Arash Bornak

Aortic Aneurysmal Repair With Surtureless Visceral Revascularization Using Novel Hybrid Vascular Graft and a Gradual Funneling Technique

This article details a novel technique in the treatment of a symptomatic thoracoabdominal aneurysm (TAA) involving the visceral segment and an infrarenal abdominal aortic aneurysm. The patient was treated in a 2-staged hybrid approach combining an endovascular repair of the infrarenal segment, followed by open TAA repair. The large visceral arteries were revascularized using expanded polytetrafluoroethylene GORE Hybrid Vascular Graft (GHVG) and a Gradual Funneling Technique with Dacron graft. This method assured a complete hemostatic seal and minimized visceral ischemic time. To our knowledge, this is the first case of sutureless visceral artery revascularization using GHVG reported in the literature.

Modified use of the Hemodialysis Reliable Outflow (HeRO) graft for salvage of threatened dialysis access.

The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere Inc, Eden Prairie, Minn) offers a new option to provide upper extremity arteriovenous (AV) dialysis access in patients with central venous occlusive disease. Creative use of this device can allow for salvage of failing or threatened AV fistulas and grafts. We present two patients who underwent a modified implantation of the HeRO device for immediate salvage of a malfunctioning AV access. Ipsilateral central venous occlusions were successfully overcome by anastomosing a HeRO device to the existing AV access and tunneled across the chest to the contralateral internal jugular vein.

Diagnosing and Treating Atypical Arterial Pathologies of Aortic Arch Vessels: Dissection and Fibromuscular Dysplasia

Although rare, pathologies of the aortic arch vessels can result in devastating sequelae. This article will address two of these pathologies, fibromuscular dysplasia and arterial dissection, along with diagnosis and treatment options.

Endovascular exclusion of a saccular aortic aneurysm using a septal occluder device

Endovascular repair of aneurysms involving the visceral segment of the abdominal aorta still remains a challenge. We report a patient with a large saccular aneurysm involving the visceral segment of the abdominal aorta that was ultimately excluded by endovascular deployment of an Amplatzer atrial septal occluder device (AGA Medical/St. Jude Medical, St Paul, Minn).

Endovascular treatment of TransAtlantic Inter-Society Consensus D aortoiliac occlusive disease using unibody bifurcated endografts

Objective: Aortobifemoral bypass has been the gold standard treatment for extensive aortoiliac occlusive disease. Endovascular therapy and stenting of aortic and iliac occlusive lesions has proven to be efficacious, especially when dealing with short segment lesions. Endovascular treatment of TransAtlantic Inter‐Society Consensus II (TASC) D aortoiliac occlusive lesions remains a challenge, but a valuable treatment option in poor surgical candidates. We present our operative technique and midterm results in treating TASC D aortoiliac occlusive disease using unibody bifurcated endografts. Methods: We performed a retrospective review of patients with TASC D aortoiliac occlusive disease who underwent transfemoral endovascular revascularization with the Endologix Powerlink unibody bifurcated endograft (Endologix, Irvine, Calif). Demographic data, operative details, and outcomes were collected. Paired t‐tests were performed to compare preoperative and postoperative ankle brachial indexes. Results: Between March 2009 and July 2011, 10 high‐risk patients (8 male and 2 female) for a traditional aortobifemoral bypass were treated using this endovascular technique. The mean age was 59 ± 6 years (range, 50‐69 years). All patients presented with rest pain, and four with tissue loss. Technical success was 100%, with two patients requiring brachial access and eight patients requiring additional stent placement. Postoperatively, all patients reported clinical improvement with resolution of ischemic symptoms. Mean improvement ankle brachial index was 0.50 ± 0.08 (P = .028) and 0.50 ± 0.01 (P = .034) in the left and right legs, respectively. Mean follow‐up time was 40 ± 24 months (range, 4‐81 months). The primary and secondary patency rates were 80% and 100%, respectively. Complications requiring early reintervention occurred in two patients and included one expanding hematoma from the percutaneous access site and one acute iliac artery thrombosis. Additionally, one patient underwent repeat angioplasty/stenting for threatened endograft limbs at 4 months. One patient expired during follow‐up from an unrelated cardiac cause 19 weeks postoperatively. Conclusions: This series demonstrates that endovascular repair using a unibody bifurcated endograft for TASC D aortoiliac occlusive disease is feasible, effective, and has excellent midterm patency. It should be considered an effective treatment option when the disease process involves the aorta, in particular if the patient is surgically unfit for a traditional aortobifemoral bypass. The unibody configuration preserves the anatomic aortic bifurcation, which is particularly important in patients with peripheral occlusive disease who are deemed to undergo subsequent endovascular interventions.

Endovascular Treatment of an Aortic Saddle Embolism Resulting in Full Neurologic Recovery

Aortic saddle embolism (ASE) and aortic saddle thrombosis are rare and occasionally associated with spinal ischemia and paraplegia. Patients have traditionally been treated with transfemoral balloon thromboembolectomy. In the following case report, we present a patient with suspected ASE and paraplegia, who was successfully treated by an endovascular approach using covered stents. Following intervention, the patient regained full neurologic function. To our knowledge, it is the first time that this type of endovascular treatment for ASE has been applied successfully.

