The use of endoanchors in repair EVAR cases to improve proximal endograft fixation.

AIM: The aim of this paper was to evaluate short-term outcome of the use of endoanchors to secure the primary migrated endograft and additional extender cuffs to the aortic wall in patients with previous failed endovascular aortic aneurysm repair. METHODS: Consecutive patients who needed proximal repair of a primary failed endograft due to migration (with or without type IA endoleaks) were treated with endoanchors, with or without additional extender cuffs. Data of this group were prospectively gathered in vascular referral centers that were early adopters of the endoanchor technique. Preprocedural and periprocedural data were prospectively gathered and retrospectively analyzed. Follow-up after endoanchor placement consisted of regular hospital visits, with computed tomography or duplex scanning at 1, 6, and 12 months. RESULTS: From July 2010 to May 2011, 11 patients (8 men), mean age 77 years (range, 59-88 years), were treated with endoanchors for a failed primary endograft (2 Excluder endografts, 1 AneuRx endograft, and 8 Talent endografts) due to distal migration of the main body, with or without type IA endoleak. Revision consisted of using endoanchors to secure the body of the primary endograft to the aortic wall to avoid persistent migration. Most patients had additional proximal extender cuffs with suprarenal fixation, which were secured with endoanchors to the aortic wall and in some patients also to the primary endograft. A median of 6 endoanchors were implanted. All endoanchors were positioned correctly but one. One endoanchor dislodged but was successfully retrieved using an endovascular snare. During a mean follow-up of 10 months (range, 3-18 months) no endoanchor-related complications or renewed migration of the endografts occurred. Two patients underwent repeat intervention due to persistent type IA endoleak during follow-up. CONCLUSION: The use of endoanchors to secure migrated endografts to the aortic wall is safe and feasible and might help to overcome persistent migration of primary failed endografts. In combination with the use of sole extender cuffs the majority of proximal EVAR failures can be solved.

First clinical use of a novel neurovascular access and neuroprotection system demonstrates complete absence of emboli by transcranial Doppler during carotid artery stenting.

This article focuses on the first use of the MICHI™ Neuroprotection System in a transcervical carotid artery stenting procedure. The patient presented with an asymptomatic, 80% stenosis of the right internal carotid artery extending into the common carotid artery. The lesion was successfully treated with transcervical carotid access and reverse flow embolic protection and the successful placement of a carotid stent followed by balloon post-dilatation. Transcranial Doppler monitoring was performed throughout the procedure and a total of two micro embolic signals were recorded over the 30 minute procedural period. There were no neurologic complications reported during the 30-day follow-up period.

Total endovascular debranching of the aortic arch.

BACKGROUND: Significant morbidity and mortality are related to conventional aortic replacement surgery. Endovascular debranching techniques, fenestrated or branched endografts are time consuming and costly. OBJECTIVE: We alternatively propose to use endovascular approach with parallel grafts for debranching of aortic arch. METHODS: Under general anesthesia, 12 F sheaths were inserted in the femoral, axillary and common carotid arteries for vascular accesses. ViaBahn grafts 10 - 15 cm in length were placed into the aortic arch from right common carotid, left common carotid and left axillary arteries, until the tip of each graft reached into the ascending aorta. Through one femoral artery, the aortic stent -graft was positioned and delivered. Soon after, the parallel grafts were sequentially delivered. Self-spanding Wallstents(R) were used for parallel grafts reinforcement. Ballooning was routinely used for parallel grafts and rarely for aortic graft. RESULTS: This technique was used in 2 cases. The first one was a lady with 72 years old, with an aortic retrograde dissection from left subclavian artery and involving remaining arch branches. Through right common carotid artery a stent-graft was placed in the ascending aorta and through the left common carotid artery a ViaBahn was inserted parallel to the former. A thoracic endograft then covered all the aortic arch dissection extending into the ascending aorta close to the sinu -tubular junction. The second case was a 82 year old male patient with a 7 cm aortic arch aneurysm. Through both common carotid arteries ViaBahn grafts were introduced and positioned into the ascending aorta. Soon after, the deployment of the thoracic stent graft covered all parallel grafts of the aortic arch, excluding the aneurysm. Both cases did not have neurologic or cardiac complications and were discharged 10 days after the procedure. CONCLUSIONS: This technique may be a good minimal invasive off-the-shelf technical option for aortic arch ''debranching''. More data and further improvements are required before this promising technique can be widely advocated.

Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney grafts--a technical description.

INTRODUCTION: So far the only endovascular option to treat patients with thoraco abdominal aortic aneurysms is the deployment of branched grafts. We describe a technique consisting of the deployment of standard off-the- shelf grafts to treat urgent cases. MATERIAL AND METHODS: The sandwich technique consists of the deployment of ViaBahn chimney grafts in combination with standard thoracic and abdominal aortic stent grafts. The chimney grafts are deployed using a transbrachial and transaxillary access. These coaxial grafts are placed inside the thoracic tube graft. After deployment of the infrarenal bifurcated abdominal graft a bridging stent-a short tube graft is positioned inside the thoracic graft further stabilizing the chimney grafts. RESULTS: 5 patients with symptomatic thoraco abdominal aneurysms were treated. There was one Type I endoleak that resolved after 2 months. In all patients 3 stentgrafts had to be used When possible all visceral and renal branches were revascularized. A total number of 17 arteries were reconnected with covered branches. During follow up we lost one target vessel the right renal artery. CONCLUSION: The sandwich technique in combination with chimney grafts permits a total endovascular exclusion of thoraco abdominal aortic aneurysms. In all cases off-the shelf products and grafts could be used. The number of patients treated so far is still too small to draw further more robust conclusions with regard to long term performance and durability.

Intraoperative adjunctive stem cell treatment in patients with critical limb ischemia using a novel point-of-care device.

INTRODUCTION: In a prospective trial we tested whether adjunctive intraoperative stem cell treatment in patients with critical limb ischemia (CLI) can be performed safely in combination with bypass surgery and/or interventional treatment. The end point of our study was the safety and integrity of a novel point-of-care system used in patients with CLI. METHODS: We included only patients with CLI and tissue loss according to Rutherford categories 4-6. The Harvest Bone Marrow Aspirate Concentrate System consists of an automated, microprocessor-controlled dedicated centrifuge with decanting capability and the accessory BMAC Pack for processing a patient's bone marrow aspirate (BMA). The centrifuge is portable and enables BMA to be rapidly processed in the operating room to provide an autologous concentrate of nucleated cells for immediate injection. The surgeon aspirated 120 ml BMA from the iliac crest. RESULTS: Eight consecutive patients were treated according to the study protocol. The mean follow-up period was 9.2 months (range 2-18). Stem cells were always injected during the final revascularization attempt. One minor amputation and two major amputations were required. In five of eight patients there was a discrete increase in the ankle-brachial index post-stem cell treatment. The dose of stem cells after centrifugation was 17.2 (range 13.8-54.2)x10E6 CD34-positive cells and 7.8 (range 1.8-35.9)x10E6 CD133-positive cells. The injected dose of VEGFR-2-coexpressing stem cells was 0.5-5.7x10E4. CONCLUSION: We were able to show that the buffy coat preparation using a point-of-care system is a simple and fast method to enrich stem cells from BMAs. This automated system gives high recovery rates and good reproducibility.

Laparoscopic hybrid techniques for ectopic or accessory renal arteries debranching in complex endovascular aneurysm repair.

The aim of this study was to report an assisted or totally laparoscopic approach for renal revascularization in patients with congenital renal vascular anomalies during endovascular abdominal aneurysm repair (EVAR). In three patients with an ectopic main or a large accessory renal artery (>3mm) arising from the aneurysm, laparoscopic exposure of the target renal artery and the ipsilateral iliac bifurcation was performed. In two patients a small incision was made over the area between the iliac bifurcation and the renal target vessel in order to facilitate the anastomotic procedure. In the third patient a totally laparoscopic bypass between a big left inferior renal polar artery and the left common femoral artery was carried out. In all patients the aneurysm was successfully excluded using an endovascular graft. Technical success was achieved in all three patients. The mean total operative time was 126 min (range 110-152 min). The mean hospital length of stay (HLS) was 3.5 days. Renal function of the patients remained unchanged. All bypasses were found to be patent and endoleaks was not observed at 6-month follow-up. Laparoscopic assisted or totally laparoscopic renal revascularization may increase the applicability of EVAR in complex abdominal aortic aneurysms.

Evaluation of an aortic stapler for an open aortic anastomosis.

