Journal of Endovascular Therapy最新文献

Purpose: The aim was to assess the mid-term aortic remodeling and bare-metal stent (BMS) integrity of the restricted bare stent (RBS) technique reconstruction in aortic dissections.

Materials and methods: This retrospective cohort study included prospectively collected patients treated with the modified RBS technique between 2017 and 2020. The preoperative, postoperative, and last follow-up computed tomographic (CT) scans were analyzed in the centerline at the mid-descending, celiac trunk (CeT), and the mid-abdominal levels for false lumen (FL) patency, aortic diameter, and true lumen (TL) diameter changes. Bare-metal stent integrity was assessed in the 3-dimensional multiplanar reformats.

Results: The median follow-up of the cohort (n=17) was 26 (11, 45) months. The procedure was mainly performed with the Relay NBS endograft (15/17; 88%) + E-XL BMS (17/17; 100%). Postoperative mortality, paraplegia, stroke, renovisceral vessel loss, and type I and III endoleaks were not observed. BMS fractured in 6 patients (6/17; 36%), damaged the dissection flap in 4/17 (24%), and led to the reperfusion of the FL and re-interventions with TEVAR (4/17; 24%). Two patients without FL reperfusion showed stable CT follow-ups 13 and 17 months after the fracture diagnosis. The TL expansion was seen at all landmarks and peaked in the thoracic aorta (+10; 6, 15; p<0.001). The FL thrombosis after modified RBS was only relevant in the thoracic aorta (p<0.001) and at CeT (p=0.003). The aortic diameter was stable in the thoracic aorta and increased at distal landmarks (CeT [+5; 1, 10; p=0.001]; mid-abdominal [+3; 1, 5; p=0.004]).

Conclusion: The modified RBS technique could not stop aortic growth below the diaphragm and prevent new membrane rupture due to the fractures of the BMS and consecutive flap damage with the reperfusion of the FL.

Clinical impact: The treatment of complicated type B aortic dissections with TEVAR has become a standard. Particularly, patients with true lumen collapse and malperfusion may benefit from a more aggressive treatment strategy including proximal TEVAR and distal bare-metal stent implantation to re-open the true lumen and to prevent distal stent-induced new entry. However, this study reports the challenges of this approach with a high rate of bare-metal stent fractures during the follow-up. The fractures that occurred at the site of vertical nitinol bridges led to the dissection membrane ruptures and the reperfusion of the false lumen with consecutive dilatation. A close follow-up is mandatory to detect this complication and to treat the patients with TEVAR extension.

Purpose: To describe the concept of aortic elastic deformation (ED) measurement using duplex ultrasonography (DUS) as a tool for detection of high aneurysm sac pressure following endovascular aortic repair (EVAR).

Technique: High aneurysm sac pressure, with or without proven endoleak, will result in a less compressible aneurysm. Using the dual image function in B-mode of the DUS device and a standardized amount of applied probe pressure, ED can be measured. It is defined as the percentage of deformation of the aneurysm sac on probe pressure application. We hypothesize that less ED of the aneurysm sac can be related with high aneurysm sac pressure and possibly the presence of clinically relevant endoleak. In this note, we describe the technical details of the procedure and report on the applicability and results of ED measurements in the framework of aortic aneurysm and EVAR follow-up in a cohort of 109 patients.

Conclusion: ED measurement is the first noninvasive pressure-based method in the quest to find a practical and reliable diagnostic tool to exclude high aneurysm sac pressure. In our patient cohort, patients with proven endoleak showed a smaller ED (less compressible), implying the presence of high aneurysm sac pressure. Further research should confirm whether ED measurement using DUS could reliably exclude endoleak after EVAR and further explore its potential for clinical application in EVAR follow-up.

