Cinical outcomes of Endurant II stent-graft for infrarenal aortic aneurysm repair: comparison of on-label versus off-label use

Nonspecific Presentation of an Infected Aorto-Iliac Artery Stent Following Endovascular Revision and Stent Insertion

Over the last few decades, the use of covered stent grafts became increasingly popular; as it plays a pivotal role in the management of various atherosclerotic diseases that are rising in both incidence and prevalence. Subsequently, vascular stent infections, although rare, are becoming a well-recognized complication with possibly devastating consequences, owing to the difficulties associated with its diagnosis and treatment. This has prompted significant interest in the condition regarding its pathophysiology, modifiable and non-modifiable risk factors, diagnostic and therapeutic approaches, and the possible implementation of prophylactic measures. We herein present a case of a patient with an infected aortoiliac stent 4 weeks after endovascular revision with atherectomy and additional stent insertion. The patient initially developed nonspecific symptoms and later developed a life-threatening hemorrhage, which was urgently controlled using a percutaneously inserted covered stent at the infected site. Definitive treatment using extraanatomical bypass implantation and an explantation of the infected stents was performed with excellent clinical response.

Trans-limb embolization for treatment of Type 2 endoleak post EVAR: Case report

Introduction

Type 2 endoleaks (T2EL) occur after 10%–25% of endovascular abdominal aortic aneurysm repairs and increase the risk factor of endograft repair failure and rupture. Herein we report a case of endovascular treatment of T2EL where we performed a trans-limb embolization.

Presentation of case

A 63-years-old male previously treated for AAA with endovascular aortic aneurysms repair (EVAR), showed an angio-CT scan followup with a type 2 endoleak fed from inferior mesenteric artery (AMI) with growth of AAA greater of 1 cm than preoperative CT-scan and increase of chronic lumbar pain. Due to high risk of rupture was performed a trans-limb embolization with complete sealing. The 6 months CT-angiography showed complete type 2 endoleak exclusion without changes of AAA.

Discussion

The risk of aneurysm rupture in the presence of an isolated T2EL is exceptionally low. However, when a persistent T2EL is associated with a significant sac size increase, commonly considered as at least 5 mm over 6 months, should be treated. Detachable coils are repositionable, allowing an extremely precise deployment and subsequent embolization of different targets.

Conclusion

In this experience trans-limb embolization was feasible and this tool should be taken in account especially when no other surgical options exists.

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Type 2 endoleaks (T2EL) are a risk factor for endograft repair failure and rupture.

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T2EL are the most common endoleaks and remain the main cause of repeat intervention.

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Trans-limb embolization is an innovative technique for T2EL without standard access.

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Concerto are detachable coils repositionable allowing an extreme precise deployment.

Transcervical approach for carotid artery stenting with transitory reversal flow: Case report

Introduction

Carotid artery stenting (CAS) has been indicated as an alternative to carotid endarterectomy in high risk patients. Sometimes, an aortic arch can be anatomically unfavourable for CAS. Herein we report our experience in a case of CAS with transcervical approach.

Presentation of case

A 77-year-old male was referred to our hospital for severe subtotal occlusion of the left internal carotid artery. He had a past medical history of radiation to the head and neck for laryngeal cancer. Previous CT-angiography had shown a type III aortic with bovine arch. CAS via transcervical approach was performed with transitory reversal flow during the placement of RX Spider Filter 6 Fr (Medtronic, Minneapolis, MN). After release of 7 × 30 mm RX Xact carotid stent (Abbott Vascular, Chicago, IL) and ballooning with a 5.5 × 30 mm Rx Submarine balloon catheter (Medtronic Minneapolis, MN), angiography check showed a good result.

Discussion

The transcervical approach is an innovative technique where usually a shunt is created, either between the common carotid artery and the internal jugular vein or between the common carotid artery and the common femoral vein. This flow reversal reduces the risk of periprocedural embolic events. In our experience a short proximal clamping with transitory reversal flow, reduces the invasiveness of procedure with good outcomes.

Conclusion

Transcervical carotid access with transitory reversal flow is a valid alternative in complicated patient with anatomy unfit for CAS.

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Carotid stenting can be an alternative to endarterectomy in high risk patients.

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Aortic arch can be anatomically unfavourable for Carotid artery stenting.

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Transcervical approach is a technique suited to patients unfit for stenting.

