Marcelo Ferreira

Technical aspects and midterm patency of iliac branched devices

OBJECTIVE This study presents technical aspects and initial results with iliac bifurcated devices (IBDs). METHODS Since 2006, 47 IBDs were scheduled for 37 patients who were followed up between 2 and 31 months. Iliac aneurysms were unilateral in 27 patients and bilateral in 10. Two patients with bilateral common iliac artery aneurysms (CIAAs) did not have a simultaneous aortic aneurysm. Two patients underwent combined thoracoabdominal aneurysm treatment with branched stent grafts, and one underwent combined juxtarenal aneurysm repair with a fenestrated device. The helical iliac side branch device was used in 11 CIAA (23.4%), and the Zenith bifurcated iliac side branch device was used in the remaining 36 (76.6%). RESULTS The technical success rate was 97.3% within the 47 intended-to-treat CIAAs (failure to introduce the delivery system in one case, converted to femorofemoral bypass). During follow-up, five (10.6%) hypogastric branch occlusions occurred in five patients. Two patients with bilateral repair had unilateral internal iliac artery side branch occlusions without ischemic symptoms. In contrast, of the three patients with unilateral side branch occlusion and simultaneous contralateral internal iliac artery occlusion (2 chronic and 1 coil embolization), persistent buttock claudication and sexual dysfunction developed in one. The secondary patency, including one redo case, was 87.3% at 22 months (standard error <10%). CONCLUSIONS The use of branched stent grafts is a feasible procedure, including for patients with bilateral iliac aneurysmal disease or concomitant juxtarenal or thoracoabdominal aortic disease.

Branched devices for thoracoabdominal aneurysm repair: Early experience

OBJECTIVE This study reports the initial clinical results and experience with the planning of branched stent grafts in high-risk patients with thoracoabdominal aortic aneurysms (TAAAs). METHODS High-risk patients with TAAAs were considered for this study. Based on evaluation with computed tomography angiography (CTA), 21 custom-made branched stent grafts were designed for the selected patients. Two patients had associated bilateral aneurysms of the common iliac arteries, so an iliac branched device was also used. RESULTS Between August 2006 and April 2008, 23 patients (10 women, 13 men) were selected to undergo endovascular TAAA repair. Mean age was 72 years old. Two patients were excluded after 1-mm-slice CTA analysis. Eleven patients have underdone TAAA repair so far. The mean follow-up period at present is 8 months (range, 18 days-21 months). Overall technical success was accomplished in all 11 patients. Two renal artery branches occluded. Operative times varied from 3 to 8 hours. Mean contrast volume was 193 mL (range, 48-420 mL). Eight patients required a stay of </=4 days at the intensive care unit. Three patients died. Two deaths were procedurally related: one patient died of myocardial infarction, and the other had ischemic cerebellar stroke and died 3 months later of pulmonary sepsis. The third patient was readmitted 3 days after hospital discharge and died of alcoholic pancreatitis. One man had permanent paraplegia. Two women had transitory paraparesis. Striking hematologic and systemic inflammatory abnormalities were observed. CONCLUSION Increasing reports on stent graft technology indicate that this procedure might become a reality in the future for endovascular treatment of complex aneurysms in all aortic segments. Branched stent grafts seem to be feasible and can be offered as an effective alternative to most patients with TAAAs, especially for those who are currently excluded from open surgical procedures.

Hybrid Repair of Aortic Arch Aneurysms: A Totally Extrathoracic Approach with Branched Endografts in Two Patients

Of all of the aortic segments, the aortic arch is the last frontier for endovascular treatment. The main difficulty for arch repair is the lack of an appropriate proximal landing zone of at least 2 to 3 cm required for endograft sealing and anchoring to diminish the risk of endoleaks or migration. We used branched endografts to treat two cases of aortic aneurysms that required complete arch endografting, with successful aneurysm exclusion.

