Holta Kasemi

Chimney Technique for Aortic Arch Pathologies: An 11-Year Single-Center Experience

Purpose To report our single-center experience with the chimney technique for aortic arch pathologies and the mid- to long-term results in these patients. Methods From June 2002 to May 2013, 26 patients (18 men; mean age 71.2 years, 53–86) underwent thoracic endovascular aortic repair (TEVAR) combined with chimney technique. Indications for treatment were: a proximal landing zone <15 mm long distal to the left subclavian artery (LSA), thoracic aortic aneurysm (n=13), complicated type B aortic dissection (n=10), type I endoleak after previous TEVAR (n=2), and penetrating aortic ulcer (n=1). Treatment was performed in the emergency setting in 7 cases. The 28 chimney stent-grafts (double chimneys in 2 patients) were deployed in the innominate artery (n=7), left common carotid artery (n=10), and LSA (n=11). All patients underwent computed tomography before discharge, at 1, 6, and 12 months, and yearly thereafter. Results Technical success was 100%. One (3.8%) perioperative death was due to a cerebral hemorrhage. No major stroke was registered, but 3 (11.5%) minor strokes occurred (all resolved). Paraparesis developed in 2 (7.7%) patients. Median follow-up was 36.8 months (range 1–131), during which an additional 4 (15.4%) patients died, but only 1 death was aneurysm-related. Chimney graft patency was 89.3% (25/28); an asymptomatic fracture was found in a patent chimney stent-graft at the 18-month follow-up. The type I endoleak rate was 23% (n=6); 3 endoleaks associated with aneurysm sac enlargement were treated. Conclusion The chimney technique for aortic arch pathologies is safe and feasible and may be an option in patients considered at high risk for surgery or who are ineligible for conventional TEVAR, especially in the emergency setting. Concern persists regarding type I endoleak, and long-term follow-up remains mandatory.

Seven-Year Approach Evolution of the Aortoiliac Occlusive Disease Endovascular Treatment

BACKGROUND Endovascular treatment is now considered the first-line therapy for the aortoiliac occlusive disease (AIOD). We report our experience with the total endovascular treatment of infrarenal and pararenal aortoiliac occlusions and the 7-year approach evolution. METHODS A total of 22 patients underwent total endovascular treatment of AIOD from January 2008 to September 2014. Bare metal stents in kissing configuration were deployed in 9 cases, covered stents in kissing configuration in 9 patients and the aortic bifurcation reconstruction with the Y-guidewire configuration technique was performed in the last 4 patients. RESULTS Technical success was 100%. Perioperative mortality rate was 4.5%. ankle-brachial index improved from 0.49 ± 0.19 to 0.96 ± 0.05 at the right side and from 0.53 ± 0.17 0.98 ± 0.04 at the left side (P < 0.01). Mean follow-up was 39.5 months (range, 5-80 months). The primary patency rate was 95.2% at 1 year and 90.5% at 3 years, and the secondary patency rate was 95.2% at 1 year and 100% at 3 years. CONCLUSIONS Different stent types and configurations used for the aortoiliac endovascular treatment offer all the benefits of these materials for treatment on a case-by-case basis. The Y-guidewire configuration technique for the aortic bifurcation reconstruction may render the procedure more feasible. More cases and longer follow-up are necessary before the widespread use of this technique.

Endovascular Treatment Options for Complex Abdominal Aortic Aneurysms

PURPOSE To report short-term and midterm outcomes of endovascular aneurysm repair (EVAR) of complex aneurysms requiring revascularization of visceral arteries. MATERIALS AND METHODS Prospective data were collected from patients deemed unsuitable for conventional EVAR and conventional surgery who were treated with different endovascular approaches according to the clinical presentation of the aneurysm. Custom-made fenestrated endovascular aneurysm repair (CM f-EVAR) was used in the elective setting, homemade fenestrated endovascular aneurysm repair (HM f-EVAR) or HM f-EVAR combined with chimney endovascular aneurysm repair (ch-EVAR) was used in the emergent setting in patients with hemodynamic stability, and ch-EVAR was used in unstable cases. The study included 34 consecutive patients. Primary outcomes measured were perioperative mortality and morbidity, renal function impairment (RFI), target vessel patency, and survival at mean follow-up. RESULTS In the CM f-EVAR group (7 of 34 patients; 20.6%), an intraoperative type III endoleak (1 of 7 patients; 14%) sealed spontaneously. At 8.9 months of follow-up, 1 (1 of 7 patients; 14%) death and 1 (1 of 7 patients; 14%) episode of transient RFI were documented. Visceral vessel patency rate was 95.2%. In the HM f-EVAR group (4 of 34 patients; 11.7%) and the combination of HM f-EVAR and ch-EVAR group (3 of 34 patients; 8.8%), no complications were observed at 17.3 months of follow-up. In the ch-EVAR group (20 of 34 patients; 58.8%), visceral patency was 95% at 30.9 months of follow-up. Two cases of transient RFI and 2 cases of permanent RFI were registered (2 of 20 patients; 10%). One asymptomatic renal artery branch occlusion was observed at 11 months of follow-up. No endoleaks were documented. CONCLUSIONS Endovascular aneurysm repair techniques including CM f-EVAR, HM f-EVAR or HM f-EVAR in combination with ch-EVAR, and ch-EVAR are valid tools to maintain blood flow in visceral arteries during treatment of complex aortic aneurysms. The proposed interventional protocol based on clinical presentation was feasible in all cases.

