Editor's Choice--First Results of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique for Aortoiliac Occlusive Disease.

OBJECTIVE: In this study the first results are presented of a new endovascular technique using covered stents to reconstruct the aortic bifurcation in patients with aortoiliac occlusive disease. With the "Covered Endovascular Reconstruction of the Aortic Bifurcation" (CERAB) technique, the anatomy and physiology of the aortic bifurcation is mimicked. MATERIAL AND METHODS: Between 2009 and March 2014, 103 patients (51 male, 52 female) suffering from obstructive lesions at the level of the aortic bifurcation were treated with CERAB in two clinics. The median age was 61 years (range 36-85 years). Lesion morphology was evaluated by CT angiography. Six TASC-II B lesions, nine TASC-II C lesions, and 88 TASC-II D lesions were treated. Follow up was a median 12 months (range 0-49 months) and consisted of clinical examination, ankle brachial indices, and duplex ultrasound examination. RESULTS: Technical success was obtained in 98 procedures (95.1%). In five cases lesions could not be recanalized. Primary patency was 87.3% at 1 year and 82.3% at 2 years, while secondary patency was 95.0% at 1 year and 95.0% at 2 years. Mean ankle brachial indices improved significantly from 0.64 ± 0.21 before to 0.91 ± 014, after the procedure (p < .001). The overall 30 day complication rate was 23.3%, including 22 minor complications and two major complications (1.9%). There was no 30 day mortality. Median hospital stay was 2 days (range 1-16 days). CONCLUSIONS: The CERAB technique appears to be a safe and feasible alternative to open surgical reconstruction of the aortic bifurcation in complex occlusive disease. Comparative studies with the current gold standards are indicated.

Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: a new approach in treating extensive aortoiliac occlusive disease.

Endovascular treatment of occlusive disease of the aortic bifurcation is challenging. We developed the Covered Endovascular Reconstruction of Aortic Bifurcation or CERAB-technique, as a new approach for extensive and/or recurrent aortoiliac occlusive disease using three covered balloon expandable stents to reconstruct the aortic bifurcation. This configuration provides the ability to deal with TransAtlantic Inter-Society Consensus (TASC II) C and D lesions, simulating a neo-bifurcation or flow divider in combination with the benefits of covered stents. The intervention can be performed percutaneously or as a hybrid procedure. Initial results are encouraging and further studies are indicated.

Role of bioresorbable stents in the superficial femoral artery.

Bioresorbable stents or scaffolds are a new technology in the treatment of coronary and peripheral vascular disease. Their goal is to provide adequate support to the dilated vessel segment for the time needed and to disappear through a controlled resorption process afterwards. Doing so they can offer the early advantages and avoid the late complications related to stent placement such as stent-induced restenosis, stent fracture and problems at reintervention. Although the first implantation dates from more than ten years ago, this technology is still in its infancy and experience is still being built up. Most studies till now have been performed in the coronary arteries although the superficial femoral artery is an equally appealing area of application. Bioresorbable scaffolds are made of resorbable polymers or metals with or without antiproliferative drug elution. Early experiences in coronary arteries as well as in other areas such as the superficial femoral artery (SFA) have shown the importance of the material that is used, the design of the device and the duration of the absorption process. They suggest that elution of an antiproliferative drug might be necessary to obtain clinically acceptable results. Although initial results are promising with some of the newer generation devices results of larger studies with longer follow-up are eagerly awaited to define the precise place of this new technology. This article gives an overview of the existing evidence, the available devices, the clinical studies that have been performed in different areas and the preliminary results of a large multicenter study with a bioresorbable stent in the SFA.

Covered stents for aortoiliac reconstruction of chronic occlusive lesions.

AIM: Bare metal stents have improved results of endovascular treatment of aortoiliac occlusive disease. Polytetrafluoroethylene covered stents may further improve patency rates by preventing tissue ingrowth, and might reduce complications. This study was conducted to assess possible assets or liabilities of covered stents used for aortoiliac occlusive disease and to conduct a comparison with bare metal stents. METHODS: A review was performed of literature published until March 2012 for infrarenal aortic lesions, iliac lesions and complex aortoiliac lesions. Outcomes were technical success, patency rates, clinical success and complication rates. Results were addressed to the three anatomic regions: the infrarenal aorta, the aortoiliac bifurcation and iliac arteries. RESULTS: A total of 51 articles were included in the study. Overall technical success varied between 73% and 100%. Randomized data have proven the superiority of covered stents in extensive iliac occlusive lesions. Case series of patients with iliac occlusive disease demonstrated a 1-year primary patency of bare metal stents between 76% and 100% with a 5-year primary patency rate of 63%-83%. One-year primary patency of covered stents varied between 70% and 100%, while no long term patency rates with covered stents have been reported so far. Reliable comparisons between groups cannot be made due to variances in patient and lesion characteristics. Covered stents seem to improve results of kissing stents and are related to excellent results in isolated aortic lesions. No difference in complication rate between bare metal and covered stents have been described, to date. CONCLUSION: Covered stents improve results of endovascular treatment of extensive iliac occlusive lesions and are related to excellent results in isolated aortic lesions. They may provide a valid alternative for surgery in patients with extensive aortoiliac disease.

