Tommaso Cambiaghi

Endovascular Stent-Grafting of the Ascending Aorta for Symptomatic Parietal Thrombus

Purpose: To present stent-graft treatment of parietal thrombus in the ascending aorta. Case Report: A 64-year-old man with no history of vascular disease developed a right cerebral hemisphere transient ischemic attack and was diagnosed with mural thrombosis of the ascending aorta involving the greater curvature just proximal to the origin of the innominate artery. He was treated for 2 months with anticoagulants, but new imaging studies showed significant increase in the size of the thrombus and an irregular aspect. The thrombus was excluded from the aortic blood flow by deployment of a custom-made stent-graft in the ascending aorta, with embolic protection of the right internal carotid artery. At 6 months, the patient was well, and the thrombus in the ascending aorta appears to be completely excluded by the stent-graft. Conclusion: In highly selected cases, custom-made thoracic stent-grafts may be used for stabilization and exclusion of symptomatic ascending aorta parietal thrombosis to prevent progression and recurrent embolization.

Management of visceral aortic patch aneurysms after thoracoabdominal repair with open, hybrid, or endovascular approach

Objective: The objective of this study was to investigate the outcomes of patients with visceral aortic patch (VAP) aneurysms after open repair of thoracoabdominal aortic aneurysm (TAAA) treated with three different approaches: open, hybrid, and endovascular repair. Methods: Between 1993 and 2016, there were 29 cases treated for VAP aneurysm after initial TAAA open repair (median time interval, 6.2 years; interquartile range, 4‐8 years). Three different treatment modalities were employed: redo open repair (O group) in 14 cases (48.3%), hybrid repair (H group) in 10 cases (34.5%), and endovascular custom‐made fenestrated endograft repair (E group) in 5 cases (17.2%). Early (30‐day) and midterm results were recorded. The primary end point was a composite major adverse event score: any 30‐day death plus any grade ≥2 postoperative complications plus any surgical revision classified according to the Society for Vascular Surgery/American Association for Vascular Surgery reporting standards. Patients were evaluated with computed tomography scans in the outpatient clinic at 3, 6, and 12 months and annually thereafter. Results: The composite major adverse event score significantly differed among groups (O group, 79%; H group, 60%; E group, 0%; P = .009). Two cases (6.9%) of temporary delayed spinal cord ischemia (grade 1) were observed in both the E and H groups. The treatment modality employed was differently associated with blood loss ≥1000 mL (O group, 79%; H group, 40%; E group, 0%; P = .007), number of packed red blood cells transfused ≥3 units (O group, 100%; H group, 90%; E group, 40%; P = .003), intensive care unit stay >1 day (O group, 71%; H group, 70%; E group, 0%; P = .014), and length of hospital stay ≥7 days (O group, 79%; H group, 80%, E group, 20%; P = .034). At short term (6 months), we observed one endovascular reintervention in the E group and one fatal visceral graft thrombosis in the H group. At a median follow‐up of 30 months (interquartile range, 15‐75 months), we observed another aneurysm‐related death in the H group due to graft infection and four unrelated deaths (one case in the H group and two cases in the O group). Conclusions: This retrospective study confirms that repair of VAP aneurysms that develop after open repair of TAAAs can be performed with open, hybrid, and endovascular techniques. Current practice favors endovascular repair if possible, but a conclusion that it is superior to any other technique requires validation in a larger sample or a randomized trial.

Fracture of a Supera Interwoven Nitinol Stent after Treatment of Popliteal Artery Stenosis

Purpose: To present a Supera stent fracture following treatment of popliteal artery stenosis. Case Report: A 60-year-old man previously treated with angioplasty/stenting of a popliteal artery lesion with a Supera stent presented at 8 months with in-stent occlusion that proved to be secondary to stent fracture. Conclusion: Supera interwoven nitinol stents, despite having higher radial force and conformability than classic tube stents, are not free from fracture. Moreover, due to their peculiar structure, a break in these stents results in complete loss of integrity and consequent device collapse, thus jeopardizing endovascular recanalization and relining.

Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair

Objective: The aim of this study was to assess the safety and effectiveness of upper extremity access (UEA) with percutaneous closure of the axillary artery (AxA) during endovascular treatment of thoracoabdominal aortic aneurysms with fenestrated and branched endografts. Methods: Between January 2014 and 2017, 34 out of 37 patients (92%) required UEA during a staged branched and fenestrated endovascular approach. A percutaneous AxA (pAxA) approach was used in 14 consecutive patients (41%) with the off‐label use of two Perclose ProGlide (Abbott Vascular, Santa Clara, Calif) devices. The results of patients who had received a pAxA access were analyzed; technical success was defined as successful arterial closure with no evidence of persistent bleeding or arterial occlusion requiring secondary interventions. Early (30 days) and short‐term (6 months) success rates were recorded. The anatomic characteristics of the AxA of the entire cohort (34 cases) were studied. Results: Primary technical success of pAxA was 100%; in one case, an adjunctive Perclose ProGlide device was used to achieve complete closure. No secondary open or endovascular procedures were required. At predischarge computed tomography, no intimal defects, pseudoaneurysms, or signs of bleeding were observed, and all patients were discharged without neurologic deficits related to the AxA puncture site. All 14 patients are alive at follow‐up, and 9 of 14 patients completed a 6‐month clinical follow‐up with computed tomography examination; no late complications were observed at the site of UEA percutaneous repair. With regard to the anatomic characteristics of the AxA, the vessel diameters in the first and third segments were statistically different (P < .001) with a median difference of 1.5 mm (1.0‐2.0 mm), with no differences between the right and left sides. The distance between the end of the first segment of the AxA and the origin from the aortic arch was statistically different between the right and left sides, with a median difference of 36 mm (17‐50 mm). A positive linear correlation was found between the diameter of the AxA and the height of the patients. Conclusions: AxA is adequate in terms of both caliber and lack of calcifications as an access vessel for large‐sheath catheterizations, and it might be considered an alternative UEA for complex aortic endovascular procedures thanks to its proximity to visceral target vessels. In this preliminary experience, percutaneous closure of AxA access with the Perclose ProGlide device is clinically safe and technically feasible with high rates of success.

