Robin Williams

Multicenter Safety and Efficacy Analysis of Assisted Closure after Antegrade Arterial Punctures Using the StarClose Device

Purpose: To evaluate the safety and efficacy of the StarClose device for closure of antegrade punctures following infrainguinal endovascular interventions. Methods: A retrospective review was conducted of 221 consecutive patients treated with the StarClose device in a 12-month period at 5 centers (4 French and 1 British). Of these, 107 patients (69 men; median age 75 years, range 44–93) were from the UK cohort (111 closures), and 94 patients (75 men; median age 67 years, range 32–95) were from the French cohort (111 closures). Technical success, complication rates, demographic data, medical history, and procedural details were gathered for all patients. Residual bleeding and the requirement for additional manual compression were recorded when the device failed. Clinical evaluation was performed at discharge; color-coded duplex ultrasonography was done in a subset of French patients. Results: The overall technical success rate was 94.6% (210/222; 95% CI 3.1%–9.2%). The results were similar in the 2 cohorts: 95.5% (106/111; 95% CI 1.9%–10.1%) in the UK and 93.7% (104/111; 95% CI 3.1%–12.4%) in France. The 12 failures (5 UK and 7 France) were due to several mechanisms: device failure (n=5), obesity (n=1), groin scarring (n=2), and unexplained (n=4). In 2 failed cases, open surgical closure of the arteriotomy was performed because pressure hemostasis failed. Two pseudoaneurysms were observed: one after immediate failure was successfully treated by prolonged pressure; the other, after apparent success of the device, required surgical therapy. The incidence of serious vascular complication was 1.8% (4/222; 95% CI 0.7%–4.5%); 2 patients from each cohort. Conclusion: The StarClose device safely and effectively closes antegrade punctures after infrainguinal endovascular intervention, even in patients who would be considered to be at high risk for puncture-site bleeding. However, a randomized trial would be required to support any definitive recommendations.

Use of a multilayered stent for the treatment of hepatic artery pseudoaneurysm after liver transplantation.

To the Editor: We would like to use this opportunity to share with the wider clinical community our experience in managing a hepatic artery pseudoaneurysm (HAP) of a 59-year-old man after liver transplant using a multilayered stent. HAP is a rare but well-recognised complication occurring after orthotopic liver transplantation (OLT). The reported incidence is 0.3% to 2.6% [1, 2]. The majority of cases of HAP occurring after OLT arise in the context of endovascular intervention or secondary to diathermy injury to the artery during surgery [3]. They have also been reported to complicate other hepato-pancreatico-biliary surgical procedures [4]. With time, the natural history of HAP is of enlargement and an associated risk of rupture, which can be fatal [5]. Patients most commonly present with intraperitoneal bleeding or gastrointestinal haemorrhage secondary to haemobilia; however, incidental and asymptomatic HAP may be recognised [6]. Established management options include surgical ligation and endovascular coil embolisation; however, both of these methods are associated with a significant risk of hepatic ischaemia, which often requires retransplantation [5]. Coronary artery stent-grafts have also been used to treat HAP, often after failure of coil embolisation [7]. The introduction of the Multilayer Aneurysm Repair System (MARS) stent (Cardiatis SA, Belgium) is a recent development in endovascular aneurysm repair. This is an uncovered stent comprised of three-dimensional braided tubing that decreases blood flow velocity in the aneurysmal sac whilst improving laminar blood flow in the main artery and surrounding arterial tributaries [8]. Its use for the treatment of HAP occurring after OLT has not previously been reported. Our case involves a 59 year-old man who underwent OLT for alcoholic cirrhosis in January 2011. The patient’s main indication for OLT was recurrent ascites. A transjugular intrahepatic portosystemic shunt was inserted in November 2010 before emergency surgical repair of a ruptured umbilical hernia. He was transplanted in early January 2011. He received a whole liver from a 74-year-old brainstem-dead donor who was involved in a road-traffic accident. His hepatectomy was performed whilst he was on veno-venous bypass and was uncomplicated. The implantation included a cavocavostomy, end-to-end pulmonary vein anastomosis using 5.0 Prolene (Ethicon, UK) suture material, end-to-end arterial anastomosis to the common hepatic artery using 6.0 Prolene (Ethicon, UK) suture material, and duct-to-duct biliary anastomosis using 5.0 polydioxanone (Ethicon, UK) suture material. The cold ischaemic time was 12 h and 40 min. During surgery, he received 4 U of blood, 1 pool of platelets, and 6 U of fresh frozen plasma. His postoperative recovery was complicated by mild acute cellular rejection on day 10, which required augmentation with intravenous methylprednisolone. He was discharged home on day 16. His immunosuppression medication included tacrolimus, azathioprine, and prednisolone. Because he was a cytomegalovirus mismatch, vanganciclovir was given for 100 days. At 3 months after OLT, the patient was admitted to our hospital for investigation of graft dysfunction. Liver histology showed evidence of perivenular haemorrhage and A. M. Elsharkawy (&) G. Sen M. Hudson S. Masson D. M. Manas Liver Unit, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, UK e-mail: ahmede@doctors.org.uk

