Aortic Healing Appears to Occur Rapidly after Successful Endovascular Sealing of Blunt Thoracic Aortic Injury.

BACKGROUND: The traumatic nature of blunt thoracic aortic injury (BTAI) would suggest that healing of the aorta would occur once the injured area is shielded from aortic pressure. This would be in contrast to degenerative aortic diseases which often continue to degenerate despite coverage. We hypothesize that after successful thoracic aortic endografting (TEVAR) that the aorta rapidly heals itself leaving minimal to no trace of the residual injury. METHODS: BTAI that were successfully covered with TEVAR from 2006 to 2019 were collected. Those with failed sealing or a lack of follow-up scans were excluded. Centerline aortic diameters were measured at healthy aorta 1 cm above (D1) and below the injury (D3) and at the widest point of injury (D2) on preoperative and initial postoperative computed tomography (CT) scans. Postoperative CTs were examined for residual signs of aortic injury including residual periaortic hematoma, persistent thrombosed pseudoaneurysm, or thickened aortic wall. Diameter changes in the healthy and injured aortic segments were compared pre and post TEVAR. Aortic diameter changes were analyzed with the Student's t-test. RESULTS: Twenty four patients were identified with sealed BTAI. The mean graft diameter was 24.2 ± 3.2 mm with oversizing of 10.74 ± 6.1 % at D1 and 19.52 ± 10.22 % at D3. Postoperative CTs occurred at 61.25 ± 123.6 days with one outlier at 602 days. Injured aortic segments (D2) had significantly larger diameters compared to D1 (28.94 ± 5.08 mm vs. 22.14 ± 3.08 mm, P < 0.001). After TEVAR, 23/24 (95.8%) had no residual radiographic evidence of aortic injury by 2 months. One patient had a persistent thrombosed pseudoaneurysm likely due to more than 50% disruption of the aortic wall. Post TEVAR, there was a significant diameter reduction at D2 by 13.8% (29.10 ± 5.27 mm vs. 24.8 ± 4.2 mm, P < 0.001) which was within 2.45% of the mean stent graft diameter. The healthy aorta dilated to accommodate the graft by 9% at D1 (21.9 ± 3.0 vs. 23.7 ± 2.5 mm, P < 0.001) and 17% at D3 (20.6 ± 3.4 mm vs. 23.6 ± 3.2 mm, P < 0.001). CONCLUSIONS: TEVAR promotes rapid aortic healing in BTAI with no evidence of residual aortic injury suggesting that a long-term seal is not necessary. The healthy aorta dilates to the stent graft size, as expected, whereas the injured aortic segment heals around the stent graft and assumes its diameter as well. Massive disruption of the aortic wall may preclude early healing.

Use of three-dimensional-three-dimensional digital subtraction angiography spin fusion protocol for complex aortoiliac endovascular interventions.

Complex endovascular aortic interventions in patients with excessive tortuosity or difficult gantry angles can be challenging. Although fusion imaging can help navigate these issues, it is based on preoperative imaging studies, which becomes skewed after introduction of stiff wires and large devices into the aorta. The subtraction spin protocol performs two cone-beam computed tomography scans to create a subtracted image of the contrast-filled vessels after wire and device placement to accommodate vessel distortion. We have reported a complex fenestrated endovascular aneurysm repair case with a highly angulated neck to highlight the advantages of the subtraction spin protocol in anatomically hostile endovascular repairs.

Endovascular Solution to Endoleak Phenomenon After Open Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) has quickly outpaced open treatment of infrarenal abdominal aortic aneurysm (AAA) and iliac artery aneurysms, relegating most open AAA repair for either young patients with long life expectancy or patients with extreme anatomic constraints. Typically, open repair involves opening the aneurysm sac with suture ligation of back-bleeding vessels. However, in situations where an aortobifemoral repair is performed, proximal and distal ligation can be performed leaving behind a "remnant" aorta and iliac arteries. Usually, major palpable vessels are ligated and small lumbars spontaneously thrombose. However, failure of this to occur can lead to a rare situation in which there is persistent filling of a remnant aorta and aneurysm sac leading to a situation similar to a type II endoleak after EVAR. Typically, this leak has been repaired by open ligation. We present a technique for endovascular coiling and thrombin injection to correct a "type II endoleak" from a back-bleeding lumbar artery after open aortoiliac and femoral aneurysm repair.

