruption or conversion. A staged approach is associated with shorter operating time, less blood loss, and lower transfusion requirements in the index procedure.

Bilateral Iliac Endobypass Solution in Iliac Artery Rupture during TEVAR Procedure: A Case Report and Review of the Literature

Iliac artery rupture is a demanding complication that can occur during endovascular procedures, particularly when large-caliber introducers are required. We present the first case in the literature on the endobypass technique, a quick and effective reconstruction method for the iliofemoral axis. This clinical case highlights that thoracic endovascular aortic repair procedures require large-caliber introducers into the femoral and iliac arteries to allow passage of the delivery system. These arteries may be diseased, representing a high risk of rupture. In our case, placing a 20 Fr introducer, the iliac artery ruptured bilaterally. Therefore, we performed an endobypass deploying Viabahn stent-grafts into the common iliac artery and manually performed distal anastomosis on the femoral bifurcation.

Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair

BACKGROUND

Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited.

METHODS

Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by Endurant^TM II (END II) or Endurant^TM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA.

RESULTS

One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs.

CONCLUSIONS

Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.

Impact of Female Sex on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair: A Ten-Year Retrospective Nationwide Study in France

The impact of sex on the outcomes of patients with cardiovascular disease is still incompletely understood. The aim of this nationwide multicenter observational study was to investigate the impact of sex on post-operative outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for intact thoracic aortic aneurysm (iTAA). The French National Health Insurance Information System was searched to identify these patients over a ten-year retrospective period. Post-operative outcomes, 30-day and overall mortality were recorded. Among the 7383 patients included (5521 men and 1862 women), females were significantly older than males (66.8 vs. 64.8 years, p < 0.001). They were less frequently diagnosed with cardiovascular comorbidities. Post-operatively, women had less frequently respiratory (10.9 vs. 13.7%, p = 0.002) as well as cardiac complications (34.3 vs. 37.3%, p = 0.023), but they had more frequently arterial complications (52.8 vs. 49.8%, p = 0.024). There was no significant difference on overall mortality for a mean follow-up of 2.2 years (26.9 vs. 27.6%, p = 0.58). In the multivariable regression model, female sex was not associated with 30-day or overall mortality. Although women had a favorable comorbidity profile, the short-term and long-term survival was similar. The significantly higher rate of arterial complications suggests that women may be at higher risk of access-vessel-related complications.

Comparison of Outcomes and Complications Among Patients with Different Indications of Acute/Subacute Complicated Stanford Type B Aortic Dissection Treated by TEVAR: Data from the JaPanese REtrospective multicenter stuDy of ThoracIc Endovascular Aortic Repair for Complicated Type B Aortic Dissection (J-Predictive Study)

PURPOSE

To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair.

MATERIAL AND METHODS

The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test.

RESULTS

Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair.

CONCLUSIONS

Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia.

LEVEL OF EVIDENCE

Level 4, Case series.

Aortic Rupture during Endovascular Aneurysm Repair. Report of Our Experience and Review of the Literature

Background  Aortic neck wall rupture during endovascular repair of abdominal aortic aneurysms (EVAR) is an underreported potentially fatal complication. Only a few cases have been reported. The main cause of this complication is repeated attempts at balloon inflation or overdilation to treat an intraoperative Type 1a endoleak. We report three cases complicated by procedure-related aortic neck wall rupture during EVAR. We also review the literature regarding the causes and outcomes of this complication.

Methods  Medical records of all patients undergoing EVAR between January 2009 and March 2019 were retrospectively reviewed.

Results  Overall, 824 EVAR procedures were performed, and rupture of the aortic neck wall was observed in three patients. In all cases, a Type 1a endoleak was observed and, in all cases, repeated ballooning attempts had been performed to resolve the endoleaks. In all cases, conversion to open repair was performed and all patients survived.

Conclusion  In cases of Type 1a endoleak, a maximum of two ballooning attempts should be performed even if a Type 1a endoleak persists. In case of intraoperative aortic neck wall rupture, control of the hemorrhage should be achieved immediately by advancing the balloon above the site of rupture. Emergency surgical conversion in case of hemodynamic stability is the first choice. According to the literature, emergency surgical conversion, especially in cases of endograft with suprarenal fixation, is associated with significant morbidity and mortality rates, mainly due to hemorrhage and to the length of the procedure required to repair the aortic neck wall injury.

