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Through and Through Wire Is the Unique Way to Force Tortuous Anatomy
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No full textParker et al,1,2 in recent years, investigated the inter-relationships of aortoiliac morphology, hemodynamic changes, and the clinical progression of 25 cases of isolated common iliac artery aneurysms (CIAAs), by reconstructing and simulating the fluid dynamics and the wall shear stress. From their findings, kinked CIAAs had less calcification and thrombosis and appeared hemodynamically stable, rarely rupture. In our study,3 we reported a European two-center experience of 256 implanted iliac branch devices (IBDs) for the endovascular treatment of aortoiliac aneurysms. Therefore, we considered aortoiliac (165 cases) and isolated iliac aneurysms (44 cases, including common, external, or internal iliac aneurysms) suitable for the treatment according to the current guidelines
Use of Shockwave Intravascular Lithotripsy in Recanalization of Calcified Visceral and Renal Arteries: A Case Report and Update of the Literature
No full textPurpose: Calcifications of the visceral and renal arteries lead to chronic mesenteric ischemia and renal artery stenosis, and both open and endovascular treatments can be proposed. Intravascular lithotripsy (IVL) has emerged as a novel technique used in peripheral and coronary interventions.
Case report: A 73-year-old man presented with chronic postprandial abdominal pain and weight loss. Computed-tomography-angiography (CTA) showed 93% calcified stenosis of the superior mesenteric artery (SMA). The plain old balloon angioplasty (POBA) was affected by immediate recoiling. The patient underwent ShockwaveTM IVL of the SMA via brachial access and stent-graft implantation. At 3-months follow-up, the patient showed symptoms resolution.
Conclusions: The use of Shockwave IVL can be an effective treatment for severely calcified SMA stenosis. A similar approach can be employed in both celiac and renal arteries as reported in 11 cases in literature and herein summarized. Intravascular lithotripsy resulted in high technical success and uneventful follow-up. However, given the small number of patients reported, larger studies are needed to confirm these findings.
Clinical impact: This article reports a case of recanalization of superior mesenteric artery with heavily calcified lesion treated with intravascular lithotripsy (IVL) with ShockwaveTM Intravascular Lithotripsy Balloon (Shockwave Medical Inc., Santa Clara, CA, USA). Beside, for the first time, we summarize the Literature on the use of IVL in the renal and visceral arteries district, providing indications, applications and useful hints for the endovascular treatment of chronic mesenteric ischemia and renal artery stenosis. This preliminary data show straightforward applicability, high technical success, and uneventful follow-up and IVL can be proposed as an useful tool for challenging revascularization of heavily calcified reno-visceral arteries
Distal Endovascular Extension After FET: Short and Mid-Term Outcome in a High-Volume Single-Center Experience
Full text linkBackground: This study aims to investigate results and outcomes of distal endovascular extensions after frozen elephant trunk (FET) procedure. Methods: Between September 2018 and December 2022, all consecutive patients who underwent thoracic endovascular aortic repair (TEVAR) or complex thoraco-abdominal repair (TAA-EVAR) after FET were included in the study. Patients were assigned to "Aneurysm" group or to "Dissection" group according to underlying patology before FET repair. The primary end points were overall technical success and early reintervention rate. Secondary end points included 30-day and mid-term overall survival. Results: A total of 29 patients were included in the study and divided as follows: n = 12 in the aneurysm group and n = 17 in the dissection group. The mean age of the population was 64.6 ± 10.2 years, and 69% were male. All patients received TEVAR as primary extension while 9 of them underwent further extension to a subsequent TAA-EVAR in a second stage. Among the dissection group, 7 patients experienced a distal stent-graft-induced new entries caused by the stent-graft portion of the FET. Technical success of the first stage (TEVAR) was fully achieved as well as for the second stage (TAA-EVAR). Within the first 30 days, no patient expired or required early reinterventions. Freedom-from-reintervention at 36 months was 72% and 64% in the aneurysm and dissection group, respectively. Overall, 1 major adverse event (3.4%) and 3 access-related complication (10.3%) occurred among the entire cohort. The Kaplan-Meier survival estimation showed a nonsignificant log-rank value (P = 0.248) with a survival rate of 91.7% and 100% at 12, 24, and 36 months each for aneurysm and dissection group, respectively. Conclusions: Distal endovascular extensions after FET repair are feasible with low perioperative morbidity and mortality regardless of the underlying pathology. Technical success rate of endovascular extension is high, but aortic-related reintervention rate remains quite consistent over time. Thus, a close surveillance is advocated for such patients