Mid-Term Outcomes of Thrombolysis for Acute Lower Extremity Ischemia at a Tertiary Care Center.

BACKGROUND: Acute limb ischemia (ALI) is challenging to treat because of high morbidity and mortality. Endovascular-first options beginning with thrombolysis are technically feasible with similar results to open surgery. We examined our experience with thrombolysis to identify patients and target conduits that are predictive of improved outcomes. METHODS: We performed a retrospective review of our institutional database of thrombolysis cases for arterial lower extremity disease. Thrombolysis was the index procedure, and any subsequent treatment was a reintervention. Conversion to open surgery perioperatively such as thromboembolectomy or bypass was considered a technical failure. Primary outcomes included primary patency, secondary patency, amputation-free survival (AFS), and survival. Secondary outcomes included conversion to open, reintervention <30 days, and amputation <30 days. Descriptive statistics and analysis of variance were performed for preoperative and intraoperative risk factors. Kaplan-Meier estimation and Cox proportional hazard models were used for primary and secondary outcomes. RESULTS: Ninety-nine patients with ALI were treated with thrombolysis from 2007 to 2017. Thrombolysis was attempted on native artery (40%), vein bypass (7%), prosthetic bypass (33%), and stent (19%). Rutherford class distribution was 50% class 1, 41% class 2a, 5% class 2b, and 3% class 3. Technical success was 70%, characterized by an all-endovascular approach, patency at 30 days, and AFS for 30 days. Primary patency at 1- and 2-years was 31% and 22%, respectively. Secondary patency at 1- and 2-years was 39% and 27%, respectively. Overall, 30% required conversion to open surgery at the time of the index procedure, 7% reintervention <30 days, 5% mortality <30 days, and 5% major amputation <30 days. Prosthetic grafts and vein bypasses had the worst primary and secondary patency (P < 0.05). Five out of 7 vein bypasses required open conversion. Thrombolysis of native arteries was most successful maintaining primary patency (P < 0.05), secondary patency (P < 0.05), and AFS (P < 0.05). Patients who had adjunctive procedures at the time of thrombolysis had a significantly greater primary patency (P < 0.05) and secondary patency (P < 0.05) but not greater AFS. CONCLUSION: Outcomes in thrombolysis for ALI have not significantly improved 20 years after the STILE trial. Technical success and mid-term patency rates are modest at best. Thrombolysis of vein bypasses and prosthetic grafts have poor technical success and primary patency compared with native arteries. However, aggressive adjunctive interventions during thrombolysis appear to improve primary and secondary patency.

Explantation of an Infected TEVAR With an Extra-Anatomic Arch Reconstruction Along the Right Heart.

This case represents the disease progression and workup of an infected thoracic endovascular aortic repair (TEVAR) graft that initially manifested as an aortic arch pseudoaneurysm. The patient underwent a 2-stage operation to resect the infected TEVAR and to reconstruct flow via an extra-anatomic aortic bypass paralleling the right heart. This is one of the few documented cases of TEVAR explantation with an extra-anatomic aortic bypass to re-establish flow.

Endovascular Repair of the Ascending Aorta for an Anastomotic Saphenous Vein Graft Aneurysm.

The ascending aorta is the final segment of the aorta to be explored with endovascular stent grafts. With a patient population of increasingly advanced age and disease, there are situations where traditional open repair for ascending aneurysms or dissections may be prohibitive. However, the ascending aorta has multiple hostile characteristics that make endovascular treatment challenging. There is also a lack of approved specialized devices in the United States for this aortic territory. We demonstrate the feasibility of adapting an abdominal aortic graft to the ascending aorta for the treatment of a saphenous vein graft aneurysm with a discussion of the technical considerations for the operation.

Parallel Stent Graft Technique for Hypogastric Aneurysm Repair With Flow Preservation of Distal Pelvic Circulation.

