Patient-Specific Rehearsal Feasibility Before Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To evaluate the feasibility of a patient-specific rehearsal (PsR) before emergency endovascular aneurysm repairs (eEVAR) and its influence on the operation. Materials and Methods: From February 2016 to October 2016, 10 consecutive patients (mean age 75±7.4 years; 9 men) presenting with a ruptured abdominal aortic aneurysm (rAAA) suitable for standard EVAR were enrolled in the study. A 3-dimensional (3D) model of the abdominal aorta was generated on a virtual reality simulator based on the patient’s computed tomography (CT) images. Following the patient-specific simulation setup, PsR was conducted during patient admission or in parallel with the preoperative eEVAR workup. Measured outcomes were PsR feasibility only in the first 4 patients and impact on operative performance thereafter (changes in device selection, the planning process, clinical outcomes, perioperative mortality, and complication rates). Technical metrics and timing of system setup, rehearsal, interval from patient arrival to the actual procedure, and eEVAR were recorded. Results: Mean time for 3D model creation was 21.3±7.8 minutes (range 13–37); there was a significant positive relationship between aortic neck diameter and segmentation time (p=0.003). The overall mean time for simulator setup and PsR was 54±14 minutes (range 37–80); PsR alone was completed in a mean 31±40 minutes (95% confidence interval −60 to −2.2). The actual eEVAR procedure duration was 69±16 minutes (range 45–90). No delay in the actual eEVAR procedure was registered owing to the PsR pathway. In 6 patients, preprocedure rehearsal induced changes in operative strategy, including device selection, main body introduction side, and/or deployment configuration. In 4 cases, rehearsal was performed twice to achieve optimal performance. Conclusion: PsR before eEVAR was feasible in all cases and caused no time delays in the actual eEVAR procedure. PsR optimized eEVAR planning by identifying optimal strategy for stent-graft component selection and deployment.

CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms

Purpose: To evaluate chimney stent-graft position and morphological changes of the aneurysm sac as visualized by postoperative computed tomography angiography (CTA) over a minimum 24-month follow-up period. Materials and Methods: Twenty-one patients (mean age 75.7±8.6 years; 20 men) with juxtarenal aortic aneurysms who underwent successful chimney endovascular aneurysm repair (ch-EVAR) with the Endurant stent-graft and had 2 postoperative CTAs separated by at least 24 months were included in the study. CTA-based measurements of aortic stent-graft migration, target vessel angle, and chimney angle were compared between the serial scans. Results: During a mean follow-up of 34.9 months (range 24-69.2), the mean migration of the aortic stent-grafts was under 5 mm (2.76±2.4 mm). The average migration distance per year was 1.15 mm. The aneurysm diameter reduced a mean 3.25 mm (p=0.048). The right renal artery angle moved significantly upward 6.72° (p=0.025), while the right renal chimney stent-graft moved significantly downward 7.83° (p=0.042). The left renal artery angle also moved upward 1.87° (p=0.388) and the corresponding chimney moved downward 5.68° (p=0.133). During the study period, no type I/III endoleak or chimney occlusion was observed. Conclusion: Midterm morphometric assessment of ch-EVAR using CTA showed significant aneurysm sac shrinkage and a stable 3-year position of the abdominal devices, with the mean downward migration of the aortic stent-graft being <5 mm in the majority of cases. The chimney grafts seem to be prone to take an oblique rather than parallel configuration during follow-up. However, there was no relevant clinical consequence related to this phenomenon.

Impact of aortic stent-graft oversizing on outcomes of the chimney endovascular technique based on a new analysis of the PERICLES Registry

OBJECTIVE

Chimney endovascular aortic aneurysm repair is gaining ever greater acceptance. However, persistent gutters leading to type IA endoleaks represent an unsolved issue. The aim of the current study was to analyze the impact of abdominal endograft oversizing to the occurrence of this phenomenon.

