Bernardo C. Mendes

Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease

OBJECTIVE To compare outcomes of mesenteric angioplasty and stenting using iCAST covered stents (CS; Atrium, Hudson, NH) or bare metal stents (BMS) in patients with chronic mesenteric ischemia (CMI). METHODS We reviewed the clinical data of 225 patients (65 male and 160 female; mean age, 72 ± 12 years) treated for CMI at two academic centers (2000-2010). Outcomes were analyzed in patients who had primary intervention or reintervention using BMS (n = 164 patients/197 vessels) or CS (n = 61 patients/67 vessels). End points were freedom from restenosis, symptom recurrence, reinterventions, and patency rates. RESULTS Patients in both groups had similar demographics, cardiovascular risk factors, and extent of disease. In the primary intervention group (mean follow-up, 29 ± 12 months), patients treated by CS had higher freedom from restenosis (92% ± 6% vs 53% ± 4%; P = .003), symptom recurrence (92 ± 4% vs 50 ± 5%; P = .003), reintervention (91% ± 6% vs 56% ± 5%; P = .005), and better primary patency at 3 years (92% ± 6% vs 52% ± 5%; P < .003) than for BMS. In the reintervention group (mean follow-up, 24 ± 9 months), patients treated by CS had higher freedom from restenosis (89% ± 10% vs 49% ± 14%; P < .04), symptom recurrence (100% vs 64%± 9%; P = .001), and reintervention (100% vs 72% ± 9%; P = .03) at 1 year, and a trend toward improved primary patency at 1 year (100% vs 63% ± 9%; P = .054). Secondary patency rates were similar in both groups. CONCLUSIONS In this nonrandomized study, CS were associated with less restenosis, recurrences, and reinterventions than BMS in patients undergoing primary interventions or reinterventions for CMI.

Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices

OBJECTIVE The purpose of this study was to evaluate the incidence and clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices (EPDs). METHODS We reviewed the clinical data of 566 patients treated by 836 endovascular femoropopliteal interventions for lower extremity claudication (46%) or critical limb ischemia (54%) from 2002 to 2012. Outcomes were analyzed in 74 patients/87 interventions performed with EPDs (Spider Rx; Covidien, Plymouth, Minn) and 513 patients/749 interventions performed without EPDs. TransAtlantic Inter-Society Consensus (TASC) II classification, runoff scores, and embolic events were analyzed. End points were morbidity, mortality, reintervention, patency, and major amputation rates. RESULTS Both groups had similar demographics, indications, cardiovascular risk factors, and runoff scores, but patients treated with EPDs had significantly (P < .05) longer lesions (109 ± 94 mm vs 85 ± 76 mm) and more often had occlusions (64% vs 30%) and TASC C/D lesions (56% vs 30%). Embolic events occurred in 35 of 836 interventions (4%), including two (2%) performed with EPD and 33 (4%) without EPD (P = .35). Macroscopic debris was noted in 59 (68%) filter baskets. Embolic events were not associated with lesion length, TASC classification, runoff scores, treatment type, or indication but were independently associated with occlusion. Patients who had embolization required more reinterventions (20% vs 3%; P < .001) and major amputations at 30 days (11% vs 3%; P = .02). There was no difference in hospital stay (2.4 ± 4 days vs 1.6 ± 2 days; P = .08), reintervention (2% vs 4%), and major amputation (1% vs 4%) among patients treated with or without EPD, respectively. The two patients who developed embolization with EPDs had no clinical sequela and required no reintervention. Most emboli were successfully treated by catheter aspiration or thrombolysis, but eight patients (24%) treated without EPD required prolonged hospital stay, seven (21%) had multiple reinterventions, one (3%) had unanticipated major amputation, and one (3%) died from hemorrhagic complications of thrombolysis. Median follow-up was 20 months. At 2 years, primary patency and freedom from reintervention was similar for TASC A/B and TASC C/D lesions treated with or without EPDs. CONCLUSIONS Rates of embolization are low in patients undergoing endovascular femoropopliteal interventions with (4%) or without (2%) EPD. Embolization is more frequent in patients with occlusions. While emboli in patients with EPD had no clinical sequel, those treated without EPD required multiple reinterventions in 21% or resulted in major amputation or death in 3%. Late outcomes were similar in patients treated with or without EPDs.

