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Ulsaker H, Lam M, Herje ML, Seternes A, Manstad-Hulaas F. A Retrospective Evaluation of Intra-Prosthetic Thrombus Formation After Endovascular Aortic Repair in Cook Zenith Alpha and Medtronic Endurant II Patients. Eur J Vasc Endovasc Surg 2023; 66:644-651. [PMID: 37286099 DOI: 10.1016/j.ejvs.2023.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/25/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate the occurrence of limb graft occlusion (LGO) and intra-prosthetic thrombus (IPT) formation in Zenith Alpha and Endurant II stent graft limbs. METHODS A single centre retrospective study was conducted on patients treated with the Zenith Alpha and Endurant II stent grafts between 2017 and 2019. All post-operative computed tomography angiography images were re-investigated for thrombus formation. Demographic, aneurysm, and stent graft data were collected and compared. LGO was defined as complete occlusion or significant stenosis (≥ 50% lumen diameter reduction). Logistic regression on pro-thrombotic risk factors was conducted. Freedom from LGO and overall limb IPT were compared using Kaplan-Meier analyses. RESULTS Seventy-eight Zenith Alpha and eighty-six Endurant II patients were studied. The median follow up was 33 (IQR 25, 44) months for Zenith Alpha patients and 36 (IQR 22, 46) months for Endurant II patients (p = .53). LGO was seen in 15% (n = 12) of Zenith Alpha patients and 5% (n = 4) of Endurant II patients (p = .032), and freedom from LGO was significantly higher among Endurant II patients (p = .024). The Zenith Alpha stent graft was an independent risk factor for LGO (OR 3.9, 95% CI 1.1 - 13.4; p = .032). Among Zenith Alpha patients, limb flare compression within the main body gate was over represented in LGO patients (p = .011). There was no difference in freedom from overall limb IPT between the stent graft systems. For Endurant II limbs, IPT was significantly less common in the integrated ipsilateral limbs (without ETLW/ETEW stent graft limbs) (p = .044). Main endograft body IPT was correlated with overall limb IPT (p = .035). CONCLUSION LGO was significantly more common among Zenith Alpha than Endurant II patients. Zenith Alpha limbs was an independent risk factor for LGO. There was no difference between stent grafts in overall limb IPT formation.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St Olavs Hospital, Trondheim, Norway.
| | - Mina Lam
- Department of Vascular Surgery, St Olavs University Hospital, Trondheim, Norway
| | | | - Arne Seternes
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Vascular Surgery, St Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St Olavs Hospital, Trondheim, Norway; Department of Radiology, St Olavs University Hospital, Trondheim, Norway
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Evaluation of factors associated with limb thrombus formation after endovascular aortic aneurysm repair. J Vasc Surg 2023; 77:440-445. [PMID: 36252827 DOI: 10.1016/j.jvs.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Limb thrombus formation is a complication that can occur after endovascular aortic repair (EVAR), and its clinical significance has continued to be debated. Our objective was to report the incidence of limb thrombus after EVAR and determine the association of specific demographic, anatomic, and/or graft variables. METHODS A retrospective analysis of EVAR patients at a single tertiary center between January 2010 and December 2018 was performed to determine the limb thrombus rate. Demographic, graft, and anatomic variables were analyzed for an association with limb thrombus. RESULTS A total of 301 patients were included. The average follow-up was 27.6 ± 4.9 months. The mean age was 76.5 ± 0.5 years, and 85% were men. Limb thrombus occurred in 22 patients (7.3%). Of these 22 patients, 11 (50.0%) had had occlusive limb thrombus, 14 (63.6%) were symptomatic, and 17 (77.3%) had required intervention. The patients with limb thrombus were younger (69.8 ± 1.3 years vs 77.1 ± 0.5 years; P < .0001) and more likely to be smokers (10.2% vs 5.2%; P = .10). The incidence of limb thrombus with the Alpha graft (10.7%; Cook Medical Inc, Bloomington, IN) was compared with that with non-Cook grafts (4.0%; P = .07). The average common iliac artery diameter for patients with and without limb thrombus was 14.1 mm and 16.1 mm, respectively (P < .01). Right-sided limb thrombus was more likely in smaller right iliac arteries (14.7 ± 0.9 cm vs 17.0 ± 0.6 cm; P < .05), with a similar finding on the left (13.6 ± 0.9 cm vs 15.2 ± 0.4 cm; P = .13). Unilateral limb thrombus was almost twice as likely on the main body side than on the contralateral side (11 vs 6). Limb thrombus was not associated with aortoiliac disease (odds ratio [OR], 1.31; 95% confidence interval [CI], 0.37-4.62), limb extension (OR, 0.47; 95% CI, 0.06-3.62), or nonmatching limb heights (OR, 1.36; 95% CI, 0.54-3.43). Limb thrombus was also not associated with increased 30-day mortality (P > .05). CONCLUSIONS Limb thrombus formation is a complication that can occur after EVAR (7.3%). In our study, limb thrombus was seen more frequently in younger patients and those who smoked. Cook Alpha grafts had a thrombus formation rate of 10.7%, which was not significantly higher than that with other brands. Limb thrombus was more likely in smaller iliac arteries and on the main body side.
