Endovascular Repair of Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using a Novel Low-Profile Fenestrated Custom-Made Endograft: Technical Details and Short-Term Outcomes.

INTRODUCTION: The aim of this study is to share preliminary experiences and outcomes with a novel custom-made fenestrated TREO® Abdominal Stent-Graft System to treat juxtarenal and pararenal abdominal aortic aneurysms (AAAs). METHODS: Juxtarenal and pararenal AAA patients treated with the custom-made fenestrated TREO® Abdominal Stent-Graft System were included from 4 high-volume European academic medical centers from June 2021 to September 2023. Technical success and 30-day/in-hospital mortality and complications were analyzed. Technical success was defined as successful endovascular implantation of the stent graft with preservation of antegrade flow to the target vessels, and absence of type 1 or 2 endoleak (EL) at the first postoperative computed tomography angiography (CTA). RESULTS: Forty-two consecutive patients were included. The majority of the devices were constructed with 2 (N=4; 9.5%), 3 (N=9; 21.4%), or 4 (N=27; 64%) fenestrations. In 1 case, the device was constructed with a single fenestration (2.4%) and 1 device contained 5 fenestrations (2.4%); 17% had previous AAA repair. Target vessel cannulation with placement of a bridging stent was successful in all but 1 vessel (99, 3%). One aneurysm-related death occurred in the direct postoperative period and 2 limb occlusions necessitated reintervention during admission. In the median follow-up period of 101 (2-620) days, 3 more patients died due to non-aneurysm-related causes. Technical success was achieved in 90% of the cases. Nineteen ELs were seen on the first postoperative CT scan: 1 type 1b EL (N=1; 2%), 15 type 2 ELs (N=15; 36%), and 3 type 3 ELs (N=3%). Eleven patients received more than 1 CT scan during a median follow-up of 361 days (82-620): 3 type 2 ELs resolved and 1 type 3 EL was treated in this period. In the follow-up, 1 patient had a coagulation disorder that caused occlusions of the branches. CONCLUSION: The results of the first experiences using the custom-made fenestrated TREO® Abdominal Stent-Graft System in Europe are promising. There was a low short-term mortality and morbidity rate in these patients of which 17% had previous AAA repair. Mid-term and long-term follow-up data are needed to evaluate endograft durability and performance. CLINICAL IMPACT: This study shows the first experiences and short-term results of a novel low-profile custom-made device: the custom-made fenestrated TREO® Abdominal Stent-Graft System. Showing these results and experiences can help the physicians in clinical decision-making for their patients.

Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism.

BACKGROUND: Exact benefits of currently recommended close monitoring in intermediate high risk acute pulmonary embolism (PE) patients are unknown. METHODS: This prospective observational cohort study determined clinical characteristics, and disease course of intermediate high risk acute PE patients in an academic hospital setting . Frequency of hemodynamic deterioration, use of rescue reperfusion therapy and PE related mortality, were outcomes of interest. RESULTS: Of 98 intermediate high risk PE patients included for analysis, 81 patients (83%) were closely monitored. Two deteriorated hemodynamically and were treated with rescue reperfusion therapy. One patient survived after this. CONCLUSIONS: In these 98 intermediate high risk PE patients, hemodynamic deterioration occurred in three patients and rescue reperfusion therapy of two closely monitored patients led to survival of one. Underlining the need for better recognition of patients benefitting from and research in the optimal way of close monitoring.

Endovascular treatment of aortic stump blow-out after extra-anatomical repair of aortoduodenal fistula: a case report and review of literature.