Technical aspects of repair of juxtarenal abdominal aortic aneurysms using the Zenith fenestrated endovascular stent graft

Fenestrated endovascular aortic repair has been used with increasing frequency to treat complex aortic aneurysms. The Zenith fenestrated stent graft system (Cook Medical Inc, Brisbane, Queensland, Australia) was approved for commercial use in the United States in April 2012, offering a custom-made design with up to three fenestrations to treat short-neck infrarenal and juxtarenal abdominal aortic aneurysms. This report and the Video presentation (online only) summarize the preoperative planning, stent graft design, and technique of implantation of a Zenith fenestrated stent graft using a totally percutaneous approach in an 80-year-old female patient with a 6-cm juxtarenal abdominal aortic aneurysm. The patient was dismissed home the next day without complications, and a computed tomography angiography at 12 months showed no endoleak or stent graft complications.

Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm using a physician-modified branched stent graft

Branched stent grafts have been widely applied to treat complex aortic aneurysms. The technique often requires brachial or axillary approach to provide antegrade access to directional branches, which are bridged to target visceral arteries by self-expandable stent grafts. Preloaded guidewire catheterization may facilitate access into directional branches, decreasing or eliminating catheter manipulations required during this step of the procedure. We describe the use of a physician-modified branched stent graft using preloaded guidewire catheterization to treat a patient with recurrent, type III thoracoabdominal aortic aneurysm. The procedure was performed with no complications, and total operative time was 300 minutes, fluoroscopy time was 81 minutes, and iodinated contrast dose was 210 mL. Computed tomographic angiography revealed no endoleak and widely patent branches at 2 months.

Current Role and Future Directions of Hybrid Repair of Thoracoabdominal Aortic Aneurysms

Hybrid procedures were introduced as a less invasive alternative to open conventional repair, avoiding thoracotomy, single-lung ventilation, and in many patients, aortic cross-clamping. Despite these potential advantages over open repair, results of hybrid repair have varied in the literature, with several reports indicating high morbidity and mortality rates. It is likely that once fenestrated and branched endografts receive approval from the Food and Drug Administration for clinical use, indications for hybrid repair of complex aortic aneurysms will further diminish. This article summarizes the current state of the art on patient selection, techniques, and results of hybrid procedures for the treatment of thoracoabdominal aortic aneurysms.

Pelvic Revascularization During Endovascular Aortic Aneurysm Repair

Endovascular repair of aortic aneurysms (EVAR) has gained widespread acceptance in the treatment of abdominal aortic aneurysms (AAAs). Prospective studies have shown advantages compared with open surgical repair, including decreased blood loss, operating time, hospital stay, morbidity, and mortality. Approximately 30% of patients treated by EVAR have ectatic or aneurysmal common iliac arteries not suitable for distal sealing zones. In these patients, one of the most commonly utilized options is exclusion of the internal iliac artery (IIA). Decreased pelvic perfusion carries the risk of ischemic complications, including buttock claudication, sexual dysfunction, and other devastating complications such as spinal cord injury, ischemic colitis, and gluteal muscle necrosis. This article summarizes the methods of pelvic revascularization in patients with aortoiliac aneurysms involving one or both common iliac arteries.