Hypogastric artery aneurysms (HAA) necessitate repair due to significant morbidity and potential mortality associated with rupture. Coverage or coiling of HAA are not always possible, as the risk of pelvic and spinal cord ischemia become especially significant in bilateral hypogastric disease as well as with prior extensive aortic coverage. We report 2 cases of endovascular HAA exclusion using parallel stent grafts for preservation of flow through the distal hypogastric artery branches and external iliac artery in patients with prior thoracic and abdominal aortic repairs, contralateral hypogastric disease, and significant anatomic constraints.

Simultaneous thoracic aortic endovascular graft and transfemoral transcatheter aortic valve replacement in a patient with a descending aortic thrombus.

Severe descending thoracic and abdominal aortic pathology can deter consideration of transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) in adults with severe symptomatic aortic stenosis (AS) and may lead to utilization of alternative access sites. We report a case of an 88-year-old frail woman with severe symptomatic AS referred for TAVR with demonstration of a large thrombus in the descending thoracic aorta immediately distal to the left subclavian artery. Given concerns of thrombus embolization with femoral advancement of the transcatheter valve, coverage with a thoracic aortic endograft was planned immediately prior to the TAVR.

Short-term results of left subclavian artery salvage in blunt thoracic aortic injury with short proximal landing zones.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the standard treatment of blunt thoracic aortic injury (BTAI). The concept of seal was derived from the treatment of aneurysms and has been adopted for BTAI. Given the location of injury in BTAI, left subclavian artery (LSA) coverage is sometimes necessary. In these often healthier aortas, a shorter proximal landing zone may be acceptable and beneficial in avoiding some complications. Current practice patterns vary, and long-term effects of LSA coverage remain unknown. METHODS: A single-institution experience with BTAI for TEVAR was examined from 2006 to 2017. The primary outcome was failure of sealing, endoleak, or persistent aortic injury on follow-up imaging. A centerline was used to measure the length of the landing zone, aortic diameter, and other parameters. Post-TEVAR computed tomography scans were examined for evidence of residual aortic injury. RESULTS: A total of 30 TEVARs were performed for BTAI. The mean age of the patients was 38.7 years (standard deviation [SD], 19.8 years), and 70% were male. The mean injury severity score was 36.75 (SD, 13.1). Treated patients had grade 2 (36.7%) or grade 3 (63.3%) BTAI. The LSA was salvaged in 23 cases and covered in seven cases. The mean landing zone in LSA uncovered cases was 16 mm (SD, 10.4 mm). There were 15 patients (65%) who had a landing zone <20 mm, and eight (35%) patients had a landing zone >20 mm. The mean landing zone in the seven covered cases was 1.8 mm (SD, 2.4 mm). Procedural success was 96% for the uncovered group and 100% for the covered group. On follow-up imaging, there was only one residual endoleak in all surviving patients (n = 25). Five patients did not have postoperative imaging, two (7%) of whom died of nonaorta-related issues. CONCLUSIONS: TEVAR for BTAI in patients with short proximal landing zones of 10 to 20 mm as well as in select patients with landing zones of 5 to 10 mm appears to be safe and efficacious. The aorta demonstrates no residual injury after TEVAR, with the graft acting potentially more as a bridge to allow healing. Long-term issues regarding LSA coverage have been difficult to ascertain and to evaluate because of historically poor follow-up in this population of patients. However, potential issues with LSA coverage and revascularization may be avoided by preserving the subclavian artery even with shorter proximal landing zones.

Transcarotid Transcatheter Aortic Valve Replacement as Preferred Alternative Access in a Patient With Bilateral Carotid Artery Disease.

A 78-year-old man presented with severe symptomatic aortic stenosis and a heavily calcified, stenotic aortic valve. Given multiple comorbidities, the heart team agreed on a transcatheter approach via the left common carotid artery.

Evolution of type II endoleaks based on different ultrasound-identified patterns.