Early results of a low-profile stent-graft for thoracic endovascular aortic repair

PURPOSE

To assess outcomes of a low-profile thoracic stent-graft in the treatment of thoracic aortic pathologies.

METHODS

A retrospective analysis of all consecutive patients with aortic thoracic pathologies treated with the RelayPro device in two university hospitals between October 2018 and July 2019.

RESULTS

23 patients (65% men; mean age 63.4 ± 15 years) were treated. Pathologies included aortic dissections (n = 10), 5 residual type A (22%) and 5 type B (22%), 6 degenerative aortic aneurysms (26%), 4 penetrating aortic ulcers (17%), and aortic erosion, intramural hematoma and aortic rupture (n = 1 and 4% in each case). Two cases (9%) were emergent and two urgent. Proximal landing was achieved in zones 0 (4%), 1 (4%), 2 (43%), and 3 (26%). Five grafts were frozen elephant trunk extensions. Technical success was 100% with accurate device deployment in the intended landing zone of the aortic arch in all 23 patients and with no Ia/III endoleaks and three (13%) type II endoleaks. Apposition was adequate in 96%. Two patients had post-implantation syndromes (one fever, one leukocytosis). Mean follow-up was 11.6 ± 3.7 months (range, 2-16) with no other complications, secondary interventions or conversions to open surgery. There was no 30-day mortality and no aortic-related mortality; all-cause mortality was 4% during follow-up.

CONCLUSION

A 3-4 French reduced profile in the current generation of stent-grafts facilitates TEVAR particularly in patients with smaller vessels access. Early safety and effectiveness outcomes are favorable, even in endpoints such as deployment accuracy and apposition which may be surrogates for longer-term clinical success and durability.

Percutaneous Endovascular Aneurysm Repair: Current Status and Future Trends

Endovascular aneurysm repair (EVAR) is a common, safe, and effective method of treating abdominal aortic aneurysms. Traditionally treated via surgical cutdown over the common femoral arteries, many recent studies demonstrate percutaneous access techniques to avoid the surgical cutdown. Developing familiarity with these percutaneous techniques, including risks, complications, adjuncts, and alternative accesses, can help improve the outcomes and availability of EVAR. As these techniques become increasingly common, it is not unlikely that they can be practiced safely in select patients in an outpatient setting.

Endovascular treatment for iatrogenic rupture of an iliac artery with severe tortuosity

Retroperitoneal hemorrhage due to iatrogenic rupture of the iliac artery is a life-threatening complication associated with endovascular intervention. We present a case of iatrogenic iliac rupture after insertion of a sheath into a severely tortuous iliac artery during coil embolization of a cerebral aneurysm. Bleeding was controlled by resuscitative endovascular balloon occlusion of the aorta followed by placement of a balloon-expandable stent graft into the iliac artery. This resulted in complete repair of the ruptured iliac artery. The patient recovered without any neurological complications.

Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Comprehensive Review

Abdominal aortic aneurysm (AAA) can be defined as an abnormal, progressive dilatation of the abdominal aorta, carrying a substantial risk for fatal aneurysmal rupture. Endovascular aneurysmal repair (EVAR) for AAA is a minimally invasive endovascular procedure that involves the placement of a bifurcated or tubular stent-graft over the AAA to exclude the aneurysm from arterial circulation. In contrast to open surgical repair, EVAR only requires a stab incision, shorter procedure time, and early recovery. Although EVAR seems to be an attractive solution with many advantages for AAA repair, there are detailed requirements and many important aspects should be understood before the procedure. In this comprehensive review, fundamental information regarding AAA and EVAR is presented.

Descending thoracic endovascular aortic repair does not require cardiothoracic surgery support

Objective

Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive “back-up plan.”

Methods

This is a retrospective analysis of data collected from March 2014 to January 2018 of 18 patients who underwent TEVAR at a tertiary care facility with a level I trauma center. There were 11 males and 7 females with an average age of 68.8 years old (range 19–97; SD ± 19.52). The average body mass index (BMI) was 24.7 kg/m2 (range 16.8–35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2).

Results

The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3–6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3–166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support.

Conclusion

These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

Iliac injury during abdominal and thoracic aortic endovascular intervention

OBJECTIVE

Iliac injury is a devastating and potentially avoidable complication of endovascular aortic intervention. To our knowledge, this study is the first investigation of demographic, anatomic, and device factors related to injury in vascular surgery patients.