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Martens A, Beckmann E, Kaufeld T, Arar M, Natanov R, Fleissner F, Korte W, Krueger H, Boethig D, Haverich A, Shrestha M. Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00082-X. [PMID: 36813586 DOI: 10.1016/j.jtcvs.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 12/06/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. METHODS A total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. RESULTS The incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. CONCLUSIONS Intraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.
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Affiliation(s)
- Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
| | - Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Morsi Arar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wilhelm Korte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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In-Stent Late Thrombus in a Patient with Aortic Coarctation. Cardiol Young 2022; 32:1860-1861. [PMID: 35301968 DOI: 10.1017/s1047951122000713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 27-year-old man applied for routine control due to aortic coarctation stent. During routine control, a late in-stent thrombus was detected. The patient was asymptomatic. Thrombus resolution was achieved with anticoagulant therapy. Anticoagulant therapy is one of the options in the treatment of aortic stent graft-associated asymptomatic thrombus. Surgical intervention might be required in case of thromboembolism, haemodynamic deterioration, and intra-aortic gradient with high blood pressure in the upper extremity.
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Russell TA, Premnath S, Mogan M, Langford G, Paice B, Kirk J, Rowlands T, Kuhan G. Escalation of Antithrombotic Therapy Should Be Considered in the Presence of Intraluminal Prosthetic Graft Thrombus Following Endovascular Aneurysm Repair. EJVES Vasc Forum 2022; 56:1-5. [PMID: 35498507 PMCID: PMC9038542 DOI: 10.1016/j.ejvsvf.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/19/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Intraluminal prosthetic graft thrombus (IPT) following Endovascular Aneurysm Repair (EVAR) can have serious consequences. The aim of this study was to assess the prevalence of IPT and to identify the risk factors for its formation and progression. Methods This was a retrospective study of 258 patients who had EVAR between 2015 and 2018. Demographic data, comorbidities, operative data, antithrombotic therapy, CT anatomical data, IPT characteristics (site, regression, and progression), and re-interventions were collected. Univariable analysis followed by multivariable logistic regression and Cox regression were used for data analysis. Results The mean age of patients was 76 years (range 55-95) and 27 (10.5 %) were females. IPT was present in 26 patients (10.1%) with a median time to occurrence of six (range 1- - 24) months. Of the group that developed IPT, six (23.1 %) developed symptoms and two (7.7%) had re-interventions. Multivariable logistic regression analysis revealed peripheral arterial disease to be associated with the formation of IPT (OR 7.4, 95% CI 1.6-35.3, p = 0.02) and escalation of antithrombotic therapy was associated with regression or prevention of progression of IPT (OR 0.1, 95% CI 0.0-0.6, p = 0.01). Conclusion PAD is associated with the formation of IPT after EVAR and warrants consideration of escalation of antithrombotic therapy to prevent further progression and complications.
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Affiliation(s)
- Terri-Ann Russell
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Sivaram Premnath
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Meera Mogan
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Grace Langford
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Bronte Paice
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - James Kirk
- Department of Radiology, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Timothy Rowlands
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Ganesh Kuhan
- Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
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Jhajj S, Kar R, Teruya TH, Patel ST. Repair of a high-flow superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis. J Vasc Surg Cases Innov Tech 2022; 8:98-101. [PMID: 35146218 PMCID: PMC8818908 DOI: 10.1016/j.jvscit.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
A 50-year-old patient had presented with recalcitrant right lower extremity venous stasis ulceration, atrial fibrillation, and congestive heart failure. He had a history of a gunshot wound to the right thigh >30 years previously, which had been managed without surgery. Computed tomography angiography indicated a fistulous communication between the right superficial femoral artery and vein with massively dilated right iliofemoral venous and arterial systems. He was treated with stent-graft coverage of the superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis. This stent-graft accommodated the diameter asymmetry in the superficial femoral artery caused by the long-standing fistula and ameliorated the symptoms that had afflicted him for decades.
