Outcomes After Endovascular Aortic Intervention in Patients With Connective Tissue Disease.

Importance: Endovascular treatment is not recommended for aortic pathologies in patients with connective tissue diseases (CTDs) other than in redo operations and as bridging procedures in emergencies. However, recent developments in endovascular technology may challenge this dogma. Objective: To assess the midterm outcomes of endovascular aortic repair in patients with CTD. Design, Setting, and Participants: For this descriptive retrospective study, data on demographics, interventions, and short-term and midterm outcomes were collected from 18 aortic centers in Europe, Asia, North America, and New Zealand. Patients with CTD who had undergone endovascular aortic repair from 2005 to 2020 were included. Data were analyzed from December 2021 to November 2022. Exposure: All principal endovascular aortic repairs, including redo surgery and complex repairs of the aortic arch and visceral aorta. Main Outcomes and Measures: Short-term and midterm survival, rates of secondary procedures, and conversion to open repair. Results: In total, 171 patients were included: 142 with Marfan syndrome, 17 with Loeys-Dietz syndrome, and 12 with vascular Ehlers-Danlos syndrome (vEDS). Median (IQR) age was 49.9 years (37.9-59.0), and 107 patients (62.6%) were male. One hundred fifty-two (88.9%) were treated for aortic dissections and 19 (11.1%) for degenerative aneurysms. One hundred thirty-six patients (79.5%) had undergone open aortic surgery before the index endovascular repair. In 74 patients (43.3%), arch and/or visceral branches were included in the repair. Primary technical success was achieved in 168 patients (98.2%), and 30-day mortality was 2.9% (5 patients). Survival at 1 and 5 years was 96.2% and 80.6% for Marfan syndrome, 93.8% and 85.2% for Loeys-Dietz syndrome, and 75.0% and 43.8% for vEDS, respectively. After a median (IQR) follow-up of 4.7 years (1.9-9.2), 91 patients (53.2%) had undergone secondary procedures, of which 14 (8.2%) were open conversions. Conclusions and Relevance: This study found that endovascular aortic interventions, including redo procedures and complex repairs of the aortic arch and visceral aorta, in patients with CTD had a high rate of early technical success, low perioperative mortality, and a midterm survival rate comparable with reports of open aortic surgery in patients with CTD. The rate of secondary procedures was high, but few patients required conversion to open repair. Improvements in devices and techniques, as well as ongoing follow-up, may result in endovascular treatment for patients with CTD being included in guideline recommendations.

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center.

OBJECTIVES: To present our experience with various therapeutic approaches for the treatment of secondary aortoenteric fistulas following open and endovascular aortic aneurysm repair. METHODS AND MATERIALS: A retrospective data analysis of patients treated for secondary aortoenteric fistulas in a single vascular institution between January 2005 and December 2018 was performed. Analyzed parameters included patients' demographics, clinical presentation, diagnostic work-up, perioperative data and repair durability during follow-up. RESULTS: Twenty-three patients with aortoenteric fistulas were treated in the target period. The fistulous connection was located in 21 cases (91.3%) in the duodenum and in two cases (8.7%) in the small intestine. Average time between the initial procedure and detection of the aortoenteric fistula was 69.4 ± 72.5 months. The most common presenting symptom was gastrointestinal bleeding (n = 12, 52.2%), followed by symptoms suggestive of chronic infection (n = 11, 47.8%). Open surgical repair was performed in 19 patients (bridging in 3 patients), and endovascular repair was carried out in two cases and one patient underwent a hybrid operation. One patient underwent abscess drainage due to significant comorbidities. Mean follow-up was 35.1 ± 35.5 months. In-hospital mortality and overall mortality were 43.5% (10/23) and 65.2% (15/23), respectively. Patients presenting with bleeding had a significantly higher perioperative mortality rate in comparison to patients presenting with chronic infection (66.7% (8/12) and 18.2% (2/11), respectively, p = 0.019). Patients who underwent stent-graft implantation for control of acute life-threatening bleeding showed significantly better perioperative survival in comparison to patients that were acutely treated with an open procedure (66.6%, (4/6) and 0% (0/6), respectively, p = 0.014). Perioperative mortality was also higher for ASA IV patients (71.4%, 5/7), when compared to ASA III Patients (31.2%, 5/16), although this did not reach statistical significance (p = 0.074). CONCLUSION: Treatment of secondary aortoenteric fistulas is associated with a high perioperative mortality rate. Patients who survive the perioperative period following open surgical repair in the absence of hemorrhagic shock show acceptable midterm results during follow-up. Stent-graft implantation for bleeding control in patients presenting with life-threatening bleeding seems to be associated with lower perioperative mortality rates.

Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. TECHNIQUE: The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. CONCLUSION: Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.

Midterm Results after Open Surgical and Endovascular Management of Arterioureteral Fistula.

BACKGROUND: Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. METHODS: We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up. RESULTS: Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. DISCUSSION: Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Midterm outcome of renal function after branched thoracoabdominal aortic aneurysm repair.

OBJECTIVE: The aim of this study was to investigate the incidence and impact of acute and chronic kidney dysfunction after branched endovascular aortic aneurysm repair (BEVAR) perioperatively and during follow-up. METHODS: Patients with a thoracoabdominal aortic aneurysm were treated with BEVAR. Serum creatinine; estimated glomerular filtration rate at baseline, after 48 hours, at discharge, and after 1 and two years; perioperative results; and outcome during follow-up were evaluated. RESULTS: Treatment of thoracoabdominal aortic aneurysm using BEVAR was performed in 113 patients (mean age, 71 years; 79 male) with 434 side branches and two additional fenestrations (0.46%) for renovisceral perfusion. Sixty patients (53%) underwent staged procedures with temporary aneurysm sac perfusion and secondary side branch completion. Perioperative mortality was 9 of 113 (8%). Postoperative acute kidney injury (AKI) was observed in 41 of 113 patients (36%) with recovery of renal function after 2 years in most patients. However, chronic kidney disease (CKD) stage progression after 1 and 2 years was observed in 25 of 104 patients (24%) and 17 of 52 patients (32.7%), respectively. Seven patients (6.7%) required permanent dialysis during 2 years of follow-up. Risk factors for AKI were nonstaged procedures (P = .02) and multiorgan failure (P = .01). CKD progression was related to renal branch reinterventions (P = .047), all branch reinterventions (P = .03), and postoperative AKI (P = .001). During follow-up, survival was decreased in patients with AKI, especially in those with nonmalignant diseases (P = .01). CONCLUSIONS: Postoperative AKI after BEVAR was observed in about one-third of patients associated with increased CKD stages after 2 years. Preoperative CKD was not a risk factor for postoperative AKI or perioperative outcome. The prevention of AKI by staged procedures, early interventions for renal side branch complications, and regular surveillance is recommended to improve outcomes.

Multicenter Analysis of Endovascular Aortic Arch In Situ Stent-Graft Fenestrations for Aortic Arch Pathologies.

BACKGROUND: In situ fenestration of aortic stent grafts for treatment of aortic arch aneurysms is a new option for endovascular aortic arch repair. So far, only few reports have shown perioperative and short-term results of in situ fenestrations for aortic arch diseases. We present the multicenter experience with the aortic arch in situ fenestration technique documented in the AARCHIF registry for treatment of aortic arch aneurysms or localized type A aortic dissections and analyzed perioperative outcome and midterm follow-up. METHODS: Patients with aortic arch pathologies treated by aortic arch in situ fenestration with proximal stent graft landing in aortic arch Ishimura zones 0 and 1 were included in the registry. Stent-graft in situ fenestrations were created using needles or radiofrequency or laser catheters and completed by implantation of covered connecting stent grafts. Single in situ fenestrations for the left subclavian artery (LSA) were excluded. RESULTS: Between 06/2009 and 03/2017, twenty-five patients were treated by in situ stent-graft fenestrations for aortic arch pathologies at 9 institutions in 7 different countries, 3 of them as bailout procedures for stent-graft malplacement. In situ fenestrations were performed for the brachiocephalic trunk (n = 20), the left common carotid artery (n = 21) and the LSA (n = 9). Technical success for intended in situ fenestrations was 94.0% (47/50), with additional supraaortic bypass procedures performed in 14 patients. Perioperative mortality occurred in 1 (4.0%) patient, treated as a bailout procedure and 3 (12.0%) perioperative strokes were observed. One proximal aortic stent-graft nonalignment and 4 type III endoleaks, 2 early and 2 late, required reeintervention. During follow-up (1-118 months), the diameter of aortic arch aneurysms decreased from 61.5 ± 4.1 mm to 48.4 ± 3.2 mm (P = 0.02) and, so far, 6 patients died from diseases unrelated to their aortic arch pathologies with a mean survival time of 79.5 months and 3 endovascular reinterventions for distal aortic expansion were performed. Cerebrovascular event (n = 4) was the most relevant prognostic factor for mortality during midterm follow-up (P = 0.003). CONCLUSIONS: The aortic arch in situ fenestration technique for endovascular aortic arch repair seems to be valuable treatment option for selected patients, although initial consideration of other treatment options is mandatory. Data about long-term durability are required.

Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm.

OBJECTIVE: The aim of this study was to evaluate the impact of intercostal and lumbar segmental arteries (SAs) detectable on computed tomography angiography (CTA) on the risk of spinal cord ischemia (SCI) in patients undergoing single-step or two-staged branched endovascular aneurysm repair (BEVAR). METHODS: A retrospective analysis of patients treated with branched stent grafts for thoracoabdominal aortic aneurysm at a single institution from January 2009 to June 2015 was performed. Data including preoperative comorbidities, perioperative and aneurysm-related parameters, presence and type of endoleak, and rate of severe SCI at discharge or 30 days after the procedure were collected. Preoperative and postoperative contrast-enhanced CTA images were semiquantitatively analyzed by two independent investigators, and the number of visible SAs in the stented aorta before and after BEVAR was evaluated to find a possible correlation with severe SCI. RESULTS: Seventy-seven patients were treated for thoracoabdominal aortic aneurysm with BEVAR (47 men; mean age, 71.0 years), 40 (51.9%) of them with temporary aneurysm sac perfusion (TASP; open branch/TASP group) and 37 without (single-step group). The groups were comparable regarding parameters related to the patient, aneurysm type, and endovascular procedure. Severe SCI or paraplegia was observed in 10 patients (12.3%), and SCI was lower in the open branch/TASP group (2/40) compared with the single-step group (8/37; P = .032). The number of visible SAs in the intentionally overstented aortic segment was significantly reduced on postoperative CTA (10.0 vs 15.57 SAs; P < .001) in comparison to preoperative CTA imaging, with similar results in the open branch/TASP group (9.48 vs 15.83 SAs) and the single-step group (10.57 vs 15.30 SAs; P < .001 for both groups). Within the open branch/TASP group, more visible SAs were detected during the TASP interval in comparison to postoperative CTA after side branch completion (12.93 vs 9.48 SAs; P < .001). Receiver operating characteristic curve analysis in the single-step group revealed a cutoff point of 15 SAs on preoperative CTA with correlation to severe SCI (P = .006). In the high-risk subgroup of patients with 15 or more overstented SAs during BEVAR, staged open branch/TASP procedures again reduced the risk of SCI in comparison to the single-step patients (1/20 vs 8/22; P = .008). CONCLUSIONS: More spinal arteries are visible during the TASP interval, supporting the open branch and TASP concept with a reduction of severe SCI during BEVAR. An intentional coverage of more than 15 SAs is related to an increased risk of SCI, and the rate of paraplegia was reduced after staged BEVAR with open branch/TASP in these high-risk patients.

Sonographic Changes in Optic Nerve Sheath Diameter Associated with Supra- versus Infrarenal Aortic Aneurysm Repair.

BACKGROUND AND PURPOSE: Quantification of changes in optic nerve sheath diameter (ONSD) using ocular sonography (OS) constitutes an elegant technique for estimating intracranial and intraspinal pressure. Aortic aneurysm repair (AAR) is associated with a reasonable risk of increased spinal fluid pressure, which is largely dependent on the extent of aneurysm repair (supra- vs. infrarenal). The aim of this study was to compare ONSD measurements in patients with suprarenal AAR (sAAR) or infrarenal AAR (iAAR). METHODS: Thirty patients who underwent elective endovascular repair of infrarenal aortic aneurysms (Group iAAR) were included in the study; the characteristics in these cases were prospectively analyzed and compared with those in a previously investigated group of 28 patients treated for suprarenal aortic aneurysms (Group sAAR). Six measurements of ONSDs were performed in each patient at five consecutive time points. Statistical analysis was performed using the Wilcoxon test. A P value < .05 was considered statistically significant. RESULTS: A highly significant difference between pre- and postinterventional values could be detected in both patient groups (P < .01). In Group sAAR, there was a mean .3-mm increase of the ONSD, whereas in Group iAAR, a mean .2-mm decrease could be detected. Both groups roughly reached baseline values by the end of their inpatient stay. CONCLUSIONS: ONSD changes seem to be a reliable marker to estimate spinal perfusion. Since OS provides a suitable bedside tool for rapid reevaluation, it may guide physicians in the identification and treatment of patients at high risk for spinal cord ischemia.

