Experience with a novel custom-made fenestrated stent graft in the repair of juxtarenal and type IV thoracoabdominal aneurysms.

OBJECTIVE: Fenestrated stent grafting has become increasingly popular as a means to manage complex aortic pathology, including juxta- and pararenal aneurysms. The design of a recently developed custom-made fenestrated stent graft, in theory, confers advantages when managing anatomically challenging aortic morphology. This study evaluated its feasibility in anatomically challenging scenarios. METHODS: Over a 12-month period, 20 patients received fenestrated stent grafts. Among those, 13 patients with juxtarenal or type IV thoracoabdominal aortic aneurysms underwent endovascular repair with the novel fenestrated stent graft at a single UK institution. Data on aneurysm morphology and immediate and short-term results were collected prospectively. RESULTS: The mean aneurysmal sac size was 7.3 cm (range, 5.5-10.0 cm). The mean infrarenal neck length was 4.4 mm (range, 0-9 mm), and in three cases was lined by a pre-existing infrarenal stent graft. Nine cases had an infrarenal neck angulation of 60(°) or more in either the anteroposterior or coronal planes. Five cases had ≥50% thrombus at the proximal landing zone. A total of 35 target vessels were cannulated, of which six right renal and four left renal arteries were angulated ≥120(°). Two-thirds of cannulated celiac trunks were angulated ≥120(°), and one cannulated superior mesenteric artery was angulated ≥ 140(°). Seven of the cannulated targets were stenosed more than 60%. One patient had two right renal arteries arising 3 mm from each other. Four right and four left common iliac arteries were angulated ≥90(°) in relation to the infrarenal aorta. Technical success was 100%. Median time from date of procedure to most recent follow-up with computed tomography scanning was 33 weeks. There was no type I or III endoleak. One type II endoleak was observed at the time of most recent computed tomography scanning and treated expectantly. There was a single incident of left renal artery occlusion. One patient required repair of a brachial artery, fasciotomies, and temporary haemofiltration. One patient died from ischemic heart disease 77 weeks after the procedure. CONCLUSIONS: The use of the novel fenestrated stent graft system in patients with hostile aortic aneurysmal morphology is feasible with acceptable short-term outcomes.

Embolization of uterine arteriovenous malformations in patients with gestational trophoblastic tumors: a review of patients at Charing Cross Hospital, 2000-2009.

OBJECTIVE: To review the indications, efficacy and follow-up for gestational trophoblastic tumor (GTT) patients treated for uterine arteriovenous vascular malformations (AVMs) and bleeding vaginal metastases with modern polyvinyl alcohol particle (PVA)-based radiological embolization. STUDY DESIGN: GTT patients undergoing embolization were identified from the Charing Cross Hospital database. The patients' records were assessed for indication, technique used, primary and overall success in controlling bleeding, complications and subsequent pregnancy outcome. RESULTS: During the period 2000-2009, 19 patients were treated for persistent or life-threatening bleeding by PVA-based uterine artery embolization performed via the femoral artery approach. Embolization resulted in control of hemorrhage in 18 of the 19 patients; 15 achieved control after the first procedure, with only 4 patients requiring a second procedure. In 1 case surgical intervention was required to control bleeding. The most frequent morbidity from the procedure was pelvic pain, requiring opiate administration; there were no other regular complications. The fertility outcome for these 19 patients indicates that 9 women have gone on to deliver a total of 12 healthy infants postembolization. CONCLUSION: For GTT patients with heavy bleeding from AVMs, uterine artery embolization is a safe and effective treatment with low short-term toxicity and no obvious detrimental effect on future fertility.

Initial experience with a new fenestrated stent graft.

OBJECTIVES: The Anaconda fenestrated stent graft (Vascutek, Inchinnan, United Kingdom) is a new device that can easily be repositioned during deployment. This study evaluated its feasibility for treating abdominal aortic aneurysms with inadequate infrarenal sealing zones. METHODS: Patients undergoing stent graft placement at two institutions in the United Kingdom were recruited. RESULTS: A total of 12 visceral vessels were accommodated with 8 fenestrations for renal arteries and 4 superior mesenteric artery valleys/scallops in 4 patients. One type Ib endoleak was identified at the 1-month follow-up and successfully treated. CONCLUSIONS: The Anaconda fenestrated stent graft device can be used for the repair of abdominal aortic aneurysms with hostile anatomy and has acceptable immediate and short-term results.

Primary suture-anastomosis of the Viabahn endoprosthesis to a native artery.

We describe the case of a ruptured woven polyester common femoral-to-popliteal artery bypass graft, in which the lack of a suitable proximal landing zone precluded a totally endovascular approach to revascularization. The patient was treated with Viabahn endoprostheses (W. L. Gore & Associates, Flagstaff, Ariz), with the proximal end of the proximal Viabahn emerging from a graft arteriotomy and sutured directly end-to-side to the native common femoral artery. We believe this is the first reported case of a sutured anastomosis of the Viabahn endoprosthesis to a native vessel. The surgical technique is illustrated, and potential indications are discussed.

Hydronephrosis after embolization of internal iliac artery aneurysms.

The treatment of internal iliac artery aneurysms is aimed at the prevention of rupture. Traditionally, this is undertaken surgically; however, endovascular techniques are an acceptable alternative and these techniques are also not without complication. Herein, the authors describe the endovascular treatment of two patients with internal iliac aneurysms. Although the treatments were initially successful, both patients presented with ureteric obstruction and hydronephrosis 2 months later.