Predicting Factors Associated with Postoperative Hypotension following Carotid Artery Stenting

BACKGROUND Prolonged hemodynamic instability after carotid artery stenting (CAS) has been associated with increased incidence of stroke and other major adverse events. The objective of this study is to determine the factors associated with hypotension following CAS. In particular, this study evaluates whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. METHODS A retrospective review of 90 CASs performed in 88 patients at a single tertiary center was completed. In patients with proximal internal carotid stenosis involving the carotid bifurcation, the extent of bifurcation/bulb calcification on preoperative computed tomography angiography was assessed using a scoring system. Calcium scores were assigned based on the percent of circumferential calcification of carotid bifurcation as follows: grade 1, <10%; grade 2, 10-50%; grade 3, 50-90%; and grade 4, >90%. Perioperative factors associated with prolonged postoperative hypotension requiring vasopressor infusion were analyzed. RESULTS Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. There were no differences in baseline demographics, comorbidities, or CAS indication between patients who required postoperative vasopressors for hypotension and those who did not. The majority of patients (64.4%) were on 2 or more antihypertensive medications preoperatively. Stenosis involved carotid bifurcation in 64 (71.1%) cases. Of these, 27 (42.2%) were grade 1, 19 (29.7%) were grade 2, 10 (15.6%) were grade 3, and 8 (12.5%) were grade 4 based on our calcium scoring system. On risk-adjusted analysis, carotid bifurcation/bulb involvement (adjusted odds ratio [aOR] 4.5, 95% confidence interval [CI] 1.1-18.5) and preoperative regimen of 2 or more antihypertensives (aOR 4.2, 95% CI 1.1-16.0) were independent predictors of hypotension requiring vasopressors following CAS. Among patients with carotid bifurcation involvement, severity of calcium score was not a significant predictor of postoperative hypotension. CONCLUSIONS CAS for carotid stenosis involving the carotid bifurcation/bulb is associated with a higher risk for postoperative hypotension requiring vasopressors. Patients with preoperative hypertension requiring 2 or more antihypertensive medications are also at increased risk. However, severity of carotid bifurcation calcification is not a significant predictor of need for postoperative vasopressors.

TEVAR for Flash Pulmonary Edema Secondary to Thoracic Aortic Aneurysm to Pulmonary Artery Fistula

Enlarging aneurysms in the thoracic aorta frequently remain asymptomatic. Fistulization of thoracic aortic aneurysms (TAA) to adjacent structures or the presence of a patent ductus arteriosus and TAA may lead to irreversible cardiopulmonary sequelae. This article reports on a large aneurysm of the thoracic aorta with communication to the pulmonary artery causing pulmonary edema and cardiorespiratory failure. The communication was ultimately closed after thoracic endovascular aortic aneurysm repair allowing rapid symptom resolution. Early diagnosis and closure of such communication in the presence of TAA are critical for prevention of permanent cardiopulmonary damage.

Endovascular Reconstruction of Aortoiliac Occlusive Disease with an Aberrant Pelvic Kidney.

Aortoiliac occlusive disease coincident with a congenital ectopic pelvic kidney is a rare occurrence. Traditionally, the treatment has been open aortobifemoral repair with reimplantation of the renal artery. We present a patient with Trans-Atlantic Inter-Society Consensus (TASC) D bilateral aortoiliac occlusive disease, an ectopic pelvic kidney, and prohibitive medical comorbidities. We describe a totally endovascular repair using a chronic total occlusion crossing device, a luminal re-entry device, and balloon-mounted covered stents to revascularize the lower extremities and the ectopic pelvic kidney. We discuss various aspects of this endovascular approach as the incidence of patients with TASC D lesions and prohibitive comorbidities continue to rise.

Treatment of an Iatrogenic Infrarenal Aortic Dissection Using a Unibody Endograft

embolized with 8–15-mm-diameter coils 1 week after TEVAR. The patient tolerated all the procedures well, and the 3-year follow-up was uneventful. CT obtained 2.5 years after TEVAR showed no growth in the diameter of the descending thoracic aorta and preservation of flow into the mesenteric and renal arteries. A type II endoleak through an intercostal artery was present (Fig 3). The maximum diameter of the descending thoracic aorta had remained at 48 mm, the same as the preoperative measurement. The efficacy of TEVAR for the treatment of chronic dissection is controversial (1). Although favorable remodeling and complete elimination of the false lumen is achievable with TEVAR in acute aortic dissection, remodeling is poor in some patients with chronic dissection (2). It is not uncommon that a thoracoabdominal aortic aneurysm develops even after TEVAR in such patients. Generally, development of a thoracoabdominal aortic aneurysm is attributed to the blood flow coming from the re-entry into the false lumen (1). In the patient described here, there was great concern about the development of a thoracoabdominal aortic aneurysm because a large reentry was intentionally created just above the proximal anastomotic site of abdominal aortic replacement. Another issue with TEVAR for chronic dissection is intimal injury at the distal end of the stent graft. As mentioned earlier, because remodeling of the true lumen can be poor in patients with chronic dissection, there is a potential risk of intimal injury (3). The minimum diameter of commercially available stent grafts is 21 mm, whereas the diameter of the true lumen of the descending thoracic aorta was 11–12 mm in the present patient. Therefore, oversizing of the stent graft would be approximately 200% in the case of normal TEVAR, and this was considered sufficiently large to create intimal injury. Landing of the device in the false lumen of the distal descending thoracic aorta may avoid the aforementioned problems associated with conventional TEVAR. Because the distal end of the device was placed in the false lumen, which potentially dilates, the possibility of developing of a thoracoabdominal aortic aneurysm still remains in the present patient. However,