Design of a Pulsatile Fresh Frozen Human Cadaver Circulation Model for Endovascular Training

BACKGROUND The objective of this project was to create a model capable of training endovascular skills using a freshly frozen human cadaver (HC). We present the results of our experience creating a cadaveric model for endovascular skills training. We undertook a unique cadaver laboratory-based research project. METHODS We favor a minimally invasive surgical technique with inflow into the right common carotid artery and outflow through the left common femoral and right superficial femoral arteries. Endovascular access was through the right common femoral artery. RESULTS Through this technique, the arch, thoracic, abdominal, and iliac vessels are all accessible. We perfuse the model through an open pulsatile flow circuit at varying rates to maximize angiographic image capture while minimizing cadaveric edema thus expanding the models longevity. CONCLUSIONS A fresh frozen pulsatile human cadaver training model is a feasible and credible training model that has exciting potential for endovascular skills training.

Endovascular Management of a Penetrating Abdominal Aortic Injury

Penetrating aortic trauma is associated with high mortality rates. We report the case of a 24-year-old man who presented with a self-inflicted abdominal aortic penetration injury, resulting in a pseudoaneurysm. Rather uniquely, he was managed through prophylactic stenting to his abdominal aorta; this case was also rare in that there were remarkably no associated visceral injuries. Stenting was preferred because of risks of an aortic graft in a young man. A 14-mm Atrium Advanta™ stent was deployed, and angiography confirmed adequate exclusion of the pseudoaneurysm. He had no complications at follow-up.

Angioplasty for Treatment of Isolated Below-the-Knee Arterial Stenosis in Patients With Critical Limb Ischemia:

In this issue of the journal Mendiz et al describe a large series of below knee angioplasty procedures in patients with critical limb ischemia (CLI) and reach the conclusion that this approach represents a safe and effective treatment option. Their technical results are good although there was no direct comparison with surgical bypass. In reality, there is very little level 1 evidence comparing endoarterial revascularization with bypass surgery for patients with severe lower limb ischemia. Consequently, there remains a lack of clarity as to how we should select treatment for individual patients. This issue is particularly important in diabetics where arteries proximal to the knee joint are often spared from occlusive disease and the majority of occlusions occur distal to the tibial bifurcation. Besides relieving pain and healing neuroischemic ulcers, the most important outcome in these patients is amputation-free survival. The BASIL trial randomized 452 patients to receive surgery first or angioplasty first to treat severe limb ischemia, and follow up finished when patients reached an endpoint: either the amputation of the trial leg above the ankle or death. The results showed that at 2 years, both strategies were associated with similar amputation-free and overall survival rates as well as no difference in improvements in health-related quality of life. However, for those patients who survived for at least 2 years after randomization, a bypass first strategy was associated with a significant increase in overall survival of about 7 months and a nonsignificant increase in amputation-free survival of about 6 months. This trial also demonstrated that vein bypass grafts performed significantly better than prosthetic bypass in terms of amputation-free survival but not overall survival. The authors concluded that patients who were expected to live less than 2 years should be offered balloon angioplasty first especially if the alternative was a prosthetic bypass. However, those expected to survive beyond this time, which was about 75% of the BASIL cohort, should be offered bypass first especially if a suitable vein was available. Essentially, the decision whether to perform bypass surgery or balloon angioplasty appears to depend upon life expectancy and availability of autologous vein. Of course, it may be argued that the technology associated with endovascular treatments is continually changing and improving. Drug-eluting stents have profoundly impacted coronary disease and the lower rate of in-stent restenosis associated with their use has significantly altered practice patterns. It is tempting to think that this success may be matched in small vessel disease encountered below the knee, improving patency rates and durability; however, this has not been proven as yet. Similarly, there is little level 1 evidence to support other innovative adjuncts to below the knee angioplasty such as cryotherapy and brachytherapy. Advances have undoubtedly been made in imaging and the technology required for treating the infrapopliteal arteries and to cross lesions. However, these technical advances cannot in themselves be taken to demonstrate a likelihood of a superior longer term outcome for the patient. We believe that multidisciplinary discussions are important in assessing these patients and prior to treating such lesions. Units treating patients with CLI should have the ability to offer both surgical and endovascular treatments and make sure that medical therapy is also optimized. Assessment of the availability of adequate autologous vein is paramount in the assessment for intervention and seems to vary widely between series and may depend on willingness to use contralateral veins, arm veins, as well as individual surgical experience. Mendiz and colleagues clearly recognize the limitations of their study. Further work is urgently needed to define more precisely the role of angioplasty over surgery in these difficult patients.

