Endovascular Rerouting the Errant Aortic Endoprosthesis.

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bailout maneuvers are sparse in the literature. Herein, we describe 7 patients with errant endoprosthesis rerouted with minimally invasive intervention into the true lumen.

Hybrid venous recanalization and cardiac implantable electronic device lead revision procedures: A single-center retrospective analysis of 38 patients.

PURPOSE: The purpose of this study was to describe the safety and efficacy of hybrid recanalization procedures in a series of patients with obstructed central veins requiring cardiac implantable electronic device (CIED) revision. METHODS: Between 2008 and 2016, 38 consecutive patients (24 M; age 60.5 ±â€¯16.2 years; range 25-87 years) with central venous obstruction underwent 42 recanalization interventions performed in conjunction with CIED revision or extraction. Fifty percent of patients (19/38) presented with veno-occlusive symptoms, and 13% (5/38) of patients had CIED leads with an ipsilateral upper extremity dialysis conduit. RESULTS: Ninety-one percent (38/42) of all procedures resulted in successful recanalization and CIED revision. Twenty-four percent (9/38) of all patients required secondary procedures due to recurrent stenosis, and 78% (7/9) of those requiring secondary procedures had indwelling dialysis conduits and/or clinical symptoms related to venous occlusion before the initial procedure. There were complications in 2 patients related to recanalization, and in 3 related to CIED revision. CONCLUSIONS: Recanalization of central venous stenosis/occlusion in patients with CIED can be technically challenging but is successful in most patients. Symptomatic patients and those with dialysis conduits often require more aggressive revascularization interventions and may be at increased risk of complication or need for secondary interventions.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study.

PURPOSE: Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation. MATERIALS AND METHODS: 406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ±â€¯15 years (range: 18-88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success. RESULTS: Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9-1353 days). CONCLUSION: Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) placement has been extensively studied in adults. The experience with TIPS placement in pediatric patients, however, is limited. OBJECTIVE: The purpose of this study was to report technical success and clinical outcomes in pediatric patients undergoing TIPS placement. MATERIALS AND METHODS: Twenty-one children - 12 (57%) boys and 9 (43%) girls, mean age 12.1 years (range, 2-17 years) - underwent TIPS placement from January 1997 to January 2017. Etiologies of hepatic dysfunction included biliary atresia (n=5; 24%), cryptogenic cirrhosis (n=4; 19%), portal or hepatic vein thrombosis (n=4, 14%), autosomal-recessive polycystic kidney disease (n=3; 14%), primary sclerosing cholangitis (n=2; 10%) and others (n=3, 14%). Indications for TIPS placement included variceal hemorrhage (n=20; 95%) and refractory ascites (n=1; 5%). Technical success, manometry findings, stent type, hemodynamic success, complications, liver enzymes, and clinical outcomes were recorded. RESULTS: TIPS placement was technically successful in 20 of 21 (95%) children, with no immediate complications. Mean pre- and post-TIPS portosystemic gradient was 18.5±10.7 mmHg and 7.1±3.9 mmHg, respectively. Twenty-two total stents were successfully placed in 20 children. Stents used included: Viatorr (n=9; 41%), Wallstent (n=7; 32%), Express (n=5; 23%), and iCAST (n=1; 5%). All children had resolution of variceal bleeding or ascites. TIPS revision was required in 9 (45%) children, with a mean of 2.2 revisions. Hepatic encephalopathy developed in 10 children (48%), at a mean of 223.7 days following TIPS placement. During the study, 6 (29%) children underwent liver transplantation. CONCLUSION: TIPS placement in pediatric patients has high technical success with excellent resolution of variceal hemorrhage and ascites. TIPS revision was required in nearly half of the cohort, with hepatic encephalopathy common after shunt placement.

Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome.

BACKGROUND: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. METHODS: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). RESULTS: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03). CONCLUSIONS: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Erratum: Pediatric Portal Interventions.

[This corrects the article DOI: 10.1055/s-0038-1642043.].

Interventional Radiology-Operated Cholecystoscopy for the Management of Symptomatic Cholelithiasis: Approach, Technical Success, Safety, and Clinical Outcomes.

OBJECTIVE: The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis. MATERIALS AND METHODS: Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded. RESULTS: Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy. CONCLUSION: Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.