METHODS

We retrospectively examined 1859 endovascular aortic interventions and found 42 iliac injuries, including 21 ruptures. Demographic, anatomic, and device data were extracted from these patients and a cohort of 200 case-matched control patients derived from the group of uninjured patients. Anatomic data include centerline and straight distance measurement of the iliac system from the aortic bifurcation to the inguinal ligament. The ratio of the two ("tortuosity index") was calculated. Additional data include midpoint and narrowest diameters in the iliac system along with the most acute angle. Each measurement was taken on both limbs of each patient.

RESULTS

Nonwhite race was the only demographic factor associated with injury (P = .028). None of the examined comorbidities were associated with iliac injury. Increasing sheath size was associated with injury (P < .001), whereas abdominal aortic segment intervention was inversely correlated with injury (P = .017). Anatomic factors that correlated with injury were decreasing iliac midpoint (P < .01), narrowest diameters (P < .001), and a higher ratio of sheath size to midpoint diameter (P < .001). Injury was associated with a longer hospital length of stay (P = .042) and inpatient death (P < .001), with iliac rupture conferring an odds ratio of 15.3 (95% confidence interval, 3.74-62.7; P < .001).

CONCLUSIONS

Iliac injury is associated with an increased hospital length of stay and death on the index admission. Nonwhite race, nonabdominal aortic segment intervention, larger relative and absolute sheath sizes, and smaller iliac artery diameters are associated with iliac injury. These findings should be prospectively evaluated along with interventions to reduce injury.

Transcaval Aortic Access for Percutaneous Thoracic Aortic Aneurysm Repair: Initial Human Experience

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. The present report describes its use for thoracic endovascular aortic repair (TEVAR) in a 61-year-old man with a descending thoracic aneurysm. Transcaval access was performed in lieu of a surgical iliac conduit in view of small atherosclerotic pelvic arteries. TEVAR was successfully performed, followed by intervascular tract occlusion with the use of a ventricular septal occluder. Computed tomography 2 d later demonstrated no extravasation. At 1 mo, the aneurysm was free of endoleaks, the aortocaval tract had healed, and the patient had returned to baseline functional status.

Management of complete iliofemoral artery avulsion with a hybrid technique

Transcatheter aortic valve replacement is a viable alternative for patients who are too high risk for traditional surgical aortic valve replacement, but it is not without risk of vascular complication. We report a case in which a hybrid stent and bypass graft technique was used to repair a complete iliofemoral artery avulsion after a transcatheter aortic valve replacement procedure. We believe that particular caution should be taken with patients with peripheral arterial disease in access vessels. Access vessel diameter must be considered in planning of procedures, and preprocedural preparation for potential major vascular complications is crucial for reducing morbidity and mortality.

Initial clinical experience with the Zenith alpha stent-graft

PURPOSE

To assess safety and short-term efficacy of endovascular repair of the thoracic aorta with the new Zenith Alpha stent-graft.

METHODS

Between August 2010 and May 2014, 33 patients (21 men; mean age 73.2±9.0 years) were treated Zenith Alpha stent-graft (group ZA). Outcomes of this group were compared with those of 34 patients (25 men; mean age 70.3±8.5 years) treated contemporaneously with the Zenith TX-2 for the same pathologies (group TX). The primary outcome measure was technical success. Data on iliac tortuosity, minimum access vessel diameter, and previous unsuccessful treatment with other endografts was also recorded.

RESULTS

Technical success was 93.9% in group ZA and 91.2% in group TX (p=0.67). There was no case of surgical death or conversion to open repair in either group. Two (6%) type I endoleaks occurred in group ZA and 3 (9%) in group TX (p=0.67). Three patients died within 30 days in group ZA vs. none in group TX (p=0.07). Mean minimum access vessel diameter was significantly smaller (5.07 vs. 6.65 mm, p=0.002) and iliac tortuosity indices significantly higher in group ZA (1.34 vs. 1.25, p=0.02). Access vessel complications occurred in 1 (3%) patient in group ZA and 4 (12%) patients in group TX (p=0.17). Significantly more patients in group ZA (6, 18%) were unsuccessfully treated previously with other endografts vs. none in group TX (p=0.01).

CONCLUSION

The new Zenith Alpha appears to be equally as safe and efficacious as the Zenith TX-2 while being used in patients with demanding access vessel morphology.