Tratamento do aneurisma da aorta toracoabdominal com endoprótese ramificada para as artérias viscerais

Apresentamos um caso de aneurisma da aorta toracoabdominal (AATA) tratado, exclusivamente, pela tecnica endovascular, utilizando uma endoprotese ramificada e customizada. Paciente do sexo feminino, 68 anos de idade, tabagista, hipertensa, portadora de extenso AATA e multiplas comorbidades que restringiam a indicacao de cirurgia convencional. O aneurisma iniciava-se na aorta toracica descendente, estendendo-se ate a aorta abdominal infra-renal, envolvendo as emergencias das arterias viscerais, tronco celiaco, arterias mesenterica superior e renais. O AATA foi tratado pela tecnica endovascular com implante de uma endoprotese ramificada. Essa endoprotese ramificada foi customizada com base nas caracteristicas anatomicas da aorta e no posicionamento dos ramos viscerais, obtidos em angiotomografia, objetivando excluir o aneurisma, mantendo a perfusao das arterias viscerais. O procedimento foi realizado em centro cirurgico, sob anestesia combinada, regional e geral, antecedido de drenagem liquorica e sob orientacao fluoroscopica. O acesso para o implante do corpo principal da endoprotese ramificada e o controle radiologico foram realizados atraves das arterias femorais, previamente dissecadas. Atraves das ramificacoes da endoprotese, foram implantadas extensoes secundarias, com stents revestidos, para as respectivas arterias viscerais, cujo acesso foi realizado via arteria axilar esquerda. O tempo total do procedimento foi de 14 horas, com 4 horas e 30 minutos de fluoroscopia, e foram utilizados 120 mL de contraste iodado. No pos-operatorio, a paciente apresentou instabilidade hemodinâmica. Ecocardiograma transesofagico mostrou disseccao retrograda da aorta toracica, tipo A, seguida de trombose espontânea da falsa luz. A tomografia de controle mostrou exclusao do AATA e perviedade das pontes para os ramos viscerais, sem vazamentos. A alta ocorreu no 13o dia de pos-operatorio. O tratamento endovascular do AATA com endoprotese ramificada e factivel. A melhora dos recursos tecnicos e da qualidade dos materiais podera ampliar a indicacao desse procedimento como alternativa a cirurgia aberta.

How to Occlude a Side Branch on a Branched Stent-Graft during an Endovascular Thoracoabdominal Aortic Aneurysm Repair

Purpose: To present a means of occluding an unneeded side branch during deployment of custom-made branched stent-grafts for thoracoabdominal aortic aneurysm (TAAA) repair. Technique: When a side branch on a customized TAAA branched stent-graft is not needed, an oversized Amplatzer Vascular Plug II can be deployed inside the side branch after the other visceral artery branches have been deployed. The plugs distal disk is placed into the side branch from the aortic lumen, as though it were a bottle cap. Pulling the device backward deploys the remainder of the body inside the 18-mm-long side branch. The result is immediate and satisfactory. Conclusion: This technique should be known to any team performing TAAA repair with branched stent-grafts. It may also serve as a means of fitting a stent-graft to a different patient in an emergency setting, as in the case illustrated here.

Alternativa técnica no tratamento endovascular dos aneurismas da artéria poplítea

Popliteal artery aneurysm is relatively rare, but represents around 85% of all peripheral arterial aneurysms. It is usually presented with ischemic complication and high risk of limb loss. For that reason, its elective treatment is indicated and currently carried through with satisfactory results using endovascular techniques. We describe our experience with the use of an ePTFE-covered nitinol self-expandable stent graft - Fluency (Bard, Germany), reinforced internally with the nitinol self-expandable Zilver stent (Cook, USA) for the treatment of a popliteal artery aneurism.

The arch and beyond: bare stents in the ascending aorta.

