Single access covered endovascular reconstruction of the aortic bifurcation.

We describe the feasibility of covered endovascular reconstruction of the aortic bifurcation (CERAB) through a single femoral access and a steerable sheath. We present the technique, which we used for a patient with severe aortoiliac calcification and bilateral involvement of the common femoral artery. The patient underwent endarterectomy of the left common femoral artery plus CERAB with an aortic stent graft and bilateral covered stents for the common iliac artery with kissing dilatation with a steerable sheath using only left femoral access. CERAB can be performed using unilateral access with the aid of a steerable sheath, reducing the potential for access site complications.

The role of thoracic endovascular repair in elective, symptomatic and ruptured thoracic aortic diseases.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) has emerged as a safe procedure in the treatment of a wide spectrum of descending thoracic aortic pathologies, with satisfactory results both in elective and urgent settings. We investigated the results of our elective, urgent and emergency TEVAR interventions. METHODS: A single-centre retrospective analysis of all consecutive patients undergoing TEVAR from 2010 to 2016 was performed. Primary end point of the study was early mortality, whereas the secondary end points included major complications according to the urgency of the procedure. The analysis was further conducted comparing symptomatic, asymptomatic and ruptured cases. RESULTS: Two hundred and eight patients were treated with TEVAR between January 2010 and April 2016 (mean age 67 ± 12 years, 142 men, 68.3%). Patients undergoing TEVAR as a first-stage procedure for complex thoraco-abdominal repair were excluded. The indication for treatment was a dissection in most cases (n = 92, 44.2%; acute dissection in 40 cases, 19.2%), followed by thoracic aneurysms (n = 64, 30.8%), penetrating aortic ulcers (n = 37, 17.8%), intramural haematomas (n = 8, 3.8%), traumatic ruptures (n = 3, 1.4%) and other indications (n = 4, 1.8%). One hundred and eight procedures were performed electively and 100 urgently. Forty-three patients were treated on an emergency bas for aortic rupture, 44 urgently for thoracic pain and 13 for acute ischaemic complications of aortic dissection or other indications. Ischaemic complications of dissection included 1 case of mesenteric ischaemia, 3 cases of acute renal failure, 4 cases of limb ischaemia and multiple ischaemic complications in 4 cases. Other causes of urgent TEVAR included 1 patient bleeding from a bronchial artery treated with TEVAR after several embolization attempts. In-hospital mortality was 7.7%, significantly higher in the urgent setting (14% vs 1.9%, P = 0.001). Urgent procedures were also more frequently associated with major adverse clinical events (7.4% vs 26%, P = 0.0003) and specifically with paraplegia (2.8% vs 10%, P = 0.043). Perioperative mortality was significantly higher in the ruptured group compared to the symptomatic group (25.6% vs 2.3%, P = 0.002). When the analysis was conducted to compare the symptomatic and the asymptomatic patients, no differences in terms of perioperative mortality were detected. CONCLUSIONS: TEVAR is an effective treatment strategy in thoracic aortic disease. Though emergency repair of the ruptured thoracic aorta still shows high rates of perioperative mortality and morbidity, symptomatic non-ruptured and asymptomatic patients have comparable early outcomes.

Fascial suture technique versus open femoral access for thoracic endovascular aortic repair.