Iliac anatomy and the incidence of adjunctive maneuvers during endovascular abdominal aortic aneurysm repair

Purpose

Challenging iliac anatomy remains an important issue during endovascular aneurysm repair (EVAR), and it is known that the length of the common iliac artery (CIA) is shorter in Asians than in Western groups. We analyzed both the iliac anatomy and the incidence of adjunctive maneuvers to overcome iliac artery-related difficulties during EVAR.

Methods

Seventy-four EVARs were performed for abdominal aortic aneurysm between January 2010 and March 2013. Patient demographic data, iliac anatomical characteristics (presence of iliac artery aneurysm, iliac artery diameter and length, and iliac tortuosity), and adjunctive iliac artery maneuvers were reviewed retrospectively.

Results

Mean CIA length was 52.8 mm (range, 6.6-98.0 mm) on the right and 56.3 mm (range, 0-94.8 mm) on the left. CIA length was ≥20 mm, except in one patient with bilateral short CIAs. Forty patients (54%) had a CIA aneurysm, and 18 had aneurysms on both sides. Iliac adjunctive procedures were performed in 38 patients (51%) as follows: 23 internal iliac artery (IIA) embolizations or ligations, seven IIA revascularizations, 16 external iliac artery (EIA) balloon angioplasties or stenting, one EIA patch angioplasty, one EIA interposition, two femoral endarterectomies with patch angioplasty, and nine femoro-femoral bypasses after EVAR with an aorto-uni-iliac device. Technical success for the adjunctive iliac procedures was achieved in all patients.

Conclusion

Short CIA length was uncommon. Although many patients had access-related difficulties, most were overcome by an endovascular or hybrid technique. Liberal use of iliac adjunctive procedures can facilitate EVAR.

Successful Endovascular Management of Intraoperative Graft Limb Occlusion and Iliac Artery Rupture Occurred during Endovascular Abdominal Aortic Aneurysm Repair

For high-risk patients, endovascular aortic aneurysm repair (EVAR) is a good option but may lead to serious complications, which should be addressed immediately. A 75-year-old man with a history of abdominal surgery underwent EVAR for an aneurysm of the abdominal aorta and iliac arteries. During EVAR, iliac artery rupture and graft limb occlusion occurred, and they were successfully managed by the additional deployment of an iliac stent graft and balloon thrombectomy, respectively. We, herein, report a rare case of the simultaneous development of the two fatal complications treated by the endovascular technique.

Delayed rupture of the iliac artery after percutaneous angioplasty

Rupture of the iliac artery during percutaneous angioplasty is a life-threatening condition that requires prompt diagnosis and treatment to rescue the patient. Recently, percutaneous angioplasty has become an outpatient procedure, but there is no reliable guideline for observation time in the hospital after percutaneous angioplasty. We describe a 67-year-old man with bilateral lesions in the iliac artery who experienced a delayed rupture of the iliac artery 2 days after percutaneous balloon angioplasty and placement of a self-expandable stent. The patient was successfully treated by endovascular intervention with a stent graft. In our department, percutaneous angioplasty is not performed in an outpatient clinic, and all patients are admitted to the hospital and observed for at least 3 days after percutaneous angioplasty. Because our patient was in the hospital when the iliac artery ruptured, prompt diagnosis and treatment were possible. Moreover, because appropriately sized stent grafts were prepared in the hospital, timely endovascular treatment could be performed, and the patient recovered successfully. From this case, we conclude that observing patients for a sufficient time in the hospital and preparing appropriately sized stent grafts are 2 important factors for the safety of patients who undergo percutaneous angioplasty.

Characterization and Outcomes of Iliac Vessel Injury in the 21st Century

Introduction:

Iliac vessel trauma (IVT) is traditionally associated with high mortality. We evaluated a modern series of patients with IVT to assess current outcomes and endovascular therapy use.

Methods:

We performed a retrospective review of the National Trauma Data Bank. Patients with IVT were stratified by blunt and penetrating mechanism and arterial and venous injury.