Long-term durability of aortic arch in situ stent graft fenestration requiring lifelong surveillance.

We report successful endovascular repair of a 61-year-old man treated for a 7.1-cm excentric aortic arch aneurysm by in situ stent graft fenestration for the brachiocephalic trunk and the left common carotid artery. Cerebral perfusion during the intervention was maintained by pump-driven extracorporal bypass to the right common carotid artery and to the left axillary artery provided with a left carotid-subclavian bypass. After 5 years of follow-up, the aortic arch in situ revascularization is still patent, the aneurysm excluded, and no endoleak detectable, although endovascular reintervention with distal aortic stent graft extension due to dilatation of the descending aorta was required.

Contrast-enhanced ultrasound to evaluate organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms.

PURPOSE: To evaluate the organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms (VAAs) by contrast-enhanced ultrasound (CEUS) and colour-coded duplex sonography (CCDS). METHOD AND MATERIALS: Between April 1995 to January 2016, 168 patients (78 males, 90 females; median age: 62 years) were diagnosed with VAAs at our hospital site. 60/168 patients (36%) fulfilled treatment criteria and had either open (29/60, 48%) or endovascular (31/60, 52%) aneurysm repair. Patients' characteristics and presentations were consecutively reviewed. Technical success and organ microvascularization were determined by CCDS/CEUS and correlated to computed tomography angiography (CTA) or magnetic resonance imaging (MRI). RESULTS: 18/60 patients (30%) presented with acute bleeding. 16/18 emergency patients (89%) were treated by endovascular means. After emergency treatment, two patients showed segmental liver malperfusion by CEUS and CTA. One small bowel resection had to be performed.42/60 patients (70%) were electively treated. 27/42 patients (64%) had open and 15/42 (36%) endovascular aneurysm repair. There were no liver or bowel infarctions after elective treatment of hepatic or mesenteric artery aneurysms (n = 13) in CCDS/CEUS and in CTA. Treatment of patients with splenic or renal artery aneurysms led to partial or complete organ loss in 42% (8/19) after operative and in 50% (5/10) after endovascular treatment (p < 0.05). CONCLUSION: The endovascular approach is the preferred therapeutic option in emergency to control bleeding. In contrast to hepatic or mesenteric procedures, patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully because of a high rate of partial or complete organ loss demonstrated by CEUS - either after open or endovascular aneurysm repair.

Standardized 2D ultrasound versus 3D/4D ultrasound and image fusion for measurement of aortic aneurysm diameter in follow-up after EVAR.

PURPOSE: To compare standardised 2D ultrasound (US) to the novel ultrasonographic imaging techniques 3D/4D US and image fusion (combined real-time display of B mode and CT scan) for routine measurement of aortic diameter in follow-up after endovascular aortic aneurysm repair (EVAR). METHOD AND MATERIALS: 300 measurements were performed on 20 patients after EVAR by one experienced sonographer (3rd degree of the German society of ultrasound (DEGUM)) with a high-end ultrasound machine and a convex probe (1-5 MHz). An internally standardized scanning protocol of the aortic aneurysm diameter in B mode used a so called leading-edge method. In summary, five different US methods (2D, 3D free-hand, magnetic field tracked 3D - Curefab™, 4D volume sweep, image fusion), each including contrast-enhanced ultrasound (CEUS), were used for measurement of the maximum aortic aneurysm diameter. Standardized 2D sonography was the defined reference standard for statistical analysis. CEUS was used for endoleak detection. RESULTS: Technical success was 100%. In augmented transverse imaging the mean aortic anteroposterior (AP) diameter was 4.0±1.3 cm for 2D US, 4.0±1.2 cm for 3D Curefab™, and 3.9±1.3 cm for 4D US and 4.0±1.2 for image fusion. The mean differences were below 1 mm (0.2-0.9 mm). Concerning estimation of aneurysm growth, agreement was found between 2D, 3D and 4D US in 19 of the 20 patients (95%). Definitive decision could always be made by image fusion. CEUS was combined with all methods and detected two out of the 20 patients (10%) with an endoleak type II. In one case, endoleak feeding arteries remained unclear with 2D CEUS but could be clearly localized by 3D CEUS and image fusion. CONCLUSION: Standardized 2D US allows adequate routine follow-up of maximum aortic aneurysm diameter after EVAR. Image Fusion enables a definitive statement about aneurysm growth without the need for new CT imaging by combining the postoperative CT scan with real-time B mode in a dual image display. 3D/4D CEUS and image fusion can improve endoleak characterization in selected cases but are not mandatory for routine practice.