Clinical impact: For the first time, a simple, fast, and inexpensive diagnostic tool is presented in this study for detecting high sac pressure following EVAR. High sac pressure is typically caused by clinically significant endoleaks, which can have significant consequences. Currently, computed tomography scanning is the most common method used to identify and characterize endoleaks. However, measuring elastic deformation may potentially replace more invasive and expensive modalities, such as the computed tomography in the future.

Purpose: Endovascular aortic repair (EVAR) is the method of choice for most abdominal aortic aneurysm (AAA) patients requiring intervention. However, chronic aortic neck dilatation (AND) following EVAR progressively weakens the structural seal between vessel and endograft and compromises long-term results of the therapy. This experimental ex vivo study seeks to investigate mechanisms of AND.

Materials and methods: Porcine abdominal aortas (n=20) were harvested from slaughterhouse pigs and connected to a mock circulation. A commercially available endograft was implanted (n=10) or aortas were left untreated as controls (n=10). Vascular circumferential strain was assessed via ultrasound in defined aortic segments as a parameter of aortic stiffness. Histology and aortic gene expression analysis were performed to investigate potential changes of aortic wall structure and molecular differences due to endograft implantation.

Results: We found that endograft implantation acutely induces a significant stiffness gradient directly at the interface between stented and unstented aortic segments under pulsatile pressure. Comparing stented aortas with unstented controls, we detected increased aortic expression levels of inflammatory cytokines (Il6 and Ccl2) and matrix metalloproteinases (Mmp2 and Mmp9) after 6 hours of pulsatile pressurization. This effect, however, was abolished when repeating the same experiment under 6 hours of static pressure.

Conclusions: We identified endograft-induced aortic stiffness gradients as an early trigger of inflammatory aortic remodeling processes that might promote AND. These results highlight the importance of adequate endograft designs to minimize vascular stiffness gradients and forestall late complications, such as AND.

Clinical impact: AND may compromise the long-term results following endovascular aortic repair. However, the mechanisms behind the underlying detrimental aortic remodeling are still unclear. In this study we find that endograft-induced aortic stiffness gradients induce an inflammatory aortic remodeling response consistent with AND. This novel pathomechanistic insight may guide the design of new aortic endografts that minimize vascular stiffness gradients and forestall late complications such as AND.

Purpose: The purpose of the study is to ascertain endovascular aneurysm repair (EVAR) suitability in relation to stent-graft-specific instructions for use (IFU) in patients with a ruptured abdominal aortic aneurysm (RAAA).

Materials and methods: Using the preoperative computed tomography angiography (CTA), the aortic morphology of patients undergoing surgical repair of a RAAA in 2 Dutch hospitals between January 2014 and December 2019 was retrospectively assessed. Three-dimensional and central luminal line reconstructions were used. Anatomical suitability was defined according to the IFU of the stent graft system used.

Results: Of 128 included patients, 112 (88%) were men and the mean age was 74.1 (SD=7.6) years. Anatomy within IFU for EVAR was present in 31 patients (24%). Overall, 94 patients (73%) were treated with open surgical repair (OSR) and 34 patients (27%) were treated with EVAR. Anatomy within IFU was present in 15 OSR patients (16%) and 16 EVAR patients (47%). In patients with anatomy outside of IFU, 90% (87/97) had unsuitable neck anatomy and 64% (62/97) had insufficient neck length. An unsuitable distal iliac landing zone was observed in 35 patients. Perioperative mortality was 27% (34/128), with no difference between OSR and EVAR (25/94 vs 9/34; p=0.989).

Conclusion: Most RAAA patients in this series did not have aortic anatomy within IFU for EVAR, mainly due to insufficient neck length. However, whether anatomy outside of IFU equates to unsuitability for EVAR in an emergency setting remains a matter of debate and warrants further research.

Clinical impact: The treatment of a ruptured abdominal aortic aneurysm can consist of endovascular repair or open repair. Retrospective anatomical assessment shows that most patients do not have anatomy inside the instructions for use for endovascular aneurysm repair, mainly due to insufficient neck length. Whether anatomy outside the instructions for use equates unsuitability for endovascular aneurysm repair remains a matter of debate.