Results:

In blunt IVT, there was no significant difference in mortality between those with and without pelvic fractures (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.36-1.06). In penetrating IVT, combined arterial and venous IVT was associated with higher mortality (OR 1.70, 95% CI 1.06-2.70) compared to isolated arterial IVT. Isolated venous IVT was associated with lower mortality (OR 0.55, 95% CI 0.35-0.85) compared to isolated arterial IVT. Endovascular stenting was utilized in 11.3% of blunt IVT with pelvic fractures, 6.3% of blunt IVT without pelvic fractures, and 1.8% of penetrating IVT.

Conclusion:

Iliac Vessel Trauma has significant mortality. Endovascular intervention for IVT is applied sparingly.

Increased glial glutamate transporter EAAT2 expression reduces epileptogenic processes following pilocarpine-induced status epilepticus

Several lines of evidence indicate that glutamate plays a crucial role in the initiation of seizures and their propagation; abnormal glutamate release causes synchronous firing of large populations of neurons, leading to seizures. In the present study, we investigated whether enhanced glutamate uptake by increased glial glutamate transporter EAAT2, the major glutamate transporter, could prevent seizure activity and reduce epileptogenic processes. EAAT2 transgenic mice, which have a 1.5-2 fold increase in EAAT2 protein levels as compared to their non-transgenic counterparts, were tested in a pilocarpine-induced status epilepticus (SE) model. Several striking phenomena were observed in EAAT2 transgenic mice compared with their non-transgenic littermates. First, the post-SE mortality rate and chronic seizure frequency were significantly decreased. Second, neuronal degeneration in hippocampal subfields after SE were significantly reduced. Third, the SE-induced neurogenesis and mossy fiber sprouting were significantly decreased. The severity of cell loss in epileptic mice was positively correlated with that of mossy fiber sprouting and chronic seizure frequency. Our results suggest that increased EAAT2 expression can protect mice against SE-induced death, neuropathological changes, and chronic seizure development. This study suggests that enhancing EAAT2 protein expression is a potential therapeutic approach.

Endovascular management of iliac vein rupture during percutaneous interventions for occlusive lesions

Iatrogenic Iliac vein rupture is a rare and potentially lethal complication. We present herein two different clinical scenarios of iatrogenic iliac vein rupture that resulted from performing percutaneous endoluminal interventions to treat symptomatic veno-occlusive lesions. The first case was due to the presence of surgical clips from the patient's previous gynecologic surgery, which caused iliac vein compression and eventually led to acute deep vein thrombosis. The second case resulted from central venous outflow obstruction ipsilateral to a lower extremity arteriovenous dialysis access site. Both Iliac vein ruptures were the result of percutaneous attempts to correct the outflow lesion (delayed in the first case and acute in the second case). Hemorrhage was successfully controlled in both cases using a self-expandable Viabahn (W. L. Gore and Associates, Flagstaff, AZ) covered stent while maintaining vessel patency and resolving symptoms related to veno-occlusive disease.

Antegrade, covered, self-expanding stent as an iliac extension in a bifurcated endograft: a feasible technical maneuver for challenging aortoiliac aneurysmal anatomy

BACKGROUND

Aneurysmal and occlusive aortoiliac disease can make the process of introducing large delivery catheters for endovascular repair challenging. We describe the case of a patient who could be treated by a bifurcated stent-graft despite having a unilateral external iliac occlusion.

METHODS AND RESULTS

From a brachial access, a covered self-expanding stent was deployed antegradely through the distal gate of the stent-graft into the common iliac artery. This technical choice helped to overcome the problem of an external iliac occlusion, so as to maintain an antegrade flow into the internal iliac and avoid the need for an interfemoral bypass.

CONCLUSION

Auto-expandable covered stent-graft with a thinner shaft can be used through a brachial access as an iliac extension of a bifurcated aortic endograft. However, a longer follow-up duration and more cases are necessary to warrant the safety and the durability of such an "off-label" endovascular material assemblage.

Kissing Iliac Artery Stent Technique for Salvage of Hypogastric Artery Occlusion Secondary to Iliac Artery Dissection During Endovascular Aneurysm Repair

While undergoing endovascular aneurysm repair (EVAR), dissection occurred in bilateral common and external iliac arteries resulting in acute bilateral hypogastric artery occlusion. Attempts were made to reestablish flow to the left internal iliac artery via retrograde ipsilateral approach without success. A left brachial approach was used to gain access to the left internal iliac artery and kissing angioplasty and subsequent stent placement with 2 self-expanding stents was performed raising the iliac bifurcation to the level of the stent graft to salvage the internal iliac artery.