Intra-arterial Thrombolysis for Extremity Frostbite Decreases Digital Amputation Rates and Hospital Length of Stay.

PURPOSE: To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). MATERIALS AND METHODS: Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40 years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53 years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p = 0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. RESULTS: Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26 h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p = 0.003). Average hospital LOS was 14 days in the treatment group and 38 days in the control group (p = 0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. CONCLUSIONS: Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

Transsplenic endovascular recanalization and stenting of a completely occluded portal vein with jejunal variceal embolization in a pediatric liver transplant recipient.

Portal vein thrombosis occurs in 1.4% of pediatric liver transplant candidates and 3.7% of liver transplant recipients. While portal vein recanalization without and with portal vein stenting has been described in adult transplant candidates and recipients, it has never been described in the pediatric transplant population. This report presents a pediatric liver transplant recipient with portal hypertension secondary to portal vein thrombosis successfully managed with transsplenic access and subsequent portal vein recanalization and stenting.

Internal iliac venous aneurysm associated with pelvic venous insufficiency.

Aneurysmal disease of the internal iliac vein is rare, with no standard indication for or accepted modality of treatment. Here we report an instance of unilateral, primary left internal iliac venous aneurysm and associated pelvic venous insufficiency. Following extensive workup for alternative causes, the aneurysm and left gonadal vein were coil embolized with good effect.

Management of type A dissection with malperfusion.

Malperfusion is a common lethal complication of acute aortic dissection following rupture, for which the optimal management strategy has yet to be clearly established. The objective of this study was to reassess the management of acute type A aortic dissection (Type A-AAD) with malperfusion. We retrospectively analyzed the outcomes of all patients with Type A-AAD with malperfusion at the University of Michigan and compared the results from patients that directly underwent open surgical repair versus those who had percutaneous reperfusion prior to open surgical repair. Based on the results, we developed a patient care protocol for the treatment of all patients with acute type A dissection. We later re-analyzed the long-term outcomes for patients using the protocol. The present study demonstrated that, although the outcomes for patients with acute type A aortic dissection with malperfusion syndrome treated with initial percutaneous reperfusion and delayed open surgical intervention are not as good as the results for patients with uncomplicated Type A-AAD that undergo immediate surgical repair, their outcomes continue the long-term outcomes of the former group are superior. To outdo patients with acute type A aortic dissection with malperfusion syndrome treated with immediate open surgical intervention. In conclusion, at the University of Michigan we continue to use our patient care protocol to treat patients with Type A-AAD.

Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) for the treatment of pediatric renovascular hypertension (RVH) in contemporary practice is accompanied with ill-defined complications. This study examines the mode of pediatric renal PTA failures and the results of their surgical management. METHODS: Twenty-four children underwent remedial operations at the University of Michigan from 1996 to 2014 for failures of renal PTA. Their clinical courses were retrospectively reviewed and results analyzed. RESULTS: Renal PTA of 32 arteries, including 13 with stenting, was performed for severe RVH in 12 boys and 12 girls, having a mean age of 9.3 years. Developmental ostial stenoses affected 22 children. PTA failures included: 27 restenoses and five thromboses. Remedial operations included: 13 renal artery-aortic reimplantations, one segmental renal artery-main renal artery reimplantation, ten aortorenal bypasses, one arterioplasty, one iliorenal bypass, and six nephrectomies for unreconstructable arteries; the latter all in children younger than 10 years. Follow-up averaged 2.1 years. Postoperatively, hypertension was cured, improved, or unchanged in 25, 54, and 21 %, respectively. There was no perioperative renal failure or mortality. CONCLUSIONS: Renal PTA for the treatment of pediatric RVH due to ostial disease may be complicated by failures requiring complex remedial operations or nephrectomy, the latter usually affecting younger children.

Propensity adjusted analysis of open and endovascular thoracic aortic repair for chronic type B dissection: a twenty-year evaluation.

