Rafael Llorens

Clinical follow‐up in endovascular treatment for TASC C‐D lesions in femoro‐popliteal segment

To demonstrate the technical success and clinical follow‐up after endovascular treatment of femoropopliteal segment TASC II C and D lesions.

Bifurcated Endoprosthesis for Treatment of Aortoiliac Occlusive Lesions

Purpose: To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease. Methods: From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter. Results: Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedurerelated complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66±0.04 before the procedure to 0.94±0.06 immediately after the procedure (p < 0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3–36), and the ABIs were stable. There was no mortality or amputation required in this series. Conclusions: Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.

Bifurcated Endograft in Aortoiliac Type C and D Lesions: Long-Term Results

PURPOSE To report long-term outcome when using a bifurcated aortic endograft for treatment of aortoiliac occlusive disease (AIOD) in Trans Atlantic Inter Society Consensus (TASC) classification C and D patients. MATERIALS AND METHODS Between May 2001 and May 2009, 14 patients (11 men, 3 women) with aortoiliac TASC C and D type lesions and a mean age of 59 years ± 10 (range 41-73 years) were treated using a bifurcated aortic endograft. Although these patients were young, all were considered at high surgical risk. Patients were followed up clinically and by computed tomography (CT) every 3 months for 1 year and yearly thereafter. RESULTS Endoprosthesis placement was performed in all patients with a technical success rate of 100%. There were no amputations or deaths at 30 days after the procedure. The mean follow-up was 62 months (range 11-96 months). One patient was lost during follow-up at 11 months, and another patient died of a nonrelated cause after 49 months. A single limb occlusion of the prosthesis was seen in two patients at 2 months and 7 months; both were successfully treated by intraarterial fibrinolysis. At a mean follow-up of 62 months, primary patency was 85.7%, and secondary patency was 100%. CONCLUSIONS This series shows promising long-term results following the use of a bifurcated aortic endograft for treatment of AIOD TASC C and D type lesions. Bifurcated aortic endograft is a good minimally invasive alternative to open surgery in high surgical risk patients.

Stent-Assisted Coil Embolization of a Mycotic Renal Artery Aneurysm by Use of a Self-Expanding Neurointerventional Stent

Mycotic aneurysms are uncommon, especially those located in visceral arteries. We present a case of a patient with two visceral mycotic aneurysms due to bacterial endocarditis, one located in right upper pole renal artery and the second in the splenic artery. Both aneurysms were treated as endovascular embolization using microcoils. In the aneurysm located at the renal artery, the technique of stent-assisted coils embolization was preferred to avoid coils migration due to its wide neck. The stent used was the Solitaire AB, which was designed for the treatment of intracranial aneurysms and was used recently in acute stroke as a mechanical thrombectomy device. Complete embolization of the aneurysm was achieved, preserving all the arterial branches without nephrogram defects in the final angiogram.

Intimal Dehiscence in the Abdominal Aorta following Balloon Fenestration for Type B Dissection

Purpose: To report a case of intimal dehiscence associated with endovascular intervention in patients with aortic dissection. Case Report: A 65-year-old man presented with a type B dissection extending to the level of the common iliac arteries. Two Talent stent-grafts were placed in the descending thoracic aorta to close the entry point, but 2 lumens remained. Three days later, abdominal pain prompted another imaging session, which demonstrated a large cylindrical filling defect in the abdominal aorta (“tube-in-tube”) assumed to be a partially or completely dehisced intima. Fenestration marginally improved flow to the visceral vessels, and the patient improved clinically. However, 4 days later, recurrent ischemic symptoms prompted surgery; a complete dehiscence of the aortic intima starting at the descending aorta extended to the distal abdominal aorta. The aorta was resected, but the patient died from disseminated intravascular coagulation. Conclusions: Intimal flap dehiscence associated with an endovascular procedure in the management of aortic dissection is an uncommon complication. Early detection and prompt surgical intervention of such a complication could save the patients life. Endovascular procedures are unlikely to resolve the hemodynamic problem caused by a dehisced, distally migrated, collapsed intima.

Endovascular Treatment of Extracranial Internal Carotid Aneurysms Using Endografts

Aneurysms of the extracranial internal carotid artery (EICA) are infrequent. They are difficult to treat with conventional surgery because of their distal extension into the skull base. We report three cases of EICA aneurysms in two symptomatic patients successfully treated with polytetrafluoroethylene self-expanding endografts using an endovascular approach. The aneurysms were located distal to the carotid bifurcation and extended to the subpetrous portion of the internal carotid artery.