Increased intravascular flow rate triggers cerebral arteriogenesis.

Peripheral arteriogenesis is distinctly enhanced by increased fluid shear stress. Thus, the aim of this study was to investigate in the rat brain whether increased fluid shear stress can also stimulate cerebral arteriogenesis. To increase fluid shear stress in the cerebral circulation, we developed different shear stress models as the ligature of both common carotid arteries (Double-Ligature model), bilateral carotid ligature followed by creation of a unilateral arterio-venous fistula (two-stage protocol, Ligature-Shunt model), and unilateral arterio-venous fistula-creation alone (Solo-Shunt model). Blood flow changes were monitored in vivo by quantitative magnetic resonance imaging-analysis. Cerebral arteriogenesis was analyzed by magnetic resonance imaging and contrast agent-angiography. For proliferation and accumulation of mononuclear cells, immunohistochemistry was performed. During the 14 days-observation period, blood flow increased maximal by 5.5-fold in the A. basilaris and 10.3-fold in the fistula-sided A. cerebri posterior of the Ligature-Shunt model. Considerable vessel growth was found in all shear stress-stimulated arteries. Comparative analysis of vessel length and diameter versus blood flow indicated a correlation between the growth of cerebral collaterals and rising intravascular flow rates (R2=0.90/0.96). Immunohistochemistry showed the typical phases of arteriogenesis and accumulation of mononuclear cells. In conclusion, we provide evidence that fluid shear stress is not only the pivotal trigger of peripheral but also of cerebral arteriogenesis.

Clinical outcome and quality of life after upper extremity arterial trauma.

We assessed the long-term clinical outcome of 33 patients treated for arterial trauma of the upper extremity at the Regensburg University Medical Center between 1996 and 2004. Along with clinical parameters, the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Short Form-36 Health Survey (SF-36) score of each patient were collected at the time of follow-up. Findings of the clinical assessment were compared to results obtained with the DASH score and the SF-36 questionnaire. The median follow-up time was 42 months. All arterial injuries had been reconstructed and were open at the time of follow-up. The prevalence of concomitant neural and/or orthopedic injuries was high (24/33, 72%). The influence of neural injury was by far greater than the impact of other factors on the long-term functional outcome. Furthermore, blunt trauma and the need for immediate fasciotomy were further markers for deficient functional recovery. Both the DASH and the SF-36 scores correlated with the clinical assessment of the severity of functional deficits. Upper extremity vascular trauma is almost always associated with severe concomitant orthopedic and/or neural injuries. The involvement of the brachial plexus and the peripheral nerves of the upper extremity is a predictor of worse long-term functional outcome.

Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention for patients with symptomatic or asymptomatic carotid artery stenosis. Although several prospective randomized trials indicate that carotid artery stenting (CAS) is an alternative but not superior treatment modality, there is still a significant lack of long-term data comparing CAS with CEA. This study presents long-term results of a prospective, randomized, single-center trial. METHODS: Between August 1999 and April 2002, 87 patients with a symptomatic high-grade internal carotid artery stenosis (>70%) were randomized to CAS or CEA. After a median observation time of 66 +/- 14.2 months (CAS) and 64 +/- 12.1 months (CEA), 42 patients in each group were re-evaluated retrospectively by clinical examination and documentation of neurologic events. Duplex ultrasound imaging was performed in 61 patients (32 CAS, 29 CEA), and patients with restenosis >70% were re-evaluated by angiography. RESULTS: During the observation period, 23 patients (25.2%) died (10 CAS, 13 CEA), and three were lost to follow up. The incidence of strokes was higher after CAS, with four strokes in 42 CAS patients vs none in 42 CEA patients. One transient ischemic attack occurred in each group. A significantly higher rate of restenosis >70% (6 of 32 vs 0 of 29) occurred after CAS compared with CEA. Five of 32 CAS patients (15.6%) presented with high-grade (>70%) restenosis as an indication for secondary intervention or surgical stent removal, and three presented with neurologic symptoms. No CEA patients required reintervention (P < .05 vs CAS). A medium-grade (<70%) restenosis was detected in eight of 32 CAS patients (25%) and in one of 29 CEA patients (3.4%). In five of 32 CAS (15.6%) and three of 29 CEA patients (10.3%), a high-grade stenosis of the contralateral carotid artery was observed and treated during the observation period. CONCLUSION: The long-term results of this prospective, randomized, single-center study revealed a high incidence of relevant restenosis and neurologic symptoms after CAS. CEA seems to be superior to CAS concerning the development of restenosis and significant prevention of stroke. However, the long-term results of the ongoing multicenter trials have to be awaited for a final conclusion.

Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts.

OBJECTIVE: The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta. METHODS: In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2-76). RESULTS: Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred. CONCLUSION: The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.

Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.

We report two cases of proximal endograft collapse with an almost complete aortic occlusion after endovascular tube-graft treatment of thoracic aortic disease (thoracic aneurysm after a type B dissection, traumatic blunt aortic rupture) using the TAG Gore system. Oversizing of endografts is known to cause this complication. In our two cases, however, the oversizing was between 12% and 21.7%, which is less than the allowed oversizing of 25% that is recommended by the manufacturer. This endograft-related complication might be due to a poor alignment of the currently available endografts in highly angulated and tight aortic arches. In the first case, a combined endovascular and open emergent repair procedure achieved a reopening of the proximal endograft by proximal extension (TAG Gore). In the second case, proximal extension was not considered owing to a precise positioning of the endograft distal to the left carotid artery. A balloon-expanding Palmaz stent was therefore placed interventionally in the proximal part of the TAG graft to expand the endograft and to avoid another collapse of the device. This proximal endograft collapse has to be acknowledged as a potentially hazardous complication. We therefore recommend that the proximal part of thoracic endografts in the aortic arch should be closely monitored and we offer two possible endovascular solutions for resolving the problem of proximal endograft collapse.

[Radiotherapy of inguinal lymphorrhea after vascular surgery. A retrospective analysis]. / Die Strahlentherapie inguinaler Lymphfisteln nach gefässchirurgischen Eingriffen. Eine retrospektive Analyse.

BACKGROUND AND PURPOSE: The formation of inguinal lymphorrhea following vascular surgery is a rare but potentially serious problem with an incidence of about 2%. There is no consensus on the most effective treatment for groin lymphorrhea. In a retrospective analysis the usefulness of irradiation in the treatment of inguinal lymph fistulas was investigated. PATIENTS AND METHODS: From 08/1997 to 12/2000, 28 patients with inguinal lymph fistulas were irradiated postoperatively (4th-19th day) with a single dose of 3 Gy up to a total dose of 9 Gy on 3 consecutive days using 120- to 300-kV photons. Three further patients received 2 x 4 Gy and 3 x 5 Gy, respectively, due to an interposed weekend. RESULTS: Secretion volume at the beginning of radiotherapy varied between 50 and 650 ml daily (mean 203 ml, median 175 ml), at the end of radiotherapy between 0 and 350 ml (mean 126 ml, median 120 ml). 3/28 lymph fistulas had resolved during radiotherapy. In 17/28 patients (60.7%) the drains could be removed within 10 days, in further 10/28 patients (35.7%) within 10-20 days after the end of radiotherapy. CONCLUSION: Overall, irradiation of inguinal lymph fistulas proved to be an effective and well-tolerated treatment, facilitating removal of fistula drains within 10-20 days (mean 10.5, median 7 days) after the completion of radiotherapy, thus appearing a good alternative to other conservative treatment modalities.

Endovascular therapy of a ruptured intercostal artery aneurysm.

PURPOSE: To report the endovascular management of a rare ruptured intercostal artery aneurysm. CASE REPORT: A 45-year-old man presented with acute upper back and chest pain. Computed tomography of the chest revealed a ruptured intercostal artery aneurysm. The lesion was treated by endovascular coil embolization distal to the aneurysm and aortic stent-grafting of the intercostal artery origin. CONCLUSIONS: Ruptured intercostal artery aneurysms can be treated by endovascular techniques. If coil embolization of the intercostal artery origin is not possible, additional aortic stent-grafting can be necessary.