Jaw claudication and branch perfusion reduction as rare complications of fenestrated thoracic endovascular aortic repair.

We report a rare case of jaw claudication following fenestrated thoracic endovascular aortic repair for a saccular aortic arch aneurysm. The brachiocephalic artery (BCA) was preserved with fenestration and intentionally half covered. Although discharged without any complications 2 weeks after the procedure, the patient subsequently experienced right mandibular fatigue at mealtime and hypotension in the right upper extremity. Angiography revealed a flap-like structure in the BCA orifice, with a 100-mm Hg pressure gradient between the aorta and BCA. Intravascular ultrasound revealed a stenosed BCA with a cord-like structure, which was considered a graft protrusion. Bare metal stenting was performed, which promptly resolved the symptoms.

Role of Percutaneous Deep Venous Arterialization for Patients with Chronic Limb-threatening Ischemia.

Efficacy of percutaneous deep venous arterialization (pDVA) has been reported for patients with no-option chronic limb-threatening ischemia (CLTI). In the countries where a manufactured device dedicated for pDVA has not been reimbursed, pDVA using the off-the-shelf technique has alternatively spread. The off-the-shelf techniques for arteriovenous fistula (AVF) creation reported are as follows: AV spear technique, venous arterialization simplified technique (VAST), and a use of penetration guidewire or a reentry device. Technical success rates of the procedures are similar to those using the dedicated device. pDVA could be a last resort for the patients with no-option CLTI, including those suffering from stump ulcer after major limb amputation or those with occluded surgical bypass.

Comparing the impact of the loss of patency between treatment with drug-coated balloon angioplasty and drug-eluting stent placement.

OBJECTIVE: To compare the results of endovascular treatment with drug-eluting stents (DES) and drug-coated balloons (DCB) in atherosclerotic lesions in the femoropopliteal artery, as well as to assess restenotic patterns. METHODS: Clinical data from 617 cases treated with DES or DCB for femoropopliteal diseases were analyzed in this multicenter, retrospective cohort study. From these, 290 DES and 145 DCB cases were extracted by propensity score matching. Outcomes investigated were 1- and 2-year primary patency, reintervention, and restenotic pattern and its impact on symptoms in each group. RESULTS: The primary patency rates at 1 and 2 years in the DES group were superior to those in the DCB group (84.8% and 71.1% vs 81.3% and 66.6%, P = .043), whereas there was no significant difference in freedom from target lesion revascularization (91.6% and 82.6% vs 88.3% and 78.8%, P = .13). Compared with what was measured before the index procedures, exacerbated symptoms, rate of occlusion, and an increase in the occluded length at loss of patency were more frequent in the DES group than in the DCB group. The odds ratios were 3.53 (95% confidence interval, 1.31-9.49; P = .012), 3.61 (1.09-11.9; P = .036), and 3.82 (1.15-12.7; P = .029), respectively. On the other hand, the frequency of an increase in lesion length and requirement of target lesion revascularization were similar between the two groups. CONCLUSIONS: Primary patency was significantly higher at 1 and 2 years in the DES than in the DCB group. However, DES were associated with exacerbated clinical symptoms and complicated lesion characteristics at the point of loss of patency.

Hemodynamic evaluation of lower limbs in patients with chronic limb-threatening ischemia.

Revascularization plays an important role in the treatment of chronic limb-threatening ischemia. Evaluation of hemodynamic compromise in the lower extremity is required to optimize the treatment strategy for each patient. A variety of methods have been reported to detect arterial obstruction or impaired foot perfusion. This article reviews each method, clarifying features and limitations.

Comparison of Outcomes and Complications Among Patients with Different Indications of Acute/Subacute Complicated Stanford Type B Aortic Dissection Treated by TEVAR: Data from the JaPanese REtrospective multicenter stuDy of ThoracIc Endovascular Aortic Repair for Complicated Type B Aortic Dissection (J-Predictive Study).

PURPOSE: To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair. MATERIAL AND METHODS: The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test. RESULTS: Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair. CONCLUSIONS: Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia. LEVEL OF EVIDENCE: Level 4, Case series.

Prediction of Abdominal Aortic Aneurysm Growth After Endovascular Aortic Repair by Measuring Brachial-Ankle Pulse Wave Velocity.

