Journal of Endovascular Therapy最新文献

Purpose: This article describes the modification of an iliac limb to incorporate a lumbar artery branch to decrease risk of spinal cord ischemia (SCI) in a patient with a symptomatic extent III thoracoabdominal aortic aneurysm (TAAA).

Case report: A 59-year-old female with a history of zone 3 to 5 thoracic endovascular aortic repair 6 weeks prior for chronic type B_3-10 dissection with 6.5 cm aneurysmal degeneration presented with sudden onset chest and abdominal pain. Imaging revealed rapid growth to 9.8 cm with a new stent graft-induced entry tear and associated fat stranding. Not medically fit for open repair, the patient was taken for an emergent fenestrated/branched endovascular aortic repair (F/BEVAR). A 32×24×150 TX2 Zenith thoracic tube graft was modified with 4 fenestrations. A 13×11×56 Z SLE Cook iliac limb was modified to create a custom iliac fenestrated endoprosthesis, as this patient's right iliac anatomy was not suitable for off-the-shelf products. After deployment of the custom iliac fenestrated device and fenestrated thoracic device, an aortogram revealed a large L5 lumbar artery we felt was amenable to fenestration to help preserve spinal perfusion. A 13×16×39 Z SLE Cook iliac limb was modified with a branch for an L5 lumbar artery. Post-operative course was uneventful without ischemic-related complications. One-month follow-up imaging reveals stable sac size with type II endoleak and patent hypogastric and lumbar artery stents.

Conclusion: Preservation of collateral pathways is understood to be critical in prevention of SCI, although the precise branches necessary are not clear. Lumbar fenestration and hypogastric preservation to reduce risk of SCI is a feasible and valid technique that should be considered when anatomy allows.Clinical ImpactThis case validates the efficacy and safety of using a physician-modified iliac limb to salvage an L5 lumbar artery after endovascular exclusion of a symptomatic extent III thoracoabdominal aortic aneurysm (TAAA). This interventional approach allows for the maintenance of perfusion to the spine and preservation of potentially hemodynamically significant collateral pathways. Our results suggest that this technique to mitigate the risk of spinal cord ischemia is safe and effective and thus may be considered for appropriately-selected cases.

Objectives: Isolated internal iliac artery aneurysm (IIIAA) is a rare condition, accounting for approximately 0.3% to 0.5% of all intra-abdominal aneurysms. This study aimed to evaluate the outcomes of endovascular treatment for IIIAA using a relatively large cohort.

Methods: A retrospective analysis was conducted on 45 patients diagnosed with IIIAA who were admitted to our hospital between April 2014 and April 2024. Patient demographics, intervention outcomes, and follow-up results were collected and analyzed.

Results: A total of 45 patients (only 2 female) with 49 IIIAAs were included, with a mean age of 70.4±9.2 years. The cohort exhibited a high prevalence of cardiovascular and cerebrovascular risk factors, and 31.1% had a history of malignancy. Thirty patients (66.7%) were diagnosed with an incidental IIIAA, while the remaining patients presented with symptoms such as abdominal or lumbar pain, dysuria, or aneurysm rupture. Stent-graft placement alone was performed in 3 patients, coil embolization alone in 5 patients, and the remaining 37 patients underwent a combined approach. The rate of complete distal branch embolization was 69.0% (29/42), and technical success was achieved in 44 patients. The mean follow-up duration was 23.8±21.5 months. During follow-up, 5 patients died from cancer or heart failure. Buttock claudication was observed in 7 patients, with only 1 case remaining unresolved after conservative treatment. Sac dilation was noted in 4 patients who had incomplete distal branch embolization; of these, 3 required re-intervention. The 12-month and 24-month re-intervention-free survival rates were 95.5% and 88.2%, respectively.

Conclusion: Endovascular treatment, particularly the combination of stent-graft implantation and coil embolization, is both safe and effective for IIIAA, with a mid-term re-intervention-free survival rate of 85.25% and an acceptable risk of pelvic ischemia. Complete embolization of the outflow branches is technically challenging in some cases, and the efficacy of sac embolization as an alternative remains debatable.Clinical ImpactIsolated internal iliac artery aneurysm (IIIAA) is an exceedingly rare condition. This retrospective study identified and included 45 patients with IIIAA who were treated at our institution to evaluate the safety and therapeutic efficacy of endovascular treatment. The majority of patients underwent stent-graft implantation to seal the internal iliac artery ostium, along with coil embolization of the distal branches. The 2-year reintervention-free survival rate for all patients was 85.25%, demonstrating the favorable efficacy of endovascular treatment. However, postoperative sac dilation was observed in 4 patients who did not receive complete distal branch embolization, emphasizing the need for rigorous follow-up in this subset of patients.