METHODS

The PERformance of the snorkel/chImney endovascular teChnique in the treatment of compLex aortic PathologiesES registry includes the largest experience with chimney endovascular aortic aneurysm repair from 13 vascular centers in Europe and the U.S. Prospectively collected data from centers with standard use of the Endurant stent-graft and balloon-expandable covered stents as chimney grafts only were included in the present analysis. The parameter which varied was the degree of oversizing of the aortic stent-graft classifying the cohort in two groups, group A (20% and less oversizing) and group B (>20% of oversizing). The primary endpoint was the incidence of persistent type IA endoleak needed reintervention. Secondary endpoints were all-cause mortality and freedom from reintervention.

RESULTS

Group A included 21 patients while group B 144. The mean preoperative pathology's neck length and diameter was 5.8 mm (±4.4) versus 4.9 mm (±3.8) and 27.6 mm (±4.7) versus 24.9 mm (±3.7) for group A and group B, respectively. The mean length of the new sealing zone after chimney graft placement was similar for both groups (group A versus group B; 17.9 mm versus 18.3 mm, respectively, P = .21). The percentage of oversizing of the aortic stent-graft ranged between 13.8 and 20% versus 22.2 and 30%, for group A and group B, respectively. Patients of group A had more type 1A endoleaks, (14.3%) versus patients of group B (2.1%) based on the first follow-up imaging, P = .02. The incidence of persistent type IA endoleaks needing a reintervention was 14.3 and 1.4% for the group A and group B, respectively, P = .01. The mean volume of contrast medium used was greater in group A versus group B with 239 ml versus150 ml, P = .05. Additionally, 14.3% of patients of group A experienced acute renal failure compared to those in group B which was 1.0%, P = .01.

CONCLUSIONS

Oversizing of ideally 30% of the Endurant stent-graft is associated with significant lower incidence of type IA endoleaks requiring reintervention for patients treated by chimney endovascular aortic aneurysm repair.

Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2

Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.

An Update on Endovascular Therapy of the Lower Extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Interventional Techniques to Facilitate Supraaortic Angioplasty and Stenting

Arterial occlusive disease involving the supra-aortic trunks (SATs) is relatively frequent. Its mere presence does not dictate the need for intervention. Revascularization options include intra and extrathoracic surgical bypasses and transpositions, and percutaneous endovascular approaches with angioplasty and stenting. This paper focuses on a description of the fundamental endovascular techniques and equipment that have proved useful in the senior author's (FJC) 15-year experience with catheter-based intervention for treatment of SAT disease. These procedures have gained in popularity over the years and become the preferred modality for management of most patients today.

Techniques for Endovascular Recanalization of Supra-Aortic Trunks

The supra-aortic arteries are no stranger to endovascular interventions. Since the 1980s, interventionists have been evaluating and refining the use of transluminal techniques for recanalizing stenotic and occlusive lesions in these large-bore, high-flow vessels. The authors present their methodologies for evaluating, selecting, and treating supra-aortic lesions with balloon angioplasty and stenting. Helpful suggestions are offered for optimizing the outcome of these endovascular approaches to atherosclerotic occlusive disease in the supra-aortic trunks.

Endovascular Surgery in Daily Practice: A Re-Appraisal

For more than 10 years, endoluminal therapy has been marked by an explosion in the number and variety of devices designed to enhance or supplant its first and still most commonly used technique, balloon angioplasty. Among all these innovative catheter-based technologies, only stents have emerged as a truly effective device capable of achieving results comparable or superior to balloon angioplasty. In combination with thrombolysis and balloon dilation, they form the triadic foundation of endovascular surgery today. The prudent and judicious use of these tools, and a few other “niche” devices, such as atherectomy, in conjunction with classical vascular surgical techniques is the special and unique purview of the vascular surgeon. His development of a therapeutic plan, whose components include patient selection, lesion assessment, device decisions, procedure monitoring, completion evaluation, and follow-up, is incumbent upon an appreciation of the capabilities of each available intraluminal device in the various arterial segments and lesion pathologies.