Emergent physician modified carotid fenestrated TEVAR for the treatment of a complicated acute type nonA-nonB aortic dissection with undetected multiorgan malperfusion
No full textComplicated acute nonA-nonB dissection with malperfusion is associated with a high in-hospital mortality up to 67%. Therefore, rapid identification and treatment are critical for clinical outcomes. We report the urgent treatment of a complicated subacute aortic dissection treated with a physician-modified-endograft (PMEG) fenestrated-TEVAR (f-TEVAR) for the left common carotid artery (LCCA). A 49-year-old male patient with acute non-A non-B aortic dissection with complete true lumen collapse and associated mesenteric and renal ischemia, was referred to another vascular center for abdominal pain and received exclusively medical treatment. After 15 days of persistent pain, the patient self-referred to our center and was treated with endovascular repair. The proximal entry tear was located at the level of the left subclavian artery: a PMEG f-TEVAR was performed with fenestration for LCCA in conjunction with carotid-subclavian bypass. In addition, spot stenting of the left renal artery was performed to resolve renal malperfusion. The final angiography showed satisfactory result. The patient soon reported significant pain relief. Follow-up at 30-days was satisfactory, with no need for further intervention. A physician-modified fenestrated-TEVAR can be used in emergency setting to treat acute non-A-non-B aortic dissection in conjunction with multiorgan malperfusion, with satisfactory results even after initial delayed treatment
Endovascular Repair With Triple Inner-Branch Endograft for Aberrant Subclavian Artery Aneurysm: A Case Report
No full textBackground: Endovascular repair of the thoracic aorta (TEVAR) is the preferred option for the treatment of the distal arch and descending thoracic aorta. Fenestrated and branched TEVAR have become an option to treat pathologies of the aortic arch, avoiding sternotomy and cardiopulmonary arrest as well as total surgical debranching. We describe here the case of a symptomatic patient with an arteria lusoria aneurysm associated with Kommerel diverticulum who underwent total endovascular repair with a triple-branched TEVAR.
Case report: A 66-year-old male patient was treated for a symptomatic arteria lusoria artery associated with a Kommerel diverticulum, resulting in difficulty swallowing and choking. We used a custom-made triple inner-branch endograft (Cook Medical, Bloomington, Indiana) following implantation of a right-sided carotid-subclavian (C-S) bypass. The C-S bypass occluded in the interval time between the 2 procedures and required recanalization and stent-graft placement during the aortic arch procedure. The arteria lusoria was embolized with a vascular plug. No complications occurred and postoperative tomography showed exclusion and thrombosis of the Kommerel diverticulum and perfusion of the supra-aortic vessels.
Conclusions: Treatment of arteria lusoria aneurysms can be performed with total endovascular arch inner-branch repair, avoiding increased risk of morbidity and mortality caused by open or hybrid procedures
Secondary Endovascular Conversions for Failed Open Repair
Full text linkLate aortic and graft-related complications after open aortic repair are not infrequent and a significant number of them are missed, diagnosed at a very late stage, or present as urgent complications such as aortic rupture or aorto-enteric fistula. Once a late complication is diagnosed and reintervention is necessary, both open and endovascular strategies are possible. Open reintervention is complex and usually associated with very high rates of morbidity and mortality. Endovascular techniques may offer several solutions for these cases, which may be tailored to the patient and specific complication. In this review, we aim to summarize current indications, options, and strategies for endovascular salvage after failed or complicated open surgical repair
Transaxillary Branch-to-Branch-to-Branch Carotid Catheterization Technique for Triple-Branch Arch Repair
No full textPurpose: To describe the transaxillary branch-to-branch-to-branch carotid catheterization technique (tranaxillary 3BRA-CCE IT) for cannulation of all supra-aortic vessels using only 1 femoral and 1 axillary access during triple-branch arch repair.
Technique: After deployment of the triple-branch arch device, catheterization and bridging of the innominate artery (IA) should be performed through a right axillary access (cutdown or percutaneous). Then, the retrograde left subclavian (LSA) branch should be catheterized (if not preloaded) from a percutaneous femoral access, and a 12×90Fr sheath should be advanced to the outside of the endograft. Subsequently, catheterization of the left common carotid artery (LCCA) antegrade branch should be performed, followed by snaring of a wire in the ascending aorta which was inserted through the axillary access, creating a branch-to-branch-to-branch through-and-through guidewire. Over the axillary access, a 12×45Fr sheath should be inserted into the IA branch and looped in the ascending aorta using a push-and-pull technique so that it faces the LCCA branch, allowing for stable catheterization of the LCCA. The retrograde LSA branch should then be bridged following the standard fashion.