BACKGROUND: Fascial suture technique (FST) has proved to be a safe and effective access closure technique after endovascular repair of the abdominal aorta. FST has not yet been investigated for closure of large-bore access after thoracic endovascular aortic repair (TEVAR). The aim of this study was to compare FST with open femoral access in terms of access safety, hemostasis efficacy, and reintervention rate after TEVAR. METHODS: A retrospective study including consecutive patients undergoing TEVAR with either FST or open femoral access between January 2010 and April 2016 was undertaken. Exclusion criteria included the use of closure devices. The composite primary end point was defined as any access-related complication (bleeding, femoral artery stenosis or occlusion, pseudoaneurysm, and wound infection) during 30 postoperative days. Preoperative and procedural variables were examined in a multiple logistic regression model as potential associated factors with access morbidity. All access vessels were postoperatively examined by clinical examination and computed tomography angiography before discharge as well as during the follow-up period. In case of suspected pseudoaneurysm, additional duplex ultrasound and computed tomography angiography confirmed the diagnosis. RESULTS: From a total of 206 patients undergoing TEVAR, 109 (53%) had FST, whereas 93 (45%) had an open femoral access. Four patients were excluded: closure device was used in one; one had primary conversion after percutaneous puncture without FST; and in two, no data were available about the femoral access. The access complication rate was higher in FST (FST, 14 [13%]; open access, 3 [3%]; P = .01). Five (4.6%) patients needed early reintervention, two for bleeding and three for vessel occlusion. Seven (6.4%) pseudoaneurysms were detected during the 30-day period in the FST group; three had successful exclusion with thrombin injection, one was treated with manual compression, one was treated with open repair, and two were managed conservatively. Four (3.6%) patients in the FST group and three (3%) patients in the open access group had wound complications. After multiple logistic regression, FST was the only independent factor for any access complication (odds ratio, 5.176; 95% confidence interval, 1.402-19.114; P = .014). During follow-up, neither new pseudoaneurysm nor stenosis or occlusion was detected. CONCLUSIONS: FST for large-hole closure had higher risk for any access complication compared with open access in TEVAR during the 30-day postoperative period. No other complications during 12 months of follow-up were observed in FST patients.

Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching.

PURPOSE: To analyze the renal function and outcome after delayed (>6 hours) endovascular revascularization of acute renal artery occlusion (RAO) in patients with fenestrated-branched endovascular aneurysm repairs (EVARs) or open visceral debranching. METHODS: A single-center retrospective analysis was conducted involving 7 patients (mean age 61 years, range 49-72; 5 women) with 9 RAOs treated with endovascular revascularization between December 2014 and March 2017. Three patients had a solitary kidney with chronic renal insufficiency; 1 patient had bilateral occlusions as the acute event. Initial aortic surgery included 5 branched and 1 fenestrated EVAR as well as 1 open visceral debranching operation. Revascularization of the RAO was performed using aspiration thrombectomy, local lysis therapy, and stent-graft relining. The median time between initial aortic surgery and RAO was 10 months (range 0.5-17). RESULTS: Median renal ischemic time to revascularization was 24 hours (range 7-168). Technical success was 100%, with 1 procedure-related access complication. Temporary dialysis dependency occurred in 4 patients. Mean in-hospital stay was 17 days (range 7-32) with 1 postoperative death at day 10 due to cardiac arrest of unknown cause. Mean follow-up was 10.3 months (range 1.5-27) in 5 of 6 discharged patients. During follow-up, 1 reintervention for recurrent occlusion was performed. At follow-up imaging, all renal arteries were patent. No permanent dialysis dependency occurred. CONCLUSION: Renal function can be salvaged by delayed revascularization for RAO with prolonged renal ischemia. The endovascular approach with aspiration thrombectomy, local lysis, and stent-graft relining is a feasible technique for revascularization after RAO in patients with fenestrated-branched EVAR or open visceral debranching.

Acute Type A Aortic Dissection Treated Using a Tubular Stent-Graft in the Ascending Aorta and a Multibranched Stent-Graft in the Aortic Arch.

PURPOSE: To describe the combined use of a tubular stent-graft for the ascending aorta and an inner-branched arch stent-graft for patients with acute type A aortic dissection. TECHNIQUE: The technique to deploy these modular, custom-made stent-grafts is demonstrated in 2 patients with acute DeBakey type I aortic dissections and significant comorbidities precluding open surgery. Both emergent procedures were made possible by the availability of suitable devices manufactured for elective repair in other patients. After preliminary carotid-subclavian bypass, a long Lunderquist guidewire was introduced from the right femoral artery to the left ventricle for delivery of the Zenith Ascend and Zenith Branched Arch Endovascular Grafts under inflow occlusion. Bridging stent-grafts were delivered to the innominate and left common carotid arteries to connect to the 2 inner branches; the left subclavian artery was occluded. Both cases were technically successful and resulted in exclusion of the false lumen in the ascending aorta. The operating and fluoroscopy times did not exceed those of comparable elective procedures. The patients were rapidly extubated shortly after the procedure and without serious immediate complications. One patient survived 11 months with a satisfactory repair; the other succumbed to complications of recurrent pneumonia after 23 days. CONCLUSION: Endovascular treatment of patients with acute type A aortic dissection using a combination of tubular and branched stent-grafts in the ascending aorta is feasible and offers an alternative strategy to open surgery.

