Jos C. van den Berg

Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia

PURPOSE Open revascularization in patients with chronic mesenteric ischemia (CMI) is considered the gold standard. Percutaneous transluminal angioplasty and stenting (PTAS) is often reserved for patients not suitable for open revascularization. In our institute, endovascular revascularization is the first-choice treatment. The purpose of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive patients with CMI at a single tertiary vascular referral center. METHODS A retrospective review was performed of all consecutive patients with CMI who underwent PTAS from July 2001 to July 2008. Only symptomatic patients treated for atherosclerotic CMI were included. Patency was evaluated using computed tomography angiography (CTA). Kaplan-Meier curves were used to calculate patency rates of the treated mesenteric arteries. RESULTS Sixty mesenteric arteries (30 celiac trunks, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Major morbidity was 4%. After dissection of the superior mesenteric artery (n = 1) and brachial artery (n = 1), respectively, both patients underwent endarterectomy and patch plasty. In three arteries, the lesion could not be crossed endovascularly and they were deemed immediate intention-to-treat failures. The initial technical success rate was 93%. No 30-day mortality was observed. Median follow-up was 25 months. During follow-up, 2 patients died from intestinal ischemia. Complete symptom relief was achieved in 78% of patients. Primary 1- and 2-year patency rates were 86% +/- 5% and 60% +/- 9%, respectively; primary-assisted patency rates were 88% +/- 5% and 79% +/- 7%, respectively. During follow-up, 6 patients underwent open revascularization due to failure of PTAS. CONCLUSION The initial technical success rate of PTAS as first-choice treatment of CMI is >90%. The 2-year primary patency rate dropped to 60%, but symptomatic in-stent stenoses could often be treated successfully with renewed endovascular techniques. Including one conversion, 14% of patients needed open revascularization during follow-up.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).

Purpose To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Endovascular stent-grafting for descending thoracic aortic aneurysms

OBJECTIVE Endoluminal placement of covered stent-grafts emerges as a less-invasive alternative to open surgical repair of thoracic aortic aneurysms (TAA). The present report describes our experience with endovascular stent-grafting in the treatment of descending TAA. METHODS From 1997 to 2001, 28 descending TAAs were treated in 27 patients (17 male, mean age 70 years) by endovascular stent-grafting. The aneurysms (mean diameter, 6.6 cm) had diverse causes, but the majority were due to atherosclerosis (71%). They were predominantly localized in the proximal (32%), central (39%), and distal part (22%) of the descending thoracic aorta. In two patients (7%), the entire thoracic aorta was treated. Preliminary subclavian-carotid artery transposition was performed in five patients. AneurX (n=6), Talent (n=9), and Excluder (n=13) stent-grafts were used. In 13 cases (46%), multiple stents were necessary for complete aneurysm exclusion. RESULTS In 27 of 28 cases (96%), the endovascular stent-grafts were successfully deployed. In one patient, stent dislocation into the aneurysm required open surgical repair in a subsequent procedure. There was no operative mortality. None of the patients developed paraplegia or paraparesis. No distal embolization occurred. After a median follow-up of 21 months (range, 1-49 months), there was one non-related late death. There was no aneurysm rupture. Maximal aneurysm diameter either remained stable or decreased slightly over time in all but one patient with evidence of an endoleak. Endoleaks occurred in eight patients (29%) during follow-up. In five of them the endoleaks sealed spontaneously, whereas in two patients a distal extension was inserted. CONCLUSIONS Endovascular repair of descending TAAs is a promising less-invasive alternative to open repair. Extended follow-up is necessary to determine its definite efficacy in the longer term.