Conclusions: This series of 5 patients demonstrates that triple-branch arch repair can be performed with the transaxillary 3BRA-CCE IT, allowing catheterization of the supra-aortic vessels without manipulation of the carotid arteries.
Clinical impact: The transaxillary 3BRA-CCE IT allows catheterization and bridging of all supra-aortic vessels in triple-branch arch repair through only 2 vascular access points, the femoral artery and the right axillary artery. This technique avoids carotid surgical cutdown and manipulation during these procedures, reducing the risk of access site complications, including bleeding and reintervention, reintubation, cranial nerve lesions, increased operating time, and so on, and has the potential to change the current vascular access standard used during triple-branch arch repair
Renal volume and renal function after type B aortic dissection dependant on the renal artery supply from the aortic vessel lumen - a course analysis
No full textDas Nierenvolumen korreliert mit der Nierenfunktion. Ziel der Studie ist, den Verlauf der Nierenfunktion und des Nierenvolumens von Patienten mit Typ B-Aortendissektion darzustellen und Aussagen über eine mögliche Beeinflussung durch die Perfusion der Nierenarterien aus wahrem (TL), falschem (FL) oder geteiltem (BL) Gefäßlumen der Aorta zu treffen.
Insgesamt konnten 69 Patienten (16 weiblich, 53 männlich) in die Studie eingeschlossen werden, die im Zeitraum vom 6. August 2008 bis 6. August 2015 an der Klinik und Poliklinik für Gefäßmedizin des Universitätsklinikums Hamburg-Eppendorf behandelt wurden. Für jeden Teilnehmer der Studie wurden Nierenfunktion (durch GFR- und Kreatinin-Werte), Nierenvolumen sowie die Lumenverteilung der Nierenarterien bestimmt. Die Daten wurden retrospektiv anhand von CT-Aufnahmen und Patientenakten erhoben. Das Nierenvolumen wurde an fünf verschiedenen Zeitpunkten bestimmt (1 = CT zum Diagnosezeitpunkt, 2 = 0-3 Monate nach dem CT zum Diagnosezeitpunkt, 3 = 3-12 Monate nach dem CT zum Diagnosezeitpunkt, 4 = 12-24 Monate nach dem CT zum Diagnosezeitpunkt, 5 = 24-48 Monate nach dem CT zum Diagnosezeitpunkt). Das Nierenvolumen sowie die Gefäßversorgung der Nierenarterie aus dem wahren, falschen oder geteilten Gefäßlumen der Aorta wurde mit Hilfe des TeraRecon Aquarius Programm beschrieben und errechnet.
64 Patienten erhielten als Therapie eine TEVAR, fünf wurden konservativ behandelt. Zum Diagnosezeitpunkt war die Gefäßversorgung der Nierenarterien folgendermaßen: 69,1%TL, 20,6%FL, 10,3%BL für die rechte Nierenarterie und 74,6%TL, 17,5%FL, 7,9%%BL für die linke Nierenarterie. Das Volumen der linken und der rechten Niere verringerte sich vom CT1 zum CT5 insgesamt durchschnittlich um 15,32 cm3. Der Mittelwert des Kreatinins stieg von 1,19 mg/dl zum Diagnose-CT auf 1,26 mg/dl zum Zeitpunkt des CT5 an; die GFR sank in diesem Zeitraum im Mittel um 18,48 ml/min. Bei einer Nierenarterienversorgung aus dem BL betrug die Nierenvolumenänderung von Zeitpunkt 1 zu Zeitpunkt 5 im Mittel -40,81 cm3, -15,65 cm3 bei Nierenarterienversorgung aus dem TL und blieb etwa konstant (im Mittel +0,82 cm3) bei Nierenarterienversorgung aus dem FL. Das Nierenvolumen scheint sich am meisten zu verringern, wenn die Nierenarterienversorgung aus dem geteilten Gefäßlumen der Aorta erfolgt. Dies könnte an der Dissektionsmembran liegen, die je nach Lage in Bezug zum Nierenarterienabgang die Perfusion der Niere beeinflussen könnte.Volume of the kidneys is known to correlate well with renal function. We aim to investigate the natural history of renal function and renal volume over time after type B aortic dissection and its correlation to perfusion of the renal arteries from the true lumen (TL), false lumen (FL) or both lumina (BL) of the aorta.
