Endovascular abdominal aortic aneurysm repair using an anatomical fixation technique and concomitant suprarenal orientation: results of a prospective, multicenter trial.

BACKGROUND: Endovascular repair of abdominal aortic aneurysms with the Endologix Powerlink System has been shown to be a safe and effective alternative to open surgery in patients having an aortic neck diameter of up to 26 mm. We report the mid-term outcomes of an endovascular repair approach wherein the infrarenal bifurcated stent graft was placed at the aortoiliac bifurcation, with concomitant placement of a proximal extension having suprarenal orientation for proximal sealing. METHODS: Between 2006 and 2008, eight US sites enrolled 44 consecutive eligible patients presenting with abdominal aortic aneurysm in a prospective, single arm pivotal trial approved by the Food and Drug Administration. Each patient received a Powerlink infrarenal bifurcated stent graft through anatomical fixation at the aortoiliac bifurcation and a suprarenal extension to achieve proximal sealing. Analysis of the primary endpoint (proximal type I endoleak) was evaluated using contrast-enhanced computed tomography scans at 30 days, with on-going long-term follow-up for safety and treatment effectiveness. RESULTS: Patients (89% male) presented at a mean age of 70 ± 10 years with mean maximal aneurysm sac diameter of 5.5 cm. Challenging infrarenal aortic neck anatomy was present in 93% of patients. Technical success was 100% over a mean procedure time of 129 minutes. No aneurysm-related deaths, conversions, ruptures, migrations, or type III or IV endoleaks have been observed. The majority of endoleaks (80%) observed to date are type II. Currently, the primary clinical success rate is 93%. Two endovascular secondary procedures have been performed for resolution of type IA or type IB endoleak, and one surgical intervention was performed for resolution of limb occlusion. Significant reduction in sac diameter is observed to up to 2 years. CONCLUSIONS: The combination of an anatomically-fixed Powerlink infrarenal bifurcated stent graft and a suprarenal proximal extension safely and effectively excludes aneurysms in eligible patients. Longer term follow-up will determine the durability of these findings.

Endovascular treatment of obliterative hepatocavopathy with inferior vena cava occlusion and renal vein thrombosis.

We describe the endovascular treatment of an occlusion of the inferior vena cava (IVC) due to obliterative hepatocavopathy with renal and iliac vein thrombosis. A 34-year-old man with nephrotic syndrome and hepatic dysfunction presented to the hospital after a 3-month history of lower extremity swelling with an acute deterioration in his condition. Magnetic resonance venography diagnosed a massive IVC occlusion with thrombosis of the entire IVC, iliac veins, and renal vein. He was treated with thrombolysis, and a chronic occlusion of the infrahepatic IVC was discovered. After venous stenting of the IVC and iliac veins, he dramatically improved. After 24 months, he remains symptom-free with a patent IVC and iliac veins.

Complete embolization of a left atrial myxoma resulting in acute lower extremity ischemia.

Atrial myxoma is the most common benign tumor of the heart. Patients who have atrial myoxmas usually present with cardiac obstruction, arrhythmias, or peripheral embolization. A tumor originating in the left atrium most often embolizes to the cerebrovascular system. Complete myxoma embolization to the peripheral vessels is rare and usually occurs with tragic consequences. We present an unusual case of acute lower extremity ischemia due to the complete embolization of a left atrial myxoma.

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report.

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.

Crossing the limbs: a useful adjunct for successful deployment of the AneuRx stent-graft.

PURPOSE: To describe a technique for deploying an AneuRx stent-graft in an abdominal aortic aneurysm (AAA) with an acutely angled aortic neck. TECHNIQUE: In routine cases, the AneuRx stent-graft main body is positioned with the nose cone notch facing the contralateral side. In severely angulated aortic necks, however, the main body of the AneuRx stent-graft can be positioned with the nose cone notch and iliac limb gate facing the ipsilateral side; this dramatically reduces the acuity of the angle at the aortic neck and the iliac gate. This technique of "crossing the limbs" has been successfully used in 7 cases since FDA approval of the AneuRx device. CONCLUSIONS: Proximal neck angulation is an important factor for successful endovascular AAA repair. Crossing the graft limbs reduces the effect of neck angulation on the proximal main body and may decrease the stress upon the contralateral limb gate, which may avoid graft gate disconnection and endoleak.

Endoluminal stent grafting of the thoracic aorta: initial experience with the Gore Excluder.

PURPOSE: The purpose of this study was to describe our experience with endoluminal graft repair of a variety of thoracic aorta pathologies with a commercially developed device currently under investigation. Our patient population included patients eligible for open surgical repair and those with prohibitive surgical risk. METHODS: From February 2000 to February 2001, endovascular stent-graft repair of the thoracic aorta was performed in 46 patients (mean age, 70 years; 29 male and 17 female patients) with the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, 14 patients (30%) had dissections, three patients (7%) had aortobronchial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcome, and complications were recorded. All patients were followed with chest computed tomographic scans at 1, 3, 6, and 12 months. Follow-up period ranged from 1 month to 15 months, with a mean of 8.5 months. RESULTS: All the procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients (64%) left the hospital within 4 days after endoluminal grafting. The overall morbidity rate was 23%. Two patients (4%) had endoleaks that necessitated a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up examination, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 months after the procedure. Both cases were treated successfully with additional stent-grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. In patients treated for aneurysm (n = 23), the aneurysm diameter ranged from 5.0 to 9.5 cm (mean, 6.8 cm). Residual sac measurements were obtained at 1, 6, and 12 months, with mean sac reductions of 0.59 cm, 0.77 cm, and 0.85 cm, respectively. In three cases, the sac remained unchanged, without evidence of endoleak. CONCLUSION: Thoracic endoluminal grafting with the Gore Excluder is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest an endoluminal approach to these disease entities may be favorable over classical resection and graft replacement.

Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts.

BACKGROUND: Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures. METHODS: Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed. RESULTS: All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months. CONCLUSION: Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.

Endoluminal stent graft repair of aortobronchial fistulas.

OBJECTIVE: To describe our experience with endoluminal stent graft repair of aortobronchial fistulas. METHODS: We reviewed the records of patients treated with endoluminal stent grafting of aortobronchial fistulas at a private teaching hospital. All patients underwent the following diagnostic studies: computed tomography, angiography, bronchoscopy, and transesophageal echocardiography. With standard endovascular techniques, two different devices were implanted. RESULTS: Between March 1997 and October 2000, we treated four patients with postsurgical fistulas. The patients were diagnosed with hemoptysis between 3 and 23 years after aortic replacement grafting for thoracic aneurysms. Diagnostic studies varied in their ability to find the fistula. Transesophageal echocardiography most reliably demonstrated the fistula in the patients. All were successfully treated by exclusion with endoluminal stent grafting. The patients had no complications and no further episodes of hemoptysis. CONCLUSION: Endoluminal stent grafting of aortobronchial fistulas is feasible and may become the preferred method of management in patients at high risk.