Objective: To assess the impact of selective supra-aortic trunk (SAT) stenting on aortic remodeling in patients with chronic type A aortic dissection (cTAAD).

Methods: Patients treated from 2017 to 2024 with aortic arch repair using double-fenestrated physician-modified endografts (PMEGs) for cTAAD were retrospectively analyzed. The objectives are to compare aortic treatment and remodeling, SAT evolution, and overall outcomes according to SAT dissection status (before and after), total aortic arch repair using a double-fenestrated PMEG.

Results: Among 42 cTAAD patients treated, 30 had SAT dissection. Thirty-five patients received a standard PMEG, while 7 underwent additional selective SAT stenting (3 LCCA, 1 brachiocephalic trunk (BT), 4 right subclavian artery (RSA), and 3 right common carotid artery (RCCA)). Technical success was 100%. At 30 days, 1 patient died from stroke, 1 from pneumonia post-discharge. During a median follow-up of 18.5 months (IQR: 38.8), no type Ia endoleaks occurred. Six type Ic endoleaks were observed; 3 patients underwent reintervention, while the remaining 3 were monitored with follow-up CT scans showing no evidence of aortic growth. Complete SAT dissection resolution occurred in 12 patients (40%), including 9 with standard PMEG. Positive aortic remodeling was seen in 32 patients (76%) with a median diameter reduction of -1% (IQR: 5.5%). Five patients died during mid-term follow-up, with no deaths related to the procedure. Positive aortic remodeling rates are 73% vs. 83% (p=0.7) between patients with and without initial SAT dissection, 83% vs 92% (p=1) between patients with initially no SAT dissection and those who healed, 61% vs 88% (p=0.07) between patients with persistent SAT dissection and the others. Patients on curative anticoagulation or dual antiplatelet therapy showed reduced positive remodeling.

Conclusion: Double-fenestrated PMEGs are effective for treating residual cTAADs, with high SAT healing and favorable remodeling. Persistent SAT dissection may hinder remodeling and require additional intervention.Clinical ImpactAortic arch repair using fenestrated physician-modified endografts without systematic SAT stenting reduces SAT manipulation and may lower stroke risk, while promoting a high rate of SAT and aortic dissection healing. In cases where SAT dissection persists and aortic growth is reported, secondary complementary SAT intervention can be performed to enhance aortic remodeling.

Aim: To present a case in which low-dose 4-dimensional computed tomographic angiography (4D-CTA) enabled precise classification of a type II endoleak following hybrid arch repair for chronic type B aortic dissection, in the setting of inconclusive findings on conventional CTA.

Case: A 74-year-old woman underwent hybrid arch repair with left common carotid-subclavian bypass and thoracic endovascular aortic repair for chronic type B aortic dissection. Six years postoperatively, aneurysm sac enlargement was noted. Conventional CTA with a 2-phase protocol (early arterial and delayed venous phases) could not distinguish between type Ia and type II endoleaks. Low-dose 4D-CTA (dose-length product: 302.6 mGy·cm) revealed delayed contrast enhancement within the sac during the late arterial phase, consistent with a type II endoleak originating from the left subclavian artery (LSCA). Targeted coil embolization was successfully performed to resolve the endoleak, and contrast inflow from a branch of the LSCA was confirmed by intraprocedural angiography.

Conclusion: Low-dose 4D-CTA allowed for precise classification of the endoleak and guided appropriate reintervention. This modality represents a useful and practical tool for endoleak evaluation, especially when standard imaging is inconclusive.Clinical ImpactThis case highlights the diagnostic value of 4-dimensional computed tomographic angiography (4D-CTA) in classifying endoleaks after thoracic endovascular aortic repair (TEVAR), particularly when standard CTA is inconclusive. The 4D-CTA identified a type II endoleak from the left subclavian artery, enabling definitive diagnosis and targeted coil embolization. Notably, the scan was performed using a low-dose protocol (dose-length product: 302.6 mGy·cm), substantially lower than the >1000 mGy·cm reported in prior studies while preserving diagnostic quality. Standardized low-dose 4D-CTA protocols may support broader clinical adoption for endoleak evaluation.

