Theodossios Perdikides

The Aorfix stent-graft to treat infrarenal abdominal aortic aneurysms with angulated necks and/or tortuous iliac arteries: midterm results.

Purpose: To present performance data on the use of the Aorfix stent-graft in patients with hostile infrarenal abdominal aortic aneurysm (AAA) anatomy. Methods: A study protocol was designed to examine the safety and efficacy of the Aorfix endovascular stent-graft in AAA patients who had a proximal neck diameter between 18 and 30 mm, neck angulation between 60° and 90°, and/or severe iliac artery angulation/tortuosity. Between September 2005 and April 2009, 20 men (mean age 72.4±7.7 years, range 55–89) were enrolled in the study. The mean AAA diameter was 61.8±14.9 mm (range 45.5–102). The mean angulation of the proximal neck was 61.9°±16.5° (range 30°– 90°); in the iliac arteries, the angulation was 59.9°±16.3° (range 30°–85°) for the left and 60.9°±17.6° (range 28°–90°) on the right. Fourteen (70%) patients had >60° proximal neck angulation. Outcome measures were analyzed using life-table analysis. Results: The graft was successfully implanted in all but 1 patient (technical success 95%); failure to cannulate the contralateral iliac limb resulted in conversion to aortomonoiliac stent-graft placement. In 1 patient, bilateral renal artery stent rescue was performed due to severe procedure-related stenosis. Occlusion of an internal iliac artery was noted in 2 patients. Mean follow-up was 26.9 months (range 4.5–43.5). No aneurysm-related rupture or death occurred. Two endoleaks were observed: 1 type I without migration at 3 years and 1 type II at 13 months. Freedom from any type of endoleak was 91.6% at 1 year and 75.9% at 2 years. Freedom from any early or late intervention was 88.8% at 1 year and 76.0% at 2 years. Aneurysm sac shrinkage (>5 mm) was evident in 79% (11/14) of the cases reaching 12-month follow-up. Conclusion: The Aorfix device seems to be safe and reliable in purely complex infrarenal AAA anatomy, demonstrating good short and midterm clinical outcomes. Further larger or multicenter studies are needed to confirm the suitability of the Aorfix stent-graft in hostile infrarenal AAA anatomy.

Fenestrated and Branched Grafts for Para-Anastomotic Aortic Aneurysm Repair

Purpose: To investigate the use of fenestration and branch artery stenting during endovascular stent-graft repair of para-anastomotic aneurysms (PAA). Methods: A retrospective review was conducted of 9 patients (all men; mean age 71 years, range 60–80) who received custom-designed fenestrated endoprostheses for PAA repair. Eight tubular fenestrated devices and 1 composite device (fenestrated tube plus modular bifurcated body) with a total of 31 fenestrations were used. Results: The mean operating time was 318±93 minutes (range 220–485); the mean fluoroscopy time was 77±38 minutes (range 39–158), during which a mean 121±81 mL (range 33–300) of contrast was used. Technical success was achieved in all cases. Over a mean follow-up of 12±5.5 months (range 6–24), 1 secondary intervention was carried out due to a break in a side branch stent-graft; 2 transient renal impairments and 1 permanent renal insufficiency unrelated to renal artery patency were observed. So far, no vessel loss has emerged. Conclusion: Conventional repair of PAA has been a standard procedure for many years, though it carries high surgical risk as well as perioperative mortality. Fenestrated endografts may be a promising alternative in selected patients.

Isolated Common Iliac Artery Aneurysms: A Revised Classification to Assist Endovascular Repair

Isolated common iliac artery aneurysms (CIAAs) are relatively rare; they typically progress asymptomatically and are revealed incidentally, usually after they have acquired significant dimensions. Traditional open reconstruction is associated with high morbidity and mortality rates. Rupture is a common initial manifestation. Endovascular repair has been proposed as a minimally invasive alternative, associated with lower morbidity and mortality rates, even in patients at high surgical risk; some specialists have recently proposed endoluminal repair as the first-choice procedure in suitable anatomies. However, only a few sporadic attempts have been made to define the “suitable” anatomy for endovascular repair. This article proposes a classification of isolated CIAAs and provides endovascular specialists with a guide to deciding which type of repair is feasible and efficacious according to the anatomical configuration of the aneurysm.

Percutaneous endovascular treatment of aortic aneurysms: Clinical evaluation and literature results

Abstract In this study we aimed to evaluate the efficiency of percutaneous endovascular aortic aneurysm repair (p-EVAR). Anatomically selected patients treated with a single 10Fr Perclose Prostar XL vascular closure device (VCD) were examined. Primary success rate and common femoral artery (CFA) open conversion (OC) requirement per sheath size used were recorded. A literature review on p-EVAR results was also performed. One-hundred patients were enrolled. Successful p-EVAR was achieved in 183 of the 196 CFA access sites (93.4%), and was specifically 85.9% and 98.3% for sheaths ≥20Fr and ≤18Fr respectively. There were 13 periprocedural complications (bleeding = 10, arterial dissection and thrombosis = 1, pseudoaneurysm = 2) all leading to OC. Use of ≥20Fr sheaths had significantly higher OC rate (P < .05). Reconstruction was achieved with primary repair (N = 11) and patch angioplasty (N = 2). Mean hospital stay was 1.8 days. The literature review (vascular closure of 2921 CFA access sites) revealed an overall technical success rate of 92.3%. Device related- were more common than patient related-OCs (P < .05). p-EVAR procedures are safe and feasible. Sheath size is a significant predictor of OC rate and more OCs might be expected with very large (≥20Fr) sheath sizes.