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Affiliation(s)
| | | | | | - Sheela T. Patel
- Correspondence: Sheela T. Patel, MD, Division of Vascular Surgery, Loma Linda University, 11175 Campus St, Ste 21123, Loma Linda, CA 92350
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Han X, Liu G, Li T, Guo X. Application of the AngioJet Ultra Thrombectomy Device for the Percutaneous Mechanical Treatment (PMT) of Iliac Limb Occlusion after Endovascular Aneurysm Repair (EVAR). Ann Vasc Surg 2021; 78:161-169. [PMID: 34474132 DOI: 10.1016/j.avsg.2021.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 06/12/2021] [Accepted: 06/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND To investigate the safety and efficacy of applying the AngioJet Ultra thrombectomy device in treating endograft occlusions in the iliac arteries following endovascular aneurysm repair (EVAR). METHODS This study utilized a retrospective analysis of 452 patients with infrarenal abdominal aortic aneurysm (AAA). Twelve of the patients experienced iliac limb occlusion during their follow-up period, and the AngioJet Ultra thrombectomy device was used in tandem with iliac angioplasty to treat these patients. The safety of the device was assessed through the amount of blood drawn, the duration of the procedure, and the occurrence of post-operative complications, while its efficacy was assessed through aortic computed tomography angiography (CTA) imaging and post-operative symptomatology results. RESULTS All 12 patients were male, and they had a mean age of 62.8 ± 11.8 years. Iliac limb occlusion occurred on the left side of 4 patients and on the right side of 8 patients. The AngioJet Ultra thrombectomy device was used together with iliac angioplasty during surgery, with a success rate of 100%. A bifurcated endograft was successfully implanted in 9 patients following AngioJet Ultra thrombectomy and balloon dilation angioplasty, while a unibody endograft was successfully implanted in 3 patients following AngioJet Ultra thrombectomy and balloon dilation angioplasty. The mean surgery duration was 2.4 hrs, and the patients were hospitalized for an average of 4.5 days. After surgery, the patients' intermittent claudication/buttock claudication gradually vanished. Two patients experienced hemoglobinuria, with one of them developing mild renal dysfunction. Currently, the twelve patients have been followed up for an average of 12 months, and none have experienced any lower extremity ischemia. CONCLUSIONS The use of the AngioJet Ultra thrombectomy device as a supplementary treatment for iliac limb occlusion following abdominal EVAR is safe, effective, and minimally invasive.
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Affiliation(s)
- Xiaofeng Han
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guangrui Liu
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tiezheng Li
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xi Guo
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Kuo MC, Meena RA, Ramos CR, Benarroch-Gampel J, Leshnower BG, Duwayri Y, Jordan WD, Rajani RR. Female gender is associated with increased late luminal narrowing within the stent graft after thoracic endovascular aortic repair. J Vasc Surg 2021; 75:67-73. [PMID: 34450242 DOI: 10.1016/j.jvs.2021.07.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Luminal narrowing, suspected secondary to thrombus, occurs within stent grafts at an unclear incidence after thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft luminal narrowing. Small graft diameter is hypothesized to be a risk factor for the development of ingraft stenosis. METHODS A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of subsequently available surveillance contrast-enhanced computed tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft luminal narrowing. RESULTS There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual rate of percent intragraft diameter reduction was 10.5 ± 7.7% for women and 7.6 ± 5.6% for men (P = .0026). Multivariate analysis demonstrated female gender (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be associated independently with ingraft luminal narrowing nor was the concomitant use of antiplatelet or anticoagulation medications. Significant amounts of ingraft luminal narrowing, defined as a greater than 20% intragraft diameter decrease, were associated with an increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimates demonstrated a significant gender-associated difference in high rates of intragraft luminal narrowing (P = .00189). CONCLUSIONS In this analysis, female gender is shown to be a significant nonmodifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with an increased need for reintervention. This finding may be attributable to differences in aortic compliance or gender-associated differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting must account for patient-specific variations in complication risk.