BACKGROUND: Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. METHODS: One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n = 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n = 105), rupture (n = 8), acute or chronic dissection (n = 8), and extension of dissection (n = 1). Open strategy included descending (n = 71) and thoracoabdominal repair (n = 19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n = 2) or without (n = 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. RESULTS: Early outcome included the following: 30-day mortality 4% (n = 5); stroke 2% (n = 2); permanent paraplegia 3% (n = 4); renal failure requiring dialysis 7% (n = 8, 5 temporary and 3 permanent); and tracheostomy 3% (n = 4). Visceral aorta intervention (odds ratio [OR] 3.5, p = 0.026) and maximum aortic diameter (OR 1.1, p = 0.001) but not treatment type (p = 0.64) independently predicted an early composite outcome comprised of these variables. Ten-year survival was 56.2%. Baseline creatinine (hazard ratio [HR] 1.7, p < 0.001) and peripheral vascular disease (HR 2.5, p = 0.021), but not treatment type (p = 0.225) predicted late mortality. Ten-year freedom from aortic rupture or need for reintervention was 78.3%. Treatment efficacy was improved after OAR (3-year freedom 96.7% vs TEVAR 87.5%, p = 0.026), and this was confirmed after Cox regression (TEVAR, HR 4.6, p = 0.046). CONCLUSIONS: Intervention for CBAD can be performed with excellent results, either by an open or endovascular approach. The higher rate of treatment failure after TEVAR warrants modification of current device design or endovascular approach before broad application of this treatment strategy.

A 20-year experience with thoracic endovascular aortic repair.

BACKGROUND: Endovascular approaches (thoracic endovascular aortic repair) have revolutionized treatment of thoracic aortic disease. OBJECTIVE: We report our 20-year experience with this therapy. METHODS: Four hundred twenty patients (mean age = 69.0 years; 54% male) underwent thoracic endovascular aortic repair (1993-2013), predominantly for fusiform aneurysm (n = 144), saccular aneurysm (n = 94), acute (n = 64) or chronic (n = 36) dissection, or traumatic injury (n = 39). Rupture was present in 80 patients (19.1%). Most patients (78.3%) were at high risk for open repair. Mean aortic diameter was 5.5 cm. Extent of repair included arch in 218 patients, total descending aorta in 193 patients, and thoracoabdominal aorta in 35 patients. RESULTS: Thirty-day mortality occurred in 20 patients (4.8%). Neurologic events included stroke (5.0%) and spinal cord ischemia (permanent 1.7%, temporary 7.9%). Although dialysis was only required in 1.4% of the patients, 19% had renal failure by RIFLE (Risk, Injury, Failure) criteria. Endoleak occurred in 32.9% of the patients. Ten-year freedom from dissection, rupture, or need for reintervention in treated or adjacent aortic segments (ie, treatment failure) was 63.2%. Independent predictors included presentation with rupture, preexisting renal failure, or intervention on the arch aorta (all Ps < 0.03). Aortic pathology also independently predicted treatment failure (P = 0.026). The 15-year survival rate was 32.3%. Advancing age, presence of coronary artery disease, rupture, or postoperative renal failure (all Ps < 0.05), but not treatment failure (P = 0.926), independently predicted late mortality. CONCLUSIONS: Thoracic endovascular aortic repair can be performed with acceptable results in a high-risk population. The risk of treatment failure persists, underscoring the importance of continued long-term endograft surveillance, but this does not seem to impact late mortality.

Alternative access techniques with thoracic endovascular aortic repair, open iliac conduit versus endoconduit technique.

BACKGROUND: Iliac artery endoconduits (ECs) have emerged as important alternatives to retroperitoneal open iliac conduits (ROICs) to aid in transfemoral delivery for thoracic endovascular aortic repair (TEVAR). We present, to our knowledge, the first comparative analysis between these alternative approaches. METHODS: All patients undergoing TEVAR with either ROIC (n = 23) or internal EC (n = 16) were identified. The mean age of the cohort was 72.4 ± 11.5 years (82.1% female). Device delivery was accomplished in 100% of cases. The primary outcome was the presence of iliofemoral complications, which was defined as: (1) the inability to successfully deliver the device into the aorta via the ROIC or EC approach; (2) rupture, dissection, or thrombosis of the ipsilateral iliac or femoral artery; and/or (3) retroperitoneal hematoma requiring exploration and evacuation. Secondary outcomes were 30-day mortality and rates of limb loss, claudication, or revascularization. RESULTS: At a median follow-up of 10.1 months, the incidence of iliofemoral complications was less for the EC approach compared with the ROIC technique (12.5% vs 26.1%; P = .301). No patients sustained limb loss. Revascularization was performed in two patients after ROIC. Lower extremity claudication occurred in one patient after EC. Early mortality was seen in one patient who underwent EC. Two-year Kaplan-Meier survival for the entire cohort was 74.4%, and did not differ between groups (ROIC, 78.3% vs EC, 68.8%; P = .350). Two-year Kaplan-Meier freedom from limb loss, claudication, or revascularization did not differ between the two approaches (ROIC, 91.3% vs EC, 93.8%; P = .961). CONCLUSIONS: Results of this early comparative evaluation of alternative access routes for TEVAR suggest that an EC approach is safe, effective, and associated with low rates of early mortality and late iliofemoral complications. In selected patients, the EC may be considered an appropriate delivery route for transfemoral TEVAR.

