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Maqsood HA, Jawed HA, Kumar H, Bansal R, Shahid B, Nazir A, Rustam Z, Aized MT, Scemesky EA, Lepidi S, Bertoglio L, D'Oria M. Advanced Imaging Techniques for Complex Endovascular Aortic Repair: Preoperative, Intraoperative and Postoperative Advancements. Ann Vasc Surg 2024; 108:519-556. [PMID: 38942370 DOI: 10.1016/j.avsg.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) requires extensive preoperative, intraoperative, and postoperative imaging for planning, surveillance, and detection of endo-leaks. There have been manyadvancements in imaging modalities to achieve this purpose. This review discussed different imaging modalities used at different stages of treatment of complex EVAR. METHODS We conducted a literature review of all the imaging modalities utilized in EVAR by searching various databases. RESULTS Preoperative techniques include analysis of images obtained via modified central line using analysis software and intravascular ultrasound. Fusion imaging (FI), carbon dioxide (CO2) angiography, intravascular ultrasound, and Fiber Optic RealShape (FORS) technology have been crucial in obtaining real-time imaging for the detection of endo-leaks during operative procedures. Conventional imaging modalities like computed tomography (CT) angiography (CTA) and magnetic resonance (MR) angiography are still employed for postoperative surveillance along with computational fluid dynamics and contrast-enhanced ultrasound (CEUS). The advancements in artificial intelligence (AI) have been the breakthrough in developing robust imaging applications. CONCLUSIONS This review explains the advantages, disadvantages, and side-effect profile of the abovementioned imaging modalities.
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Affiliation(s)
| | | | | | - Radha Bansal
- Government Medical College and Hospital, Chandigarh, India
| | | | | | - Zainab Rustam
- Wilmer Eye Institute, John Hopkins Medicine, Baltimore, MD, USA
| | - Majid Toseef Aized
- Ascension St. Mary's Hospital, Vascular Health Clinics, Saginaw, MI, USA
| | | | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, Brescia University School of Medicine, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, University Hospital of Trieste ASUGI, Trieste, Italy
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Brand M, Yoel B, Eichler E, Speter C, Halak M, Marom G. The effect of stent graft curvature on the hemodynamic displacement force after abdominal aortic aneurysm endovascular repair. ROYAL SOCIETY OPEN SCIENCE 2023; 10:230563. [PMID: 37416831 PMCID: PMC10320339 DOI: 10.1098/rsos.230563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023]
Abstract
Endovascular aortic aneurysm repair is a minimally invasive procedure with low mortality and morbidity. Clinical studies have revealed that a displacement force (DF) can cause stent graft (SG) migration in some circumstances requiring repeated intervention. This study aims to determine the relationship between the SG curvature and the calculated DF from four patient-specific computational fluid dynamics models. The SG's curvature was defined according to the centrelines of the implanted SG's branches. The centrelines were defined as either intersecting or separated lines. The centreline curvature (CLC) metrics were calculated based on the local curvature radii and the distances from the centrelines of idealized straight branches. The average CLC value and average variation were calculated to represent the entire graft's curvature. These CLC calculations were compared, and the method that gave the best correlation to the calculated DF was found. The optimal correlation is obtained from calculating the CLC average variation using separated centrelines and distance from straight lines, with an R2 = 0.89. Understanding the relationship between vascular morphology and DF can help identify at-risk patients before the procedure. In these cases, we can provide appropriate treatment and follow up with the patient to prevent future failure.