Endovascular Repair of Saccular Ascending Aortic Aneurysm After Orthotopic Heart Transplantation Using an Investigational Zenith Ascend Stent-Graft:

Purpose: To report the use of an investigational stent-graft to treat an ascending aortic aneurysm in a patient with a heart transplant. Case Report: A 48-year-old man presented with a 3.5×1.5-cm saccular aneurysm in the mid anterior ascending aorta, abutting the sternum. The patient’s history was notable for placement of a left ventricular assist device followed by orthotopic heart transplantation 2 years prior to treat end-stage familial dilated cardiomyopathy. Under compassionate use, a custom-designed ascending aortic stent-graft (Zenith Ascend) was successfully delivered via an 18-F system and deployed just distal to the origin of the left main coronary artery under pulmonary artery catheter–guided rapid ventricular pacing. The patient was discharged the next day, and 6-month follow-up was unremarkable. Imaging at 5 months showed an excluded aneurysm sac with no endoleak or migration. Conclusion: The ideal ascending aortic stent-graft should be low profile, conformable to the arch anatomy, with short tip delivery system and a stepwise deployment mechanism that allows precise placement relative to the ostia of the coronary arteries and the innominate artery. This case illustrates the advancement of endovascular techniques to the most challenging segment of the aorta to decrease morbidity and mortality in high-risk patients.

Patency and clinical success 22 years after the Palma procedure

Surgical reconstruction for chronic iliofemoral venous occlusive disease is rarely performed. These interventions are fraught with frequent early graft occlusions with the best results achieved with autologous venous conduits. Suprapubic great saphenous vein (GSV) transposition to bypass the occluded iliofemoral vein (IFV) with the contralateral GSV was described by Palma and Esperon with a reported patency of 70% to 85% at 3to 7-year follow-ups. Questions have been raised about longterm patency, and functional and clinical success that can be achieved with a relatively small conduit compared with the size of an iliac vein. We present a case of a patient who underwent a Palma procedure for chronic left IFV occlusion 22 years ago. The patient consented to publish this report. A 20-year-old woman presented in 1990 with symptoms of exertional pain and swelling consistent with chronic venous insufficiency without skin changes or ulcers. Two years previously she had postpartum deep venous thrombosis, treated with heparin and warfarin. A venogram showed left IFV occlusion with extensive collaterals. A Palma procedure, femorofemoral GSV transposition using the right GSV was performed (A). She was maintained with lifelong oral anticoagulation and advised to wear elastic stockings. At the 12-year follow-up, a mildly symptomatic 2.5-cm right saphenous vein aneurysm at the saphenofemoral junction was identified and a portion of the wall was excised (B). At the 22-year follow-up, the patient had minimal symptoms with no edema, skin changes, or varicosities. A computed tomography venogram showed a patent Palma graft with rapid flow, and diameter that was equal to that of the right common iliac vein, and no evidence of stenosis or aneurysm (C and D/Cover). This case shows an excellent result two decades after the Palma procedure and supports its use in select patients. Results tend to be the best in patients with good inflow, no significant infrainguinal obstruction or incompetence, and a saphenous vein size >5 mm. In our experience with 25 patients a 78% patency at 5 years was shown. Long-term dilation of the vein is possible and can provide good outflow. The Palma procedure continues to be our first treatment option for patients with symptomatic unilateral iliac vein occlusion, who are not candidates for, or in whom endovascular treatment has failed.

Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts

Objective The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated‐branched endovascular aortic repair (F‐BEVAR) and present a new classification system for assessment of AWT burden. Methods The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F‐BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal‐mesenteric (C). Volumetric measurements (cm3) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30‐day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End‐stage renal disease [RIFLE]), and solid organ infarction. Results The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal‐mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016). Conclusions AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F‐BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Posterior reversible encephalopathy syndrome from induced hypertension during endovascular thoracoabdominal aortic aneurysm repair

Endovascular repair of thoracoabdominal aortic aneurysm has been increasingly performed using fenestrated and branched endografts. Spinal cord injury is a complication of complex endovascular aortic repair, especially in patients with extensive aortic involvement. Maneuvers commonly used to avoid spinal cord injury include cerebrospinal fluid drainage and induced hypertension. Posterior reversible encephalopathy syndrome is associated with abnormal cerebral autoregulation through endothelial and blood-brain barrier dysfunction; the pathophysiology involves vasogenic edema, and severe hypertension is a recognized trigger. We report on a patient who developed posterior reversible encephalopathy syndrome associated with induced hypertension used to prevent spinal cord injury during endovascular repair of a type II thoracoabdominal aortic aneurysm using fenestrated and branched stent grafts.