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Affiliation(s)
| | - R Anthony Meena
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Christopher R Ramos
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jaime Benarroch-Gampel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Ravi R Rajani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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Updated outcomes from the TRANSFIX study to evaluate endovascular repair of blunt thoracic aortic injuries with the Zenith Alpha thoracic device. J Vasc Surg 2020; 71:1851-1857. [DOI: 10.1016/j.jvs.2019.05.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 05/03/2019] [Indexed: 11/23/2022]
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11
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Bianchini Massoni C, Ucci A, Perini P, Azzarone M, Mariani E, Bramucci A, D'Ospina RM, Freyrie A. Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:729-737. [PMID: 32241093 DOI: 10.23736/s0021-9509.20.11267-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim was to define the prevalence, the evolution and the clinical relevance of the intraprosthetic thrombus deposit (IPT) after endovascular abdominal aortic repair (EVAR). METHODS Patients treated with EVAR from 2009 to 2017 for abdominal aortic aneurysm were retrospectively considered. Patients with at least one postoperative computed tomography angiography (CTA) performed after a 3-month follow-up were included. Postoperative medical therapy (antiplatelet and/or oral anticoagulant) were recorded. Aorto-iliac anatomical characteristics were measured on pre-operative CTA, while structural and dimensional endograft features were extracted from instructions for use. IPT was defined as intra-endograft thrombus with minimum thickness of 2mm and longitudinally extended for minimum 4 mm, and was assessed in all postoperative CTA. Primary endpoints were freedom from IPT occurrence, risk factors for IPT and evolution of IPT. Secondary endpoints were the prevalence of overall and IPT-related tromboembolic events (TEE: main-body or limb occlusion, distal embolization) during follow-up and its correlation with IPT. RESULTS Two-hundred twenty-one patients (mean age 76±7 years; male 94%) were included. Deployed endografts were: aorto-biiliac 96%, aorto-uniiliac 3%, aortic tube 1%; dacron 90%, ePTFE 10%. Mean follow-up was 30±25 months. Overall IPT prevalence was 36% (80/221). At 6, 12, 24 and 48 months, overall estimated freedom from IPT occurrence was 86%, 80%, 60% and 52%, respectively (Kaplan-Meier analysis). At Cox uni-variate analysis, postoperative medical therapy has no influence on IPT; aorto-iliac anatomical risk factors for IPT were larger neck diameter (P<0.001), severe neck thrombus (P=0.043), higher percentage of sac thrombus (P<0.001), hypogastric occlusion/coverage (P=0.040); endograft risk factors were proximal diameter ≥30mm (P<0.001), longer main body (P=0.002), dacron fabric (P=0.025), higher ratio between main body area/gate areas and main body area/distal iliac areas (P<0.001 and P<0.001, respectively). At Cox multi-variate analysis, independent risk factors for IPT were larger neck diameter (P=0.003), higher percentage of sac thrombus (P=0.005) and longer main body (P=0.028). During follow-up, IPT disappeared in 14 cases (18%). Overall TEE prevalence was 4% (8/221) and overall estimated freedom from TEE occurrence at 6, 12, 24 and 48 months was 99%, 99%, 95.3%, 94.1%, respectively (Kaplan-Meier analysis). TEE was IPT-related in 5/8 cases (63%). No statistical correlation were found between IPT and TEE. CONCLUSIONS The development of intraprosthetic graft thrombus (IPT) is a frequent event after EVAR. The risk of IPT is closely correlated with the proximal aortic neck size, the presence of intra-aneurysmal sac thrombus, and the length of the endograft main body. However, there was no statistical correlation between the presence of IPT and TEE.
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Affiliation(s)
- Claudio Bianchini Massoni
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy -
| | - Alessandro Ucci
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Paolo Perini
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Matteo Azzarone
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Erica Mariani
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alberto Bramucci
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Rita M D'Ospina
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Antonio Freyrie
- Section of Vascular Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
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Coelho A, Nogueira C, Lobo M, Gouveia R, Campos J, Augusto R, Coelho N, Semião AC, Ribeiro JP, Canedo A. Impact of Post-EVAR Graft Limb Kinking in EVAR Limb Occlusion: Aetiology, Early Diagnosis, and Management. Eur J Vasc Endovasc Surg 2019; 58:681-689. [DOI: 10.1016/j.ejvs.2019.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/26/2022]
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Raptis A, Xenos M, Spanos K, Kouvelos G, Giannoukas A, Matsagkas M. Endograft Specific Haemodynamics After Endovascular Aneurysm Repair: Flow Characteristics of Four Stent Graft Systems. Eur J Vasc Endovasc Surg 2019; 58:538-547. [PMID: 31431336 DOI: 10.1016/j.ejvs.2019.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/09/2018] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The implication of haemodynamics in the occurrence of complications after endovascular aneurysm repair (EVAR) has been raised in the literature. Different aortic stent graft configurations may lead to different haemodynamic properties. The current study deals with the post-operative haemodynamic variability between four stent graft systems with different structure, material, and type of fixation. METHODS Computed tomography data of 32 patients were used, equally distributed among the four endograft groups, namely the AFX, Endurant, Excluder, and Nellix. Velocity, wall shear stress (WSS), and helicity statistics were calculated, in regions around the flow division where disturbances are expected. The haemodynamic data were compared between and within the groups. RESULTS The morphology of AAAs pre-operatively did not vary significantly among the four groups. Before the flow division, lowest velocity was observed in Endurant cases and highest in Nellix cases. Endurant induced the lowest peak WSS and Nellix the highest (p = .03). The helicity levels were low in AFX and Nellix cases and high in Endurant and Excluder cases. After the flow division, the trend in the results was preserved. Nellix induced the highest velocity and WSS, followed closely by Excluder and AFX. There was a significant increase of helicity before and after flow division in AFX (p <0.001, R2 = 0.09) and Nellix (p <0.001) cases. CONCLUSIONS It has been shown that different types of endografts induce variable haemodynamic conditions around the flow division. The parallel limb structure, featured by Nellix, seems to induce favourable flow conditions in terms of velocity and WSS, while helical flow before the flow division is suppressed. High WSS is generally considered to be a desirable flow characteristic in endovascular devices, whereas helicity extremes (very low or high) are potentially a negative sign. Endurant, with the stiffer material and the short neck structure, was associated with the lowest blood velocity and WSS values but preserved high helicity levels. The AFX and Excluder, which include the same material, induced similar haemodynamic conditions.