OBJECTIVE: The objective of this study was to delineate the specific types of waveforms that exist in type II endoleaks (T2ELs) and their effect on aneurysm sac size. METHODS: Patients who underwent an endovascular aneurysm repair and were diagnosed with a T2EL were included in the study. The flow velocity characteristics of the T2ELs were evaluated in detail with duplex ultrasound. Four different flow patterns were identified: high resistance, low flow; low resistance, low flow; low resistance, high flow; and to-fro flow. The type and number of vessels involved, time at detection, evolution, and need for treatment were recorded. The aneurysm sac diameter was monitored with duplex ultrasound. A computed tomography scan was always performed at baseline within 1 month of the procedure and repeated only when symptoms developed or there were changes in the ultrasound examination findings, such as sac enlargement. RESULTS: Of 382 patients who underwent endovascular aneurysm repair in our institution, 56 (14.65%) were found to have a T2EL. There were 52 male and four female patients with a mean age of 74 years (61-86 years). The T2EL was diagnosed within the first month in 32 patients; 9 patients were diagnosed at 3 months, 5 patients at 6 months, 3 patients at 9 months, and 7 patients at 1 year or later. There were 43 patients who had a T2EL involving one vessel; two vessels were involved in 11 patients and three vessels were involved in two patients. During follow-up, several changes were observed for the different types of T2EL. High-resistance, low-flow endoleak was detected in 14 patients; of those, 13 were occluded and 1 converted to high flow. Low-resistance, low-flow endoleak was detected in seven patients; of those, 5 were occluded, 1 remained stable, and 1 converted to high flow with sac enlargement requiring treatment. Low-resistance, high-flow endoleak was found in 13 patients; of those, 8 were occluded, 3 remained stable, and 2 had sac enlargement requiring treatment; 1 patient presented with rupture. Finally, to-fro flow was identified in the majority of the patients (22); of those, 14 occluded, 3 remained stable, and 5 had sac enlargement requiring treatment; 2 patients presented with rupture. No deaths due to T2EL were encountered. CONCLUSIONS: Most of the T2ELs resulted in spontaneous occlusion and were not associated with sac enlargement. A low-resistance, high-flow or to-fro flow T2EL has higher chances of sac enlargement, rupture, and requiring reintervention.

Clinical characteristics and outcome of isolated infrarenal aortic stenosis in young patients.

OBJECTIVE: The objective of this study was to identify young patients with isolated infrarenal aortic atherosclerotic stenosis and to determine the clinical characteristics and midterm results of angioplasty and stenting. METHODS: Data from patients younger than 50 years with significant infrarenal aortic stenosis and at least 1 year of follow-up were prospectively collected. Patients with coexistent suprarenal or iliofemoral disease and Takayasu arteritis were excluded. All patients were treated with percutaneous transluminal angioplasty (PTA), primary stenting, or both. Pressure gradient was measured intraoperatively before and after the intervention. Every patient was monitored postoperatively with clinical examination, ankle-brachial index, and duplex ultrasound during follow-up. RESULTS: There were 51 patients, of whom 34 were excluded. Seventeen patients ranging in age from 37 to 49 years (mean, 43.7 years) met the study criteria, and they were all female. Fifteen patients had both history of hyperlipidemia and smoking with a mean of 53.2 pack-years. Fourteen patients were claudicants, whereas seven patients presented with distal embolization. Six patients were treated with primary stenting; four had PTA plus stent and seven had PTA alone. The length of the stenotic segments treated was <2 cm in 7, between 2 and 4 cm in 8, and >4 cm in 2. The mean follow-up for this cohort was 4.2 years. Mean pressure gradient before intervention was 49.06 ± 12.75 mm Hg, decreasing to 6.13 ± 2.06 mm Hg after intervention with a mean reduction of 42.75 ± 11.59 mm Hg. Mean ankle-brachial indices before the intervention were 0.67 ± 0.07, increasing to a mean of 0.92 ± 0.06 after the procedure. Stenosis developed in three patients during follow-up, requiring reintervention for a primary assisted patency of 100%. CONCLUSIONS: Isolated infrarenal aortic stenosis in young patients is primarily a disease of women. Most of these patients are heavy smokers with hyperlipidemia. PTA alone or with stenting has favorable midterm results.

A rare case of idiopathic bilateral ovarian vein thrombosis.