The strategies that facilitate optimum matching of endoluminal tools and techniques to each patient situation form the basis of this report. They offer today's vascular surgeon a guide to the use of intraluminal therapies in daily practice. On the horizon is the new and exciting technique of endoluminal grafting, which, if it proves efficacious, will bring about profound changes in our specialty.

Technical Strategies to Expand Stent-Graft Applicability in the Aortic Arch and Proximal Descending Thoracic Aorta

The endovascular repair of thoracic aortic pathology is on an evolutionary threshold, as advancing technologies and techniques combine to offer the interventionist expanded treatment opportunities. A variety of maneuvers are recommended to address the landing zone limitations to thoracic endografting imposed by the arch vessels: transostial bare stent placement, intentional occlusion of the arch vessel origin, vessel transposition, and bypass grafting. These adjunctive techniques can help us extend the option of a minimally invasive treatment to a greater number of patients with severe thoracic aortic lesions and comorbidities that place them at high risk for standard surgical intervention.

Outpatient Endovascular Intervention: Is it Safe?

Purpose:

To evaluate the feasibility and safety of outpatient percutaneous endovascular intervention in the treatment of arterial occlusive disease.

Methods:

The records of 134 patients who underwent 151 outpatient endovascular procedures between 1992 and 1997 were reviewed retrospectively. According to established protocol, focal lower limb (n = 145) and subclavian (n = 6) arterial lesions requiring relatively straightforward endoluminal interventions were appropriate for outpatient management provided the patients were free of significant comorbidities. A percutaneous transfemoral approach was used for lower limb lesions, while subclavian angioplasty was performed via a brachial access. Heparin anticoagulation was administered conservatively. Patients were discharged 3 hours after sheath removal.

Results:

The majority (98%) of patients were discharged as planned. Three (2%) patients were observed overnight in the hospital for treatment of acute iliac artery thrombosis, puncture-site bleeding, and suboptimal angioplasty. No patient required hospitalization following discharge. Periprocedural morbidity Was confined to 2 (1.5%) groin hematomas and 1 (0.7%) femoral pseudoaneurysm.

Conclusions:

Outpatient endovascular intervention appears safe; however, proper case selection and technical excellence are inseparable components for the success of this strategy.

Results with the Talent thoracic stent graft in the VALOR trial

OBJECTIVE

We report the 5-year outcomes of thoracic endovascular aneurysm repair (TEVAR) using the Medtronic Vascular Talent Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) in patients considered low or moderate risk for open surgical repair.

METHODS

The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial was a prospective, nonrandomized, multicenter, pivotal study conducted at 38 U.S. sites. Between December 2003 and June 2005, VALOR enrolled 195 patients who were low or moderate risk (0, 1, and 2) per the modified Society for Vascular Surgery and American Association for Vascular Surgery criteria. The patients had fusiform thoracic aortic aneurysms (TAAs) and/or focal saccular TAAs/penetrating atherosclerotic ulcers. Standard follow-up interval examinations were conducted at 1 month, 6 months, 1 year, and annually thereafter.

RESULTS

Over the 5-year follow-up, 76 deaths occurred (43.9%). Freedom from all-cause mortality was 83.9% at 1 year and 58.5% at 5 years. Most deaths were due to cardiac, pulmonary or cancer-related causes. Freedom from aneurysm-related mortality (ARM) was 96.9% at 1 year and 96.1% at 5 years. There was only 1 case of ARM after the first year of follow-up. Over the 5-year follow-up period, four patients were converted to open surgery and four patients experienced aneurysm rupture. The 5-year freedom from aneurysm rupture was 97.1% and the 5-year freedom from conversion to surgery was 97.1%. The incidence of stent graft migration (>10 mm) was ≤ 1.8% in each year of follow-up. The rate of type I endoleak was 4.6% at 1 month, 6.3% from 1 month to 1 year, and 3.8% during year 5. The rate of type III endoleak was 1.3% at 1 month, 1.9% from 1 month to 1 year, and 1.9% during year 5. Through 5 years, 28 patients (14.4%) underwent 31 additional endovascular procedures on the original target lesion. The 5-year freedom from secondary endovascular procedures was 81.5%.

