Chimney grafts preserve visceral flow and allow safe stenting of juxtarenal aortic occlusion

Trapdoor endarterectomy for coral reef plaque of the paravisceral aorta in the modern era

Coral reef atherosclerosis of the paravisceral aorta is a rare disease whose description is confined to before contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with coral reef aorta treated with trapdoor endarterectomy at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients with coral reef aorta were treated with trapdoor endarterectomy. The patient data were obtained via a retrospective medical record review. The patients were predominantly women (79%) with a median age of 65 years (interquartile range [IQR], 60-70 years). The patients universally had a tobacco smoking history and hypertension. More than 85% had previously diagnosed carotid stenosis. Two patients (14%) had undergone prior aortofemoral reconstruction, and one patient (7%) had undergone prior axillobifemoral bypass. The most common presenting symptoms were claudication (71%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Of the 14 patients, 8 (57%) underwent isolated endarterectomy and 6 (43%) underwent concomitant aortobifemoral bypass. In addition, 13 patients (93%) required a supraceliac aortic clamp position with a median clamp time of 23 minutes (IQR, 20-30 minutes). The median estimated blood loss was 1650 mL (IQR, 1025-3000 mL). A cell saver was used in 13 procedures (93%), with a median transfusion of 563 mL (IQR, 231-900 mL). The median operative time was 341 minutes (IQR, 315-416 minutes). Eight patients (57%) experienced acute kidney injury in the postoperative period with a peak creatinine of 1.96 mg/dL (IQR, 1.50-2.84 mg/dL). The median length of stay was 11 days (IQR, 6-16 days), with an intensive care unit stay of 4 days (IQR, 2-7 days). One patient (7%) required reoperation in the immediate perioperative period for a retroperitoneal hematoma. The postoperative ankle brachial index increased from a median of 0.58 (right) and 0.57 (left) bilaterally in the preoperative period to 1.09 (right) and 1.10 (left) postoperatively. Eight patients (57%) had follow-up data available for >2 years postoperatively, with five patients (36%) having follow-up data available for >3 years. Two major adverse cardiac events were reported at the last follow-up. One patient reported mild recurrent symptoms of chronic mesenteric ischemia during 3 years of postoperatively, with no concurrent imaging findings or loss of patency found on computed tomography angiography. Symptomatic coral reef atherosclerosis of the paravisceral aorta is a complex disease rarely encountered even at high-volume referral centers. These patients can be expected to experience short-term postoperative morbidity and require intensive care. Despite these challenges, trapdoor endarterectomy is a safe and effective procedure for coral reef aorta, and most patients achieve dramatic symptomatic improvement with durable results.

Transaxillary Tri-Branch Aortic Endovascular Graft Repair of Recurrent Thoracoabdominal Aneurysm With Pararenal Aortic Occlusion

The absence of an adequate ileo-femoral access is usually considered an absolute contraindication to fenestrated and branched aortic repairs. Alternative routes and dedicated stent-graft designs have been advocated. Hereby, we describe the case of a 73-year-old man with a recurrent type IV thoracoabdominal aortic aneurysm and complete thrombotic pararenal aortic occlusion treated successfully with a tri-branch custom-made endograft deployed via a transaxillary access.

Endovascular Reconstruction for Total Aorto–Iliac Occlusion

Objectives:

To analyze outcomes following endovascular treatment of total occlusion of the infrarenal aorta and aorto–iliac bifurcation in a multicenter Italian registry.

Methods:

It is a multicenter, retrospective, observational cohort study. From January 2015 to December 2018, 1306 endovascular interventions for aorto–iliac occlusive disease were recorded in the vascular registry. For this analysis, only patients treated for total occlusion of the infrarenal aorta and aorto–iliac bifurcation were included. Early (<30 days) primary outcomes of interest were technical success and mortality. Late major outcomes were primary and secondary patency and freedom from conversion to open aortic surgery.