Open repair for aortic pathology requires clamping of the aorta. Aortic clamp time is an important predictor of outcome following open aortic reconstruction. In an attempt to decrease aortic clamp time, an aortic stapler was developed. The purpose of this clinical study was to evaluate the performance of the aortic stapler in the creation of a sutureless aorta-graft anastomosis. A single-center, intention to treat study was performed. Data were prospectively collected and retrospectively analyzed. The study protocol was approved by the institutional review board and all patients gave informed consent. Ten patients were analyzed. Patients with infrarenal abdominal aortic aneurysms and aorto-iliac occlusive disease who were candidates for elective, open aortic repair were included. All proximal anastomoses were completed in an end-to-end fashion using the aortic stapler. Time to complete the anastomosis (defined as time required to achieve anastomotic integrity and hemostasis) was the primary endpoint. Secondary endpoints were patency and anastomotic complications (pseudoaneurysm, hematoma, fistula) as diagnosed by duplex evaluation at one month follow-up. The aortic stapler was successfully used in all cases. Open aortic staplers of 14, 16, and 18 mm diameters were used in the procedures. Either woven dacron tube grafts or a bifurcated prosthesis were mounted on the staplers. In all cases only the proximal anastomosis was performed using the open aortic stapler. The distal anastomosis was sutured in a conventional manner using a continuous prolene suture. There were no stapler related deaths or anastomotic complications observed. The aortic stapler was successfully used in all cases. The mean time to complete the stapled proximal anastomosis was 10.2 min (7-18 ). The mean number of additional sutures required with the aortic stapler was 1.20 (0-6). Mean total aortic clamping time was 50.1 min (22-66). Duplex and CT imaging obtained at one-month confirmed the integrity of the proximal anastomosis as well as the patency of the vascular grafts. The aortic stapler can create a uniform staple line between a vascular prosthesis and the aortic wall. It is a simple, safe, rapid and reliable means for creation of a sutureless, end-to-end anastomosis in patients with aortic pathology, however, more patients and longer follow-up are required prior to concluding superiority to conventional suturing.

Totally laparoscopic aortohepatic bypass for aortic debranching during endovascular thoracoabdominal aneurysm repair.

INTRODUCTION: Endovascular grafting of the aorta is gaining widespread acceptance for treating aortic aneurysms. Para-renal aneurysms or thoraco-abdominal aneurysms may be a relative contra-indication for endovascular aneurysm repair (EVAR) unless visceral vessels can be debranched. REPORT: We describe a case of thoraco-abdominal aneurysm extending from the descending thoracic aorta to the level of coeliac artery. A totally laparoscopic retrograde aorto-hepatic bypass was performed in conjunction with endograft exclusion of the aneurysm and coverage of the coeliac artery ostium. DISCUSSION: Laparoscopic debranching of visceral vessels extends the indications of EVAR.

Stem cell use in critical limb ischemia.

The following paper gives an overview of the current status of stem cell use in vascular medicine. The role of endothelial progenitor cells (EPCs) is discussed. Different approaches to use cellular based concepts are outlined: among these are the treatment of patients with critical ischemia with bone marrow derived mononuclear cells as well as our own experience with purified and highly selected CD133 and CD34 cells. The pro and cons of these different treatment regimens are discussed. An outlook is given discussing a combination of gene therapy and stem cell injections. The clinical and laboratory results of 15 patients with end-stage critical ischemia are discussed with implications for future clinical trials. We conclude that, despite all open questions, the outlook for EPC-based therapies for tissue ischemia and blood vessel repair appears promising.

Intravascular stapler for "open" aortic surgery: preliminary results.

OBJECTIVES: The aim of this study was to assess the efficacy of a new stapling device using a pig model. METHODS: Straight 12 mm Gore-Tex grafts were inserted end to end into the aorta of 12 pigs. One anastomosis was performed with the stapler and the other using 4/0 prolene sutures and 13 mm needles. The animals were sacrificed at one week, one and three months and all grafts underwent histological examination. Leakage from the anastomoses was assessed in a separate specially designed circulation model using saline as a perfusate. RESULTS: The stapled anastomoses took 1.0+/-0.25 minutes to complete while suturing took 8.5+/-1.5 minutes. There was no difference in the histology between the two types of anastomosis. The leak rate was six times greater at the sutured compared to the stapled anastomosis. CONCLUSION: The use of stapled anastomoses may allow a significant shortening of aortic cross clamping time, reduce anastomotic leakage and may be particularly useful in laparoscopic aortic repair. A randomised trial is required to assess the efficacy of this device.

Laparoscopic assisted aortic surgery. A review.