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Affiliation(s)
- Anastasios Raptis
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece
| | - Michalis Xenos
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece; Department of Mathematics, University of Ioannina, Ioannina, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece; Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece; Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
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Perini P, Bianchini Massoni C, Azzarone M, Ucci A, Rossi G, Gallitto E, Freyrie A. Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis. Ann Vasc Surg 2018; 53:234-242. [PMID: 30012445 DOI: 10.1016/j.avsg.2018.04.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/12/2018] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TEs; endograft or limb thrombosis, or distal embolization) after EVAR. METHODS A systematic review of English literature was undertaken until November 2017. Studies providing 2-group comparison (patients with IPT development on postoperative computed tomography angiography versus patients without IPT) with extractable outcome data (TE related to IPT and/or risk factors for IPT development) were included. Meta-analysis was performed when comparative data were given in 2 or more articles. RESULTS Five single-center studies (808 patients) were analyzed. IPT detection at any time during follow-up occurred in 20.8% (168/808) of patients. Extractable data for postoperative TE were available in 4 studies (613 patients): on comparative meta-analysis, IPT was not significantly associated with TE occurrence during follow-up (odds ratio 2.25, 95% confidence interval [CI] 0.50-10.1; P = 0.29). IPT is generally detected during the first year after EVAR (maximum reported median: 12 months, range: 1.2-23). Polyester graft material (odds ratio 2.34, 95% CI 1.53-3.58; P < 0.001) and aorto-uni-iliac configuration of the endograft (odds ratio 3.27, 95% CI 1.66-6.44; P = 0.001) were confirmed as risk factors for IPT formation on meta-analysis. The literature systematic review suggests that IPT formation may be also associated with long main bodies and large necks. CONCLUSIONS IPT detection on postoperative computed tomography angiography was not significantly associated with the occurrence of TE over time. The aorto-uni-iliac configuration and the use of polyester fabric for endografts were confirmed as risk factors for IPT development.
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Affiliation(s)
- Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | | | - Matteo Azzarone
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alessandro Ucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giulia Rossi
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Enrico Gallitto
- Vascular Surgery Unit, Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Tasso P, Raptis A, Matsagkas M, Lodi Rizzini M, Gallo D, Xenos M, Morbiducci U. Abdominal aortic aneurysm endovascular repair: profiling post-implantation morphometry and hemodynamics with image-based computational fluid dynamics. J Biomech Eng 2018; 140:2682796. [PMID: 30029263 DOI: 10.1115/1.4040337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Indexed: 11/08/2022]
Abstract
Endovascular aneurysm repair (EVAR) has disseminated rapidly as an alternative to open surgical repair for the treatment of abdominal aortic aneurysms (AAAs), because of its reduced invasiveness, low mortality and morbidity rate. The effectiveness of the endovascular devices used in EVAR is always at question as postoperative adverse events can lead to re-intervention or to a possible fatal scenario for the circulatory system. Motivated by the assessment of the risks related to thrombus formation, here the impact of two different commercial endovascular grafts on local hemodynamics is explored through 20 image-based computational hemodynamic models of EVAR-treated patients (N=10 per each endograft model). Hemodynamic features, susceptible to promote thrombus formation, such as flow separation and recirculation, are quantitatively assessed and compared with the local hemodynamics established in image-based infrarenal abdominal aortic models of healthy subjects (N=10). The hemodynamic analysis is complemented by a geometrical characterization of the EVAR-induced reshaping of the infrarenal abdominal aortic vascular region. The findings of this study indicate that: (1) the clinically observed propensity to thrombus formation in devices used in EVAR strategies can be explained in terms of local hemodynamics by means of image-based computational hemodynamics approach; (2) reportedly pro-thrombotic hemodynamic structures are strongly correlated with the geometry of the aortoiliac tract postoperatively. In perspective, our study suggests that future clinical follow up studies could include a geometric analysis of the region of the implant, monitoring shape variations that can lead to hemodynamic disturbances of clinical significance.
