Piervito D'Elia

Endovascular treatment of thoracoabdominal aortic aneurysms

BACKGROUND Development in endograft design has extended endovascular treatment to include thoracoabdominal aortic aneurysms (TAAA). We report our experience using fenestrated and branched endografts in the management of TAAA. METHODS We analyzed a cohort of consecutive patients treated electively for TAAA using endovascular techniques between 2006 and 2011. All data were collected prospectively. The relationships between preoperative risk factors and clinical outcome were examined using univariate and multivariate statistical techniques. We also compared the outcomes between 33 previously published early cases (EC) with the last 56 later cases (LC). RESULTS Eighty-nine patients (83 men) were treated. Median age was 69 years. All patients were deemed unfit for open surgery. The 30-day and in-hospital mortality rates were 8.9% and 10%, respectively. Multivariate analysis showed in-hospital mortality was associated with preoperative chronic renal failure and advanced age. Higher postoperative mean arterial blood pressure was a protective factor. Technical success rate was 96.6% (94% and 98% in the EC and LC groups, respectively; P = .14). The spinal cord ischemia (SCI) rate was 7.8% (15% and 3% in the EC and LC groups, respectively; P = .063) and was associated with chronic obstructive pulmonary disease and procedure duration. Six patients (6.7%) required temporary filtration, but none required permanent renal support (associated with left ventricular ejection fraction <40% and procedure duration). Median procedure duration decreased from 232 to 203 minutes (P = .01) in the EC and LC groups, respectively. Actuarial survival was 86.8% ± 3.7% at 1 year and 74.7% ± 6% at 2 years. CONCLUSIONS Although we have treated a cohort at high operative risk, our midterm results compare favorably with the published series of conventional surgery. Accurate hemodynamic control represented by high-normal perioperative blood pressure seems to protect against severe postoperative complications.

Endovascular Repair of Thoracoabdominal Aortic Aneurysms

OBJECTIVES To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts. DESIGN AND MATERIALS AND METHODS: A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24 months, and annually thereafter. RESULTS Thirty-three consecutive patients (30 males) were treated over 33 months (August 2006 to April 2009). Median age and aneurysm size were 70 years (range 50-83 years) and 64 mm (range 55-100 mm) respectively. 114/116 (98%) of the targeted visceral vessels were successfully catheterised and perfused. The in-hospital mortality rate was 9% (3/33). Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and permanent paraplegia in one (3%). The median follow-up period was 11 months (range 1-33 months). Endoleaks were identified in 5/33 (15%) patients: type II in four patients and a type III endoleak in one patient which required the only secondary intervention. During follow-up, two patients died: one from stroke and the other from myocardial infarction 9 and 29 months respectively after the procedure. CONCLUSION This preliminary study, which includes our learning curve, confirms the feasibility and safety of the endovascular repair of TAAA in high-risk patients. Meticulous follow-up to assess sac behaviour and visceral perfusion is critical in order to ensure optimal results of these complex endovascular repairs requiring numerous mating components.

Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study.

Prosthetic vascular graft infection (PVGI) is a devastating complication, with a mortality rate of up to 75%, which is especially caused by aortic graft infection. The purpose of this study was to evaluate factors associated with in-hospital mortality of patients with definite graft infection, and with long-term outcome. We reviewed medical records of 85 patients treated for PVGIs defined by positive bacterial culture of intraoperative specimens or blood samples, and/or clinical, biological and radiological signs of infection. In-hospital patient mortality was defined as any death occurring during the initial treatment of the graft infection. Cure was defined as the absence of evidence of relapsing infection during long-term follow-up (≥1 year). Eighty-five patients (54 aortic and 31 limb graft infections) treated by surgical debridement and removal of the infected prosthesis (n=41), surgical debridement without removal of prosthesis (n=34) or antimicrobial treatment without surgery (n=10) were studied. The only microbiological difference observed between patients with early (occurring within 4 months after surgery) vs. late PVGI and between those with aortic vs. limb PVGI was the incidence of PVGI caused by Staphylococcus aureus, which was greater in patients with limb PVGI. Overall cure was observed in 93.2% of 59 patients with a follow-up of a minimum of 1 year. Overall in-hospital mortality was 16.5% (n=14). Two variables were independently associated with mortality: age >70 years (OR 9.1, 95% CI 1.83-45.43, p 0.007) and aortic graft infection (OR 5.6, 95% CI 1.1-28.7, p 0.037).

Factors predictive of treatment failure in staphylococcal prosthetic vascular graft infections: a prospective observational cohort study: impact of rifampin