CONCLUSIONS

Through 5-year follow-up in patients who were candidates for open surgical repair, TEVAR using the Talent Thoracic Stent Graft System has demonstrated sustained protection from ARM, aneurysm rupture, and conversion to surgery, and durable stent graft performance. Close patient follow-up remains essential after TEVAR.

Aortic dissection: a 250-year perspective

Two hundred fifty years have passed since Frank Nicholls' history-making, accurate observations on the anatomic findings and cause of death of King George II were published. Several decades later, the disease was named, using--for the first time--the terms dissection and dissecting attached to an aortic disease process. Another century went by before effective surgical treatment was developed. In sharp contrast, the evolution of the last 20 years has been nothing short of amazing. Our understanding of AD, while not yet complete, has improved dramatically. In addition, the introduction of nonsurgical endovascular therapy has had a profoundly transformative impact--and we are just at the beginning! It would not be unreasonable to predict that stent-graft repair will likely replace (or nearly replace) open surgery in the treatment of complicated type B dissection in the near future, especially as technologies continue to improve and indication-specific designs are developed and tested in the clinical setting. Moreover, it is predictable that endovascular solutions for some patients with type A aortic dissection will become available in the years to come as surgical results continue to be suboptimal. Finally, and amidst this plethora of “good news,” it is appropriate to reflect on the formidable challenge that endovascular therapies face as they gear to “compete” with optimal medical therapy in the management of patients with acute uncomplicated type B dissection, because it will obviously be difficult (if not impossible) to improve on the already-achieved 30-day mortality rate of less than 10%. Long-term gains may well become the winning card when and if the late results of TEVAR can be shown to improve on the rather compromised outlook of medically treated dissection patients. Stay tuned.

A 5-year evaluation using the talent endovascular graft for endovascular aneurysm repair in short aortic necks

BACKGROUND

Although endovascular aneurysm repair has been shown to be an effective way to treat abdominal aortic aneurysm (AAA), certain anatomic characteristics such as a short aortic neck, limit its applicability. Initially, commercially available devices were approved only for the treatment of AAA with an aortic neck length ≥ 15 mm. The purpose of this study was to evaluate the outcomes of the recently approved Talent endograft for AAAs with a short aortic neck length (10-15 mm).

METHOD

Data were obtained from the prospective, nonrandomized, multicenter Talent enhanced Low Profile Stent Graft System trial which enrolled patients between February 2002 and April 2003. A total of 154 patients with adequate preoperative imaging were identified for this study. Subgroup analyses were performed for AAA with 10-15 mm aortic neck and those with >15 mm neck. Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years postprocedure.

RESULTS

Patients treated with aortic neck lengths of 10-15 mm (n = 35) and those with >15 mm (n = 102) had similar age, gender, and risk factor profile. Both groups had similar preoperative aneurysm morphology in terms of maximum aneurysm size, degree of neck angulation, or proximal neck diameter. There were no statistically significant differences in freedom from major adverse events and mortality rates at 30 and 365 days. Similarly, there was no difference in the effectiveness endpoints at 12 months. At 5 years, there was no difference in migration rate, endoleaks, or change in aneurysm diameter from baseline. In addition, there is no difference in freedom from aneurysm-related mortality (94% vs. 99%).

CONCLUSIONS

AAAs with short aortic necks (10-15 mm) and otherwise suitable anatomy for endovascular repair can be safely and effectively treated with the Talent endograft with excellent 1 and 5 year outcomes.