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Affiliation(s)
| | | | | | - Chen Speter
- Department of Vascular Surgery, The Chaim Sheba Medical Centre, Tel Hashomer, Israel
| | - Moshe Halak
- Department of Vascular Surgery, The Chaim Sheba Medical Centre, Tel Hashomer, Israel
| | - Gil Marom
- Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
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Taneva GT, Mirgolbabaee H, Groot Jebbink E, Reijnen MMPJ, Donas KP. Systematic Review of the Current In Vitro Experience of the Endovascular Treatment of Juxtarenal Abdominal Aortic Aneurysms by Fenestrated and Parallel Endografting. J Endovasc Ther 2023; 30:8-17. [PMID: 35114834 DOI: 10.1177/15266028221075242] [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: 01/25/2023]
Abstract
OBJECTIVE To identify and analyze the published in vitro benchtop experiments for the assessment of endovascular techniques used for the treatment of juxtarenal abdominal aortic aneurysms (jAAAs). DATA SOURCES Scopus, PubMed, and Web of Science. REVIEW METHODS A systematic literature search was carried out throughout March 2021 following PRISMA guidelines. Two investigators independently performed title and abstract screening to reveal all benchtop testing evaluating the endovascular treatment of jAAA. RESULTS A total of 19 studies were included, 8 evaluating fenestrated (FEVAR) and 11 parallel grafts (PGs). FEVAR studies used different custom testing apparatus (n=7) or 3D-printed models (n=1) to analyze dislodgement and migration resistance, misalignment consequences and causation, and bridging stents' radial force, flareability, fatigue, and fracture resistance. All PG studies used silicone-based models to analyze optimal oversizing, sealing length, gutter behavior, and possible reduction. Test evaluation in FEVAR in vitro testing was based on pullout force analysis (N=5), photo evaluation (n=1), fluoroscopy (n=1), X-rays (n=4), CT analysis (n=3), macro- and microscopic evaluation (n=4), water permeability (n=1), and fatigue simulator testing (n=1), while it was based on CT analysis in all PG studies adding ECG-gate in one study. The most frequently tested devices were Zenit (Cook) (n=7), Endurant (Medtronic) (n=5), and Excluder (Gore) (n=5) as main grafts, and Advanta V12 (n=14) as the bridging device. CONCLUSIONS This systematic review presents a broad analysis of the current in vitro methods evaluating the endovascular treatment of jAAA. Fundamental issues have been benchtop tested in both FEVAR and PGs. The analysis of the included studies allowed to recommend an optimal testing design. In vitro testing is a potential tool to further elucidate points of attention hard to investigate in vivo to finally enhance the endovascular treatment outcomes. Future in vitro studies are needed to evaluate the in vitro performance of all indistinctively used devices in the clinical practice.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Hadi Mirgolbabaee
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Erik Groot Jebbink
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel M P J Reijnen
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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Georgakarakos E, Ioannidis G, Raptis A, Xenos M. Computational Fluid Dynamic Analysis Supports the Hemodynamic Stability of Hybrid Combinations With the AFX Bifurcate and Nitinol-Based Proximal Segments in Solutions of Failed Endovascular Aneurysm Repair. Vasc Endovascular Surg 2021; 55:907-909. [PMID: 34348516 DOI: 10.1177/15385744211037490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hybrid endograft combinations of two or more different types of covered stents are rarely reported to treat complex abdominal aortic aneurysm cases or primary and secondary endoleaks. Clinical and laboratory data regarding the clinical efficacy and mechanical stability of such combinations are lacking. Based on a recently published case report, we describe and comment on the hemodynamic profile of a representative simulated hybrid case of AFX and Nitinol-based proximal cuff and support the stability of this combination in non-angulated cases.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Georgios Ioannidis
- Department of Radiotherapy, University Hospital of Larissa, Larissa, Greece
| | - Anastasios Raptis
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece.,Biofluid Mechanics and Biomedical Engineering Laboratory, Fluids Section, School of Mechanical Engineering, National Technical University of Athens, Zografou, Greece
| | - Michalis Xenos
- Department of Mathematics, 37796University of Ioannina, Ioannina, Greece