Ovarian vein thrombosis (OVT) is a rare medical disorder most often diagnosed in the peripartum period and maybe associated with other risk factors for thrombosis. Rarely, OVT is considered idiopathic. It occurs in the right ovarian vein alone in two-thirds of patients. In this report, we present a case of idiopathic and bilateral OVT in a 35-year-old woman who presented with 2-day history of left flank pain. Duplex ultrasound imaging and computed tomography confirmed the diagnosis. Oral anticoagulation achieved a favorable outcome.

Fluoroscopy time is not accurate as a surrogate for radiation exposure.

Objective The Food and Drug Administration and the Vascular Quality Initiative still utilize fluoroscopy time as a surrogate marker for procedural radiation exposure. This study demonstrates that fluoroscopy time does not accurately represent radiation exposure and that dose area product and air kerma are more appropriate measures. Methods Lower extremity endovascular interventions ( N = 145) between 2013 and 2015 performed at an academic medical center on a Siemens Artis-Zee floor mounted c-arm were identified. Data was collected from the summary sheet after every case. Scatter plots with Pearson correlation coefficients were created. A strong correlation was indicated by an r value approaching 1. Results Overall mean AK and DAP was 380.27 mGy and 4919.2 µGym2. There was a poor correlation between fluoroscopy time and total AK or DAP ( r = 0.27 and 0.32). Total DAP was strongly correlated to cine DAP and fluoroscopy DAP ( r = 0.92 vs. 0.84). The number of DSA runs and average frame rate did not affect AK or DAP levels. Mean magnification level was significantly correlated with total AK ( r = 0.53). Conclusions Fluoroscopy time shows minimal correlation with radiation delivered and therefore is a poor surrogate for radiation exposure during fluoroscopy procedures. DAP and AK are more suitable markers to accurately gauge radiation exposure.

Inguinal pain and fullness due to an intravascular leiomyoma in the external iliac vein.

Intravascular leiomyomatosis (IVL) is a benign smooth muscle tumor that evolves from the pelvic veins and can spread to the central veins and heart. Cardiac involvement is the most commonly reported presentation. Initial diagnosis is difficult, and IVL is commonly misdiagnosed as thrombus or atrial myxoma. Appropriate imaging and a high clinical suspicion are required for accurate diagnosis. We report a rare case of IVL in the external iliac vein that recurred 4 years after hysterectomy. Only four cases have been reported in the literature to involve the external iliac vein as it has no direct connection to pelvic venous drainage.

Delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac resulting in continued sac expansion and rupture.

We present the case of delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac that expanded and ruptured. Dilation of the aortic neck likely led to endograft migration and exposure of the occluded endograft and aneurysm sac to systemic pressure. Although no endoleak was identified, a key finding on ultrasound showed mobility of the sac thrombus. This may be an indicator of flow within the sac that may predict potential for rupture. Despite thrombosis of the aortic sac and endograft, the risk of rupture still lingers, and thus continued surveillance of occluded endografts may be prudent.

Tibioperoneal Trunk Aneurysm Resulting in Compartment Syndrome with Associated Aneurysms of the Popliteal and Dorsalis Pedis Arteries.

True aneurysms of the tibioperoneal trunk are rare. Given the scarcity of reports, the clinical presentation and treatment is not well defined. This is a case report of a 50-year-old male patient presenting with severe lower extremity swelling and compartment syndrome with neurological compromise secondary to a tibioperoneal trunk aneurysm. He was also noted to have discrete ipsilateral popliteal and dorsalis pedis artery aneurysms. Given the location and size of the aneurysm, the severe leg swelling, and venous hypertension, aneurysmorrhaphy or aneurysm sac excision with arterial reconstruction was prohibitively dangerous. Thus, following fasciotomies, a hybrid repair utilizing a saphenous vein superficial femoral to anterior tibial artery bypass along with coil embolization of the aneurysm sac was performed. The patient recovered full function of his leg and follow-up computed tomography angiogram demonstrated thrombosis and regression of the aneurysm sac with a patent bypass.

Coil embolization of an aortic pseudoaneurysm after open repair of type A aortic dissection.