Results:

A total of 54 (4.1%) patients met the inclusion criteria. Total percutaneous revascularization was possible in 41 (75.9%) patients and hybrid (endo plus open) intervention in 13 (24.1%) patients. The kissing-stent-graft technique was used in 45 (83.3%) cases, covered endovascular reconstruction of the aortic bifurcation (CERAB) in 5 (9.2%), and a unibody endograft deployed in 4 (7.4%). Technical success was 98.1% (n = 53). There were no episodes of intraoperative or perioperative vessel rupture. Conversion to open surgery was not necessary, and there were no in-hospital deaths. The median patient follow-up time was 16 months (interquartrile range [IQR], 6-27). The estimated primary patency rate was 95.8% ± 0.03 (95% confidence interval [CI]: 85.5-98.9) at 1 year, 91.4% ± 0.05 (95% CI: 76.2-97.2) at 2 years, and 85 ± 0.08 (95% CI: 64.5-94.6) at 3 years. Cox regression analysis demonstrated that sex (hazard ratio [HR]: 0.96; 95% CI: 0.15-6.23, p = 0.963), extent of the occlusion (HR: 0.28; 95% CI: 0.05-1.46, p = 0.130), calcium score (HR: 1.88; 95% CI: 0.31-11.27, p = 0.490), or type of endovascular reconstruction (HR: 0.80; 95% CI: 0.13-5.15, p = 0.804) did not affect primary patency. Secondary patency was 95.5% ± 0.04 (95% CI: 78.4-99.2) at 3 years. No patients required late conversion to open surgical bypass.

Conclusions:

Endovascular reconstruction for total occlusion of the infrarenal aorta and aorto–iliac bifurcation was successful using a combination of percutaneous and hybrid revascularization techniques. Estimated patency rates at 3 years of follow-up are promising and are unaffected by the extent of occlusion or type of revascularization.

Transbrachial and transfemoral approaches combined with visceral protection for the treatment of juxtarenal aortoiliac occlusive disease: Technical issues and clinical outcomes

PURPOSE

To evaluate the safety and efficacy of transbrachial and transfemoral approaches combined with visceral protection for the endovascular treatment of juxtarenal aortoiliac occlusive disease (AIOD) over an average 19-month follow-up period.

METHODS

In this retrospective analysis, all patients with juxtarenal AIOD at a single institution were reviewed from June 2015 to January 2020. Patient characteristics, angiographic results, and follow-up outcomes were retrospectively recorded. The indications for treatment were critical limb threatening ischemia in 12 patients and bilateral claudication in five patients. Percutaneous access via the left brachial artery was first obtained to recanalize the infrarenal occluded lesions. After that, femoral accesses were achieved. A 4-Fr catheter, a 4 mm balloon, or a 6-Fr 90-cm-long sheath was used to complete visceral artery protection.

RESULTS

A total of 17 juxtarenal AIOD patients (14 males; mean age, 63.4 ± 8.1 years) underwent endovascular treatment. The technical success rate was 100%. Complete reconstruction was achieved in 15 (88.2%) patients. The infrarenal aorta was reconstructed with kissing covered stent grafts (n = 7), kissing bare-metal stents (n = 2), covered stent grafts (n = 2), bare-metal stents (n = 1), or the off-label use of iliac limb stent grafts (n = 5). Renal embolization was found in 3 (17.6%) patients during intraoperative angiography. There was 1 (5.9%) case of distal runoff embolization after CDT and 1 (5.9%) case of left iliac artery rupture. One (5.9%) death occurred due to acute myocardial infarction 20 days after the operation. The average follow-up period was 19.3 ± 16.7 months (range, 1-54 months) in the remaining 16 cases. The renal artery patency rate was 100%. The estimated cumulative primary patency rates were 92.3% at 12 months and 59.3% at 36 months according to the Kaplan-Meier method.

CONCLUSIONS

Transbrachial and transfemoral approaches combined with visceral protection offer a safe and effective alternative to open revascularization for the endovascular treatment of juxtarenal AIOD.