We give an overview of different laparoscopic assisted techniques to perform aortic surgery. In a meta-analysis the paper describes the combined experience of two vascular surgical centers who together have performed more than 524 laparoscopic assisted aortic procedures. Basically the following techniques can be used to perform a laparoscopic assisted procedure: 1) transperitoneal approach (the Alimi procedure); 2) hand assisted laparoscopy (the Ferrari technique); 3) left retrocolic laparoscopic assisted; 4) combining laparoscopic assisted and total laparoscopy techniques. In all cases a transperitoneal approach was chosen to dissect the aorta. This was either accomplished directly or using a left retrocolic access originally described by Dion as the apron technique. In some cases a hand assist device was used, which permits the surgeon to introduce the non dominant hand while maintaining the pneumoperitoneum. The mortality in abdominal aortic aneurysm (AAA) patients in either center did not exceed 1.8%. ICU stay, postoperative ileus and length of stay were significantly shorter compared to patients with a full length incision. The Pisa group showed that there is still a significant reduction of operating time as well as aortic cross clamping time beyond the learning curve of the first 30 patients. The analysis of the pooled data shows that even in AAA patients the laparoscopic assisted procedure can be performed with operating times of less than 3 h and hospital stays up to 4 days, which we only know from endovascular aneurysm exclusion. This is the first publication of hand assisted laparoscopic endoaneurysm repair involving a large number of patients. The operations can be performed with expediency and safety. We can use these laparoscopic procedures to perform even complex aortic operations including suprarenal aneurysms with revascularization of the renal and visceral arteries. An outlook of future developments including stapling technology is given.

Total laparoscopic iliac artery aneurysm repair using endoscopic techniques and endovascular balloon occlusion.

UNLABELLED: We present a novel total laparoscopic technique to treat patients with iliac and aorto iliac aneurysms. The laparoscopic procedure does not require clamping of the iliac arteries because of a hybrid approach. REPORT: Laparoscopic exposure of the aorta is performed using transperitoneal left retrorenal access. A transfemorally placed balloon catheter blocks the external iliac artery. Two haemostatic sheaths are inserted directly through the skin into the abdominal cavity. Balloons are passed through these sheaths to block the common iliac artery and the hypogastric artery, allowing bypass grafting to be performed with appropriate haemostatic control. DISCUSSION: The technique described preserves inflow into the hypogastric arteries . This is accomplished by a combination of laparoscopic and endovascular techniques reducing the problems that can be caused by clamping diseased arteries.

Total laparoscopic aortic aneurysm surgery.

UNLABELLED: This paper describes our technique and results with total laparoscopic aortic aneurysm repair. MATERIAL AND METHODS: A transperitoneal left retrorenal access was used in all cases. Special laparoscopic clamps often in combination with balloon catheters were used to occlude the aorta and the renal arteries. Exactly the same techniques like in open surgery were used. Either a tube graft or a bifurcated graft,anastomosed with the iliac arteries or the femoral arteries, was implanted to exclude the aneurysm. Laparoscopic surgery is becoming a third way to perform aortic aneurysm repair. In contrast to EVAR it can offer to aneurysm patients the same definitive outcome which we obtain in open surgery.

Combining laparoscopic and endovascular techniques to improve the outcome of aortic endografts. Hybrid techniques.

Aortic endografting can be performed with a high initial success rate yet with the need for lifelong surveillance because of numerous long term problems. Among these graft migration, typ II endoleaks and endotension require treatment to prevent abdominal aortic aneurysm (AAA) rupture. We describe our experience with laparoscopic clipping of lumbar arteries and the inferior mesenteric artery (IMA) to prevent Type II leaks as well as with different banding procedures. Several ways to perform active graft fixation are described. Since we believe that active downsizing of the aneurysm reduces some of the intermediate term problems we go a step further and evacuate the thrombus to downsize the aneurysm to prevent longitudinal shrinkage. Laparoscopic techniques can also be used to obtain direct vascular access. This permits insertion of a thoracic endograft directly into the aorta in patients with diseased iliac vessels. Endovascular aneurysm repair (EVAR) insertion under laparoscopic navigation without contrast dye in cases with renal insufficiency is described. We describe our technique of total laparoscopic conversion after failed endografting. Future perspectives and preliminary experience with an aortic stapler are discussed.

Powered phlebectomy (TriVex) in treatment of varicose veins.

