Brian G. Peterson

Coil embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac artery occlusion

Pancreaticoduodenal arcade aneurysms are rare. Untreated, these lesions enlarge progressively and have the potential for spontaneous rupture. Aneurysmal degeneration of pancreaticoduodenal arcade vessels is known to be associated with celiac artery occlusion, vasculitis, and certain connective tissue disorders. Given their precarious location, surgical expiration is a challenging endeavor. Innovations in endovascular techniques offer a possible alternative. We report a case of a 55-year-old gentleman with a 2.2x2.1-cm aneurysm of one of the inferior pancreaticoduodenal arteries and a concomitant finding of occlusion of the celiac artery trunk. Percutaneous coil embolization of the aneurysm was employed as the treatment in this case with the successful exclusion of the aneurysm sac, while maintaining continuity of the native circulation. This case report demonstrates that, due to the success rate of aneurysm exclusion and the relatively low morbidity and mortality rates seen with endovascular repair as compared to surgical intervention, endovascular treatment has become the treatment of choice for pancreaticoduodenal artery aneurysms.

Conduits and endoconduits, percutaneous access

Despite technologic improvements in endovascular devices used to treat thoracic aortic diseases and rapidly growing physician familiarity with the use of these devices, access-related complications remain one of the most common sources of morbidity and mortality during thoracic endovascular aortic repair (TEVAR). Standard, remote arterial access through a femoral artery approach is often not possible during TEVAR when these patients have smallcaliber or diseased iliofemoral vessels. Various methods have been developed to combat these issues and include the use of open iliac conduits or direct aortic access through retroperitoneal exposures, or more recently, endoconduits that enable treatment of remote disease processes in the thoracic aorta through a femoral approach. One of the goals of this article is to discuss the options available for addressing these access-related limitations of TEVAR— conduits and endoconduits—and provide physicians with descriptions of techniques that can become part of their armamentarium in treating these difficult patients. The standard approach to the femoral arteries during TEVAR is through open groin exposure. This is largely because TEVAR requires delivery sheath sizes of 18F to 24F. An effort has been made to make these procedures even less invasive and to avoid the complications inherent in surgical exposure of the femoral arteries. As endovascular specialists have become more familiar with percutaneous closure devices routinely used in interventions that use smaller sheaths, the use of a totally percutaneous approach has been adopted by many physicians who perform TEVAR. This article will discuss the “Preclose” technique used in percutaneous endovascular aortic repair and review the current literature related to this approach. CONDUITS AND ENDOCONDUITS Besides having an adequate proximal or distal seal zone, one of the major determinants of whether a patient is a candidate for TEVAR is the status of the iliofemoral arterial system. Small-caliber vessels or the presence of occlusive disease often prevents femoral access. This, combined with the need for large-diameter delivery sheaths, makes remote

Prospective, multicenter study of endovascular repair of aortoiliac and iliac aneurysms using the Gore Iliac Branch Endoprosthesis

Objective: The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, Ariz) is an iliac branch stent graft system designed to preserve internal iliac artery perfusion during endovascular repair of aortoiliac aneurysms (AIAs) and common iliac artery (CIA) aneurysms (CIAAs). We report the 6‐month primary end point results of the IBE 12‐04 United States pivotal trial for endovascular treatment of AIAs and CIAAs using the IBE device. Methods: The trial prospectively enrolled 63 patients with AIA or CIAA who underwent implantation of the IBE device at 28 centers in the United States from 2013 to 2015. All patients underwent placement of a single IBE device. Twenty‐two patients (34.9%) with bilateral CIAs were enrolled after undergoing staged coil or plug embolization (21 of 22) or surgical revascularization (1 of 22) of the contralateral internal iliac artery. Follow‐up at 30 days and 6 months included clinical assessment and computed tomography angiography evaluation as assessed by an independent core laboratory. The primary effectiveness end point was freedom from IBE limb occlusion and reintervention for type I or III endoleak and ≥60% stenosis at 6 months, and the secondary effectiveness end point was freedom from new onset of buttock claudication on the IBE side at 6 months. Results: Mean CIA diameter on the IBE side was 41.0 ± 11.4 mm (range, 25.2‐76.3 mm). There were no procedural deaths, and technical success, defined as successful deployment and patency of all IBE components and freedom from type I or III endoleak, was 95.2% (60 of 63). Data for 61 patients were available for primary and secondary effectiveness end point analysis. Internal iliac limb patency was 95.1% (58 of 61), and no new type I or III endoleaks or device migrations were observed at 6 months. The three patients with loss of internal iliac limb patency were asymptomatic, and freedom from new‐onset buttock claudication on the IBE side was 100% at 6 months. New‐onset buttock claudication occurred on the non‐IBE treatment side in six of 21 patients (28.6%) who underwent staged internal iliac artery coil embolization. Conclusions: These results confirm that the IBE device is effective at treating CIAAs and AIAs, maintaining blood flow into the internal iliac artery, and avoiding complications associated with internal iliac artery sacrifice. Follow‐up will be continued for 5 years to establish the long‐term durability of iliac aneurysm repair with the IBE device.

Embolic Protection in Infrainguinal Interventions

The benefits of the use of embolic protection devices (EPDs) in saphenous vein coronary artery bypass grafts and carotid arteries have been shown, but the utility of their application during infrainguinal endovascular interventions is somewhat unclear. Patients with specific anatomical features or lesion characteristics, or patients undergoing specific types of endovascular interventions may benefit from the off-label use of EPDs, but this has yet to be determined. This report will examine the current literature related to the use of EPDs in infrainguinal endovascular interventions and attempt to identify the patients who would most likely benefit from their use. In addition, the setting in which EPDs have been used at one institution is briefly described. This discussion will serve as a general guideline for the use of EPDs and act as an impetus for the development of future clinical trials to help elucidate the patients who will truly benefit from EPDs use when undergoing lower extremity endovascular revascularization procedures.