Chimney grafts in renal arteries: a clinical model for coronary perfusion in future transcatheter aortic root repair techniques

OBJECTIVES

Given the similarities between coronary ostia and renal arteries, chimney grafts (CG) for kidney perfusion during abdominal endovascular aneurysm repair (EVAR) can be considered for coronary perfusion in future transcatheter aortic root repair (TARR) techniques. We analysed the results of renal CG and compared anatomic and technical details with root and coronary anthropometric data.

METHODS

Current status of kidney perfusion with CG was reviewed from literature. Anatomic details, technical data, CG performance and clinical outcome were collected and analysed. Anatomic details of aortic landing zone and renal arteries were compared with human anthropometric data of aortic root, ascending aorta and coronary ostia.

RESULTS

Seventeen articles reported 430 patients (mean age:74.5 ± 2.9 years) treated with renal CG. Mean length and diameter of proximal landing zone were 2.0 ± 2.0 mm and 26.4 ± 4.3 mm, respectively (anthropometric correspondence: ascending aorta diameter of 29.3 mm). Aortic endograft mean diameter was 26.4 ± 7.3 mm with reported oversize of 19.5 ± 6.0%. In total, 590 renal arteries were treated (left:325; right:265; bilateral:139 cases). Mean left and right renal artery diameters were 5.7 ± 0.6 mm and 5.8 ± 0.7 mm, respectively (anthropometric correspondence: coronary ostia diameters of 4.8 mm (left) and 3.7 mm (right)) with reported CG oversize of 19.75 ± 6% (left) and 18.1 ± 5.1% (right). Mean follow-up time was 16.5 ± 8.5 months, CG occlusion rate was 3.2% and endoleak I or II was reported in 83 patients (19.3%), requiring 7 procedures.

CONCLUSIONS

CG provides satisfactory results in patients with suitable renal artery diameter. Based on aortic root and coronary anthropometric data, CG can be considered in future TARR technologies for coronary perfusion but further tests for flow evaluations are mandatory.

Chimney Technique to Preserve Visceral Flow in a Coral Reef Aorta

The coral reef aorta (CRA) is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. Open revascularization has an overall in-hospital mortality rate of 13%. We present a patient with a suprarenal CRA with colon ischemia. She has an extensive past medical history of percutaneous transluminal angioplasty and stenting of the celiac trunk (CT) and superior mesenteric artery (SMA). The computed tomography angiography showed a CRA of the suprarenal aorta with occlusion of the CT stent and near occlusion of the SMA stent. Our case illustrates that the CRA in the suprarenal part of the aorta can be treated well by chimney graft procedure, although owing to lack of long-term follow-up, it might be reserved for high-risk candidates for (thoraco)abdominal aortic surgery.

Covered endovascular repair of the paravisceral aorta

Open aortic repair is considered the “gold standard” treatment for aortic occlusive disease. We present the case of an 83-year-old patient with refractory hypertension caused by paravisceral aortic stenosis including both renal arteries and the superior mesenteric artery. We planned an endovascular approach and treated the patient with parallel stent grafts in the paravisceral aorta. At 1.5 years after the operation, the patient was free of hypertensive episodes. Covered endovascular repair of the paravisceral aorta may be a valuable alternative to open aortic repair in patients unfit for open surgery. More research is needed to evaluate the long-term effects of this technique.

Endovascular treatment for chronic lower extremity ischaemia with sub-acute deterioration

OBJECTIVES

The purpose of this study is to report the efficacy of endovascular treatment for patients with sub-acute (14-day to 2-month) deterioration of chronic lower extremity ischaemia.

MATERIALS AND METHODS

Between June 2013 and May 2015, 26 consecutive patients (22 men, 4 women; mean age, 68.6 years; range, 50-86 years) were treated for sub-acute deterioration of chronic lower extremity ischaemia in our hospital. All patients were treated with catheter-directed thrombolysis initially and then adjunctive percutaneous transluminal angioplasty and/or stenting was performed to correct underlying lesions.