This study assesses the operation of transilluminated powered phlebectomy for removal of varicose veins. It was a prospective, noncomparative, multicenter, pilot study designed to evaluate the safety and efficacy of the powered varicose vein extractor for ablation of primary varicose veins. A total of 114 patients (117 limbs) were recruited from four centers in Europe and four centers in the United States. Safety of the varicose vein extractor was evaluated by recording nature and severity of all adverse events and complications. Efficacy was assessed by the patient, an independent study nurse, and the surgeon. Operations were performed under general, spinal, or epidural anesthesia and tumescent anesthesia was added with infusions of dilute lidocaine with epinephrine. Transillumination was achieved with a specially designed cannula, and the vein extraction was done using a vein resector with a rotating tubular inner cannula encased in a stationary outer sheath dissector. Demographic information regarding the 28 men and 89 women included in the study are detailed. Eighty-four percent of the limbs were CEAP class 2 with only 16% being in classes 3 and 4. Accompanying greater saphenous vein stripping was done in 67% of the limbs in the United States and 88% in those in Europe. Proximal ligation only was used in one limb in the United States and eight in Europe. The study showed that transilluminated powered phlebectomy used in varicose vein removal is swift and efficacious with a conservation of operating time and the results being satisfactory to the patient and clinician alike.

The feasibility of hand-assisted laparoscopic aortic bypass using a low transverse incision.

BACKGROUND: Hand-assisted laparoscopy can be used to perform aortoiliac reconstructive procedures. This study aimed to evaluate the safety and feasibility of a hand-assisted aortofemoral bypass in patients with occlusive disease using a low abdominal transverse incision to reduce postoperative respiratory problems. METHODS: In 18 patients, a modified Pfannenstiel incision was performed. A hand-assist device was inserted, and the aorta was exposed using transperitoneal laparoscopy. Tunneling was performed under laparoscopic control. The anastomosis was always performed proximally to the inferior mesenteric artery. In three patients, the proximal anastomosis had to be performed laparoscopically. The indication for surgery was occlusive disease in 16 patients and a combination of an aneurysm and aortoiliac occlusion in 2 patients. RESULTS: Conversion was required in one patient (1/18). In 13 patients (13/18), the total operating time did not exceed 180 min, and 61% of the patients (11/18) could be discharged by postoperative day 5. None of the patients died perioperatively (0/18). Complications were observed in six patients (6/18). Only one of these patients had respiratory problems (1/18). The remaining five patients had local complications such as wound healing problems. The anastomosis was sutured laparoscopically in three patients (3/18). CONCLUSIONS: Hand-assisted laparoscopy can be performed safely using a low transverse abdominal incision. In our experience this laparoscopic access can reduce the incidence of postoperative respiratory problems and incision-related complications.

Laparoscopy-assisted aneurysm resection as a minimal invasive alternative in patients unsuitable for endovascular surgery.

OBJECTIVE: So far, endovascular surgery has been the only minimal invasive way to treat patients with abdominal aortic aneurysms (AAAs). With hand-assisted laparoscopic surgery (HALS), laparoscopic transperitoneal endoaneurysm repair can be performed through a 6-cm mini-incision only. We wanted to evaluate whether this laparoscopic technique can be offered as a minimal invasive alternative in patients unsuitable for endovascular AAA repair. MATERIAL AND METHODS: Forty patients were referred for endovascular AAA repair. Three patients had to be excluded from the study. Endovascular AAA exclusion was finally performed in 13 patients. Laparoscopic AAA resection was performed in 24 patients. Hand-assisted laparoscopic surgery with transperitoneal access and endoaneurysm repair was accomplished in all patients unsuitable for an endovascular procedure. The outcome after endovascular repair was compared with the outcome of patients who underwent laparoscopy. RESULTS: In the laparoscopic group, conversion to an open procedure was necessary in one case. One patient in this group died (4.1%) postoperatively. There were four complications in each group. In the endovascular group we had one endoleak type II and one graft thrombosis, which required a reoperation. After endovascular treatment, patients were transferred significantly less frequently to the intensive care unit, and they could resume oral feeding earlier. Mobilization and postoperative hospital stay did not differ significantly between the groups. CONCLUSION: Laparoscopic AAA resection with the use of the technique described can be routinely offered to patients unsuitable for endovascular AAA exclusion with excellent long-term results similar to open surgery. A controlled study is clearly indicated to evaluate the role of laparoscopic techniques in aneurysm surgery.

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.