Purpose: Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy.

Methods: This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients.

Results: There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%-95.3%) and 87.9% (95% CI: 80.3%-92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups.

Conclusion: Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Clinical impact: This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Purpose: The purpose of the study is to describe carotid artery stenting (CAS) via distal transradial access (dTRA) facilitated by additional superficial temporal artery (STA) access, in a patient with complex aortic arch vessel anatomy.

Technique: A 72-year-old woman with a prior history of complex cervical surgery and radiotherapy due to laryngeal malignancy, presented with a symptomatic 90% stenosis of the left internal carotid artery (ICA). Due to high cervical lesion, the patient was rejected from carotid endarterectomy. Angiography demonstrated 90% stenosis of the left ICA and a type III aortic arch. After failure of left common carotid artery (CCA) cannulation with appropriate catheter support via dTRA and transfemoral approaches, CAS was attempted a second time. After percutaneous ultrasound guided access to right dTRA and left STA, a 0.035 inch guidewire introduced to the left CCA from the contralateral dTRA was snared and externalized via left STA to improve wire support for guiding advancement. Thereafter, the left ICA lesion was successfully stented with a 7×30 mm self-expanding stent via right dTRA. All vessels involved were patent at 6-month follow-up.

Conclusion: The STA may be a promising adjunctive access site to increase transradial catheter support for CAS or neurointerventional procedures in the anterior circulation.

Clinical impact: Transradial cerebrovascular interventions have been gaining popularity, however, unstable catheter access to distal cerebrovascular structures limits its widespread use. Guidewire externalization technique via additional STA access may improve transradial catheter stabilty and increase procedural success with possibly low access stie complication rate.

Purpose: To report the initial outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for pararenal aneurysms (PRAs), thoracoabdominal aortic aneurysms (TAAAs), and aortic arch aneurysms in high-surgical-risk patients.

Materials and methods: A total of 10 patients (6 men; median age, 83.0 years) treated using PMiBEVAR were enrolled in this retrospective, single-center study. All patients were at high surgical risk because of severe comorbidities (American Society of Anesthesiologists physical status score≥3 or emergency repair). End points were defined as technical success per patient and per vessel (successful deployment), clinical success (no endoleaks postoperatively), in-hospital death, and major adverse events.

Results: There were 3 PRAs, 4 TAAAs, and 3 aortic arch aneurysms with 12 renal-mesenteric arteries and 3 left subclavian arteries incorporated by inner branches. The technical success rate was 90.0% (9/10) per patient and 93.3% (14/15) per vessel. The clinical success rate was 90% (9/10). There were 2 in-hospital deaths, unrelated to aneurysms. Paraplegia and shower emboli occurred separately in 2 patients. Three patients experienced prolonged ventilation for 3 days after surgery. Aneurysm sac shrinkage occurred in 4 patients, and aneurysm size stabilized in 1 patient during follow-up, more than 6 months later. None of the patients required intervention.

Conclusion: PMiBEVAR is a feasible approach for treating complex aneurysms in high-surgical-risk patients. This technology may complement the existing technology in terms of improved anatomical adaptability, no time delay and practicability in many countries. However, long-term durability remains undetermined. Further large-scale and long-term studies are needed.

Clinical impact: This is the first clinical study to investigate outcomes of physician-modified inner branched endovascular repair (PMiBEVAR). PMiBEVAR for treating pararenal aneurysm, thoracoabdominal aortic aneurysm, or aortic arch aneurysm is a feasible procedure. This technology is likely to complement existing technology in terms of improved anatomical adaptability (compared to off-the-shelf devices), no time delay (compared to custom-made devices), and the potential to be performed in many countries. On the other hand, surgery time varied greatly depending on the case, suggesting a learning curve and the need for technological innovation to perform more consistent surgeries.