Lukas Hechelhammer

10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned.

Objective:To evaluate a single centers 10-year experience with emergency endovascular aneurysm repair (eEVAR) in 102 patients with ruptured abdominal aortoiliac aneurysms (RAAA). Methods:Data from 102 patients (mean age, 73 ± 9 years) with RAAA treated by eEVAR from January 1998 to April 2008 were retrospectively reviewed. From January 2000, all patients were treated according to an intention-to-treat protocol. The only exclusion criterion was unsuitable anatomy. 31/102 patients had moderate shock and 14/102 patients had severe shock with a systolic blood pressure <70 mm Hg or <50 mm Hg, respectively. 71/102 procedures were carried out under local anesthesia. Endograft types used were mainly bifurcated (92/102). Open abdomen treatment (OAT) because of abdominal compartment syndrome (ACS) was used when signs of organ failure occurred and/or bladder pressure rose >20 mm Hg. Results:The 30-day mortality for eEVAR was 13% (13/102). Technical success (defined as successful deployment of the endograft, absence of extravasation in the postprocedural contrast enhanced CT scan and hemodynamic stabilization) was 99% (101/102). Nineteen unstable patients (19%) required transfemoral supraceliac aortic balloon occlusion. ACS was detected and treated by OAT in 20 patients (20%). 16 type I, 26 type II and 1 type III endoleaks were detected on postoperative CT examination. Two patients had a combined type I and II endoleak. 11 patients were retreated for immediate correction of 10 type I and 2 type II endoleaks. 6 type I and 1 type III low-flow endoleaks were observed and resolved spontaneously within 30 days. Major 30-day morbidity was 35%. Conclusion:In this 102 patient contemporary series of eEVAR for RAAA, endografting proved to be safe with a 30-day mortality of 13%. Key components of this favorable outcome result were adequate preoperative diagnostic imaging, hypotensive hemostasis, selective transfemoral supraceliac aortic balloon occlusion, predominantly local anesthesia, detection and treatment of ACS, and attention to logistics. Widespread adoption of these treatment components is recommended.

Multiple periscope and chimney grafts to treat ruptured thoracoabdominal and pararenal aortic aneurysms.

Purpose To report midterm outcomes after urgent endovascular repair of ruptured pararenal or thoracoabdominal aortic aneurysms using multiple periscope and chimney grafts to preserve renovisceral branch perfusion and facilitate aneurysm exclusion. Methods Nine consecutive men (mean age 72±14 years, range 40–88) presenting with ruptured thoracoabdominal (n=6), pararenal (n=2), or infrarenal (n=1) aortic aneurysm underwent urgent endovascular repair with at least 1 periscope graft delivered via a transfemoral access; chimney grafts were installed from an axillary access. In all, 17 periscope and 7 chimney grafts were used to reperfuse 11 renal and 13 visceral arteries in the 9 patients. The aortic aneurysms were excluded using thoracic devices (n=7), an aortic extension cuff (n=1), and bifurcated stent-grafts (n=2). Results All procedures were completed without technical complications except for a dislocated stent-graft from the right renal artery; the artery could not be re-accessed, and the right kidney was sacrificed. One patient died of multiple organ failure (11% 30-day mortality). At a mean follow-up of 10 months (range 3–24), 5 of the 9 patients had recovered completely; 3 patients died of unrelated causes. Imaging showed no aneurysm growth in any patient, with a mean 20% shrinkage in aneurysm size. All periscope and chimney grafts remained patent, and no aortic stent-graft migration was observed. Renal function and the glomerular filtration rate remained stable in all patients. Conclusion The periscope and chimney graft technique provides a simpler, less invasive way to maintain blood flow to the renovisceral arteries during urgent endovascular aortic repairs. The very low 30-day mortality rate and the stability of the repairs in the midterm are encouraging. This technique has the potential to profoundly influence the treatment of acute aortic pathologies.

Imaging findings predicting the outcome of cervical facet joint blocks

To determine which cross-sectional imaging findings predict the short-term outcome of cervical facet joint blocks (FJB) and to evaluate the effect of combined intra-/periarticular versus periarticular injection on pain. Fifty facet joints in 37 patients were included in the study. Single, unilateral FJBs in 24 patients, and bilateral single level FJBs in 13 patients were performed, respectively. In all patients, pain relief was assessed using a visual analogue scale. All computed tomography (CT) examinations were blindly reviewed by two radiologists. Osteoarthritis was rated using the Kellgren classification. The presence of combined intra-/periarticular vs. sole periarticular injection of contrast was evaluated. Kellgren Grades 0 (n=23), 1 (n=5), 2 (n=3), 3 (n=9), and 4 (n=10) were found. Mean pain relief after injection was 35% (range: 0–100%). 40% of all injections were combined intra-/periarticular. There was neither a statistically significant difference between pain relief and combined intra-/periarticular versus sole periarticular injection (p=0.64) nor the grade of osteoarthritis (p=0.49). Pain relief after cervical FJBs does not correlate with morphologic alterations seen on CT. Periarticular FJBs are not less successful than combined intra-/periarticular FJBs.