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Affiliation(s)
- Paola Tasso
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Anastasios Raptis
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Ioannina 45500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, Larissa 41334, Greece
| | - Maurizio Lodi Rizzini
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Diego Gallo
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Michalis Xenos
- Department of Mathematics, University of Ioannina, Ioannina 45500, Greece
| | - Umberto Morbiducci
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
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Sun Z, Ng CKC. Use of Synchrotron Radiation to Accurately Assess Cross-Sectional Area Reduction of the Aortic Branch Ostia Caused by Suprarenal Stent Wires. J Endovasc Ther 2017; 24:870-879. [PMID: 28922970 DOI: 10.1177/1526602817732315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare in vivo the use of synchrotron radiation to computed tomography angiography (CTA) for the measurement of cross-sectional area (CSA) reduction of the aortic branch ostia caused by suprarenal stent-graft wires. METHODS This study was performed with a Zenith stent-graft placed in a phantom of the human aorta to simulate treatment of abdominal aortic aneurysm. Synchrotron radiation scans were performed using beam energies between 40 and 100 keV and spatial resolution of 19.88 μm per pixel. CSA reduction of the aortic branch ostia by suprarenal stent wires was calculated based on these exposure factors and compared with measurements from CTA images acquired on a 64-row scanner with slice thicknesses of 1.0, 1.5, and 2.0 mm. RESULTS Images acquired with synchrotron radiation showed <10% of the CSA occupied by stent wires when a single wire crossed a renal artery ostium and <20% for 2 wires crossing a renovisceral branch ostium. The corresponding areas ranged from 24% to 25% for a single wire and from 40% to 48% for double wires crossing the branch ostia when measured on CT images. The stent wire was accurately assessed on synchrotron radiation with a diameter between 0.38±0.01 and 0.53±0.03 mm, which is close to the actual size of 0.47±0.01 mm. The wire diameter measured on CT images was greatly overestimated (1.15±0.01 to 1.57±0.02 mm). CONCLUSION CTA has inferior spatial resolution that hinders accurate assessment of CSA reduction. This experiment demonstrated the superiority of synchrotron radiation over CTA for more accurate assessment of aortic stent wires and CSA reduction of the aortic branch ostia.
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Affiliation(s)
- Zhonghua Sun
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
| | - Curtise K C Ng
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
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A new approach for the pre-clinical optimization of a spatial configuration of bifurcated endovascular prosthesis placed in abdominal aortic aneurysms. PLoS One 2017; 12:e0182717. [PMID: 28793343 PMCID: PMC5549977 DOI: 10.1371/journal.pone.0182717] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 07/24/2017] [Indexed: 11/19/2022] Open
Abstract
Complexity of the spatial configuration of an aortic implant with bifurcation in the distal part is related to changes in blood hemodynamic in the area of bifurcation which may disturb blood flow and lead to thrombus formation. This study was designed to characterize parameters which define spatial configuration of an aortic implant for which the risk of thrombus formation is the smallest. We used AngioCT data from 74 patients, aged 55 ±10 years, after endovascular procedure to prepare 3D geometries of stent-grafts. Computational Fluid Dynamics (CFD) simulations were used to reconstruct blood hemodynamic and simulate thrombus formation. Next, geometric parameters of stent-grafts included the ratio of volume of upper part to the bifurcations, the relation of inlet and outlet diameters of a stent-graft and deformations in the iliac part of the stent-graft were analyzed. We also analyzed tortuosities (spiral twisting of the flow around the flow direction) and bends (the largest angulation in distal part of a stent-graft). The CFD results were confronted with AngioCT data to verify if computer generated thrombus appeared in particular patient. Additionally, geometric parameters of analyzed stent-grafts were used to propose a mathematical tool for prediction of thrombus appearance. The results showed that tortuosities and bends of a stent-graft had the highest impact on thrombus formation. Formation of thrombi was observed in 22% to 31% of cases (at blood hematocrit Hct = 40%) even for small values of tortuosities and bends indicating that these parameters are dominant in determining blood clotting. Our calculated results overlapped with clinical data in 80% to 91%. Therefore, we conclude that tortuosities and bends have high impact on thrombus formation and should be under special attention during stent-graft recommendation and patients’ follow-ups.
