Giuliano de A. Sandri

Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia

Objective: Retrograde open mesenteric stenting (ROMS) through laparotomy was introduced as an alternative to surgical bypass in patients with acute mesenteric ischemia (AMI). The purpose of this study was to evaluate the indications and outcomes of ROMS for treatment of AMI and chronic mesenteric ischemia. Methods: We reviewed the clinical data and outcomes of all consecutive patients treated by ROMS in seven academic centers from 2001 to 2013. ROMS was performed through laparotomy with retrograde access into the target mesenteric artery and stent placement using a retrograde or antegrade approach. End points were early (<30 days) and late mortality, morbidity, patency rates, and freedom from symptom recurrence and reintervention. Results: There were 54 patients, 13 male and 41 female, with a mean age of 72 ± 11 years. Indications for ROMS were AMI in 44 patients (81%) and subacute‐on‐chronic mesenteric ischemia with flush mesenteric occlusion in 10 patients (19%). A total of 56 target mesenteric vessels were stented, including 52 superior mesenteric arteries and 4 celiac axis lesions, with a mean treatment length of 42 ± 26 mm. Retrograde mesenteric access was used in all patients, but 16 patients also required a simultaneous antegrade brachial approach. The retrograde puncture was closed primarily in 34 patients and with patch angioplasty in 17 patients; 1 patient had manual compression. Bowel resection was needed in 29 patients (66%) with AMI because of perforation or gangrene. Technical success was achieved in all (98%) except one patient for whom ROMS failed, who was treated by bypass. Early mortality was 45% (20/44) for AMI and 10% (1/10) for subacute‐on‐chronic mesenteric ischemia (P = .04). Early morbidity was 73% for AMI and 50% for subacute‐on‐chronic mesenteric ischemia (P = .27). Patient survival for the entire cohort was 43% ± 9% at 2 years. Primary patency and secondary patency at 2 years were 76% ± 8% and 90% ± 8%, respectively. Freedom from symptom recurrence and freedom from reinterventions were 72% ± 8% and 74% ± 8% at the same interval. Conclusions: ROMS offers an alternative to bypass or percutaneous stenting in patients with AMI who require abdominal exploration and in those who have flush mesenteric occlusions and have failed to respond to or are considered unsuitable for stenting by a percutaneous approach. Despite high technical success, mortality remains elevated in patients with AMI. Patency rates and freedom from symptom recurrence and reinterventions are comparable to the results achieved with stenting using percutaneous technique.

Severe infolding of fenestrated-branched endovascular stent graft

Infolding of a fenestrated-branched stent graft is an infrequent complication due to excessive oversizing. We report the case of an 89-year-old man who underwent a four-vessel fenestrated-branched endovascular aortic repair for a pararenal aortic aneurysm. Computed tomography angiography revealed severe infolding across the mesenteric-renal vessels. The patient was treated by angioplasty and placement of Palmaz stent. Cone-beam computed tomography confirmed patent visceral vessels with resolution of the infolding. This case illustrates an uncommon complication that can be prevented by modifications in the stent design and by immediate assessment using intraoperative cone-beam computed tomography.

Outcomes of upper extremity during fenestrated-branched endovascular aortic repair

Objective Upper extremity (UE) access is frequently used during fenestrated‐branched endovascular aortic repair (F‐BEVAR) to facilitate catheterization of downgoing vessels. Limitations include risk of cerebral embolization and of UE arterial or peripheral nerve injury. The aim of this study was to assess outcomes of F‐BEVAR using UE access. Methods We reviewed the clinical data of 334 consecutive patients (74% males; mean age 75 ± 8 years) treated by F‐BEVAR for thoracoabdominal aortic aneurysms or pararenal aortic aneurysms between 2007 and 2016. Patients who underwent F‐BEVAR with an UE approach for catheterization of the renal and/or mesenteric arteries were included in the study. End points were technical success, mortality, and a composite of access‐related complications including cerebral embolization (stroke/transient ischemic attack), peripheral nerve injury, and axillary‐brachial arterial complications requiring intervention. Results There were 243 patients (73%) treated by F‐BEVAR with UE access, including 147 patients (60%) with thoracoabdominal aortic aneurysms and 96 patients (40%) with pararenal aortic aneurysms. A total of 878 renal–mesenteric arteries were incorporated by fenestrations or branches with a mean of 3.6 ± 0.8 vessels per patient. All patients had surgical exposure of the brachial artery. The left side was selected in 228 (94%) and the right side in 15 (6%). The technical success of target vessel incorporation was achieved in 99% of patients (870 of 878). Arterial closure was performed using primary repair in 213 patients (88%) or bovine patch angioplasty in 29 (12%). Patch closure was required in 13% of patients (21 of 159) treated by 10‐ to 12F sheaths and 8% (7 of 83) of those who had 7‐ to 8F sheaths (P = .19). There were six deaths (2.5%) at 30 days or within the hospital stay, none owing to access‐related complications. Major access‐related complication occurred in eight patients (3%), with no difference between the 10‐ to 12F (6 of 159 [4%]) or 7‐ to 8F sheaths (2 of 83 [2%]; P = .45). Two patients (1%) had transient median nerve neuropraxia, which resolved within 1 year. One patient (0.5%) required surgical evacuation of an access site hematoma. There were no UE arterial pseudoaneurysms, occlusions, or distal embolizations. Five patients (2%) had strokes (three minor, two major), occurring more frequently with right side (2 of 15 [13%]) as compared with left‐sided access (3 of 228 [1%]; P = .03). After a mean follow‐up of 38 ± 15 months, there were no other access‐related complications or reinterventions. Conclusions UE arterial access with surgical exposure was associated with a low rate of complications in patients treated with F‐BEVAR. Closure with patch angioplasty is frequently needed, but there were no arterial occlusions, pseudoaneurysms, or distal embolizations requiring secondary procedures. Graphical Abstract Figure. No caption available.