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Transcervical access with transitory reversal flow is useful in complicated patient.

Iliac-femoral stent-graft infection after hybrid procedure redo: Case report

Introduction

Stent-graft infection in peripheral arteries is rare and potentially dangerous. The use of hybrid procedures, in complicated patients previously treated, involves an increase of infective risk especially in no collaborative patients.

Presentation of case

We report a case of rare stent-graft infection in a patient treated for a Rutherford IV Multiple Peripheral Arterial Disease (MPAD) involving the right iliac-femoral axis with stenosis on deep femoral artery due to a previously stenting procedure for Superficial Femoral artery (SFA) stenosis. The first simultaneous hybrid intervention consisted of an endovascular iliac stent-graft placement and a surgical common femoral patch angioplasty. After two months the patient was readmitted to our unit for a purulent secretion through a fistulous channel and a suspect infection of stent-graft. Subsequently, the stent-graft was completely removed without possibility to have a surgical revascularization. An amputation major amputation was needed for irreversible ischemia of right leg.

Discussion

The incidence of stent-graft infection after endovascular aortic aneurysm repair had been reported as 0.4–1.0% while Aortoiliac graft infection occurs in 2–6% of patients. Hybrid procedures are secure and need close follow-up for cases of redo and patient with comorbidities.

Conclusions

Graft infection is a rare complication after endovascular treatments. Hybrid procedures outcomes are good with less morbidity but in patient with high risk of infection is important a close follow-up.

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Stent-graft infection in peripheral arteries is rare and potentially dangerous.

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Stent-graft infection after angioplasty Aortoiliac occurs in 2–6% of patients.

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Hybrid procedures are useful, patients high risk for infection need a close followup.

Type 1A endoleak detachable coil embolization after endovascular aneurysm sealing: Case report

INTRODUCTION

Endovascular aneurysm sealing (EVAS) with the Nellix system was introduced to reduce endovascular aneurysm repair (EVAR) perioperative complications, especially endoleaks. Herein we report a case of successful type 1A endoleak managed with detachable coils embolization after EVAS.

PRESENTATION OF CASE

A 77-year-old male was referred for abdominal pain. The angio-CT scan confirmed the previous EVAS procedure and showed a type Is2 endoleak below the right renal artery resulting in a 2.5 cm aortic blister with contrast medium filling the space between the aortic wall and the endobags. The patient was considered unfit for conventional open surgery and an endovascular approach with coil embolization Concerto Helix Detachable Coil System was chosen under local anesthesia. After intervention, a complete abdominal pain regression was registered. The 12- month CT follow-up showed endoleak sealing and Nellix system stability.

DISCUSSION

EVAS has been associated to a high endoleaks and complications incidence when compared to EVAR. The EVAS different device concept led to a different endoleak classification and management. Endoleak management main options include the Nellix system explantation or the Nellix in Nellix application, however these are nearly always not applicable, respectively, due to the high surgical risk condition and the Nellix system availability, especially in emergent setting. Despite the use of coil embolization is controversial, this tool is off-the-shelf and leads to a disease resolution in most of patients without other surgical options.

CONCLUSION

Proximal type Is2 embolization after EVAS is feasible with limited invasiveness.

Simultaneous endovascular treatment of synchronous symptomatic acute type B aortic dissection and large infrarenal aortic aneurysm. Technical tips and case report

INTRODUCTION

Data from the literature suggest that in patients with acute type B aortic dissection (ATBAD), associated with AAA, rupture risk is higher at the confluence tract than isolated lessions. Herein, we report a case of ATBAD and AAA managed with simultaneous intervention.

CASE PRESENTATION

We report a complicated case of a symptomatic patient presenting with a type B aortic dissection and false lumen extension into superior mesenteric artery (SMA) with an infrarenal abdominal aortic aneurysm (AAA). Severe back pain and hypertension were the patient's initial complaints. This patient underwent endovascular repair with a thoracic and infrarenal aortic endograft.

DISCUSSION

AAA rupture has been detected at admission in three-fourths of patients with ATBAD that extended to or involved a coexisting unoperated atherosclerotic aneurysms. Prompt surgical intervention is essential to deal with this dreadful aortic emergency.

CONCLUSION

In our experience a totally endovascular solution to treat a complicated ATBAD plus AAA was a rapid solution with low invasivity, no complication and complete healing of patients.