Use of the profunda femoris to facilitate closure of an antegrade puncture with the StarClose device after proximal SFA angioplasty.

Purpose: To report a novel technique for safely closing antegrade common femoral artery (CFA) punctures using the StarClose device after proximal superficial femoral artery (SFA) angioplasty. Technique: The vessel locator of the StarClose device should not be deployed within a recently dilated vessel, so after proximal SFA angioplasty, the sheath is withdrawn into the CFA. A second guidewire is inserted into the profunda femoris artery followed by insertion of the StarClose sheath. The vessel locator is deployed in the profunda main stem and withdrawn into the CFA until resistance is felt, indicating apposition to the luminal aspect of the vessel wall. The device is subsequently deployed according to the manufacturers instructions. Conclusion: Use of profunda femoris artery allows safe closure of the CFA using the StarClose device following antegrade puncture for proximal SFA angioplasty.

Ruptured Juxtarenal Abdominal Aortic Aneurysm Treated With a Fenestrated EVAR Graft Intended for a Different Patient.

Treatment of juxtarenal abdominal aortic aneurysms (AAAs) remains challenging. A 79-year-old male who had infrarenal endovascular repair of abdominal aortic aneurysm (EVAR) 13 years previously presented with leaking juxtarenal AAA. Emergency fenestrated EVAR (FEVAR) was performed utilizing a stent graft designed and built for a different patient. Despite the need to embolize the celiac artery prior to covering it with the stent graft in order to achieve adequate proximal seal, the patient had uneventful recovery.

Physician-Modified Fenestrated Endografts for Managing the Ruptured or Symptomatic Aortic Aneurysm: Technique Overview and Clinical Outcomes

Purpose: Fenestrated endovascular aneurysm repair (FEVAR) grafts have a 10- to 12-week manufacturing time and are generally not available for emergency cases of symptomatic or ruptured aortic aneurysm. In the absence of other alternatives, conventional off-the-shelf stent grafts can be modified by trained operators to treat these complex cases. The aim of this study is to present a single-center experience of physician-modified FEVAR. Methods: A retrospective review was performed of all physician-modified FEVAR identified from the hospital endovascular database at a single tertiary referral center between September 1996 and September 2017. Results: Eight cases of urgent or emergency endovascular aneurysm repair (EVAR) with physician-modified grafts were identified. Mean follow-up was 44 weeks (range: 5-106 weeks). Outcomes for all implanted grafts (7/8 cases) included 100% technical success, 14% rate of endoleak, no procedure-related complications, no adverse visceral events, 0% 30-day mortality and 100% 1-year target vessel patency, and freedom from aneurysm-related death. There was a 14% (1/7 cases) per patient reintervention rate. Conclusion: Modifying EVAR grafts is a highly technical process requiring meticulous planning and extensive elective experience with FEVAR. The current series demonstrates that physician modification of endografts for urgent or emergency abdominal aortic aneurysm repair is feasible and a safe alternative to open surgical aneurysm repair.

Managing a Mycotic Thoracoabdominal Aneurysm: The Importance of Molecular Diagnostics

Pneumococcal mycotic aneurysms are rare and associated with significant mortality and morbidity. Early intravenous antibiotic therapy and surgical intervention is the mainstay of treatment. Pneumococci frequently autolyze in blood cultures, making microbiological diagnosis challenging. We present the case of a man in his mid 70s with multiple thoracoabdominal mycotic aneurysms. Surgery was performed to a threatening saccular aortic arch aneurysm. Samples were sent for microbiological analysis and all were culture negative. The samples were then referred for bacterial 16S ribosomal RNA sequencing, which revealed evidence of infection with Streptococcus pneumoniae.

Anatomic factors in patient selection for carotid artery stenting (CAS): a new scoring system

Results: The 30-day mortality was 2·6% in AAD and 7·5% in CAD. The 30-day stroke and paraplegia rates were 5·3% and 0% in AAD and zero in patients with CAD. At 30 months, the cumulative re-intervention rate was 62% and 55% in AAD and CAD, respectively. In AAD, at 12 months, the false lumen thrombosis rate was 85% at the stent and 60% below it. In CAD, thrombosis rates were 68% above the stent and 33% below it. Conclusion: Aortic remodelling is greater in AAD. In AAD and in the segment, for both dissection types, false lumen thrombosis rates are higher. In AAD and CAD there is a significant re-intervention rate. The length of aorta covered with the stent should be greater, particularly in CAD.