BACKGROUND: An aortoduodenal fistula (ADF) is an unusual, but serious complication following surgical or endovascular aortic repair. The optimal treatment for ADF consists of removal of the infected graft with in situ or extra-anatomical repair and is associated with high mortality. Part of this mortality is caused by re-bleeding or aortic stump ruptures. Classical treatment of an aortic stump rupture involves immediate re-laparotomy, removal of infected tissue, aortic stump formation and reinforcement with soft tissue flaps. However, this invasive treatment is often difficult to perform and the condition of the patient frequently requires a more rapid response. We describe a case in which an aortic stump rupture was treated endovascularly by using an Amplatzer® Vascular Plug, which successfully stopped the bleeding. CASE PRESENTATION: This report describes a 67-year-old man who was presented with persistent duodenal leakage (due to secondary duodenal perforation) after resection and open in-situ repair of an infected aorto-bi-femoral prosthetic graft. An extra-anatomical reconstruction was performed with an axillo-bi-femoral bypass, followed by excision of the prosthesis, aortic stump formation, partial duodenal resection and duodenojejunal reconstruction. Twelve weeks later, sudden severe hematemesis with severe hemodynamic instability occurred. Computed tomography angiography showed extravasation of blood from the aortic stump into the duodenal loop. Endovascular treatment of the aortic stump blow-out with an Amplatzer® Vascular Plug was performed, which successfully stopped the bleeding and stabilized the patient. The duodenal fistula was treated conservatively. Three months later, the patient was discharged to a rehabilitation clinic in a good clinical condition. The patient was still alive after a follow-up of 4 years. CONCLUSIONS: Rapid treatment is requested in cases of aortic stump rupture. Re-laparotomy is practically never the most suitable solution and most of these aortic stump ruptures are fatal. Endovascular treatment could be a suitable alternative. Whether the endovascular treatment of aortic stump rupture is a definitive treatment or a bridge to surgery remains to be elucidated.

Safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension in the Netherlands.

BACKGROUND: Balloon pulmonary angioplasty (BPA) is an emerging treatment in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic disease (CTED). We describe the first safety and efficacy results of BPA in the Netherlands. METHODS: We selected all consecutive patients with inoperable CTEPH and CTED accepted for BPA treatment who had a six-month follow-up in the St. Antonius Hospital in Nieuwegein and the Amsterdam University Medical Center (UMC) in Amsterdam. Functional class (FC), N­terminal pro-brain natriuretic peptide (NT-proBNP), 6­minute walking test distance (6MWD) and right-sided heart catheterisation were performed at baseline and six months after last BPA. Complications for each BPA procedure were noted. RESULTS: A hundred and seventy-two BPA procedures were performed in 38 patients (61% female, mean age 65 ± 15 years). Significant improvements six months after BPA treatment were observed for functional class (63% FC I/II to 90% FC I/II, p = 0.014), mean pulmonary artery pressure (-8.9 mm Hg, p = 0.0001), pulmonary vascular resistance (-2.8 Woods Units (WU), p = 0.0001), right atrial pressure (-2.0 mm Hg, p = 0.006), stroke volume index (+5.7 ml/m2, p = 0.009) and 6MWD (+48m, p = 0.007). Non-severe complications occurred in 20 (12%) procedures. CONCLUSIONS: BPA performed in a CTEPH expert centre is an effective and safe treatment in patients with inoperable CTEPH.

[Should every doctor be allowed to use ultrasound? Dilemmas surrounding broad application of ultrasound in clinical practice]. / Mag iedere arts zonder meer echo's maken?

Ultrasound is rapidly gaining ground in clinical medicine. This offers distinct advantages for diagnosis and treatment. This is notably the case when moving images are created by the treating physician, who can integrate them immediately with all other clinical information. The downside of a broad application of ultrasound is an increase in the number of incidental findings and missed diagnoses. This is amplified by the frequent lack of formal requirements for training and skills. Storage of ultrasound images may furthermore lead to verifiable misinterpretations. We are of the opinion that responsible integration of ultrasound in clinical practice requires clear peer agreements without sectarian thinking. To illustrate this, we discuss the dilemmas surrounding increased use of ultrasound from a medicolegal perspective.

[Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension]. / Ballonpulmonalisangioplastiek voor chronische trombo-embolische pulmonale hypertensie.