Preoperative splenic artery embolization in klippel-Trenaunay syndrome with massive splenomegaly: A case report.

The authors describe a case of Klippel-Trenaunay syndrome (KTS) with massive splenomegaly in a 29-year-old woman. Preoperative splenic artery embolization using the "double embolization technique" (a combination of distal selective splenic artery embolization and proximal splenic artery occlusion) facilitated open splenectomy.

The impact of acute renal failure on early and late outcomes after thoracic aortic endovascular repair.

BACKGROUND: The incidence of acute kidney injury (AKI) after thoracic aortic endovascular repair (TEVAR) is variably reported at 1% to 34%. This study utilized the RIFLE (risk, injury, failure) criteria to evaluate the incidence, risk factors, and late implications of AKI after TEVAR. METHODS: In all, 350 patients without prior dialysis requirement underwent TEVAR (1993 to 2013). The mean age was 68.7 years (54% male). The mean preoperative glomerular filtration rate was 76.5 ± 37.6 mL/min, with 39 patients (11.7%) in chronic kidney stage 3 or 4. The TEVAR was performed for rupture in 20.6%. The mean contrast volume administered was 95.7 ± 52.9 mL. RESULTS: Early mortality was seen in 17 patients (4.9%). Acute kidney injury defined as RIFLE classes risk, injury, or failure was seen in 59 patients (17%; risk = 36, injury = 14, failure = 9). Independent predictors of AKI included history of saccular aneurysm, presentation with rupture, or need for arch repair or red blood cell transfusion (all p < 0.05). Only 2 patients (0.6%) needed dialysis, with none requiring permanent dialysis. Importantly, 10-year freedom from dialysis was 97.7%. Development of AKI predicted early mortality (p < 0.001, odds ratio 9.8). Ten-year survival was 38.1%. Both injury and failure AKI classes independently predicted late mortality (p < 0.05). CONCLUSIONS: The prevalence of AKI after TEVAR as assessed by RIFLE criteria is higher than seen in previous reports. Despite its infrequent progression to permanent dialysis dependence, AKI remains an important risk factor for both early and late mortality. Future studies should evaluate strategies to reduce the incidence of AKI after TEVAR to improve both early and late outcomes.

Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm.

OBJECTIVE: Repair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort. METHODS: Of 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias. RESULTS: Early mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P = .055) and performance of a hybrid procedure (P = .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P < .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P = .018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P = .017) and an endovascular or hybrid procedure (P = .001) independently predicted late aortic rupture or need for reintervention. CONCLUSIONS: Isolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.

Iliofemoral complications associated with thoracic endovascular aortic repair: frequency, risk factors, and early and late outcomes.

BACKGROUND: Risk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair. METHODS: All patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy. RESULTS: The complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P < .05). Multivariate analysis identified the (1) difference between average iliac diameter and sheath size (P = .014), (2) iliac artery morphology score (P = .033), and (3) ankle-brachial index (P = .012) as independent predictors for iliofemoral complications. Early mortality was higher in those with complications (13.3% vs 1.8%, P = .069). Four-year freedom from limb loss, claudication, or revascularization was 97.9%. Iliofemoral complications reduced late survival primarily as a result of increased mortality within the first year (P = .047). CONCLUSIONS: Thoracic aortic endovascular repair can be performed safely via a transfemoral approach. Alternative access in patients with high preoperative iliac artery morphology scores and device delivery size requirements over the native iliofemoral size may reduce iliofemoral complications. If early complications occur, prompt repair results in low rates of ischemic limb complications at late follow-up.