Lukla Biasi

Intraoperative DynaCT Detection and Immediate Correction of a Type 1a Endoleak Following Endovascular Repair of Abdominal Aortic Aneurysm

Reintervention following endovascular aneurysm repair (EVAR) is required in up to 10% of patients at 30 days and is associated with a demonstrable risk of increased mortality. Completion angiography cannot detect all graft-related anomalies and computed tomographic angiography is therefore mandatory to ensure clinical success. Intraoperative angiographic computed tomography (DynaCT; Siemens, Germany) utilizes cone beam reconstruction software and flat-panel detectors to generate CT-like images from rotational angiographic acquisitions. We report the intraoperative use of this novel technology in detecting and immediately treating a proximal anterior type Ia endoleak, following an endovascular abdominal aortic repair, which was not seen on completion angiography. Immediate evaluation of cross-sectional imaging following endograft deployment may allow for on-table correction of clinically significant stent-related complications. This should both improve technical success and minimize the need for early secondary intervention following EVAR.

Hybrid repair of complex thoracoabdominal aortic aneurysms using applied endovascular strategies combined with visceral and renal revascularization

OBJECTIVE We sought to report our experience with combined retrograde visceral revascularization and endovascular exclusion (hybrid procedure) of thoracoabdominal aortic aneurysms. METHODS From February 2005 to October 2007, the prospectively collected data of 18 consecutive patients undergoing hybrid repair were analyzed. Median age was 73 years; Crawford-Safi extent included 2 type I, 8 type II, 7 type III, and 1 type V thoracoabdominal aortic aneurysms; 13 were atherosclerotic and 5 were postdissecting aneurysms. Previous open or endovascular aortic surgery had been performed in 11 (61.1%) patients. Society for Vascular Surgery/North American Chapter of the International Society for Cardiovascular Surgery preoperative risk stratification identified mild-to-severe hypertension and pulmonary and cardiac status in 88.9%, 67.7%, and 88.9% of the patients, respectively. RESULTS Fifty-four visceral vessels were bypassed in 18 patients. As an adequate inflow site, the common iliac artery was identified in 15 (83.3%) patients, the infrarenal native aorta was identified in 1 (5.6%) patient, and a previous tube graft was identified in 2 (11.1%) patients. Median operating time was 360 minutes (range, 210-600 minutes), and median blood loss was 3200 mL (range, 1000-18,000 mL). Aneurysm exclusion was achieved in 17 patients. Thirty-day mortality was 16.7% (n = 3/18). Complications included paraplegia (n = 1) and acute myocardial infarction (n = 2). Median follow-up was 23 months (range, 8-42 months), with visceral graft patency at follow-up or death of 98.1% (n = 53/54). One early and 1 late type Ia endoleak (11.8%, n = 2/17), no type III endoleaks, and 5 type II endoleaks were detected, none necessitating adjuvant procedures. CONCLUSION The visceral hybrid repair is a feasible and relatively safe procedure for extensive thoracoabdominal aortic aneurysms. Even considering the significantly high mortality and morbidity rates, it might represent a viable alternative in a cohort of patients historically deemed at high risk for traditional surgical intervention.

Intra-operative dynaCT in visceral-hybrid repair of an extensive thoracoabdominal aortic aneurysm

Fig. 1. Intra-operative Angiographic CT (DynaCT, Axiom-Artis, Siemens, Germany): a t of 50% diluted medium) is injected via a transfemoral 4F pigtail catheter. Angiograph projection, 2208 total angle, 208/s, 20 frames/s with 248 projections. The time interva with an acquisition time of 8 s (4 s delay). Multiplanar reconstructions are performed with the images being presented as maximum intensity projection images (MIP). 3574.0 microGY/m). 3-D rendering: an inverted 16 8 mm Dacron graft is anastom mesenteric artery and the coeliac trunk with a lazy ‘C’ configuration. Renal arteries a of the inflow-graft. Aneurysm exclusion is achieved by the subsequent deployment

Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization.