BackgroundThere exists considerable debate concerning management of prosthetic vascular graft infection (PVGI), especially in terms of antimicrobial treatment. This report studies factors associated with treatment failure in a cohort of patients with staphylococcal PVGI, along with the impact of rifampin (RIF).MethodsAll data on patients with PVGI between 2006 and 2010 were reviewed. Cure was defined as the absence of evidence of infection during the entire post-treatment follow-up for a minimum of one year. Failure was defined as any other outcome.Results84 patients (72 M/12 F, median age 64.5 ± 11 y) with diabetes mellitus (n = 25), obesity (n = 48), coronary artery disease (n = 48), renal failure (n = 24) or COPD (n = 22) were treated for PVGI (median follow-up was 470 ± 469 d). PVGI was primarily intracavitary (n = 47). Staphylococcus aureus (n = 65; including 17 methicillin-resistant S. aureus) and coagulase-negative Staphylocococcus (n = 22) were identified. Surgical treatment was performed in 71 patients. In univariate analysis, significant risk factors associated with failure were renal failure (p = 0.04), aortic aneurysm (p = 0.03), fever (p = 0.009), aneurysm disruption (p = 0.02), septic shock in the peri-operative period (p = 0.005) and antibiotic treatment containing RIF (p = 0.03). In multivariate analysis, 2 variables were independently associated with failure:septic shock [OR 4.98: CI 95% 1.45-16.99; p=0.01] and antibiotic containing rifampin [OR: 0.32: CI95% 0.10-0.96; p=0.04].ConclusionResults of the present study suggest that fever, septic shock and non-use of antibiotic treatment containing RIF are associated with poor outcome.

Challenging treatment of a secondary endoleak in a fenestrated endograft.

Purpose: To describe the novel use of an Amplatzer occluder device to seal a secondary endoleak arising at a scallop in a fenestrated stent-graft. Case Report: A 67-year-old man with comorbidities precluding standard endovascular repair of a pararenal aortic aneurysm was treated with a fenestrated endoprosthesis containing one fenestration for the left renal artery and one scallop for the celiac trunk; the right renal and superior mesenteric arteries were occluded at presentation. Interval imaging at 2 years showed a proximal type I endoleak at the celiac trunk scallop associated with expansion of the aneurysm sac. Attempted repair with an aortic extension cuff and a “chimney” stent was unsuccessful. An Amplatzer Patent Foramen Ovale occluder device was deployed across the endoleak to provide aneurysm sac exclusion, which has been maintained at 6-month follow-up. Conclusion: Treatment of a secondary type I endoleak after implantation of a fenestrated endoprosthesis is challenging. The novel use of an Amplatzer occluder in this setting may be applicable to other situations in which an endovascular solution is desirable for complications of complex endovascular aneurysm repair.

Inverted Limbs in Fenestrated and Branched Endografts

Purpose: To describe our experience with the use of custom-designed branched or fenestrated endoprostheses incorporating an inverted contralateral limb in the bifurcated component. Methods: Retrospective analysis was performed of a prospectively maintained database of all patients undergoing endovascular aneurysm repair using modular branched or fenestrated devices at a university teaching hospital between January 2004 and February 2010. Of 102 cases, 7 male patients (mean age 69 years) were treated with modular devices that incorporated an inverted contralateral limb in the bifurcated component. Five patients had thoracoabdominal aortic aneurysm (4 type IV and 1 type II), 1 patient had a pararenal abdominal aortic aneurysm, and another had type I endoleak from a migrated AneuRx stent-graft. The technique was used primarily because of an existing bifurcated prosthesis (n=5), but in 2 patients without prior open surgery, this technique was needed because of anatomical constraints. Results: All devices were implanted as planned. There was no mortality. One patient required temporary hemodialysis prior to discharge; another patient developed permanent paraplegia, likely related to extensive aortic coverage. No device migration, component separation, or type I or III endoleaks were detected during a mean follow-up of 25 months, and no reinterventions have been necessary. Conclusion: The use of an inverted limb in the bifurcated component of modular endografts may allow endovascular treatment in scenarios where there is insufficient space to deploy a standard bifurcated component. This design modification allows an adequate sealing zone between the iliac extension limbs and the bifurcated component.

Challenging catheterization of a branch in an endovascular thoracoabdominal aneurysm repair.

Purpose: To describe a novel technique of cannulating a side branch during endovascular repair of a thoracoabdominal aneurysm (TAAA). Technique: The approach evolved during endovascular repair of a type III TAAA in which a custom-designed graft with 3 caudally directed branches was being deployed in a patient who had a prior surgical repair for a type IV TAAA. Two of the branches were successfully cannulated and stented, but repeated efforts to cannulate the left renal branch and artery via the standard brachial approach were unsuccessful. A catheter positioned between the graft and the aneurysm sac was used to gain retrograde access to this branch. From a left brachial access this guidewire was snared and used to allow bridging stent deployment between the branch and the renal artery, thus completing the procedure. Conclusion: This report describes a novel technique to deal with challenging side branch cannulation that may be encountered during branched stent-graft deployment.

Hepatorenal bypass allowing fenestrated endovascular repair of juxtarenal abdominal aortic aneurysm: a case report.

A 61-year-old man presented with a 66-mm juxtarenal aortic aneurysm. He was unfit for open repair. The anatomical proximity of his right renal artery (RRA) and his superior mesenteric artery (SMA) precluded fabrication of an endograft allowing perfusion of both vessels. He underwent a hepato-renal bypass to his RRA and subsequent fenestrated endovascular aneurysm repair (EVAR) using an endoprosthesis with fenestrations for the SMA and the left renal artery (LRA), and a scallop for the coeliac trunk. Follow-up imaging showed all visceral vessels to be perfused. The use of this limited hybrid approach allows endovascular treatment of aneurysms that are initially unsuitable for such an approach.