Thrombolysis for acute arterial occlusion

INTRODUCTION Acute leg ischemia is one of the most challenging and dangerous conditions in vascular surgical practice and carries a high risk of amputation and death when left untreated. This article provides an overview of the currently held opinions on the role of catheter-based thrombolytic therapy in patients with acute leg ischemia. METHODS A systematic review of literature from 1980 to 2009 was performed. The literature analyzed included randomized trials, large single-center case series, and review articles. RESULTS Three large randomized trials and 14 review articles were identified. Pharmacologic aspects and the results of thrombolytic therapy, as well as indications, contraindications, and complications are described. CONCLUSIONS Catheter-directed thrombolysis can be considered a complementary and not a competing technology with surgical or percutaneous revascularization, with an acceptably low complication rate.

Stent fracture after endoluminal repair of a carotid artery pseudoaneurysm.

Purpose: To present a case in which a covered stent fractured 7 months after implantation in the internal carotid artery (ICA). Case Report: A 59-year-old man presented with a large traumatic pseudoaneurysm of the left ICA. Seven months after successful treatment with a covered Symbiot stent, clinical complaints recurred because the pseudoaneurysm recanalized due to fracture of the stent at its midsection. Surgical stent explantation was needed, with polytetrafluoroethylene graft reconstruction of the ICA. No complications occurred in the periprocedural period. A control duplex scan 12 months later showed exclusion of the pseudoaneurysm and no graft-related complications. Conclusions: This case demonstrates an as yet unreported complication of stent-grafting in a carotid artery.

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease ☆

OBJECTIVE Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented. PATIENTS AND METHODS From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter. RESULTS Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50. CONCLUSIONS Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.

Carotid Artery Dynamics during Head Movements: A Reason for Concern with Regard to Carotid Stenting?

Purpose: To evaluate carotid artery mobility patterns during head movements following carotid angioplasty/stenting (CAS). Methods: In 7 patients (all men; mean age 69 years, range 65–76) who had undergone unilateral CAS, 3D time-of-flight magnetic resonance angiography was performed, visualizing both carotid arteries in 5 different head positions (neutral, turned left and right, and bent forward and backward). Maximum intensity projection reconstructions were obtained to measure angulation at the proximal and distal stent junction. Configuration changes of the stented section of the carotid artery and the unstented contralateral artery were judged. Secondly, transverse sections at the level of the carotid bifurcation and at the skull base were used to calculate torsion shear in the common and internal carotid arteries (CCA, ICA) during turned left and right head position. Results were expressed as median (range). Results: In neutral head position, maximal angulation at the distal stent junction was 34.3° (32.3°–55.6°). With the head bent forward, this angulation changed to 47.6° (42.6°–85.2°, p=0.028) and when bent backward to 26.5° (25.0°–48.7°, p=0.027). In all patients, configuration changes of the stented sections were absent. The contralateral unstented side showed diffuse configuration changes without specific angulation at one location. With the head turned left and right, the CCA on the stented side was subjected to 28.6° (13.6°–53.7°) and 24.9° (2.0°–50.6°) of torsion shear, respectively. Torsion of the ICA was subsequently 18.1° (12.7°–40.5°) and 15.2° (2.9°–69.4°). Conclusions: Following carotid stenting, sharp ICA angulations that are aggravated by forward bending of the head occur at the distal stent junction. The stented section of the carotid artery shows complete lack of flexibility despite highly flexible features of the stents ex vivo. Both the CCA and ICA are subjected to considerable torsion shear with the head turned left and right. This shear is not accommodated by the current stent designs.

Endovascular Recanalization of Chronic Long-Segment Occlusions of the Inferior Vena Cava: Midterm Results

Purpose: To report the midterm results of endovascular recanalization of chronic long-segment (>5 cm) occlusions of the inferior vena cava (IVC) with stent placement. Methods: Nine patients (5 men; median age 30 years, range 14–58) with disabling complaints for more than 6 months caused by IVC occlusions were treated by endovascular recanalization. Mean occlusion length was 11 cm (range 6–22); some occlusions extended to the iliac (n=3) or common femoral (n=2) veins. All procedures were performed under local anesthesia via a bilateral femoral (n=7) or popliteal (n=2) approach. In 3 patients, combined access to the brachial or internal jugular vein was necessary. Patients with acute-on-chronic thrombosis were pretreated with urokinase. After guidewire recanalization, the chronic occlusions were predilated and self-expanding Wallstents were implanted. Results: The initial technical and clinical success was 100%. The venous clinical severity score (pain, venous edema, inflammation, and active ulceration) decreased from a mean 8±2 to 5±1 after the procedure. Over a median follow-up of 9 months (mean 21, range 4–110), 3 patients died. One rethrombosis occurred, and an asymptomatic restenosis was discovered on routine imaging. The primary patency rate was 78%, and the 9-month occlusion-free survival rate was 56%. Conclusion: Endovascular recanalization of chronic long-segment occlusions of the IVC is a safe and worthwhile technique to offer patients with debilitating symptoms.