69 patients (16 female, 53 male) with type B aortic dissection were treated during a 7-year period at the „Department of vascular medicine, University Heart Center, University Medical Center Hamburg-Eppendorf”. Renal function, renal volume and false/true lumen perfusion of the kidneys were evaluated for all subjects included. Data were retrospectively collected from contrast CTs of good quality to measure renal volume at five different time points (1=baseline CT scan, 2=0-3 months after baseline CT, 3=3-12 months after baseline CT, 4=12-24 months after baseline CT, 5=24-48 months after baseline CT). Renal function was controlled by GFR and creatinine. Renal volume as well as vascularization of the renal arteries of TL, FL or BL were calculated and described from the CT-scans using the TeraRecon Aquarius program.
64 patients underwent TEVAR, five patients were treated conservatively. At baseline, distribution of perfusion was: 69,1%TL, 20,6%FL, 10,3%BL for the right renal artery and 74,6%TL, 17,5%FL, 7,9%%BL for the left renal artery. The volume of the right and the left kidney both decreased from baseline to last CT-scan by 15,32 cm3. Mean creatinine value increased from 1,19 mg/dl at baseline to 1,26 mg/dl at latest follow-up. GFR decreased by average value of 18,48 ml/min. When vascularization originated from BL, renal volume decreased by 40,81 cm3, by 15,65 cm3 when vascularization originated from TL and remained almost unchanged +0,82 cm3 when originating from FL.
Although not reaching statistical significance in this small cohort of patients, renal volume appears to decrease more frequently when the artery of the respective kidney originates from both lumina. This could be potentially attributed to an on-off phenomenon caused by the dissection membrane at the ostium of the vessel, affecting the perfusion of the kidney
Management von Standard- und komplexen Aorten Pathologien
Full text linkEinleitung
Aufgrund der Entwicklung von Technologie und chirurgischen Verfahren ist die Aortenchirurgie zu einem routinemäßigen chirurgischen Eingriff geworden. Die Sterblichkeits- und Morbiditätsraten haben sich in den letzten Jahrzehnten aufgrund eines verbesserten perioperativen Managements stetig verbessert. Trotz dieser Entwicklung bleibt die Behandlung der „komplexen“ Aorta eine große Herausforderung für Chirurgen und Anästhesisten (1).
Definitionen
Der Begriff „Standard“-Aortenchirurgie hängt in den meisten Fällen vom geplanten chirurgischen Eingriff ab. Er bezeichnet einige morphologische und anatomische Kriterien, die ein gutes und problemloses Vorgehen bei der Aortenoperation vorhersagen können (1, 2). Aus diesem Grund tauchen Begriffe wie „Standard-EVAR-Chirurgie“, oder „Standard-offene-Aortenchirurgie“ eher in der Alltagssprache der Gefäßchirurgen auf. Mit der Weiterentwicklung zahlreicher neuer Modalitäten in der minimalinvasiven Aortenchirurgie, und der Standarisierung von Aorteneingriffen werden neue Begriffe wie „Standard-TEVAR“, „Standard-Iliac-Side-Branch“ oder „Standard-fEVAR“ möglicherweise häufiger in der Sprache der Gefäßchirurgen verwendet (3). Bei der Standard-EVAR-Operation handelt es sich in den meisten Fällen um ein infrarenales Aortenaneurysma mit einer proximalen Halslänge von mindestens 10 mm und einer ausreichenden iliakalen Landezone.
Darüber hinaus bedeutet „Standard-offene-Aortenchirurgie“ eine Operation, bei der eine infrarenale Klemmung der Aorta möglich ist.
Für die komplexe Aortenchirurgie gibt es in der Literatur keine klare oder einheitliche Definition (4). Die meisten Definitionen der „komplexen“ Aorta basieren auf morphologischen und anatomischen Abweichungen von den EVAR-Gebrauchsanweisungen (Instructions for Use, IFU) oder auf der Ausdehnung des Aneurysmas oberhalb der Nierenarterien. In diese Kategorie fallen juxta- und supra-renale Aneurysmen, sowie thorakale und thorako-abdominelle Aneurysmen, die keine proximale und distale Landungszone aufweisen (5, 6). Andere Kriterien wie Ruptur oder Infektion der Aorta sind in diesen Definitionen nicht enthalten
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