Non-protected carotid artery stent without angioplasty in high-risk patients with carotid and coronary artery disease undergoing cardiac surgery

Abstract Hemodynamic depression (HD) is a frequent complication related to carotid endartherectomy or carotid artery stenting (CAS), often not well tolerated in patients with coronary artery disease. The purpose of this study is to assess whether CAS without angioplasty is beneficial in patients with severe carotid artery disease before coronary revascularization surgery (CABG) regarding the occurrence of HD. Between October 2002 and August 2006, 39 CAS were performed in 35 patients before cardiac surgery. Outcome measures, including periprocedural and 30-day post stenting and cardiac surgery complications, were assessed. Twenty-seven patients underwent CABG and eight combined CABG and valve replacement. During or immediately after CAS there was no episode of bradycardia or hypotension necessitating medical treatment. In the period between CAS-CABG, there was no case of HD. We also found no myocardial infarction. There were five neurological complications, two of them in the period between CAS-CABG (one transitory ischemic attack (TIA) and one minor stroke) and three after CABG (one TIA and two strokes). Three of them were discharged symptom-free. CAS without angioplasty can be a safe alternative to treat patients with coexistence of carotid and cardiac disease, since does not produce hemodynamic depression, therefore diminishing the cardiac complications.

Retrograde Embolization of the Left Vertebral Artery in a Type II Endoleak After Endovascular Treatment of Aortic Thoracic Rupture: Technical Note

Endoleak is a frequent complication after endovascular repair of aortic rupture. We describe the case of a female patient with traumatic aortic injury, treated with endograft, who developed a type II endoleak through the left subclavian and vertebral arteries. Both arteries originated independently from the aortic arch, and were managed with coil embolization of each vessel. We also report our experience with treating the left vertebral artery by placing a microcatheter through the right vertebral one.

Endovascular treatment for a thoracic-abdominal aortic aneurysm without fenestrations or branches

Abstract We describe a case of a patient with a thoraco-abdominal aortic aneurysm, affecting the origin of the celiac trunk, with the particularity of the normal aortic diameter in the segment between superior mesenteric artery and both renal arteries. Endovascular treatment was performed with no fenestrated or branch endoprosthesis. The procedure was divided into two steps. In the first attempt, an aortic prosthesis was deployed at the infrarenal aorta. Then, a thoracic endoprosthesis was deployed in a second procedure. In this case, the celiac trunk was intentionally occluded in order to increase the distal landing zone. At the end, the segment between the superior mesenteric artery above and below the renal arteries was covered by the uncovered struts of both endoprosthesis, with no effects in visceral artery flow. Multislice computed tomographic angiography after six months revealed complete patency of the superior mesenteric artery, both renal arteries and good back-filling of the branches of the celiac axis, with no evidence of aortic endoleak.

190. Extubación en el Quirófano Como Rutina Tras Cirugía Cardíaca: 500 Casos Consecutivos

Objetivos existen distintos protocolos de fast-track que persiguen la extubacion del paciente en el quirofano y una minima estancia en unidad de vigilancia intensiva (UVI). Este estudio analiza de forma retrospectiva la viabilidad y la seguridad de la extubacion inmediata tras cirugia cardiaca. Material y metodos se analizan 502 pacientes consecutivos no seleccionados intervenidos de cirugia cardiaca desde septiembre de 2009 a octubre de 2010, con la intencion en todos ellos de ser extubados en el quirofano. Para ello se empleo un protocolo anestesico basado en el uso de agentes de vida media ultracorta. La edad media fue de 64,7 anos (rango 25–88 anos), siendo 170 de ellos mujeres. El EuroSCORE logistico medio era de 8,17 (rango 0,88–66,6). Resultados se logro extubar en el quirofano dentro de los primeros 15 min tras el cierre de la piel a 485 pacientes (96,6%). Como factores predictores significativos de fallo en la extubacion o necesidad de reintubacion se identificaron la ventilacion mecanica previa, el tiempo de circulacion extracorporea (CEC), la disfuncion renal preoperatoria y la necesidad de nitratos endovenosos antes de la cirugia. La mortalidad hospitalaria fue del 5,8%. La estancia media en unidad de cuidados intensivos (UCI) fue 2,6 dias (rango 1–74 dias). La estancia hospitalaria media fue de 9,9 dias (rango 3–78 dias). Conclusiones la extubacion en el quirofano de forma rutinaria en pacientes sometidos a cirugia cardiaca es viable y segura. La necesidad de reintubacion o reingreso en UCI es baja. Contribuye a la recuperacion precoz del paciente y disminuye los tiempos de estancia y consumo de recursos hospitalarios.