Malpositioned or dislocated aortic endoprostheses: repositioning using percutaneous pull-down maneuvers

Endovascular maneuvers for contralateral stent graft limb misplacement in endovascular aortic repair

Cannulation and placement of the contralateral stent graft limb during endovascular aortic repair (EVAR) procedure are crucial steps as mispositioning may lead to conversion to open aortic repair. Endovascular bail-out strategies for stent graft relocation in EVAR are underreported though detailed knowledge may facilitate application and prevent conversion. We present three endovascular bail-out strategies for repositioning of a mispositioned contralateral stent graft limb. (1) Retraction of the mispositioned component with an inflated reliant balloon and placement of an interposition stent graft after successful cannulation; (2) Push-maneuver of the mispositioned stent graft into the infrarenal aortic aneurysm with an inflated reliant balloon supported by a large lumen introducer sheath and (3) Parallel placement of a second contralateral stent graft limb displacing the mispositioned one against the atrial wall in cases with adequate vessel diameter. Prevention of stent graft mispositioning by applying recognized tests to ensure correct placement are essential, following the slogan: check twice, deploy once.

Cranial Dislocation of Infrarenal Aortic Endoprostheses During Transcatheter Aortic Valve Replacement

This report describes the complexity of transcatheter aortic valve replacement in which rare complications sometimes occur, even at experienced centers. This is a case of cranial migration of an infrarenal aortic aneurysm endograft while advancing the balloon-expandable prosthesis through the infrarenal aorta, which was subsequently successfully treated by deploying a thoracic endoprosthesis after deployment of the aortic valve bioprosthesis.

Management of Renal Artery Occlusion during Endovascular Aortic Repair

A 67-year-old man was admitted to the emergency unit with abdominal pain. An infrarenal aortic aneurysm with a diameter of 70 millimeters was detected by computed tomography. In the catheter laboratory, graft stents were implanted into the infrarenal aorta. Total occlusion of the right renal artery was seen in angiography. The graft stent was punctured with a 30° angled Brockenbrough catheter, and another stent was implanted.

Salvage of bilateral renal artery occlusion after endovascular aneurysm repair with open splenorenal bypass

We report renal salvage maneuvers after accidental bilateral renal artery coverage during endovascular aneurysm repair of an infrarenal abdominal aortic aneurysm. A 79-year-old man with an infrarenal abdominal aortic aneurysm was treated with endovascular aneurysm repair. Completion angiography demonstrated coverage of the renal arteries. Several revascularization techniques were attempted, including endograft repositioning and endovascular stenting through the femoral and brachial approach. The patient eventually underwent open splenorenal bypass with a Y Gore-Tex graft (W. L. Gore & Associates, Flagstaff, Ariz). After 3 months, computed tomography showed no evidence of endoleak and patent renal arteries. Renal function was well maintained, and the patient did not require dialysis.

Initial Experience with Intentional Stent-Graft Coverage of the Subclavian Artery during Endovascular Thoracic Aortic Repairs

Purpose:

To investigate the extent to which clinical status is affected by covering the left subclavian artery (LSA) with stent-grafts in the thoracic aorta.

Methods:

Stent-graft reconstruction of the thoracic aorta was performed in 23 patients (20 men; mean age 50.8 years, range 17–77) for management of rupture (n = 11), type B dissection (n = 9), or aneurysm (n = 3). All patients had bilaterally equal systolic and diastolic blood pressures (141.3 ± 19.8 and 78.9 ± 11.0 mmHg, respectively). Twenty Gore TAG and 1 Talent thoracic endografts were used; 2 cases required a combination of prostheses. In all patients, the stent-graft was intentionally placed to cover the LSA. Follow-up included clinical examination with blood pressure measurements and computed tomography during the first postoperative week and at 3-month intervals thereafter.

Results:

After coverage of the LSA by the stent-graft, systolic pressure fell by a mean 48.3 ± 23.4 mmHg. In 4 cases of proximal endoleak, however, systolic pressure fell by only 25.0 ± 15.0 mmHg. Twenty (78.5%) patients reported no complaints during a mean follow-up of 12.1 ± 7.3 months. Postinterventional complaints reported by 3 patients included exercise-dependent paresthesias; nonexercise-dependent, intermittent, and completely reversible dizziness; and a temperature difference between the upper extremities with no decrease in strength.

Conclusions:

Covering the LSA is generally well tolerated by patients and increases the landing zone for the placement of thoracic stent-grafts. Long-term studies, however, must investigate the hemodynamic effects of this procedure on the vertebrobasilar circulation.

Detecting Aortic Graft Complications: A Spectrum of Computed Tomography Findings

Endovascular aneurysm repair (EVAR) is a successful technique as well as an excellent alternative to the surgical management of abdominal aortic aneurysms. EVAR has improved the mortality and morbidity of many patients who would have otherwise suffered greatly from the consequences of abdominal aortic aneurysms. However, EVAR is not without complications. Some complications require lifelong surveillance, whereas others may necessitate immediate surgical intervention. We discuss the various modalities available for the surveillance as well as the common complications that can be seen on computed tomography.

Complications after endovascular aneurysm repair

Endovascular aneurysm repair (EVAR) has become an established technique for the treatment of many infrarenal aortic aneurysms. Although EVAR is obviously less invasive than open surgical repair, it is not free of complications. These can potentially result in severe morbidity or even mortality, stressing the need for an early detection and subsequent treatment. In this review article, the pathophysiology, diagnosis, and treatment of the most common complications of EVAR, with the exception of endoleaks, are described.

Endovascular Treatment of Proximal Bilateral Iliac Limb Dislocation and Kinking following Endovascular Abdominal Aortic Aneurysm Repair

We report the case of a 69-year-old man with a late type 1b endoleak due to proximal migration of both iliac limbs 5 years after endovascular repair of an abdominal aortic aneurysm. The endovascular method used to correct bilaterally this condition is described. Final angiographic control shows patency of the stent-graft without signs of endoleak.

Acute aortic insufficiency complicating stent treatment of supravalvular aortic stenosis: Successful release of trapped leaflets by wiring the stent

This report shows the findings observed in a 7-year-old boy patient having severe supravalvular aortic stenosis who was treated by stent implantation. Immediately after deployment, a severe acute aortic insufficiency developed due to leaflets trapped by the stent. Release was attempted percutaneously. After wiring the proximal stent, snaring the wire and pulling smoothly, the leaflets came free and valve competence was completely restored. The procedure was then successfully completed, with no residual gradient or aortic insufficiency.

A useful endovascular technique for treating modular limb disconnection in a bifurcated stent-graft

PURPOSE

To report a technique for treating a type III endoleak owing to disconnection of an iliac graft limb from a modular aortic stent-graft.

TECHNIQUE

A hydrophilic guidewire is introduced via a homolateral femoral access and passed through the thrombosed iliac extension. Once the errant graft limb is recanalized, wire exchange for an extra stiff guidewire facilitates passage of an angioplasty balloon into the stent. Inflated under low pressure, the balloon is used to push the thrombosed limb retrograde into the aneurysm sac. With the aortoiliac axis restored, a new covered stent can be deployed.

CONCLUSIONS

This approach is one of several that may be used to treat a type III endoleak arising from a disconnected and occluded stent-graft limb. It avoids the bleeding complications of thrombolysis and restores the aortoiliac axis so that another stent-graft may be implanted to re-exclude the aneurysm.