RESULTS

The 26 intra-arterial thrombolysis procedures were all performed in native lower arteries including 8 iliac, 13 femoropopliteal and 5 diffuse occlusions involving the iliac and femoropopliteal segments. Lesion length decreased from 194 mm (70-350 mm) to 92 mm (20-270 mm) after the thrombolytic procedures, and the residual lesions were corrected with percutaneous transluminal angioplasty alone in 4 (15.4%) limbs and stenting in 22 (84.6%) patients. No cross-joint stenting was seen in the 22 affected limbs that used stents. Throughout the treatment process, nine patients with intermittent claudication achieved an unrestricted walking distance, and 17 patients with rest pain or foot ulcers showed significant symptom improvement. The mean ankle-brachial index increased from 0.42 ± 0.16 preoperatively to 0.81 ± 0.25 postoperatively ( p < 0.01).

CONCLUSION

Endovascular therapy with catheter-directed thrombolysis and percutaneous transluminal angioplasty/stenting is feasible for sub-acute deterioration of chronic lower extremity ischaemia patients with favourable midterm results.

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions

OBJECTIVE

Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions.

METHODS

Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive.

RESULTS

Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases.

CONCLUSIONS

The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.

Immediate hemodynamic changes after revascularization of complete infrarenal aortic occlusion: A classic issue revisited

Chronic total occlusion of the infrarenal aorta (CTOA) is a rare disease, characterized by severe impairment of limb perfusion. It is advocated that revascularization may improve survival rates, presumably due to improved cardiovascular performance; however no experimental or clinical data exist to identify a clear causative correlation and provide a relevant pathophysiologic background. Therefore we conducted a pilot study based on pulse wave analysis to detect the hemodynamic changes immediately after revascularization, in a group of six consecutive patients with CTOA. All patients were subjected to non-invasive measurements 1 day before surgery and at the end of the 1st postoperative month. Pulse wave analysis was performed noninvasively with a novel validated brachial cuff-based automatic oscillometric device. All patients had markedly preoperative high Augmentation Index (adjusted at heart rate 75 beats/min, AI@75). The AI@75 decreased from 46 ± 6.6 preoperatively to 24 ± 5.7 (p 0.0002). Wave reflection magnitude decreased from 72.3 ± 5.2% to 63 ± 6.7% (p 0.02). Cardiax index increased from 2.8 ± 1.2 to 3.4 ± 1.2l/min × 1/m(2) (p 0.41). Pulse wave velocity remained practically unchanged post-interventionally. These findings show that central aorta hemodynamics can be improved immediately following revascularization procedures in patients with complete occlusion of the entire length of the infrarenal aorta and can constitute the background of improved postoperative life-expectancy.

Results of Open Surgical Repair of Chronic Juxtarenal Aortic Occlusion

PURPOSE

The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO).

MATERIALS AND METHODS

We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9±9.3 years [range, 44-79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (<30 days) postoperative surgical morbidity (particularly renal function), operative mortality, and longterm patient survival. We conducted risk factor analysis for postoperative renal insufficiency.

RESULTS

The mean intraoperative RIT was 10.7±5.5 minutes (range, 3-25), including 6 patients who underwent concomitant pararenal aortic thromboendarterectomy. Postoperatively, five (11%) patients had transient renal insufficiency, one had pneumonia, and one patient had an acute myocardial infarction. However, there was no operative mortality or newly developed dialysis-dependent renal failure. Postoperative follow up was available in 36 (77%) patients for a mean period of 6.3 years (range, 1 month-17 years). Kaplan Meier calculations of patient survival at 5 and 10 years after surgery were 91.2% and 83.6%, respectively.

CONCLUSION

We have experienced short RIT, acceptable early postoperative results and long-term survival after OSR of chronic JRAO.

The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair

OBJECTIVES

The objective of the present study was to evaluate short- and mid-term outcomes of the left subclavian artery (LSA) chimney stent implantation (LSACSI) during thoracic endovascular aortic repair (TEVAR), and to summarize our experience with this technique.