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Effect of aortic angulation on the outcomes of fenestrated-branched endovascular aortic repair. J Vasc Surg 2021; 74:372-382.e3. [PMID: 33548434 DOI: 10.1016/j.jvs.2021.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/03/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate the effect of aortic angulation on the early and midterm outcomes of fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms (PRAA). METHODS We retrospectively reviewed the data of consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study (2013-2018). The infrarenal, suprarenal, and supraceliac aortic angles were measured on three-dimensional reconstructions of the preoperative computed tomography angiogram; a 45° cutoff was used for the analysis. End points were technical success, freedom from endograft-related complications (defined by type IA/IB/IIIA/IIIB/IIID endoleaks, and limb thrombosis); and freedom from target vessel instability (defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak, or disconnection). Cox proportional hazard multivariable regression analyses were preformed to assess impact of covariates. RESULTS There were 298 patients treated for 102 PRAAs (34%) and 196 TAAAs (66%) (78 extent IV, 118 extent I-III) with 1156 renal-mesenteric vessels incorporated. An angulation of >45° was present in the infrarenal aortic axis in 94 patients (32%), suprarenal axis in 39 (13%), and supraceliac axis in 93 (31%). A supraceliac angle of >45° was more common with extent I-III TAAAs (P = .01). Technical success was 97% and was not significantly related to aortic angulation; the total operating time and fluoroscopy time were significantly longer in patients with any aortic angulation of >45°. Freedom from endograft-related complications was 93% (95% confidence interval [CI], 90%-97%) at 42 months, and was not associated with infrarenal (HR, 1.0; 95% CI, 0.4-2.9; P = .976), suprarenal (HR, 1.7; 95% CI, 0.5-1.8; P = .428), or supraceliac (HR, 0.9; 95% CI, 0.3-2.6; P = .886) aortic angles of >45°. Overall freedom from target vessel instability was 92% (95% CI, 90%-94%) at 42 months. By multivariable analysis, target vessel instability was not affected by an infrarenal angle of >45° (HR, 1.5; 95% CI, 0.9-2.4; P = .135) and a supraceliac angle of >45° (HR, 0.9; 95% CI, 0.5-1.5; P = .627), but was associated with a suprarenal angle of >45° (HR, 5.6; 95% CI, 3.5-9.1; P < .001), even after adjustment for aneurysm extent and type of bridging stent. In this subgroup of patients, the use of directional branch vs fenestration (P = .10) and the type of bridging stent (P = .10) did not significantly impact target vessel instability. CONCLUSIONS Fenestrated-branched endovascular aneurysm repair can achieve excellent early and midterm results among patients with an aortic angulation of >45°, with no increase in rates of graft-related complications. However, increased aortic angulation was associated with longer operative and fluoroscopy times. The suprarenal aortic angle was the most important determinant of more target vessel events, independent of stent design or which bridging stent was selected.
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Computational Fluid Dynamics Modeling of Hemodynamic Parameters in the Human Diseased Aorta: A Systematic Review. Ann Vasc Surg 2020; 63:336-381. [DOI: 10.1016/j.avsg.2019.04.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/09/2019] [Accepted: 04/18/2019] [Indexed: 02/07/2023]
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Gibello L, Ruffino MA, Varetto G, Frola E, Rispoli P, Verzini F. Current results of balloon expandable visceral stent-grafts in fenestrated endografting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:37-46. [DOI: 10.23736/s0021-9509.19.11199-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Torsello GF, Herten M, Frank A, Müller M, Jung S, Torsello GB, Austermann M. Performance of BeGraft and BeGraft+ Stent-Grafts as Bridging Devices for Fenestrated Endovascular Aneurysm Repair: An In Vitro Study. J Endovasc Ther 2019; 26:787-794. [PMID: 31379276 DOI: 10.1177/1526602819866435] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate 2 generations of balloon-expandable covered stents as potential bridging devices using an in vitro model of stent-graft fenestrations. Materials and Methods: Twenty BeGraft and 20 BeGraft+ cobalt-chromium stents covered in expanded polytetrafluoroethylene (ePTFE) in 6- and 8-mm diameters were tested in sheets mimicking stent-graft fenestrations. Microscopy and radiography were employed to evaluate