Aortic Arch and Descending Thoracic Aortic Saccular Aneurysms Treatment with Fenestrated Endograft and Chimney Technique for Aortic Branch Rescue

We report the case of a 76-year-old man presented with three saccular aneurysms at the aortic arch and descending thoracic aorta. A two-staged hybrid approach was performed. A left common carotid-to-left subclavian artery bypass and a custom-made fenestrated endograft were used for the two proximal aneurysms. The endograft deployment was complicated by the unadverted coverage of the left common carotid artery ostium, promptly corrected with the chimney technique. The endovascular treatment was completed with the third endovascular aneurysm exclusion 5 months after the first procedure to reduce the risk of spinal cord ischemia. Yearly follow-up computed tomography scan confirmed aortic arch and descending thoracic aorta aneurysms exclusion with supra-aortic vessels, bypass, and stent patency. Endovascular repair of the aortic arch aneurysm with a fenestrated endograft is safe and feasible in selected patients. Complications may be solved with total endovascular approach. Long term follow-up remains mandatory.

Novel Approach for Juxtarenal Aortic Occlusion Treatment: The Y-Guidewire Configuration for Aortic Bifurcation Reconstruction

Infrarenal aortic occlusion accounts for 3–8.5 % of aortoiliac occlusive disease with the juxtarenal form affecting [50 % of patients [1, 2]. TASC II guidelines recommend reconstructive surgery as the best treatment for juxtarenal aortic occlusion (JAO) [3]. Endovascular therapies, widely used for less complex lesions, actually are becoming an attractive option for JAO treatment, especially in patients considered at high risk for open surgery. Antegrade recanalization from the brachial access and retrograde angioplasty and stenting using bare stents from bilateral femoral accesses is the treatment strategy reported [4, 5]. Protective measures for the renal arteries, such as guidewires, filters, or balloons, become necessary when the distance between the ostium of the lower renal artery and the aortic occlusion is\2 cm [1, 4]. Goverde et al. [6] performed the covered endovascular reconstruction of aortic bifurcation (CERAB) technique for extensive aortoiliac occlusive disease with balloonexpandable covered stents to limit complications, such as dissection, arterial rupture, or embolization, and to prevent late intrastent restenosis. Antegrade recanalization and retrograde stenting were performed. We report a new approach to reconstruct the aortoiliac bifurcation using self-expandable covered stents: antegrade aortic and retrograde iliac recanalization and stenting with the Y-guidewire configuration. A 58-year-old man presented to our department with lower-limb rest pain. The patient was classified as American Society of Anesthesiology category III and New York Heart Association category III. The ankle–brachial index was 0.32 (right) and 0.28 (left). Computed tomography (CT) scan showed the JAO up to the iliac artery bifurcation, two right and one left renal arteries. The distance between the lower right renal artery (2.5-mm diameter) and the occluded aorta was 3 mm. To avoid open reconstruction, the patient was offered a less invasive endovascular procedure. Written informed consent was obtained before the procedure. Institutional Review Board approval was obtained before data collection. With the patient under local anesthesia, and after systemic heparinization was achieved, a 12F, 45 cm-long sheath (Flexor RB-RAABE; Cook Medical, Bloomington, IN) was placed through an open surgical brachial access. A 7F, 90 cm-long sheath (Destination Straight CCV; Terumo, Tokyo, Japan) was introduced into the suprarenal aorta, and preliminary angiography was performed (Fig. 1). Transbrachial recanalization was obtained using a 0.03500 hydrophilic, angled guidewire (Radiofocus Guide Wire, Terumo). Once the wire crossed the proximal cap, the Destination sheath was placed inside the proximal level of the occlusion to obtain a more stable position, thus decreasing the risk of thrombus mobilization. After successful recanalization, each femoral artery was punctured under fluoroscopic guidance. After placing the 7F, G. F. Fadda C. L. Di Angelo R. Borghesi M. Marino Vascular Surgery Unit, Department of Surgery, San Francesco Hospital, Via Mannironi 1, 08100 Nuoro, Italy e-mail: gffadda@gmail.com