Purpose: To describe the management of complications from an unsuccessful hybrid repair of an aortic arch aneurysm. Case Report: A 63-year-old man with acute type B dissection and retrograde dissection into the aortic arch underwent emergent hybrid repair, with partial debranching (ascending aorta to left carotid artery bypass) and proximal stent-graft deployment. At 3 months, computed tomography (CT) showed stent-graft migration, causing a large type I endoleak; flow through the patent left subclavian artery (LSA) caused a large type II endoleak. At a second operation, a bilateral subclavian-to-carotid transposition was performed; the LSA was ligated and a Zenith TX2 thoracic endograft was deployed to seal the leak. Recurrent type I endoleak a year later prompted the final endovascular solution: total supra-aortic vessel debranching, proximal stent-graft deployment, and the unprecedented use of bare Z stents in the ascending aorta. CT at 18 months confirmed stable stent-graft position and no endoleak. Conclusion: Based on this initial experience, bare Z stents can be used to enhance proximal aortic stent-graft fixation and accommodation within the aortic arch.

Endoprótese ramificada de artéria ilíaca interna no tratamento de aneurisma aórtico associado a aneurisma bilateral das artérias ilíacas comuns

Embolization of internal iliac arteries is usually performed during endovascular repair of aortoiliac aneurysms, with the aim of preventing occurrence of endoleaks. However, the association of this procedure with several postoperative sequelae is frequent, due to reduced pelvic blood flow. For this reason, there is the need to develop devices and strategies to preserve internal iliac arteries during endovascular repair of aortoiliac aneurysms. In this study, we describe a pioneering use of a Helical Sidebranch (Cook) branched stent-graft to the internal iliac artery, which was performed with immediate technical success and satisfactory postoperative control.

Commentary: new problems, new solutions: novel methods to treat a secondary type I endoleak in a fenestrated stent-graft.

Creativity is and always will be an essential requirement for the modern vascular surgeon. New technologies bring new problems to which one must find new solutions. In their article, d’Utra and colleagues from the Université Lille describe an interesting case of a type I endoleak after a fenestrated device was used for a short-necked aortic aneurysm. A proximal endoleak in a fenestrated stent-graft can be very difficult to treat without compromising the fenestrations, especially the lower one. The authors first tried a chimney technique, which proved of no value in this case, and then they were successful with an Amplatzar PFO (Patent Foramen Ovale) occluder. The chimney technique has a growing number of enthusiasts, although there is a lack of scientific data to support it. Leaks are very common after the chimney procedures, which is why we reserve them only for emergency situations where no other option is available. We have faced a similar situation, and based on that experience, we would like to propose another possible solution for this type of case. A branched extension with one branch for the renal artery and another for the celiac trunk could have fixed the problem and, in our view, perhaps have provided a better long-term result. The penalty for using a branched extension would be a higher proximal landing zone, with a theoretical increase in medullary ischemic complications. Finally, it should be understood that we are writing a new chapter in the history of vascular surgery with these new devices to treat complex aortic aneurysms. I congratulate the authors for their brilliant solution to a vexing problem.

Recanalização da artéria femoral superficial com stents Zilver: técnica padronizada e análise retrospectiva de 3 anos

OBJECTIVES: To describe the endovascular recanalization technique of the superficial femoral artery and perform a 3-year retrospective analysis of the technique. METHODS: Retrospective analysis of the patients treated between 2001 and 2004, with the aim of obtaining the patency rates of the recanalizations. The sample consisted of 79 recanalized superficial femoral arteries in 61 patients, exclusively using the described technique and the same nitinol self-expanding stent model (Zilver, COOK). RESULTS: Of the 61 patients, 8% had critical lower limb ischemia and 92% had incapacitating claudication refractory to the clinical treatment. Clinical improvement was observed and reported by the patients in a direct correlation with the recanalization patency. The statistical analysis showed accumulated assisted primary patency rates of 98, 91 and 84% in 12, 24 and 37 months, respectively. The patency rates, considered as the continuous flow in the treated area, were 96, 93 and 93% in 12, 24 and 37 months, respectively. CONCLUSIONS: We consider the recanalization technique of the superficial femoral artery a less invasive method, with few complications and considerable anatomic success and patency rates, which are able of promoting satisfaction and quality of life to patients with peripheral obstructive arterial disease.