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Stefanov F, McGloughlin T, Morris L. A computational assessment of the hemodynamic effects of crossed and non-crossed bifurcated stent-graft devices for the treatment of abdominal aortic aneurysms. Med Eng Phys 2016; 38:1458-1473. [PMID: 27773830 DOI: 10.1016/j.medengphy.2016.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 08/22/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
There are several issues attributed with abdominal aortic aneurysm endovascular repair. The positioning of bifurcated stent-grafts (SG) may affect SG hemodynamics. The hemodynamics and geometrical parameters of crossing or non-crossing graft limbs have not being totally accessed. Eight patient-specific SG devices and four pre-operative cases were computationally simulated, assessing the hemodynamic and geometrical effects for crossed (n= 4) and non-crossed (n= 4) configurations. SGs eliminated the occurrence of significant recirculations within the sac prior treatment. Dean's number predicted secondary flow locations with the greatest recirculations occurring at the outlets especially during the deceleration phase. Peak drag force varied from 3.9 to 8.7N, with greatest contribution occurring along the axial and anterior/posterior directions. Average resultant drag force was 20% smaller for the crossed configurations. Maximum drag force orientation varied from 1.4° to 51°. Drag force angle varied from 1° to 5° during one cardiac cycle. 44% to 62% of the resultant force acted along the proximal centerline where SG migration is most likely to occur. The clinician's decision for SG positioning may be a critical parameter, and should be considered prior to surgery. All crossed SG devices had an increased spiral flow effect along the distal legs with reductions in drag forces.
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Affiliation(s)
- Florian Stefanov
- Galway Medical Technologies Centre, Department of Mechanical and Industrial Engineering, Galway Mayo Institute of Technology, Galway, Ireland
| | - Tim McGloughlin
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Liam Morris
- Galway Medical Technologies Centre, Department of Mechanical and Industrial Engineering, Galway Mayo Institute of Technology, Galway, Ireland.
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Chuter TAM, Pak LK, Gordon RL, Reilly LM, Messina LM. Heparin-Induced Thrombocytopenia and Graft Thrombosis following Endovascular Aneurysm Repair. J Endovasc Ther 2016; 10:1087-90. [PMID: 14723565 DOI: 10.1177/152660280301000610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To report a case of heparin-induced thrombocytopenia (HIT) complicated by stent-graft thrombosis. Case Report: An 82-year-old woman underwent endovascular aortic aneurysm repair using a Zenith stent-graft. She returned 2 weeks later with an occluded graft limb, large quantities of thrombus lining the remainder of the stent-graft, thrombocytopenia, and antiplatelet antibodies. There were no signs of kinking or compression of the graft, nor was there any thrombosis of the native arteries downstream from the occluded graft limb. Thrombolysis restored graft patency. Anticoagulation was induced using hirudin and warfarin. The graft remains patent at 6-month follow-up. Conclusion: HIT is a rare cause of postoperative endograft thrombosis. In this case, the presumed source of the inciting heparin dosage was the stent-graft itself, which had been soaked in a concentrated heparin solution prior to insertion.
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Affiliation(s)
- Timothy A M Chuter
- Division of Vascular Surgery, University of California, San Francisco, California 94143, USA.
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Concepción Rodríguez N, Fernández Heredero Á, Paluso Montero A, Alvarez García J, Rojas Esquivel D, Riera de Cubas L. Incidencia y evolución del trombo intraprótesis tras reparación endovascular de aneurismas aortoilíacos infrarrenales. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Oliveira N, Hoeks S, Ten Raa S, Ultee K, Rouwet E, Hendriks J, Verhagen H, Bastos Gonçalves F. Trombo intraprotésico após tratamento endovascular de aneurismas da aorta. ANGIOLOGIA E CIRURGIA VASCULAR 2015. [DOI: 10.1016/j.ancv.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Oliveira N, Verhagen H. Should I Treat Asymptomatic Thrombus Lining an EVAR Stent Graft Limb Detected During Surveillance Imaging and, if so, How? Eur J Vasc Endovasc Surg 2015; 50:122. [DOI: 10.1016/j.ejvs.2015.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/28/2015] [Indexed: 11/16/2022]
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Oliveira NF, Bastos Gonçalves FM, Hoeks SE, Ten Raa S, Ultee KH, Rouwet E, Hendriks JM, Verhagen HJ. Clinical outcome and morphologic determinants of mural thrombus in abdominal aortic endografts. J Vasc Surg 2015; 61:1391-8. [DOI: 10.1016/j.jvs.2015.01.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/18/2015] [Indexed: 11/29/2022]
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Studying the Flow Dynamics in an Aortic Endograft with Crossed-limbs. Int J Artif Organs 2014; 37:81-7. [DOI: 10.5301/ijao.5000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2013] [Indexed: 11/20/2022]
Abstract
Purpose To evaluate the flow phenomena within an aortic endograft with crossed-limbs, comparing to an endograft with the ordinary limb bifurcation. Methods An endograft model with crossed-limbs was computationally reconstructed based on Computed Tomography patient-specific data, using commercially available software. Accordingly, its analogue model was reconstructed in the ordinary fashion (ordinary bifurcation). Computational fluid dynamics analysis was performed to determine and compare the flow fields, velocity profiles, pressure and shear stress distribution throughout the different parts of both endograft configurations, in different phases of the cardiac cycle. Results The flow patterns between the “Ballerina” and the classic endograft were similar, with flow disturbance near the inlet zone at late diastole and smooth flow patterns during the systolic phase. Both configurations presented similar pressure distribution patterns throughout the cardiac cycle. The highest and lowest pressures were demonstrated in the inlet-main body area and the iliac limbs, respectively. Marked differences were observed in the velocity profiles of the proximal limb segments between the two configurations, mostly in the peak- and end-systolic phase. The regions of lower velocities correlated well to low shear values. Differences in the shear stress distribution were noted between the two configurations in the systolic and, predominantly, in the diastolic phase. Conclusions There are differences in the velocity profiles and shear distribution between the limbs of the two endograft configurations. The pathophysiologic implication of our findings and their possible association with clinical events, such as thrombus apposition, deserves further investigation.