stent morphology after flaring. In vitro bench tests measured maximum pullout (perpendicular displacement) and the shear stress (axial displacement) forces needed to dislocate the stents. Results: No alteration of ePTFE coverage was detected in the flared stents. Digital radiography and computed tomography showed marked alteration of the stent geometry, which was more pronounced in the BeGraft group. No fractures were detected. Median (minimum-maximum) pullout forces for the 6-mm stent-grafts were 17.1 N (15.8-19.6) for the BeGraft device and 30.4 N (20.2-31.9) for the BeGraft+ device (p=0.006). Median (minimum-maximum) pullout forces for the 8-mm stent-grafts were 11.3 N (11-12.1) for the BeGraft device and 21.8 N (18.2-25.5) for the BeGraft+ device (p<0.001). The shear stress test showed median forces of 10.5 vs 15.28 N at 150% of the stent diameter for the 6-mm BeGraft and BeGraft+ stent-grafts, respectively, and 15.23 vs 20.72 N at 150% stent diameter for the 8-mm models (p=0.016 and 0.017, respectively). Conclusion: Flaring changed the stent geometry but did not provoke stent fractures. The BeGraft+ is superior to the BeGraft in terms of pullout and shear stress forces, demonstrating greater resilience.
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Affiliation(s)
- Giovanni Federico Torsello
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Charité Campus Virchow-Klinikum, Charité University Medicine Berlin, Germany.,Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
| | - Monika Herten
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany.,Department of Orthopedic and Trauma Surgery, Essen University Hospital, Essen, Germany
| | - André Frank
- Biomechanics Laboratory, Department for Hand, Trauma, and Reconstructive Surgery, University Hospital Münster, Germany
| | - Markus Müller
- Biomechanics Laboratory, Department for Hand, Trauma, and Reconstructive Surgery, University Hospital Münster, Germany
| | - Susanne Jung
- Department of Cranio-Maxillofacial Surgery, University Hospital Münster, Germany
| | | | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
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Swaelens C, Poole RJ, Torella F, McWilliams RG, England A, Fisher RK. Type IIIb Endoleak and Relining. J Endovasc Ther 2016; 23:297-301. [DOI: 10.1177/1526602816631106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To examine the changes in distraction force following relining of a conventional abdominal aortic stent-graft with a type IIIb endoleak using the Nellix endovascular sealing device compared to a unilateral stent-graft. Methods: Relining is often used to repair type IIIb endoleaks, but the consequences to graft stability are unknown. A mathematical model was constructed based on pressure and volume flow through the stent-grafts, incorporating recognized distraction force equations. Steady flow was presumed at peak systolic pressures to calculate the maximum distraction force, with gravity ignored. Distraction forces for 28- to 36-mm-diameter stent-graft bodies with 16-mm limbs were calculated and compared to forces following relining with single and double Nellix devices or the Renu unilateral device. Results: Distraction forces for the 28-, 32-, and 36-mm stent-grafts prior to relining were 5.99, 10.21, and 14.99 N, respectively. Similar forces were reported after relining with bilateral Nellix devices (5.86, 10.08, and 14.86 N, respectively). However, use of a unilateral Nellix increased the distraction forces to 9.92, 14.14, and 18.92 N, respectively. These were comparable to the increase observed after relining with a Renu unilateral stent-graft (9.87, 14.09, and 18.86 N, respectively). The proportional increase in distraction force for a unilateral relining ranged from 26% to 66%, with the greatest increase noted in the smaller diameter main bodies. Conclusion: Relining a stent-graft with a type IIIb endoleak using bilateral Nellix devices does not increase the distraction force. However, a unilateral Nellix device or the Renu system could theoretically increase the distraction force by up to 66%, potentially risking migration and type Ia endoleak. In clinical practice, these results suggest that a relining with bilateral Nellix may have benefits over the Renu unilateral stent-graft.
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Affiliation(s)
- Charles Swaelens
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard G. McWilliams
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Robert K. Fisher
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
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