Introduction: Although transcarotid arterial revascularization (TCAR) may offer several advantages, the first commercial TCAR system (EnRoute; Boston Scientific, Marlborough, Massachusetts) is not available in many countries. Therefore, a suitable and simple technique for transcarotid treatment of high-risk carotid stenosis is needed.

Case report: We report a hybrid approach to carotid stenosis treatment: stenting with surgical exposure of the carotid artery, forming a flow reversal circuit, with a feasibility to add a distal filter. Sheaths are placed in the carotid artery and femoral vein to accomplish cerebral protection, forming a flow reversal circuit. In addition, a distal filter device was placed for cerebral protection. Technical success was achieved and the patient experienced no complications.

Conclusion: Our modified TCAR technique may be effective in patients with high-risk carotid stenosis.Clinical ImpactThis research work is aimed at high-risk patients with carotid artery stenosis who need surgical treatment. When there are no commercialized devices similar to Tcar but surgical treatment is urgently needed, This modified surgical approach can be adopted to reduce the incidence of ischemic stroke caused by intraoperative embolus detachment. The innovative significance of this research lies in using local materials and simple, practical instruments to reduce the risk of stroke caused by embolus detachment during surgery.

This study reports our experience with intravascular lithotripsy (IVL) in managing heavily calcified peripheral arterial disease (PAD) at a tertiary center in Southeast Asia. A total of 50 procedures were performed in 49 patients between October 2022 and April 2024. The cohort had a high burden of comorbidities, with 94% presenting with chronic limb-threatening ischemia, 62% classified as wound, ischemia, and foot infection (WIfI) stage 4, and 31% having end-stage renal failure. Severe vascular calcification (Peripheral Artery Calcification Scoring System [PACSS] grade 4) was present in 84% of lesions. IVL was employed as a vessel preparation strategy prior to definitive treatment, with adjunctive therapies used in all cases. Technical success was achieved in 100% of procedures, with a mean luminal gain of 71.4%±21.8%. Bailout stenting was required in 16% of cases, and there were no incidents of distal embolization. At 1-year follow-up, the target lesion revascularization rate was 6.1%, the overall reintervention rate was 14%, limb salvage was 84%, and mortality was 31%. Our findings suggest that IVL is a safe and effective option for vessel preparation in patients with severely calcified PAD, achieving high technical success and favorable mid-term outcomes in a complex, high-risk population.Clinical ImpactCalcified peripheral arterial disease remains a challenging subset in endovascular therapy, often limiting luminal gain, increasing dissection risk, and impairing drug delivery. This single-center experience demonstrates that IVL is a safe and effective vessel-preparation strategy in a real-world population with high comorbidity burden and predominantly PACSS grade 4 disease. IVL achieved 100% technical success, substantial luminal gain, low complication rates; and favorable 1-year limb salvage and reintervention outcomes. These findings support IVL as a practical method for modifying severe calcification and improving procedural reliability in high-risk patients undergoing endovascular treatment.

Background: This study compares the outcomes of endovascular repair using pre-curved fenestrated endografts and open surgery with total arch replacement for aortic arch aneurysm repair.

Methods: Patients who underwent aortic arch aneurysm repair with fenestrated endograft or total arch replacement between 2009 and 2021 were retrospectively analyzed. Subjects were limited to true aortic arch aneurysms, and cases with a history of thoracic aortic surgery, connective tissue disorder, or concomitant procedure were excluded. The Kaplan-Meier method was used to calculate cumulative survival and freedom from aorta-related death, and the Fine and Grey methods were used for re-intervention rates.