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterised by an elevated average blood pressure in the pulmonary artery (≥ 25 mmHg). This increase is secondary to fibrous organization of thromboembolic obstructions in the pulmonary arteries. CTEPH is associated with significant morbidity and mortality due to right-sided heart failure and ventilation-perfusion discrepancy. Therapy is aimed at normalising pulmonary artery pressure, and pulmonary endarterectomy is usually the treatment of first choice. When surgery is not possible because of peripheral disease localisation or comorbidity, percutaneous balloon pulmonary angioplasty (BPA) can be used. BPA is associated with improvements in functional status and haemodynamic profile. Initially procedural complications often occurred, but improvements in procedural technique have ensured that BPA is used increasingly worldwide. In this article, we discuss the history, procedural aspects and outcomes of BPA, and present our first experiences with BPA in a patient with CTEPH.

Low-dose thrombolysis for thromboembolic lower extremity arterial occlusions is effective without major hemorrhagic complications.

OBJECTIVE: To evaluate the efficacy and bleeding complications associated with a low-dose thrombolysis protocol for thromboembolic lower extremity arterial occlusions. DESIGN: A retrospective cohort study. MATERIALS AND METHODS: A retrospective analysis was performed using data from all consecutive patients who underwent catheter-directed, intra-arterial thrombolysis for thromboembolic lower extremity arterial occlusions between January 2004 and May 2013. All patients were treated on a standard surgical ward. Endpoints were incidence of bleeding complications, duration of thrombolysis, angiographic patency rate, 30-day mortality rate, and amputation-free rate at 6 months. RESULTS: Of the 171 cases analyzed, 129 cases underwent low-dose thrombolysis and 42 underwent high-dose thrombolysis. No major bleeding complications occurred in the low-dose group versus 5% in the high-dose group (p = .01). The median duration of thrombolysis was 67 hours (4-304 hours) in the low-dose and 49 hours (2-171 hours) in the high-dose group (p = .027). Angiographic patency was restored in 67% of the cases in the low-dose group versus 79% of the high-dose group (p = .17). The 30-day mortality rates were 1% in the low-dose versus 5% in the high-dose group (p = .09). However, this higher mortality rate was not related to bleeding complications. Major amputation-free rates at 6 months were 81% in the low-dose group and 88% in the high-dose group (p = .22). CONCLUSIONS: Based on this data series, low-dose thrombolysis for thromboembolic lower extremity arterial occlusions is as effective as high-dose thrombolysis; however, the risk of major bleeding complications is substantially lower when using low-dose thrombolysis.

Stand-alone performance of a computer-assisted detection prototype for detection of acute pulmonary embolism: a multi-institutional comparison.

OBJECTIVE: To assess whether the performance of a computer-assisted detection (CAD) algorithm for acute pulmonary embolism (PE) differs in pulmonary CT angiographies acquired at various institutions. METHODS: In this retrospective study, we included 40 consecutive scans with and 40 without PE from 3 institutions (n = 240) using 64-slice scanners made by different manufacturers (General Electric; Philips; Siemens). CAD markers were classified as true or false positive (FP) using independent evaluation by two readers and consultation of a third chest radiologist in discordant cases. Image quality parameters were subjectively scored using 4/5-point scales. Image noise and vascular enhancement were measured. Statistical analysis was done to correlate image quality of the three institutions with CAD stand-alone performance. RESULTS: Patient groups were comparable with respect to age (p = 0.22), accompanying lung disease (p = 0.12) and inpatient/outpatient ratio (p = 0.67). The sensitivity was 100% (34/34), 97% (37/38) and 92% (33/36), and the specificity was 18% (8/44), 15% (6/41) and 13% (5/39). Neither significantly differed between the institutions (p = 0.21 and p = 0.820, respectively). The mean number of FP findings (4.5, 6.2 and 3.7) significantly varied (p = 0.02 and p = 0.03), but median numbers (2, 3 and 3) were comparable. Image quality parameters were significantly associated with the number of FP findings (p<0.05) but not with sensitivity. After correcting for noise and vascular enhancement, the number of FPs did not significantly differ between the three institutions (p = 0.43). CONCLUSIONS: CAD stand-alone performance is independent of scanner type but strongly related to image quality and thus scanning protocols.