Carbon Dioxide Flushing Technique to Prevent Cerebral Arterial Air Embolism and Stroke During TEVAR.

PURPOSE: To describe the technique of carbon dioxide (CO2) flushing of thoracic stent-grafts to reduce the risk of cerebral air embolism. TECHNIQUE: To remove room air, thoracic stent-grafts were preoperatively flushed 2 minutes with carbon dioxide from a cylinder connected to the flushing chamber of the captor valves of Zenith custom-made endografts; this was followed by the standard saline flush. Thirty-six patients undergoing thoracic endovascular aortic repairs (TEVAR) involving the ascending aorta and the aortic arch received CO2-flushed Zenith endografts. One patient with a highly calcified arch experienced a minor stroke. CONCLUSION: Arterial air embolism is a potentially underappreciated problem of aortic endografting, especially in the proximal segments of the aorta. CO2 flushing may have the potential to reduce air embolization during TEVAR.

How to calculate the main aortic graft-diameter for a chimney-graft.

BACKGROUND: The aim of this paper was to present a mathematical model to calculate the required main aortic graft-diameter for parallel chimney-grafts. METHODS: Geometric approximation model, developed to allow for a standardized calculation of the main aortic graft-diameter determined by the aortic diameter and the diameter of the chimney-graft. RESULTS: We propose a mathematical formula using circular segments of the aorta and the chimney-graft and provide a table with recommended main aortic graft-diameters for single chimney-grafts of 6 and 8 mm. CONCLUSION: Geometric approximation can be used to calculate the required main aortic graft-diameter. For parallel running chimney-grafts a significant degree of oversizing is necessary to allow the main aortic body to surround the chimney and to prevent the occurrence of gutters, which may cause type-1 endoleaks.

Proximal thoracic endograft displacement rescued by balloon-assisted pull-back, external shunting, and in situ fenestration of the left carotid artery.

Proximal displacement of thoracic aortic endografts is a catastrophic adverse event, which rarely occurs but is associated with extremely high morbidity and mortality. We describe herein the case of a patient with accidental proximal displacement of a thoracic endograft with occlusion of all supra-aortic branches, successfully rescued by the combination of three advanced endovascular techniques: (1) aggressive pull-back maneuver with a compliant balloon; (2) establishment of an arterio-arterial temporary shunt to the occluded carotid artery over sheaths; and (3) in-situ fenestration of the occluded carotid artery.

Transcardiac endograft delivery for endovascular treatment of the ascending aorta: a feasibility study in pigs.

PURPOSE: To compare the technical feasibility and hemodynamic alterations during antegrade transcardiac access routes vs conventional transfemoral access (TFA) for endovascular treatment of the ascending aorta in a porcine model. METHODS: Antegrade transseptal access (TSA), transapical access (TAA), and TFA were used for implantation of custom-made endografts into the ascending aorta under fluoroscopy (6 pigs each). Hemodynamic parameters, myocardial and cerebral blood flow, and carotid artery blood flow were evaluated during baseline (T1), sheath advancement (T2), after sheath retraction (T3), and after endograft deployment (T4). RESULTS: Endograft deployment was feasible in all animals; all coronary arteries remained patent. Hemodynamic parameters were comparable in all 3 study groups during all measurements. During T2, transient hemodynamic alteration occurred in all groups, with transient severe valve insufficiency in TSA and TAA reflected by the higher pulmonary to mean arterial pressure ratio (p<0.05) as compared with TFA. Values stabilized again at T3 and remained stable until T4. The innominate artery was partially occluded in 4 (TSA), 3 (TAA), and 5 (TFA) animals. There was no deterioration of myocardial or cerebral perfusion during the procedures. Endograft deployment and fluoroscopy times during TAA were shorter than in TSA and TFA. CONCLUSIONS: TSA, TFA, and TAA to the ascending aorta are feasible for endograft delivery to the ascending aorta in a porcine model. Transient hemodynamic instability in TSA and TAA recovered to near preoperative values. TAA appeared technically easier.

Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique.

PURPOSE: To describe an innovative technique to occlude distal backflow into a false lumen aneurysm by controlled rupture of the dissection membrane after stent-graft implantation. TECHNIQUE: The "Knickerbocker technique" involves relining the true lumen in the descending aorta with an oversized thoracic tubular endograft, followed by controlled rupture of the dissection membrane using a large compliant balloon within the graft's midsection. This maneuver, which allows expansion of the stent-graft's midsection into the false lumen, was developed in order to occlude the large false lumen distally and thus prevent continued false lumen perfusion through distal abdominal entry tears. The technique has been successfully used in 3 patients with ruptured or symptomatic chronic false lumen aneurysm in type B aortic dissection. There was no short-term mortality associated with the procedure. After a mean follow-up of 8 months, the false lumen aneurysm remained thrombosed, with no mortality after a mean clinical follow-up of 22 months. CONCLUSION: The Knickerbocker technique appears to be feasible and effective in inducing false lumen thrombosis in selected patients who undergo stent-grafting for chronic type B aortic dissection.

Antegrade in situ stent-graft fenestration for the renal artery following inadvertent coverage during EVAR.

PURPOSE: To report the use of antegrade in situ fenestration as a bailout technique to rescue a renal artery after inadvertent coverage during endovascular aneurysm repair (EVAR). TECHNIQUE: The technique is demonstrated in a patient with a 6-cm infrarenal abdominal aortic aneurysm (AAA) and a short, angulated proximal neck. A type I endoleak persisted on completion angiography after implantation of a bifurcated Zenith stent-graft despite dilation with a compliant balloon. A Giant Palmaz stent mounted on a large compliant balloon successfully resolved the endoleak. After placing the stent, the left renal artery was covered completely by the main aortic graft material, leading to only marginal opacification on angiography. To preserve flow to the renal artery, a transseptal sheath and transseptal needle were introduced from the right femoral artery and used to puncture the abdominal stent-graft antegrade at the site of the left renal artery. A 0.018-inch guidewire could then be introduced into the left renal artery; following a number of maneuvers, a balloon-expandable stent was placed through the fenestration into the target vessel. On computed tomographic angiography 4 days postoperatively, the AAA remained excluded and both renal arteries were patent, with all side branches fully preserved. Renal function was completely restored. CONCLUSION: Antegrade in situ fenestration can facilitate immediate revascularization of inadvertently covered side branches in EVAR using a transseptal sheath and needle. If the anatomical features are supportive, antegrade in situ fenestration can be a useful bailout technique.

Antegrade side branch access in branched aortic arch endografts: a porcine feasibility study.

PURPOSE: To describe the deployment technique for a single side branch arch endograft in a porcine model and prove the concept of transseptal or transapical antegrade access for catheterization and introduction of the mating stent-graft. METHODS: Six domestic pigs were operated with retrograde delivery of a single side branch arch endograft and antegrade introduction of a mating stent-graft using transseptal access (n=3) and transapical access (n=3). Technical feasibility, operating time, radiation parameters, and hemodynamic changes were studied. RESULTS: Transseptal and transapical access techniques were feasible in all animals. Catheterization and introduction of the mating stent-graft was feasible in 2 of 3 animals in the transseptal group and all animals in the transapical group. Technical feasibility was better in the transapical group, with shorter operating and fluoroscopy times and less hemodynamic impact during endograft deployment. Hemodynamic changes were short and reversible in all animals in both groups. CONCLUSION: Antegrade transcardiac access to the aortic arch for implantation of mating stent-grafts in branched arch endografting is feasible in a porcine model with reversible impact on hemodynamic measures during deployment. Transapical access was technically easier, with shorter operating and fluoroscopy times.

