Large-diameter graft-stent (Advanta V12) implantation in various locations: early results

BeGraft Aortic Stents: A European Multi-Centre Experience Reporting Acute Safety and Efficacy Outcomes for the Treatment of Vessel Stenosis in Congenital Heart Diseases

BACKGROUND

Stent implantation has become the preferred method of treatment for treating vessel stenosis in congenital heart diseases. The availability of covered stents may decrease complications and have an important role in the management of patients with complex anatomy.

AIM

This study aims to evaluate the feasibility and safety of the pre-mounted cobalt-chromium stent-graft-covered ePTFE Aortic BeGraft in a broad spectrum of vascular lesions.

METHODS

This is a multicenter retrospective results analysis of 107 implanted BeGraft stents between 2016 and 2022 in six different European centers.

RESULTS

One hundred and four patients with a mean age of thirteen years (range 1-70 years) and with the body weight of 56.5 kg (range 11-115 kg) underwent the BeGraft stent implantation. Stents were implanted in the following conditions: aortic coarctation (74 patients), RVOT dysfunction (12 patients), Fontan circulation (7 patients), and miscellaneous (11 subjects with complex CHD). All the stents were implanted successfully. The median stent diameter was 16 mm (range 7-24 mm), and the median length was 39 mm (range 19-49 mm). Major complications occurred in five subjects (4.7%). During a median follow-up of fourteen (1-70) months, stents' re-dilatation was performed in five patients.

CONCLUSIONS

The BeGraft stent can be used safely and effectively in a wide spectrum of congenital heart diseases. Whether these good results will be stable in the longer term still needs to be investigated in a follow-up given its recent introduction into clinical practice, in particular regarding stent fracture or neointimal proliferation.

Iliac occlusion due to covered stent deformation following abdominal massages

Extrinsic compression is a potential cause of stent failure. We have described the case of a 65-year-old paraplegic patient with acute right leg ischemia. His medical history was relevant for aortobifemoral bypass, followed by kissing covered stent reconstruction of a proximal anastomotic false aneurysm. The computed tomography scan showed collapse of the right iliac covered stent with ipsilateral iliofemoral graft thrombosis and partial collapse of the left iliac covered stent. He underwent emergent right iliac limb open thrombectomy and redo covered stent relining. The cause of compression was found to be daily deep abdominal massages for intestinal evacuation. The endovascular device should be tailored to the patient's particularities.

Covered Stents in the Management of Aortic Coarctation and Right Ventricular Outflow Tract Obstruction

PURPOSE OF REVIEW

To review the use of covered stents in the treatment of coarctation of the aorta (CoA) and right ventricle to pulmonary artery (RV-PA) conduit obstruction.

RECENT FINDINGS

The only commercially available covered stent approved for treatment of CoA and dysfunctional RV-PA conduits is the covered Cheatham-Platinum stent (CCPS). Early outcomes have demonstrated its safety and have suggested its efficacy in treating or preventing aortic wall injury (AWI) or conduit disruption. A recent study of CCPS use for CoA reported a progressive risk of stent fracture over time and a risk of AWI despite the purported protection that the CCPS provides. The use of other covered stents has been reported, but large, systematic studies are lacking. CCPS use may reduce but does not eliminate the risk of conduit disruption or AWI. Structural limitations of the CCPS may predispose it to stent fracture. Access to a broad range of covered stents continues to be an unmet need in the field of congenital interventional cardiology.

Predictors of long-term outcomes after polytetrafluoroethylene-covered stent-graft repair of peripheral arterial aneurysms, pseudo-aneurysms, and arterio-venous fistulas

OBJECTIVES

To evaluate the primary patency rate at three years for the infra-aortic peripheral arterial pathologies treated with polytetrafluoroethylene-covered stent-grafts.

METHODS

Patients treated with self-expandable polytetrafluoroethylene-covered stent-grafts for infra-aortic peripheral arterial aneurysms, pseudo-aneurysms, and arterio-venous fistulas were evaluated retrospectively. A total of 48 patients (35 male, 13 female; mean age: 53.8 ± 13.5) were included with 29.0 ± 16.5 months (median 27, range 4-70) mean follow-up period. The primary objective was to determine the primary patency rate at three years. The secondary objectives were to compare type and localization of pathology, and length and diameter of the stent-grafts with primary patency rate. Kaplan-Meier test was used as the main statistical method.

RESULTS

Overall mean primary patency rate at three years was 77.10%. Polytetrafluoroethylene-covered stent-graft implantation in aneurysms had worse primary patency rate than pseudo-aneurysms and arterio-venous fistulas (66.6%, P = 0.03; 76.9%, P = 0.03; 88.2%, P = 0.01, respectively). Stent-graft location, length, and diameter are not associated with primary patency rate (P > 0.05) but stent diameter is associated with better primary assisted and secondary patency rates (P < 0.05).