Dissection of the common carotid artery: a case report.

Carotid artery dissection is an important cause of stroke in patients under forty years of age. A dissection of the common carotid artery is relatively rare. This condition can easily be overlooked because symptoms may be lacking or may seem trivial. Carotid artery dissection occurs mostly in previously healthy patients. Urgent treatment however, by means of coumarines or antiplatelet agents, is of life-saving importance, because this disease can lead to permanent neurological deficits or even death. We report a case of a 36-year-old patient who was admitted to the intensive care unit with hemi-paralysis and acute abdomen after a period of severe vomiting. A perforated bulbar ulcer was visible on abdominal CT scan. The patient underwent laparoscopic repair of the perforation. CT scan of the brain showed an extensive area of infarction at the region of the left medial cerebral artery. The cause of the infarction was revealed by angio CT of the supra-aortic arteries, showing a floating thrombus and a possible dissection of the left common carotid artery. Under Clopidogrel therapy, the right-sided paralysis partially recovered. Ten days post-admission, an endarterectomy of the left carotid artery was successfully performed. The patient recovered well and was discharged from the ICU 28 days after admission.

Laparoscopic transperitoneal versus extraperitoneal inguinal hernia repair: a prospective clinical trial.

A prospective series of 106 inguinal hernias in 91 patients is studied, comparing two methods of laparoscopic hernia repair: a transperitoneal technique with preperitoneal stapled mesh fixation (TransAbdominal PrePeritoneal or TAPP-technique) performed in 33 patients, and a totally extraperitoneal placement of non stapled mesh (Totally ExtraPeritoneal Approach or TEPA-technique) performed in 58 patients. Conversions to open repair were equally frequent (5% vs. 7% respectively) and were due to adhesions, haemorrhage, irreducible intestinal loop in the hernial sac or important subcutaneous emphysema. Minor postoperative complications included regional seroma or haematoma, testicular pain and meralgia paraesthetica. There was no mortality nor long lasting complication. Recurrence rates in both groups amounted 2.7% (TAPP) and 2.8% (TEPA) respectively after a mean follow-up of 15.8 months (TAPP) and 17.6 months (TEPA). In both groups early recovery of normal activities was noted, after a mean of respectively 13.6 days (TAPP) and 12.9 days (TEPA). It is concluded that the transabdominal route and the totally extraperitoneal approach for laparoscopic herniorrhaphy are both adequate techniques for inguinal hernia repair with similar complication and short-term recurrence rates.

Chronic herniation of the lung in a patient with chronic obstructive pulmonary disease. Case report and review of the literature.

Lung herniation is a rare condition and can be classified by both anatomical site and etiology. A 70-year-old man was referred with dyspnea, productive cough, and right-sided chest pain. Radiological investigation showed healed rib fractures and a lung herniation between ribs 8 and 9. Two years after surgical repair the patient is free of complaints. Treatment can be conservative or surgical, but as experience is limited no long-term results have been reported.

Traumatic type B aortic dissection.

A 37-year-old man was referred with thoracic pain after a deceleration trauma. He also had a cerebral contusion and a wrist fracture. There were no sings of hypovolemic shock. Computerized tomography (CT) of the chest and transoesophageal echocardiography (TEE) demonstrated a type B aortic dissection originating just distal to the left subclavian artery. There was a patent false lumen without rupture or distal ischaemia. Conservative treatment was given. A paralytic ileus developed and abdominal complaints persisted for several months. Angiography showed normal patency of mesenteric vessels. On follow-up, 3 years after the accident a slight aortic dilation was found on CT thorax without development of a post-dissection aneurysm. Blunt thoracic injury to the aorta usually gives rise to aortic rupture in the region of the isthmus, which can be complete or partial. In the latter case a false aneurysm may develop. An intimal tear after blunt trauma leading to type B aortic dissection rarely occurs. General principles regarding treatment of type B dissection also apply to this particular condition.