Hybrid Endovascular Solutions for Supra-Aortic Vessels Extra-Anatomic Bypass Infection

The use of extra-anatomic bypasses for the hybrid repair of thoracic aortic pathologies should consider the risk of vascular graft infection. Graft infections at cervical level are extremely rare and are associated with high mortality and morbidity rates. We report 2 cases of infected extra-anatomic bypasses for supra-aortic vessels debranching treated with a hybrid approach: re-extra-anatomical bypass with the Viabahn Open Revascularization Technique (VORTEC) in the first patient and the EndoVAC approach in the second case. Endovascular techniques may offer bail-out solutions in a hybrid fashion to treat vascular graft infection in patients considered unfeasible for the conventional surgical repair, associated with appropriate antibiotic therapy.

Ruptured Thoracoabdominal Aneurysm Treatment With Modified Chimney Stent Graft

A 76-year-old woman presented with symptomatic contained-ruptured thoracoabdominal aneurysm at the level of the superior mesenteric artery (SMA) and the hepatic artery origin from the SMA. The chimney technique for celiac trunk, SMA, and right renal artery (periscope configuration) was performed. An endovascular leak from the distal landing zone of the SMA stent graft was treated using a second modified stent graft with the SMA branches preservation. The 18-month follow-up computed tomography angiography demonstrated the aneurysm exclusion, no endovascular leak, and visceral and renal arteries patency.

Percutaneous Embolization of Delayed External Carotid Artery Pseudoaneurysm Eight Years after Partial Parathyroidectomy

External carotid artery pseudoaneurysm (ECAP) is very rare. The usual mechanism is trauma or iatrogenic. We report a case of a patient with an asymptomatic, chronic ECAP secondary to partial parathyroidectomy. Percutaneous injection of the 2-component Fibrin Sealant (Tisseel; Baxter int, Deerfield, IL) with the 2 active ingredients (Sealer Protein Solution and Thrombin Solution) was carried out with successful occlusion of the pseudoaneurysmal sac. The 6-month follow-up computed tomographic scan confirmed the ECAP thrombosis. The ECAP endovascular approach is less invasive and reduces the complications of the open surgical intervention, especially in high-risk patients or presenting with hostile neck.

Complicated Fenestrated Endovascular Repair of a Pararenal Aortic Aneurysm.

We report the case of a 77-year-old man treated with a custom-made fenestrated endograft for pararenal aortic aneurysm repair. Fenestrations for the superior mesenteric and both the renal arteries and augmented anterior valley and/or scallop for the celiac trunk were performed. The procedure was complicated by the superior mesenteric artery stent-graft entrapment from the endograft delivery system release wires and total dislodgement into the endograft main body. Superior mesenteric artery restenting and displaced stent-graft removal completed the intervention. Fenestrated-endograft deployment should be performed by a team familiar with the device, deployment system, and bail out solutions.

From Aortouniiliac Bifurcated to Aortobisiliac Trifurcated Endograft for Hypogastric Artery Preservation during EVAR

An 81-year-old man presented with rapid enlargement of a 2-year known abdominal aortic and common iliac aneurysms. A hybrid approach to preserve both hypogastric arteries (HAs) was planned: a bifurcated endograft for the right aortoiliac axis, right femoral-to-left femoral artery bypass, and left external-to-internal iliac artery stent graft placement. Urethral stenosis requiring an epicystostomy rendered this approach not feasible. After left HA embolization, a bifurcated endograft was deployed for the abdominal aortic aneurysm exclusion. The endograft right limb was extended using a second bifurcated endograft for the ipsilateral aortoiliac axis. Surgical femoral accesses were used for the 2 bifurcated endografts and left HA embolization. Through the left brachial access, 2 stent grafts were used to preserve the right hypogastric artery revascularization. The 5-year follow-up computed tomography scan demonstrated complete aneurysm exclusion and HA patency.