Statins and venous thromboembolism: a novel effect of statins?

ABSTRACT Statins play a key role in the management of hypercholesterolemia and other dyslipidemias. However, statins exert several other actions, often referred to as ‘pleiotropic’. This Editorial looks at the JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), examining, in particular, the occurrence of venous thromboembolism in the rosuvastatin and placebo groups, and discussing these findings in the context of the current literature. The authors conclude that statin use could perhaps be associated with reductions in the risk of venous thromboembolism, and call for further appropriately designed studies.

A novel approach to minimize sealing defects: EndoAnchors reduce gutter size in an in vitro chimney graft model.

During the past 25 years, many evolutionary devices and techniques have been invented to improve early and late outcomes related to endovascular aneurysm repair (EVAR). Unfortunately, imperfect proximal seal and fixation is still the major drawback of this technique. The chimney graft technique (Ch-EVAR) is a novel approach to deal with unfavorable infrarenal, juxtarenal, pararenal, and, rarely, thoracoabdominal (TAAA) or arch aneurysms. This technique was invented to overcome the drawbacks of the fenestrated and branched approach (F-EVAR), mainly cost and the lack of off-the-shelf availability. Unfortunately, proximal seal is imperfect due to gutters (type Ia endoleak pathways) alongside the chimney grafts that may persist over time, jeopardizing permanent sac exclusion. In this issue of the JEVT, Niepoth et al. describe the effect of adding Aptus EndoAnchors to chimney grafts in a silicone juxtarenal aortic aneurysm model to reduce the size of gutters produced between these parallel grafts and the main body stent-graft. To appreciate the magnitude of their experiment and the potential applicability to everyday clinical practice, we review the current status of proximal sealing and fixation in EVAR, as well as the techniques available to deal with complex landing zones. PROXIMAL STENT-GRAFT SEALING AND FIXATION

Bilateral giant femoropopliteal artery aneurysms: a case report

IntroductionPopliteal artery aneurysms are the most common peripheral arterial aneurysms, and are frequently bilateral. Acute limb ischemia, rupture and compression phenomena can complicate these aneurysms when the diameter exceeds 2 cm.Case PresentationWe report an 82-year-old male patient with two giant femoropopliteal aneurysms, 10.5 and 8.5 cm diameters, managed in our institution. Both aneurysms were resected and a polytetrafluoroethylene (PTFE) femoropopliteal interposition graft was placed successfully. Management and literature review are discussed.ConclusionWe believe this is the first report in the medical literature of bilateral giant femoropopliteal aneurysms.

Improving Endograft Stability by Accommodation onto the Aortic Bifurcation

Purpose: To report the technique for deploying a 3-part endovascular graft onto the native aortic bifurcation for greater stent-graft stability. Technique: The Zenith Composite Endovascular Graft is a 3-part system consisting of a proximal tubular body with an uncovered Gianturco Z stent, a distal bifurcated body, and a contralateral leg. Proximally, 8-mm flexible interstent gaps facilitate precise infrarenal aortic placement, even in angulated necks. Technically, the bifurcated part is deployed first and pulled down to the aortic bifurcation, while the tubular main body and contralateral leg deployment follow. Using this technique to accommodate the graft onto the natural aortic bifurcation, distal stability can be enhanced and graft migration minimized. Conclusion: The Composite configuration can be an alternative to ensure a higher security index in difficult anatomies. It may be beneficial in patients with short (10–15 mm), angulated (>60°), or conical necks and deserves investigation in these patient populations.

Thoracic Aortic Injury: Embolization of the Tenth Intercostal Artery and Endovascular Treatment in a Young Woman after Posterior Spinal Instrumentation.

Iatrogenic aortic injuries are rare and well-recognized complications of a variety of procedures, including spinal surgery. The placement of pedicle screws is sometimes associated with devastating consequences. Aortic perforation with rapid hematoma formation and delayed aortic trauma leading to pseudoaneurysm formation have been described in the literature. A case describing a significant time interval between iatrogenic aortic injury and diagnosis in the absence of pseudoaneurysm formation is described in this paper and, according to our knowledge, is unique in the literature. The aortic injury was successfully treated, selecting the appropriate graft and, as a consequence, normal spinal cord blood flow was achieved.

Translumbar Infusion of N-Butyl Cyanoacrylate for the Treatment of Type II Endoleaks

PURPOSE To evaluate long-term efficacy of translumbar embolization of type II endoleaks exclusively supplied by the lumbar arteries in patients with growing abdominal aortic aneurysm sacs using N-butyl cyanoacrylate (NBCA) instilled via percutaneous needle access. MATERIALS AND METHODS The study included 25 patients who developed type II endoleak after endovascular aneurysm repair. Inclusion criteria for intervention were defined as sac expansion > 5 mm detected with CT angiography at 6-month follow-up or later. Translumbar infusion of NBCA directly into the patent portion of the aneurysm sac was performed in all cases. Duplex US was performed the day after the intervention, and CT angiography was performed within the first month. Subsequently, duplex US was performed at 3, 6, and 9 months, and CT angiography or CT was performed at 12 months and annually thereafter. RESULTS Translumbar embolization was achieved in all 25 patients. The endoleak resolved in 22 patients (88%) on duplex US performed 1 day after the embolization procedure. Three patients with persistent endoleak (12%) required repeat embolization. Two complications were detected and were managed conservatively. CONCLUSIONS This study demonstrates the safety and efficacy of NBCA injection for treatment of type II endoleaks. This technique provides another option for the management of type II endoleaks.