CT-guided Navigation of Percutaneous Hepatic and Renal Radiofrequency Ablation under High-frequency Jet Ventilation: Feasibility Study

PURPOSE Computed tomography (CT)-guided navigation during percutaneous radiofrequency (RF) ablations of liver and kidney lesions is hampered by respiratory motion and time-dependent lesion conspicuity after contrast agent injection. Therefore, target immobilization by general anesthesia with high-frequency jet ventilation (HFJV) instead of conventional ventilation (CV) with repeated breath-holds may facilitate and speed up navigation of RF ablation probes. MATERIALS AND METHODS Nineteen consecutive patients who underwent percutaneous RF ablation of liver (n = 9) or renal tumors (n = 10) with CT guidance under HFJV (n = 9) or CV (n = 10) were included. The choice of the anesthesiologic technique was left to the discretion of the interventionalist. Complexity of the intervention (ie, number of lesions ablated per session, conspicuity of the lesion on nonenhanced CT, and access pathway), volume of the ablated tissue, radiation exposure, and complications were compared between the HFJV and CV groups. RESULTS In this feasibility study, a statistically significant radiation dose reduction (P < .05) was noted in the HFJV group compared with the CV group for liver and renal RF ablation. No complications were observed in the HFJV group, whereas renal subcapsular hematoma (n = 2) and pulmonary embolism (n = 1) occurred in the CV group. CONCLUSIONS Percutaneous CT-guided navigation of RF ablation probes under HFJV is feasible and safe. It might be advantageous for the treatment of complex kidney and liver tumors, allowing less irradiation exposure to the patient and the interventional radiologist.

Endovascular Repair of Inflammatory Abdominal Aneurysm: A Retrospective Analysis of CT Follow-up

Retrospective radiologic and clinical midterm follow-up is reported for 10 patients with inflammatory abdominal aortic aneurysm (IAAA) after endovascular aortic aneurysm repair (EVAR). At a mean follow-up of 33 months, regression of the thickness of the perianeurysmal fibrosis (PAF) and decrease of aneurysmal sac diameter was observed in nine patients. Four EVAR-associated complications were observed: periinterventional dissection of femoral artery (n = 1), blue toe syndrome (n = 1), and stent-graft disconnection (n = 2). EVAR is the less invasive method of aneurysm exclusion in patients with IAAA with a comparable evolution of the PAF as reported after open repair.

Thrombosis of a Superior Mesenteric Vein Aneurysm: Transarterial Thrombolysis and Transhepatic Aspiration Thrombectomy

We report the case of a 31-year-old woman presenting with abdominal pain due to acute thrombosis of a superior and inferior mesenteric vein aneurysm, which was treated by a combination of arterial thrombolysis and transhepatic thrombus aspiration. At the last follow-up CT, 21 months following this procedure, there was no evidence of rethrombosis, and the patient continues to do well under oral anticoagulation. The literature regarding these uncommon mesenteric vein aneurysms without portal vein involvement, as well as their treatment options, is reviewed.

Midterm outcome of endovascular repair of ruptured isolated iliac artery aneurysms