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Incidence and treatment results of Endurant endograft occlusion. J Vasc Surg 2013; 57:1246-54; discussion 1254. [DOI: 10.1016/j.jvs.2012.11.069] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 11/16/2012] [Accepted: 11/16/2012] [Indexed: 11/17/2022]
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Katsargyris A, Chatziioannou A, Lioudaki S, Papapetrou A, Klonaris C. Late renal artery occlusion following endovascular repair of abdominal aortic aneurysm: a possible complication of mural thrombus formation within aortic endografts. Vascular 2013; 22:209-13. [PMID: 23508389 DOI: 10.1177/1708538113479515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mural thrombus formation within aortic endoprostheses has been described to occur in up to one-third of aortic endografts depending on the device type. Data regarding the clinical significance of such a phenomenon are scarce, but in most cases it is considered to be clinically innocent. The authors describe a rare case of late renal artery occlusion due to intraprosthetic thrombus formation and extension into the right renal orifice 30 months after endovascular abdominal aortic aneurysm repair. Additionally, a brief literature review regarding the incidence and natural history of mural thrombotic deposits within aortic endografts is also conducted.
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The Significance of Endograft Geometry on the Incidence of Intraprosthetic Thrombus Deposits after Abdominal Endovascular Grafting. Eur J Vasc Endovasc Surg 2009; 38:741-7. [DOI: 10.1016/j.ejvs.2009.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 09/07/2009] [Indexed: 11/23/2022]
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Chong CK, How TV, Harris PL. Flow Visualization in a Model of a Bifurcated Stent-Graft. J Endovasc Ther 2005; 12:435-45. [PMID: 16048375 DOI: 10.1583/04-1465.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To use an in vitro flow model to investigate the flow patterns in a bifurcated stent-graft for abdominal aortic aneurysm (AAA) repair. METHODS Experiments were performed in an in vitro test rig incorporating a simplified non-planar model of an AAA. A two-component bifurcated device consisting of a stent structure and transparent polyurethane "graft" was deployed in the AAA model. Using a blood analogue fluid, a pulsatile blood flow waveform simulating resting flow condition was produced by means of a piston pump system. Flow patterns in the lateral and anteroposterior planes of the stent-graft were recorded and analyzed using flow visualization techniques. RESULTS The flow patterns within the stent-graft were complex and influenced by the geometry of the stent-graft itself, as well as that of the aortic neck and iliac vessels. Regions of flow separation, low velocity and stagnation, and slow oscillatory flow near the walls were seen in the main body of the stent-graft. Constriction at the stump in the contralateral limb resulted in flow disturbances and flow separation. Kinking at the junctions of stent segments and folding of the graft compounded these complex flow structures. CONCLUSIONS The flow structures within stent-grafts are complex, with features that may predispose to thrombus formation. Arterial geometry, including aortic neck angulation and iliac vessel tortuosity, and the design of the stent-graft are factors that influence hemodynamics and may impact the performance of aortic stent-grafts.
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Affiliation(s)
- Chuh K Chong
- School of Clinical Sciences, University of Liverpool, UK
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Taketani T, Morota T, Shibata K, Kotsuka Y, Takamoto S. Thrombus originating from frayed distal edge of an aortic stent-graft. ACTA ACUST UNITED AC 2004; 52:95-7. [PMID: 14997982 DOI: 10.1007/s11748-004-0094-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
An 87-year-old woman who had undergone a stent-graft repair of a descending aortic aneurysm had additional stent-graft implantation for endoleak. The postoperative course was eventful reflecting her preexisting multiple organ disorder, and despite intensive treatment over a span of 2 months, she died of disseminated intravascular coagulation due to intestinal ischemia. Autopsy revealed a thrombus originating from the frayed distal edge of the graft. Although the relation between intestinal ischemia and the thrombus remains to be proven, this is considered a vital finding.
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Affiliation(s)
- Tsuyoshi Taketani
- Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan
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