Up-and-Over Technique for Implantation of Iliac Branch Devices After Prior Aortic Endograft Repair:

Purpose: To describe a modified up-and-over access technique for treatment of iliac artery aneurysms in patients with prior bifurcated stent-grafts for endovascular aneurysm repair (EVAR). Technique: This technique uses a coaxial 12-F flexible sheath that is docked with a through-and-through wire into a 7-F sheath advanced from the contralateral femoral approach. This maneuver allows both sheaths to be moved as a unit while maintaining position of the apex of the system as it loops over the flow divider, avoiding damage to or displacing the extant endograft. Once the 12-F sheath is positioned in the iliac limb of the aortic stent-graft and secured in place with the through-and-through wire, the repair is extended into the internal iliac artery using a bridging stent-graft or covered stent introduced via a coaxial sheath. Conclusion: The up-and-over technique with a flexible 12-F sheath mated with a 7-F sheath from the opposite side allows bilateral femoral access to be used for iliac branch device placement after prior aortic endograft procedures that create a higher, acutely angled bifurcation. Use of a through-and-through wire and a coaxial sheath for stent delivery creates a very stable platform for intervention.

PC092 Prospective Validation of High-Fidelity Simulation of Endovascular Aortic Aneurysm Repair Using 3D Printed Aortic Model and Fluid Pump

Objectives: Median arcuate ligament syndrome (MALS) remains a challenging vascular problem to treat, in part because the symptoms overlap with many other gastrointestinal (GI) diagnoses as well as chronic abdominal pain. In our previous work, we have demonstrated that children (aged <17 years) with MALS have similar psychosocial profiles to children with other GI disorders resulting in chronic abdominal pain. The goal of this study was to outline the psychosocial profile of adults presenting with MALS, to define the patient-reported outcomes of surgery, and to determine whether psychologic comorbidities impact these outcomes. Specifically, we tested four separate hypotheses: (1) adults with MALS have psychiatric comorbidities; (2) surgery does not ameliorate these comorbidities; (3) presurgical mood symptoms would significantly impact postsurgical outcomes; and (4) quality of life (QOL) would improve overall following surgery. Methods: Patients aged >18 years were sequentially enrolled in a prospective Institutional Review Board-approved observational trial. Fiftyone patients completed psychologic and QOL assessments before and 6 months after laparoscopic release of the artery. Descriptive analyses, t-tests, and linear regressions were conducted to characterize the sample, compare hemodynamic, psychosocial, and QOL items, and determine the predictive impact of symptoms. Results: The mean follow-up for the cohort was 19.3 months. Surgery significantly improved hemodynamics in the entire cohort (peak systolic velocity, celiac/aortic ratio, respiratory variation; P < .005). Psychiatric diagnoses were common in this cohort, with 14 of 51 (27.5%) meeting criteria for a psychiatric diagnosis. There was no evidence to suggest significant differences in the number of psychiatric diagnoses between presurgical and postsurgical evaluations (P 1⁄4 .8). Having a psychiatric diagnosis at the presurgical evaluation predicted significantly lower postsurgical physical QOL (b 1⁄4 0.349, P 1⁄4 .02), work QOL (b 1⁄4 0.367, P 1⁄4 .01), psychosocial QOL (b 1⁄4 0.309, P 1⁄4 .04), and overall QOL (b 1⁄4 0.373, P 1⁄4 .01). Finally, patient-reported QOL improved following surgery (Table). Conclusions: Surgery overwhelmingly improves patient-reported QOL in patients undergoing surgery for MALS. However, psychiatric diagnoses are common in adult patients with MALS and predict worse patient-reported outcomes. This leads us to further hypothesize that treatment of psychological disorders before surgery may improve patient reported outcomes.

Planning endovascular aortic repair with standard and fenestrated-branched endografts

Endovascular aortic repair (EVAR) has been accepted as the first treatment option in most patients with infrarenal and thoracic aortic aneurysms. Advantages include its minimal invasive approach and lower risk of mortality and morbidity compared to open surgical repair. In patients with complex aneurysms involving side branches, novel techniques of parallel, fenestrated and branched endografts have expanded the indications of EVAR. Preoperative planning is of paramount importance to achieve technical success and to minimize risks of these procedures. In most centers, anatomical measurements are based on helical computed tomography angiography and/or magnetic resonance angiography. This article summarizes the most important aspects on planning standard and complex EVAR to treat aortic aneurysms and dissections.