BACKGROUND: Although endovascular aortic repair (EVAR) has become the dominant therapeutic approach for abdominal aortic aneurysm (AAA), continued sac growth after EVAR remains a major concern and is still unpredictable. Since AAA formation is thought to arise from atherosclerotic vascular damage of the aortic wall, we hypothesize that the severity of atherosclerosis in the AAA wall may influence sac growth. Therefore, we investigated whether brachial-ankle pulse wave velocity (baPWV), a marker of atherosclerosis severity obtained by noninvasive automatic devices, can predict sac growth after EVAR. METHODS: The data from all patients who underwent elective EVAR for AAA at a single institution from January 2012 to March 2019 were reviewed. We extracted the baPWV before EVAR and divided patients into 2 groups according to the baPWV cut-off value identified by a classification and regression tree (CART). The primary outcome was significant sac growth, defined as an increment of 5 mm or more in aneurysm size after EVAR relative to the aneurysm size before EVAR. Cox regression analysis was performed to assess the potential predictors of sac growth. RESULTS: During the follow-up period, 222 consecutive patients underwent elective EVAR for AAA. Of these, 175 patients with a median follow-up period of 36 months were included. The baPWV values were classified as <1854 cm/s (Group 0) in 100 patients and ≥1854 cm/s (Group 1) in 75 patients according to the cut-off value identified by CART. During the follow-up period, 10 (10.0%) patients in Group 0 and 18 (24.0%) patients in Group 1 demonstrated significant sac growth (P = 0.021). Risk factors for significant sac growth included baPWV (hazard ratio [HR], 3.059; 95% confidence interval [CI], 1.41-6.64; P = 0.005), age (HR, 1.078; 95% CI, 1.01-1.16; P = 0.036), and persistent type II endoleak (HR, 3.552; 95% CI, 1.69-7.48; P < 0.001). Multivariate analysis revealed that baPWV remained a significant risk factor for sac growth after adjustment for age (HR, 2.602; 95% CI, 1.15-5.82; P = 0.02) and persistent type II endoleak (HR, 2.957; 95% CI, 1.36-6.43; P = 0.006). CONCLUSIONS: The baPWV before EVAR was associated with significant sac growth after EVAR; thus, measuring the baPWV may be useful for assessing the risk of future sac growth in patients after EVAR.

Efficacy of Multichannel Balloon Angioplasty in Calcified Common Femoral Artery Lesions.

This report describes 7 cases in which multichannel balloon angioplasty was performed for severely calcified common femoral artery stenosis. After the successful passage of a guidewire through the stenosis, another guidewire with a tip load of 12g or 14 g was passed through a different channel inside the calcified plaques, followed by balloon angioplasty via each route. After the procedure, ankle brachial index improved from 0.49 ± 0.23 to 0.89 ± 0.05 on an average, and 6 of the 7 patients had patent arteries at a median follow-up period of 13 months. Multichannel balloon angioplasty offers the promise of being an effective endovascular intervention to expand calcified lesions.

Management of Renal Arteries in Conjunction with Thoracic Endovascular Aortic Repair for Complicated Stanford Type B Aortic Dissection: The Japanese Multicenter Study (J-Predictive Study).

Background Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: -16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: -13% ± 14 vs 8.5% ± 14, P = .004). Conclusion Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss. © RSNA, 2019 Online supplemental material is available for this article.

Conformability and Efficacy of the Zenith Spiral Z Leg Compared with the Zenith Flex Leg in Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: The aim of this study is to compare the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using the Zenith® Spiral Z abdominal aortic aneurysm iliac leg (ZSLE) versus the Zenith® Flex abdominal aortic aneurysm iliac leg (TFLE). METHODS: Patients undergoing EVAR using TFLE or ZSLE between October 2009 and December 2017 were retrospectively reviewed. Clinical end points were freedom from limb-related complications and change in arterial tortuosity indexes. Limb-related complication was defined as limb stenosis or occlusion, stent kink, stent disconnection, and type 1b endoleak. Tortuosity indexes were measured on the preoperative and postoperative computed tomography and compared. RESULTS: A total of 56 patients (11 female, average age 78.5 ± 5.5 years), 111 limbs, were enrolled. One patient was treated using aortouni-iliac device. TFLE was deployed in 43 limbs (22 patients) and ZSLE in 68 limbs (34 patients). Average follow-up was 43.6 ± 27.6 months. During follow-up, 8 limb-related complications occurred in the TFLE group and 2 in the ZSLE group. Freedom from limb-related complications at 3 years was 84.4% in the TFLE group and 96.1% in the ZSLE group (P = 0.039). There was no statistically significant difference between the TFLE and the ZSLE group in the aortoiliac tortuosity change (TFLE versus ZSLE -6.1 ± 5.8 vs. -4.9 ± 6.4, P = 0.324). However, there was significance in the iliac tortuosity change (-7.4 ± 11.7 vs. -3.0 ± 7.9, P = 0.022). CONCLUSIONS: Spiral Z leg showed less occurrence of limb-related complications and less iliac artery tortuosity index change compared to Zenith Flex leg. The spiral Z leg provided better conformability as a stent-graft limb.