Central venous catheterization is routinely required in a wide range of clinical situations such as hemodynamic monitoring, delivery of blood products and drugs, hemodialysis, total parental nutrition, and management of perioperative fluids. Pseudoaneurysms account for 4% of all innominate artery aneurysms. Clinical presentation may include airway and neurological compression, chest pain, mediastinal syndrome, upper limb ischemia, and hemodynamic instability. We report what we believe is the first documented case of a successful endovascular stent-graft repair of an innominate artery iatrogenic pseudoaneurysm.

Usefulness of new imaging methods for assessment of type B aortic dissection

While the medical management of uncomplicated type B aortic dissection has good outcomes in the short term, the longer term mortality can be in the region of 50% at 5 years. Up to 40% of the survivors can have significant dilatation of the false lumen with the risk of aneurysm formation and death due to rupture. The results of the randomized controlled trials ADSORB and INSTEAD-XL have shown that beneficial aortic remodelling occurs after endoluminal stent graft placement, but these trials were underpowered to show any effect on survival. Static computed tomography (CT) angiography imaging methods have been used to try to identify high risk patients using parameters such as diameter, the position and size of the entry tear, and the amount of false lumen thrombus, but these so far are not able to clinically risk stratify individual patients. In this manuscript, we present our initial experience with new MR imaging methods. These have allowed us to develop a greater understanding of aortic dissection by providing information regarding the underlying hemodynamic and biomechanics of the dissection, as well as more accurate assessment of important clinical imaging endpoints, such as false lumen thrombosis.

Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease.

Both infrapopliteal (IP) bypass surgery and percutaneous transluminal angioplasty have been shown to be effective in patients with critical limb ischaemia (CLI). The most appropriate method of revascularization has yet to be established, as no randomized trials have been reported. The aim of this study was to compare the outcomes of patients with similar characteristics treated using either revascularization method.

Endovascular Stent Grafting of a Posterior Tibial Artery Pseudoaneurysm Secondary to Penetrating Trauma: Case Report and Review of the Literature

Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.

Superior Mesenteric Artery Aneurysm Caused by Aortic Valve Endocarditis: The Case Report and Review of the Literature.

Infectious aneurysms of the superior mesenteric artery are a rare but life-threatening condition due to the risk of visceral ischemia, sepsis, or hemorrhage. In this study, we report the case of a superior mesenteric artery aneurysm (SMAA) secondary to a bioprosthetic valve endocarditis, successfully managed with aneurysm resection and saphenous vein interposition graft. We performed an extensive PubMed-based rewiew of the literature of the last 10 years on SMAA, which include the detection of 38 articles quoting 41 SMAAs. The case histories were divided in 2 groups: 18 cases belonged to nonmycotic group A and 23 cases were included in mycotic group B. In group A, 44.4% of patients were treated surgically, whereas in group B, 90.5%. The 2 study groups significantly differed (P = .01) in terms of surgical treatment. The surgical approach still remains the first choice of treatment in mycotic aneurysm.

Atherosclerotic aneurysms. Comparisons between thoracic stentgrafts--how do we know which stent graft to select?

Abstract Surgical intervention for thoracic aortic aneurysms (TAA) greater than six centimetres is warranted in most patients deemed fit enough to withstand surgery as the annual risk of death, rupture or dissection is estimated to be 16%. Traditional surgical repair of thoracic aortic aneurysms however carries an attendant risk of significant morbidity and mortality. Endovascular repair (TEVAR) has emerged as a feasible alternative which is associated with significantly improved patient outcomes even in the highest risk patients. Improvement in stent-graft design has increased the rates of technical success of aneurysm exclusion and promises to offer further midterm reductions in the need for re-intervention and the risk of aneurysm related death. This review article highlights the advances made in thoracic stent-graft design and discusses patient outcomes for each of the most widely used endografts in clinical practice to date.