Anastomotic pseudoaneurysms represent an uncommon and challenging complication of open aortic repair with prosthetic graft. First characterized by Clayton et al. in 1956, they affect approximately 1.4-4% of arterial anastomoses. These pseudoaneurysms are the result of many factors, foremost of which are infection, integrity of the host tissue, surgical technique, and location of the anastomosis. Pseudoaneurysms were traditionally treated with open resection of the pseudoaneurysm and revision of the anastomosis. This case presents a novel approach to the treatment of pseudoaneurysms in a difficult location. The patient was a 77-year-old man status after repair of a type A aortic dissection with a Dacron tube graft. Follow-up imaging 18 months postoperatively showed a 1.6 cm×1.7 cm pseudoaneurysm off of the posteromedial proximal suture line. Through a right brachial artery approach, a diagnostic angiogram was performed demonstrating a bilobed pseudoaneurysm. A Judkins left 3.5 catheter and 0.035″-angled Glidewire was used to engage the orifice of the pseudoaneurysm. Two 4 mm×6 cm Boston Scientific Interlock coils were then deployed into the pseudoaneurysm sac. Completion angiogram demonstrated complete exclusion of the pseudoaneurysm. The patient did well and was discharged the following day. Follow-up computed tomography scan at 3 months showed regression and complete thrombosis of the pseudoaneurysm. Traditional operative repair of anastomotic pseudoaneurysms can lead to long operations, high blood loss, and increased morbidity and mortality as a result of their reoperative nature. Coil embolization is a safe and effective approach for the treatment of anastomotic pseudoaneurysms in difficult locations.

Mid- and long-term results of the treatment of infrainguinal arterial occlusive disease with precuffed expanded polytetrafluoroethylene grafts compared with vein grafts.

BACKGROUND: Prosthetic grafts for lower-extremity bypass have limited patency compared with autologous vein grafts. Precuffed expanded polytetrafluoroethylene (ePTFE) grafts alter the geometry of the distal hood to improve patency. This study reports the authors' long-term results on the use of precuffed ePTFE grafts for infrainguinal bypasses in patients with arterial occlusive disease and compares these with results of reversed great saphenous vein grafts (rSVG). METHODS: A retrospective review of billing codes identified 101 polytetrafluoroethylene (PTFE) and 47 rSVG bypasses performed over a 6-year period. Femoral to below-knee popliteal and femoral to tibial bypasses were analyzed. Data collected consisted of risk factors, Rutherford classification, bypass inflow and outflow, runoff vessels, patency, amputation, and death. Primary end points consisted of primary, assisted-primary, and secondary patency along with limb salvage. RESULTS: Mean age of the patients was 76 years in the PTFE group and 69.8 years in the rSVG group. For femoral to below-knee popliteal bypasses, primary patency at 1, 3, and 5 years in the PTFE group was 76.9%, 48.7%, and 43.3%, respectively, compared with 77.1%, 77.1%, and 77.1%, respectively, in the rSVG group (P = 0.225). Secondary patency was 89.2%, 70.9%, and 50.6% in the PTFE group compared with 84.4%, 84.4%, and 84.4% in the rSVG group (P = 0.269). Limb salvage was similar in the PTFE compared with the rSVG group (97.7%, 90.5%, and 79.4% vs. 83.3%, 83.3%, and 83.3%; P = 0.653). For femoral to tibial bypasses, primary patency in the PTFE group at 1, 3, and 5 years was 57.1%, 40.4%, and 22.1%, respectively, compared with 67.4%, 67.4%, and 50.6%, respectively, for the rSVG group (P = 0.246). Secondary patency was 75.5%, 44.9%, and 22.7% in the PTFE group compared with 91.8%, 91.8%, and 52.5% in the rSVG group (P = 0.022). Limb salvage at 1, 3, and 5 years was 79.2%, 55.7%, and 55.7%, respectively, in the PTFE group compared with 96.4%, 96.4%, and 64.3%, respectively, in the rSVG group (P = 0.046). CONCLUSIONS: Precuffed ePTFE grafts demonstrate similar 1-year patency to that of rSVG. However, mid- and long-term patency is reduced compared with saphenous vein grafts (SVG), especially to tibial targets. PTFE grafts to the popliteal demonstrate limb salvage rates similar to those of SVG. In the tibial vessels, limb salvage rates for PTFE grafts are significantly worse compared with SVG.