Treatment of aortic arch aneurysms with a modular transfemoral multibranched stent graft: initial experience.

OBJECTIVES: To present initial experience with a new modular transfemoral multibranched stent graft for treating aortic arch aneurysms. METHODS: Six patients, considered high risk for open surgery, were treated with custom made branched stent grafts. All patients had a staged left carotid subclavian bypass before the endovascular procedure. Each branched graft had a 12 mm side branch for the innominate artery and an 8 mm side branch for the left common carotid artery. RESULTS: Four patients out of six had uneventful placement of the prostheses, with successful exclusion of their aneurysms. One patient developed a type I endoleak that was managed successfully with coiling and gluing of the aneurysm sac. In one patient, cannulation of the innominate branch was unsuccessful and an extra-anatomic bypass was necessary to perfuse the right carotid and vertebral arteries. This patient developed a stroke, while one more suffered a right cerebellar infarct. CONCLUSION: We have demonstrated the technical feasibility of a modular transfemoral branched stent graft for treatment of aortic arch aneurysms. The method is relatively safe based on initial experience. More cases and long-term follow up are necessary to evaluate the efficacy and safety of this new device.

The combined treatment of aortic stenosis and abdominal aortic aneurysm using transcatheter techniques: a case report.

We describe the case of an 85 year old lady with symptomatic aortic stenosis (AS) with a history of previous coronary artery bypass grafting (CABG), who was referred for consideration of aortic valve replacement (AVR). Echocardiography revealed severe AS with peak gradient of 92 mmHg, orifice area of 0.6 cm2 and preserved left ventricular function. Computed tomography (CT) aortogram revealed a diffusely calcified aorta and an infrarenal abdominal aortic aneurysm (AAA) measuring 6.5 cm. For symptomatic and prognostic reasons she needed treatment of both the AAA and AS. Her calculated logistic EuroSCORE for AVR was 39%. Following discussion at a multidisciplinary forum, it was agreed that the best way to offer her treatment with the lowest risk was by using transcatheter techniques for both pathologies. She subsequently underwent transcatheter aortic valve implantation (TAVI) via the transapical approach to treat her AS, and 3 months later, endovascular stenting of her infrarenal AAA. She recovered well from both procedures. At 6 week follow up, her cardiac symptoms had improved considerably, and echocardiography revealed a mean AV gradient of 7 mmHg with good left ventricular function. Ultrasound of her abdomen revealed exclusion of the aneurysm sac with no endoleak. This is the first described case of TAVI and endovascular treatment of an AAA as a staged procedure.

Giant abdominal aortic aneurysms: clinical and technical considerations.

The rupture risk of abdominal aortic aneurysms (AAA) depends primarily on their diameter and increases substantially in large aneurysms. Only a few cases of giant AAAs, with a maximum diameter > 13 cm have been reported in the English literature. This case series report describes 3 cases of giant AAAs presented with rupture. All cases were managed with open surgical repair, since anatomic factors prevented us from choosing an endovascular approach. The huge size of the aneurysm, the short length of the neck and the dislodgement of abdominal organs, that may be densely adhered to its surface with fistula formation, make surgery of this entity very challenging. Open repair of giant AAAs is often the only available treatment, though not always with good results.

Autogenous brachial-brachial fistula for vein access. Haemodynamic factors predicting outcome and 1 year clinical data.

UNLABELLED: Two-stage autogenous brachial vein-brachial artery access (ABBA) has been proposed as an option where adequate superficial vein is not available for the creation of conventional haemodialysis fistulae. METHODS: This report depicts the clinical outcome of a series of 17 consecutive patients who underwent ABBA in a single centre. Of the 17 patients, nine had had at least one previous arterioventricular (AV) fistula or graft, and eight were new to haemodialysis. Patencies were assessed using the Kaplan-Meier survival analysis. RESULTS: In 14 patients, the brachial vein was transposed (82%) and the time to transposition ranged from 4 to 26 weeks (median time: 6 weeks). The functional patency rate was 45.75% at 12 months. After stage one, all fistulas that went on to develop well had a brachial vein flow of at least 900 ml min(-1), and this was significantly higher than in fistulas that failed to develop (p=0.005). The maturation rate in our study was 65% and the median time to cannulation of the fistula was 8 weeks from the stage 1. Of the 17 patients, 12 (71%) experienced at least one complication. Ten (59%) demonstrated moderate-to-severe stenoses; eight of which necessitated angioplasty and/or percutaneous mechanical thrombolysis. CONCLUSIONS: ABBA was characterised by a high incidence of complications and a long period to achieve maturation. Despite close monitoring and a high rate of secondary interventions, the patency rate was low. With this experience, we now only consider it an alternative in patients without adequate superficial veins, who have had failed grafts or where there is a very high risk of infection.