Results: A total of 106 cases were included, with fenestrated endografts (F group, n=58) and total arch replacement (T group, n=48). The median follow-up times were 48.0 (25.5, 94.8) and 62.5 (46.0, 110.8) months (p=0.038) in the F and T group, respectively. The median age (76.5 [71.3, 80.0] vs 71.5 [66.0, 77.0], p<0.001) and European System for Cardiac Operative Risk Evaluation II (11.0 [10.0, 14.0] vs 8.5 [6.0, 11.0], p<0.001) were higher in the F group. Intraoperative blood transfusions (19 [32.8%] vs 48 [100%], p<0.001), operative times (145.0 [113.3, 191.0] vs 464.5 [413.8, 531.5], p<0.001), postoperative intubation times (0 [0, 0] vs 68.0 [20.0, 150.0], p<0.001), intensive care unit stays (1.0 [1.0, 2.0] vs 6.5 [5.0, 11.0], p<0.001) and in-hospital stays (10.0 [8.0, 12.0] vs 27.0 [22.0, 41.3], p<0.001) were significantly reduced in the F group. In-hospital mortality (2.0 [3.5%] vs 0 [0%], p=0.50), perioperative cerebral infarction (2 [3.5%] vs 3 [6.3%], p=0.66), and spinal cord injury (1 [1.7%] vs 0 [0%], p>1) were comparable between the 2 groups. The 5-year survival rates were 68.9% (standard error [SE]=6.85) and 81.5% (SE=6.00) in the F and T groups, respectively (p=0.003); however, freedom from aorta-related death rate (100% vs 100%, p=0.32) and the re-intervention rates (19.0% vs 6.30%, p=0.08) at 5-year showed no significant difference.

Conclusions: Fenestrated endovascular aortic repair reduces operative time, postoperative intubation, intensive care unit and in-hospital stays, and blood transfusions. The 5-year freedom from aorta-related death and re-intervention rates were comparable to those of total arch replacement.Clinical ImpactPre-curved fenestrated endografts provide a less-invasive yet effective option for aortic arch aneurysm repair, compared to total arch replacement. They offer shorter operative and intubation times, reduced transfusion rate, and shorter ICU stays, without increasing aorta-related mortality or reintervention during follow-up. This approach expands treatment opportunities for elderly and high-risk patients who previously could not undergo conventional arch repair.

Objective: To evaluate the clinical application and outcomes of physician-modified endografts (PMEG) made from a prefenestrated custom-made device (CMD) from COOK Medical with one reinforced fenestration and prefabricated diameter-reducing ties for the treatment of complex abdominal aortic aneurysms.

Methods: All patients treated with this adapted PMEG technique were included in the study. The single prefabricated fenestration was located 57 mm from the proximal edge. Two proximal graft diameters (34 mm and 36 mm) tapered to 22 mm distally, with tapering beginning 67 mm from the top and extending 40 mm were used. All grafts had a fixed length of 160 mm.

Results: Ten patients, of which 8 male (80%) and with a mean age of 74 (IQR: 70-78 y) were included. Indications included degenerative abdominal aortic aneurysms (n=6 [60%]), penetrating aortic ulcers (n=2 [20%]), and mycotic aneurysms (n=2 (20%). Three (30%) presented with contained rupture, six (60%) were symptomatic without rupture, and one (10%) was asymptomatic. Median diameter of the aneurysm was 53mm (IQR 48.3-73.2 mm). Physician modification involved creation of at least three additional fenestrations, all reinforced with Goose Snare wires and secured with sutures. All target vessels were successfully bridged. The median operating time was 208.5 min (IQR: 161.3-290 min), while the median modification time was 71.5 min (IQR 55-96 min). The in-hospital mortality rate was 20 %, both were patients with ruptured mycotic aneurysms. The remaining eight patients have all regained their baseline functional status and are currently undergoing follow-up (median follow-up time: 4.5 months; IQR: 1-13 months), with maintained patency of all target vessels to date. Postoperative CT revealed one type III endoleak, one type Ib, and two type II endoleaks. The type III endoleak between the TEVAR and the fenestrated aortic graft was treated with a giant Palmaz stent (one endovascular reintervention), while the others remain under follow-up.

Conclusions: Use of a simplified PMEG with one prefabricated fenestration and diameter-reducing ties is feasible and offers favorable early outcomes with technical advantages in modification and deployment.Clinical ImpactUsing an endograft with a single prefabricated fenestration as the outset graft for physician-modified endografts enhances procedural efficiency by reducing customisation time and simplifying the modification process. This approach lowers technical complexity, improves procedural reproducibility, and broadens the applicability of PMEG techniques. Consequently, PMEGs can be more readily used across a wider range of complex aortic anatomies, expanding endovascular treatment options for patients who might otherwise have limited or higher-risk surgical alternatives.