METHODS

From June 2010 to September 2012, 59 patients (49 men; mean age of 57.4 ± 13.3 years, range from 26 to 83 years) who underwent TEVAR and LSACSI were enrolled. Patients suffered from Stanford type B aortic dissection (n = 27), penetrating aortic ulcer (n = 18), aortic arch aneurysm (n = 9), pseudoaneurysm of the aortic arch (n = 4) and proximal type I endoleak after TEVAR of aortic dissection (n = 1). Elective settings were performed in 72% and emergent in 38% of all patients. Follow-up was performed at postoperative 3 months, 6 months and yearly thereafter.

RESULTS

The technical success rate was 98.3% (58/59), and 69 thoracic stent grafts were used. Sixty-two chimney stents, including 55 uncovered and 7 covered stents, were implanted in 59 LSAs. The overall immediate endoleak rate was 15.3% (9/59); type I endoleak was observed in 5 patients and type II in 4 patients. The difference in the immediate endoleak rate related to the anatomy between the outer and the inner curvature was statistically significant (35 vs 4%, P = 0.018). Chimney stent compression was observed in 3 patients and another stent was deployed inside the first one. Perioperative complications included stroke (3.4%, 2/59) and left upper limb ischaemia (1.7%, 1/59). The median follow-up period was 16.5 (range 1–39 months). The mortality rate during follow-up was 5.4% (3/56). Complications during follow-up included endoleak [overall, n = 8 (14.3%, 8/56); type I, n = 5; type II, n = 3], retrograde type A aortic dissection (n = 1), collapse (n = 3, 5.4%) or occlusion (n = 2, 3.6%) of the chimney stent.

CONCLUSIONS

Short- and mid-term results showed that it is feasible to preserve the patency of the LSA in TEVAR with the chimney technique for thoracic aortic pathologies close to the LSA. However, TEVAR combined with LSACSI was not advocated for lesions located at the outer curve of the aortic arch due to a high possibility of endoleak.

Percutaneous Endovascular Recanalization of a Thrombosed Aortic Graft Limb with Stent Placement

Common practice in recanalization of a thrombosed prosthetic graft limb in an aortoiliac bypass focuses on balloon-catheter thrombectomy and angiographic exploration followed either by open surgical revision or endovascular management. This report describes the technique of percutaneous endovascular recanalization of an early thrombosed aortic graft limb with stent placement and subsequent restoration of patency and adequate limb perfusion, which remains patent after one year. Percutaneous intervention with stent placement and angioplasty for early graft limb recanalization avoids femoral incisions, and complications or morbidity associated with open surgery, while permitting rapid mobilization of the patient.

Transbrachial and femoral artery approach endovascular therapy for flush infrarenal aortic occlusion

OBJECTIVE

The purpose of this study is to report the efficacy of transbrachial and femoral artery approach endovascular therapy with catheter-directed thrombolysis (CDT) and adjunctive therapy for flush infrarenal aortic occlusion (FIAO).

MATERIALS AND METHODS

From March 2012 to December 2013, 11 consecutive patients (9 males; mean age 68 years; range 54-80 years) were submitted to endovascular therapy for FIAO. All patients were treated with CDT initially and then adjunctive endovascular treatments were performed to correct the underlying lesions.

RESULTS

Complete reconstruction of occluded aortoiliac arteries was successfully achieved in 81.8% (9/11) of patients. Left brachial and bilateral femoral arterial accesses were obtained in nine patients, and brachial and unilateral femoral in two patients. The residual lesions after CDT were corrected in nine patients and concomitant endovascular recanalization of superficial femoral artery was performed in two patients. Self-expandable stents were implanted in the all aortoiliac lesions with pre- and post-dilation. No renal or distal runoff embolization was seen during intraoperative angiography. Seven (7/9) patients with rest pain or tissue loss showed significant improvements in symptoms and two (2/9) patients with intermittent claudication gained an improved walking distance. The ABI rose significantly between pre- and post-procedure (0.84 ± 0.18 vs. 0.44 ± 0.13 on the right leg, p < .01; 0.89 ± 0.23 vs. 0.48 ± 0.16 on the left, p < .01).

CONCLUSIONS

Transbrachial and femoral artery approach endovascular therapy for FIAO offers an alternative to surgical reconstruction with immediate outcomes.