Hemodynamic impact of transseptal access to the ascending aorta in a porcine model.

PURPOSE: To evaluate the hemodynamic impact of transseptal sheath access to the ascending aorta using increasing sheath diameters. METHODS: Transseptal puncture was performed in 6 pigs (62±9 kg) facilitating guidewire passage across the left heart to the descending aorta to establish transseptal through-and-through access into the ascending aorta. Hemodynamic parameters were evaluated during 6- to 16-F sheath deployments and after sheath retraction according to a standardized protocol. Fluorescent microspheres were injected for quantitative assessment of myocardial and cerebral perfusion and left-right shunting volume. RESULTS: Cardiac output, heart rate, and central venous pressure (CVP) were stable throughout the study in all animals. The ratio between pulmonary artery pressure and mean arterial pressure was significantly higher during sheath deployment compared to after retraction (p<0.01), indicating transient mitral valve insufficiency. The ratio between left atrial pressure and CVP was significantly higher with the sheath in place (p<0.01), signaling transient left-right shunting; the hemodynamic alteration disappeared after sheath retraction. Myocardial perfusion (p=0.224), cerebral perfusion (p=0.209), and left-right shunting volume (p=0.111) were not significantly affected by the transseptal access. CONCLUSION: Transseptal access to the ascending aorta in a porcine model is feasible without persisting hemodynamic impairment or severe influence on myocardial or cerebral perfusion even with up to 16-F sheaths. Potential adverse effects need to be addressed before clinical use of this alternative access to the ascending aorta, aortic arch, and its side branches.

Transapical access for thoracic endograft delivery.

The purpose of this paper is to describe the technique of transapical deployment of a thoracic endograft and to discuss the specifics of this access. The technique of endograft deployment through a transapical access is demonstrated in a patient with a symptomatic 14-cm aortic arch aneurysm. The 73-year-old patient, with concomitant chronic obstructive airway disease and cardiovascular disease, had been denied open surgery. Femoral artery access was deemed contraindicated because of a more distal concomitant type III thoracoabdominal aneurysm, borderline renal failure and heavily calcified iliac arteries. Bilateral iliac-subclavian debranching and thoracic endografting via a combined transapical and left subclavian access successfully excluded the thoracic aortic aneurysm. The patient died within 24 hours postoperatively due to a massive myocardial infarction. In conclusion, transapical access for thoracic endograft delivery is feasible. Combined with complex debranching procedures in a challenging aneurysmal anatomy, it carries a high risk for periprocedural complications.

Detection of tumor-specific DNA in blood and bone marrow plasma from patients with prostate cancer.

Tumor tissues, blood plasma and bone marrow (BM) aspirates of 57 prostate cancer patients (PCa) without clinical signs of overt metastases were assessed for LOH (loss of heterozygosity) by a PCR-based fluorescence microsatellite analysis, using a panel of 15 markers. Additionally, micrometastatic tumor cells in BM were monitored by an immunocytological cytokeratin assay. In total, 25 (44%), 32 (56%) and 41 (72%) of the patients had at least 1 LOH in their blood, BM and tumor samples, respectively. Among the informative cases, the frequency of LOH was highest in blood plasma for the markers D8S360 (18%) and D10S1765 (15%), and in BM plasma for THRB (24%) and D8S137 (22%). Comparison of blood plasma and BM with tumors showed discrepant results in 35% and 45% of patients, respectively. Whereas all LOHs at THRB in BM plasma were also detected in the autologous tumor tissues, LOHs at D6S474 and D11S898 in BM were not retrieved in the tumors. The comparison with established risk factors showed a correlation of borderline significance for LOH at D9S1748 in the BM aspirates (p=0.055) and a significant correlation in the tumor samples (p=0.004) with increasing pathologic Gleason scores. Interestingly, 22% of the PCa patients harbored tumor cells in their BM and tended (p=0.065) to have more frequent LOH (16%) in BM plasma compared to patients without tumor cells (9%). These data demonstrate, for the first time, the presence of free tumor-specific DNA in blood and BM of PCa patients and suggest a possible relationship to BM micrometastasis.