CONCLUSIONS

Pathology of the lesion is associated with the long-term primary patency rate of polytetrafluoroethylene-covered stent-grafts but not the stent-graft location, length, or diameter. Stent diameter is associated with primary assisted and secondary patency rates.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

The use of expanded polytetrafluoroethylene in depressed deformities of the face

Expanded polytetrafluoroethylene (ePTFE) has been extensively used for facial soft tissue augmentation procedures, and is regarded as safe and reliable and suitable as a permanent implant. This implant is generally used in the lower third of the face for lips filling, nasal augmentation, nasolabial folds and chin augmentation, and rarely for congenital or acquired depressed deformities of the face. The aim of the present study was to assess the effects of ePTFE in congenital or acquired depressed deformities of the face. From September, 2008 to January, 2014, 26 patients were implanted with the material ePTFE to correct depressed deformities of the face. The average age at operation was 23.2 years, with a range of 17-45 years. The depressed deformities were lateralized. The follow-up period was 6-18 months (average 9 months). The etiologies of the depressed deformities included stable hemifacial atrophy (3 cases), craniofacial microsomia (13 cases), bony depression after trauma (8 cases), and other unclear reasons (2 cases). The operations were performed under local anesthesia. ePTFE was inserted in different tissue planes that varied among the different subanatomical areas in the face: beneath the superficial temporal fascia in the temporal area, and on the surface of the superficial musculoaponeurotic system in the zygomatic area, cheek and mandibular area. All of the patients were followed up. Most of the patients [25 of 26 patients (96.2%)] were satisfied with the results, while 1 patient (3.8%) was not satisfied for incomplete correction of the depressed deformity. In conclusion, aside from lipofilling and a free flap transfer, the results showed that ePTFE was an alternative treatment for facial depressed deformity.

Endovascular repair of aortic coarctation pseudoaneurysm using an off-label "hourglass" stent-graft configuration

PURPOSE

To describe an endovascular technique for treating a pseudoaneurysm of the thoracic aorta using an off-label "hourglass" stent-graft configuration.

CASE REPORT

A 68-year-old patient with prior open thoracic aorta coarctation repair presented with recurrent coarctation and concurrent enlarging 6-cm bilobed pseudoaneurysm involving the previous anastomosis. There was significant discrepancy in the aortic diameter (measured from wall to wall) proximal to the coarctation (14 mm), at the narrowest segment (8 mm), and distally (23 mm). Endovascular repair included deployment of an inverted iliac limb proximally, followed by an inverted aortic converter distally, giving an "hourglass" configuration. There were no perioperative or stent-graft-related complications at 5-year follow-up. The aneurysm regressed from 61 to 25 mm.

CONCLUSION

The use of inverted stent-grafts can allow tapering and flaring to adapt to discrepant aortic diameters. This technique may be useful in select patients with prior coarctation repair who do not need excessive dilation of the narrow aortic segment.

Stents in paediatric and adult congenital interventional cardiac catheterization

A 'stent' is a tubular meshed endoprosthesis that has contributed to the development of interventional catheterization over the past 30 years. In congenital heart diseases, stents have offered new solutions to the treatment of congenital vessel stenosis or postsurgical lesions, to maintain or close shunt patency, and to allow transcatheter valve replacement. First, stents were made of bare metal. Then, stent frameworks evolved to achieve a better compromise between radial strength and flexibility. However, almost all stents used currently in children have not been approved for vascular lesions in children and are therefore used 'off-label'. Furthermore, the inability of stents to follow natural vessel growth still limits their use in low-weight children and infants. Recently, bioresorbable stents have been manufactured and may overcome this issue; they are made from materials that may dissolve or be absorbed in the body. In this review, we aim to describe the history of stent development, the technical characteristics of stents used currently, the clinical applications and results, and the latest technological developments and perspectives in paediatric and adult congenital cardiac catheterization.

Aortic coarctation associated with aortic valve stenosis and mitral regurgitation in an adult patient: a two-stage approach using a large-diameter stent graft

We report a case of a staged surgical and endovascular management in a 62-year-old woman with aortic coarctation associated with aortic valve stenosis and mitral regurgitation. The patient was admitted for severe aortic valve stenosis and mitral valve incompetence. During hospitalization and preoperative imaging, a previously undiagnosed aortic coarctation was discovered. The patient underwent a 2-stage approach that combined a Bentall procedure and mitral valve replacement in the first stage, followed by correction of the aortic coarctation by percutaneous placement of an Advanta V12 large-diameter stent graft (Atrium, Mijdrecht, The Netherlands) which to our knowledge has not been used in an adult patient with this combination of additional cardiac comorbidities. A staged approach combining surgical treatment first and endovascular placement of an Advanta V12 stent graft in the second stage can be effective and safe in adult patients with coarctation of the aorta and additional cardiac comorbidities.