New Technique to Facilitate Renal Revascularization with Use of Telescoping Self-Expanding Stent Grafts: VORTEC

This article describes a new, less invasive prosthetic graft anastomotic technique that uses self-expanding stent grafts that are “telescoped” into aortic branches. This method, the VORTEC (Viabahn Open Revascularization TEChnique), obviates the need for potentially difficult complete vessel exposure and graft anastomoses, thereby reducing the duration of flow interruption and simplifying the performance of complex aortic reconstructions and so-called debranching procedures requiring reconstruction of major branches such as renal arteries. Minimal exposure of one surface of the renal artery allowed introduction and deployment of a self-expanding Viabahn (W.L. Gore & Associates, Flagstaff, AZ) device using the Seldinger technique. The Viabahn devices used were 5 to 8 mm in diameter and 5 to 15 cm in length depending on individual anatomy (assessed by preoperative computed tomographic angiography). Overall, 82 renal arteries have been revascularized in 58 patients using the VORTEC. The technical success rate was 100%, with all of the stent grafts implanted as intended with maintenance of flow. The patency rates were 97% after 30 days and 96% after a mean follow-up of 18 months (range 1–38 months). The VORTEC allows performance of safe and expeditious revascularization of renal arteries. This new technique may represent significant improvement over the standard approach of surgical exposure and sutured anastomosis.

Endovascular techniques for supra-aortic trunk intervention

Endovascular techniques have gradually become the preferred treatment modality for occlusive disease of the supra-aortic trunks (SAT). Stenotic lesions are particularly amenable to catheter-based therapy. Standard cervical bypasses or intrathoracic reconstruction is now generally reserved for cases of extensive, multivessel involvement or after failure of previous endovascular procedures. Angiographic assessment of aortic arch anatomy and equipment and technical choices for arch branch catheterization constitute the foundations. The left subclavian artery is most frequently diseased; interventional options revolve around antegrade and retrograde techniques. Preservation of the left vertebral artery-and at times of the internal mammary-is an important issue. Treatment of lesions in the proximal common carotid arteries tends to be straightforward when dealing with focal stenoses. Embolic protection should be used whenever feasible and reasonable. The innominate is often the most challenging SAT vessel because of its large diameter and short length, as well as the fact that it bifurcates into the right subclavian and common carotid arteries. Right subclavian artery intervention tends to be more difficult than its left-side counterpart, which is related to fluoroscopic visualization and the tendency for stenoses to develop in the very short segment between its origin and the take-off of the right vertebral artery. Supra-aortic trunk intervention has become more commonplace at present, but it is frequently difficult and carries significant potential for failure and mishap. These risks can be minimized through a complete understanding of the full spectrum of technical and catheter choices that are available to the interventionist.

Iliac arterial conduits for endovascular access: technical considerations

PURPOSE

To describe the relevant technical details that have proved helpful in a 10-year experience using iliac access conduits.

TECHNIQUES

Standard surgical techniques are used to achieve retroperitoneal exposure of the common iliac artery (CIA) via a relatively short oblique incision in the lower quadrant of the abdomen. On occasion, the distal abdominal aorta is the only reasonable or available target for anastomosis and conduit attachment. A left-side approach is preferred. A 10-mm-diameter Dacron graft is the best conduit because it provides enough luminal space for introduction of all delivery systems. The anastomosis is sewn end-to-side between the graft and the CIA using a running suture technique. After completion of the anastomosis, the conduit is exited through the abdominal wall via a small stab incision made just above the inguinal ligament, providing a smooth angle of entry that will facilitate introduction of the large devices to be passed through the conduit. Upon completion of the endovascular procedure, the iliac conduit is excised, leaving behind only a short stub that is carefully oversewn with a running propylene suture. After achieving perfect hemostasis, the incision is closed in layers using standard technique.

CONCLUSION

Access challenges requiring an iliac conduit may also be overcome by direct puncture and repair of the CIA following retroperitoneal exposure, without attaching a conduit or retrograde endarterectomy via a femoral artery exposure, with or without subsequent relining with a covered stent. While such techniques may have merit, we continue to rely on the iliac conduit approach for all such cases.