Reentry Devices for Lamella Neofenestration During Endovascular Aortic Repair of Chronic Type B Aortic Dissection

Purpose: To present a technique that creates a neofenestration in the dissecting lamella of chronic aortic dissections using standard or intravenous ultrasound (IVUS)–guided reentry devices. Technique: To create a neofenestration, a standard or IVUS-guided reentry device is deployed in either the true or false aortic lumen while a balloon is simultaneously inflated in the opposite lumen to stabilize the lamella, provide needle counterforce, and prevent displacement of the lamella away from the reentry needle. Once the lamella is perforated and a guidewire passed across the 2 lumens, progressive dilation of the neofenestration is performed to establish persistent communication. Conclusion: The balloon-supported lamella neofenestration technique involving off-label application of two currently available reentry devices can be applied to endovascular treatment chronic aortic dissections. While the technique will definitely not become a standard of practice, it provides a safe, effective, and readily available option for endovascular management of those patients with complex chronic aortic dissections requiring bailout maneuvers or elective treatment.

Preliminary Outcomes of the LifeStream Balloon-Expandable Covered Stent in Fenestrated and Branched Thoracoabdominal Endovascular Repairs:

Purpose: To evaluate the 1-year outcomes of thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent-grafts and a novel balloon-expandable covered stent. Methods: Between March 2015 and January 2017, 18 patients (median age 74.7 years; 14 men) received 43 LifeStream balloon-expandable covered stents in conjunction with Zenith fenestrated/branched stent-grafts to bridge 11 celiac trunks, 8 superior mesenteric arteries, and 24 renal arteries (total 32 fenestrations and 11 branches). Results: Stent delivery and deployment was successful in all cases. At 30 days, 5 patients presented with perifenestration endoleaks (type IIIc) secondary to inadequate sealing of the LifeStream covered stent in 7 (22%) of 32 fenestrations. No type IIIc endoleaks were reported in the branched cases. Four patients had a secondary endovascular reintervention with proximal relining by means of a bare balloon-expandable stent at the perifenestration transition area, with complete resolution of the endoleak at 1-year follow-up. One patient refused reintervention. The last 4 fenestrated stent-grafts of this series had prophylactic perifenestration bare stent relining with no evidence of type IIIc endoleaks at imaging. At a median follow-up of 14.1 months (interquartile range 11, 22), the 12-month LifeStream patency rate was 100%. Conclusion: This single-center preliminary experience with the LifeStream balloon-expandable covered stent in fenestrated/branched stent-grafts for TAAA repairs demonstrated good patency; however, an unexpectedly high rate of type IIIc endoleaks was observed. These endoleaks were resolved with reintervention or during the index procedure by proximal relining with a bare balloon-expandable stent, achieving adequate perifenestration sealing.

Custom-Made E-Vita Graft for Frozen Elephant Trunk With Arch-First Technique

A novel custom-made E-Vita Open prosthesis (JOTEC GmbH, Hechingen, Germany) has been designed with 2 additional side branches. The first one, the reperfusion branch, allows distal aortic perfusion after the collar anastomosis of a frozen elephant trunk repair has been performed. The second one, the debranching branch, permits reimplantation of any configuration of supraaortic debranching to the dacron graft. This modified graft provides two main advantages: first, combined with prior carotid-subclavian bypass and bilateral axillary perfusion, it allows continuous bihemispheric antegrade perfusion and arch-first technique under mild hypothermia (32°C); second, it grants distal aortic reperfusion after distal anastomosis completion performed under moderate hypothermia (28°C).

Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients

BACKGROUND Endotension can present a real challenge for the long-term success of endovascular aortic repair (EVAR). Sometimes, it can be associated with liver dysfunction and consequent plasmatic alterations as in the 2 cases reported here. METHODS Significant and progressive abdominal aortic aneurysms (AAA) sac enlargement, without radiologic signs of endoleak, was observed in 2 patients during a 3-year follow-up after EVAR. The first was a 70-year-old man affected by viral liver cirrhosis and the second was a 71-year-old man with cirrhosis due to alcoholic liver disease. RESULTS Both patients underwent successful conversion to open AAA repair; intraoperative findings confirmed the diagnosis of endotension. CONCLUSIONS Cirrhosis-induced plasmatic alterations may affect long-term efficacy of EVAR and should be considered when weighing endovascular treatment against open AAA repair in these high-risk patients. Surgical conversion is feasible despite the high procedural risk associated with liver disease.