PURPOSE This study analyzed the clinical and morphologic outcomes of endovascular treatment of ruptured isolated iliac artery aneurysms (RIIAA) at midterm follow-up. METHODS Eleven patients with RIIAA (1 woman, 10 men; mean age, 73 years; mean IIAA diameter, 69.1 mm) were identified in a single-center database of patients who underwent endovascular aortoiliac aneurysm repair between April 2001 and December 2009. Devices inserted included 9 leg endografts in 7 patients (Excluder, n=7; Zenith, n=2), 3 bifurcated stent grafts in 3 patients (Excluder), and 1 aortouniiliac stent graft in 1 patient (Zenith). Endovascular occlusion of the internal iliac artery or its branches was performed in all cases by coils (n=10) or Amplatzer occluder plug (n=1). Immediately after endovascular aneurysm exclusion, a computed tomography (CT) angiography was obtained in nine patients. Except for this adjunct postimplantation CT scanning, the imaging follow-up was the same as for nonruptured aortoiliac aneurysms at 3, 6, and 12 months and annually thereafter. RESULTS Mean delay from hospital admission to intervention was 78.5 minutes. Mean intervention time was 150 minutes. The assisted primary technical success rate was 100%. Median lengths of stay were 2 days in the intensive care unit and 13 days in the hospital. Abdominal compartment syndrome developed in three patients who received open abdomen treatment. The 30-day mortality was 18%. The mean follow-up was 23 months (range, 0-69 months). There were no late deaths during the follow-up. There was no need for late surgical conversion. Aneurysm sac shrinkage (defined as >5 mm) was recorded in five patients, whereas the sac diameter remained stable in four. There was no patient with aneurysm sac growth. Additional stent graft insertion as the only secondary intervention for a type Ib leak was performed. Type II endoleaks (primary and secondary) were found in 36% and secondary Ib in 9% of the patients. CONCLUSION Emergency stent grafting of RIIAA is feasible and safe with good midterm outcome.

Logistic Considerations for a Successful Institutional Approach to the Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

The value of emergency endovascular aneurysm repair (EVAR) in the setting of ruptured abdominal aortic aneurysm remains controversial owing to differing results. However, interpretation of published results remains difficult as there is a lack of generally accepted protocols or standard operating procedures. Furthermore, such protocols and standard operating procedures often are reported incompletely or not at all, thereby making interpretation of results difficult. We herein report our integrated logistic system for the endovascular treatment of ruptured abdominal aortic aneurysms. Important components of this system are prehospital logistics, in-hospital treatment logistics, and aftercare. Further studies should include details about all of these components, and a description of these logistic components must be included in all future studies of emergency EVAR for ruptured abdominal aortic aneurysms.

Pull-down technique to allow complete endovascular relining of failed AAA Vanguard endografts with Excluder bifurcated endografts.

INTRODUCTION Endovascular replacement of failed Vanguard endoprosthesis with a newly inserted bifurcated Excluder endograft in 6 selected patients over a 10-year period is reported. REPORT Six male patients were treated by secondary EVAR procedures for endograft failure (type I and/or III endoleaks caused by endograft disintegration and/or migration). All failed endografts (1 tube, 5 bifurcated) were Vanguard prostheses. Technically, a new bifurcated Excluder endograft was placed within the old failing Vanguard endograft. All reinterventions were performed under local anesthesia supplemented by systemic analgesia/sedation. In 3 patients, insertion of the new Excluder endograft was possible without any additional technical measure as the failing Vanguard endograft trunk had migrated distally. In another 3 patients, the failed Vanguard endograft trunk was still in place. In these patients, the Vanguard main body was pulled caudally with a transfemoral cross-over guide wire in order to gain sufficient length to allow the short limb of the Excluder endograft to open within the trunk of the failed Vanguard endoprosthesis. This guide wire was introduced through a second femoral 5F in the main access and exeteriorized with a snare through the contralateral 12 Fr sheath. The main body and short limb of the Excluder was then deployed whilst pulling on the cross-over wire. RESULTS Six patients initially treated by a Vanguard endograft underwent complete relining with a newly inserted Excluder bifurcated stentgraft. The mean interval from the first EVAR procedure to the described replacement procedure was 75+/-20.2 months (range: 53-109). The new bifurcated Excluder endografts were successfully deployed in all patients (technical success: 100%). Primary sealing (defined as absence of endoleaks type I, III or IV in the postoperative contrast enhanced CT scan) was achieved in 6 of the 6 patients. There was no operative mortality. No further endovascular or open treatment was needed in the other 5 patients. During the mean follow-up period of 26+/-20.1 months (range 2.5-50 months), 2 patients died from unrelated causes. CONCLUSION Secondary endovascular replacement of failed Vanguard endografts with a bifurcated Excluder endograft proved to be feasible and safe with no 30-day mortality. Technical detail requires traction on a cross-over wire to pull the old graft caudally and create enough space for the new bifurcated graft to be deployed.

Transvenous Biopsy of Cavo-Atrial Tumors with the Quick-Core Needle

A variant application of the renal Quick-Core needle in 3 patients with cavo-atrial tumors is reported. In all 3 patients either a transjugular or transfemoral venous biopsy approach with this device yielded sufficient tissue for histological diagnosis at the first attempt. Bioptic diagnoses were confirmed either by surgery or radiological and clinical response to a specific chemotherapy. There were no procedure-related complications.