Three-Dimensional Rotational Angiography in Peripheral Endovascular Interventions

PURPOSE To demonstrate the feasibility and applicability of 3-dimensional rotational angiography (3D-RA) in the assessment of candidates for endovascular treatment of occlusive or aneurysmal arterial disease. TECHNIQUE In 3D-RA, a continuous rotation of the fluoroscopic tube around the region of interest is made while intra-arterial contrast is continuously infused. The area of interest is placed in the isocenter in both frontal and lateral planes. Images are acquired at a rate of 12.5 frames per second at a rotation speed of 30 degrees per second. Injection protocols are adjusted according to the anatomical location. The acquisition takes 8 seconds and yields 100 contrast-enhanced cinefluoroscopic images that are automatically reconstructed within 5 minutes to yield a 3D volume that can be rotated and viewed in any direction. Measuring the diameter of the target vessel and length of the lesion can be performed in the same session. An initial evaluation of this technique in 101 patients with known peripheral vascular disease yielded diagnostically adequate images preprocedurally while adding a maximum of only 10 minutes to the endovascular procedure: 5 minutes for reconstruction and another 2 to 5 minutes for measurements, which were made without difficulty in all cases. 3D-RA aided in selection of the optimal fluoroscopic tube angulation for the endovascular procedures and provided assessment of the interventional results comparable to angiography. CONCLUSIONS Our preliminary experience suggests that 3D-RA appears to be a valid tool in the pre- and periprocedural assessment of patients treated endovascularly for both aneurysmal and occlusive peripheral arterial diseases.

Use of a Balloon-Expandable, Radially Reinforced ePTFE Endograft after Remote SFA Endarterectomy: A Single-Center Experience

PURPOSE To report our experience with endovascular femoropopliteal bypass grafting using a distensible, radially reinforced polytetrafluoroethylene endograft combined with remote endarterectomy. METHODS Forty-one patients (33 men; mean age 70 years, range 45-79) with symptomatic femoropopliteal occlusive disease underwent remote endarterectomy of the superficial femoral artery (SFA) followed by implantation of a balloon-expandable Enduring endovascular graft. All patients entered an extensive surveillance program, including angiography and duplex scanning at regular intervals. RESULTS Endarterectomy and endograft implantation were ultimately successful in all patients; 5 (12%) technical difficulties occurred intraoperatively and were treated with additional endovascular techniques. Control angiography at 1 week postoperatively demonstrated a patent endograft in 39 (95%) patients. Mean ankle-brachial index increased significantly from 0.57 to 0.91 (p < 0.001). Including the 2 early failures, 18 occlusions were documented over a median 15-month follow-up (range 3-24), due mainly to significant stenosis at the proximal and distal anastomoses. In 8 of 10 successfully reopened and revised endografts, reocclusion occurred after a median interval of only 1.8 months. Life-table analysis revealed cumulative primary and secondary patency rates of 42% and 56%, respectively, at 18 months. In the last 12 cases, the proximal end of the graft was sutured end-to-end to the transected SFA, which improved the short-term secondary patency rate to 83%. CONCLUSIONS Insertion of the Enduring endovascular graft following remote endarterectomy effectively results in a less invasive treatment for femoropopliteal occlusive disease. Additional technical refinements of the procedure may be required to avoid early procedure- and graft-related failures.