In Situ Laser Stent Graft Fenestration of the Left Subclavian Artery during Thoracic Endovascular Repair of Type B Aortic Dissection with Limited Proximal Landing Zones: 5-Year Outcomes

PurposeTo assess safety and feasibility of in situ laser stent graft fenestration to revascularize the left subclavian artery (LSA) during thoracic endovascular repair (TEVAR) of type B aortic dissection (TBAD) with limited proximal landing zones with 5 years of follow-up.Materials and MethodsIn a single-center retrospective study, 130 patients with TBAD with limited proximal landing zones (≤ 1.5 cm) underwent in situ laser stent graft fenestration revascularizing the LSA during TEVAR from April 2014 to April 2019. Outcomes were assessed by CT angiography and clinic visits, including technical success rate, operative time, LSA patency, ischemic events, and late aorta-related complications during follow-up.ResultsMean age of patients was 53 y (range, 33–73 y). Primary technical success rate was 96.9% (126/130). Three chimney stents were placed instead of fenestration, and 1 LSA fenestration was combined with a left common carotid artery (LCCA) chimney stent. Mean operative time was 53 min ± 28 with fluoroscopy time of 40 min ± 15. There were no neurologic complications and no deaths, with a mean duration of hospital stay of 9 d (range, 5–21 d). At a mean follow-up of 42 mo (range, 5–60 mo), there was a 97% primary LSA patency. Four patients had a type I endoleak, which disappeared during follow-up. One LCCA became occluded after 6 months. No type II or III endoleaks were found. Retrograde type A aortic dissection and stent graft–induced new distal entry were not found during follow-up.ConclusionsIn situ laser fenestration to revascularize the LSA during TEVAR of TBAD with limited proximal landing zones was efficient, safe, and feasible based on 5-year follow-up.     

Endovascular Preservation of Segmental Arteries during Treatment of Thoracoabdominal Aortic Aneurysms with Fenestrated/Branched Stent Grafts: Feasibility and Outcomes

PurposeTo evaluate the technical success, feasibility, and outcomes of endovascular preservation of segmental arteries (SAs) during fenestrated/branched endovascular aortic repair (F/B-EVAR).Materials and MethodsA multicenter, retrospective study was conducted in consecutive patients treated with F/B-EVAR and a branch or fenestration for SA preservation. Eleven patients (median age, 57 years; range, 45–73 years; 7 men) were included.ResultsTwelve SAs were preserved. Stent grafts were custom made with fenestrations, branches, or a combination of both in 1, 2, and 5 patients, respectively. A t-Branch stent graft was used in 2 patients, and a physician-modified thoracic stent graft with a branch was used in 1 patient. Eight branches and 4 fenestrations were used for the preservation of 12 SAs. Four fenestrations and 1 branch for the SAs were not bridged and were left for perfusion of the corresponding SAs. Technical success was achieved in 10 of 11 (91%) patients. No early mortality occurred. Early morbidities included renal insufficiency without dialysis in 1 patient and partially delayed paraplegia in 1 patient. Before discharge, computed tomography angiography (CTA) showed patency of all the SAs. The median follow-up duration was 30 months (range, 10–88 months). Late death occurred in 1 patient. Two SAs were occluded in 1 patient with 2 unstented fenestrations, as determined using 1-year follow-up CTA. This patient did not develop spinal cord ischemia (SCI). Other SAs remained patent during follow-up. One patient with a type IIIc endoleak was treated by relining of bridging stents.ConclusionsEndovascular preservation of SAs with F/B-EVAR for thoracoabdominal aortic aneurysm is feasible and safe in select patients and may add to preventive measures for SCI.     

Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma

PurposeTo evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH).Materials and MethodsFrom April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases.ResultsSuccessful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57.ConclusionsTEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.     

Feasibility of Augmented Reality–Guided Transjugular Intrahepatic Portosystemic Shunt

PurposeTo investigate an augmented reality (AR)–guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS).Materials and MethodsAn AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully.ResultsEndovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5–10 s in the phantom experiments and 10–30 s in the canine experiments.ConclusionsThe feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.     

Vascular Pathology and Impact of Stent Eccentricity for Stent Restenosis in Femoropopliteal Endovascular Therapy

PurposeTo explore the clinical features associated with stent eccentricity and reveal the impact of stent eccentricity on the risk of 1-year restenosis after femoropopliteal stent implantation for symptomatic atherosclerotic peripheral artery disease (PAD).Materials and MethodsThe clinical database of a multicenter prospective study was used. It registered 2,018 limbs of 1,766 patients in whom intravascular ultrasound (IVUS)-supported femoropopliteal endovascular therapy (EVT) for symptomatic atherosclerotic PAD was planned from November 2015 to June 2017. The study included 1,233 limbs of 1,088 patients implanted with a bare nitinol stent, drug-eluting stent (DES), or stent graft and administered ≥2 antithrombotic drugs. The stent eccentricity was evaluated using IVUS, calculated as [(maximum diameter) / (minimum diameter) ? 1] at the cross-sectional segment with the lowest lumen area after stent implantation.ResultsChronic total occlusion and bilateral arterial calcification (peripheral artery calcification scoring system Grades 3 and 4) were positively associated with stent eccentricity, whereas renal failure while receiving dialysis, DES use, and stent graft use were negatively associated with stent eccentricity (all P < .05). Stent eccentricity was associated with an increased risk of 1-year restenosis (odds ratio [OR], 1.18; 95% CI, 1.01–1.37; P = .034). However, after adjustment for lesion severity and implanted stent types, the association was no longer significant (OR, 1.07; 95% CI, 0.91–1.24; P = .43).ConclusionsStent eccentricity was not significantly associated with the risk of 1-year restenosis after femoropopliteal EVT.     

Endovascular Outcomes in Aortic Arch Repair with Double and Triple Parallel Stent Grafts

PurposeTo report early and midterm outcomes of treating thoracic aortic aneurysm (TAA) and aortic dissection (AD) involving zone 1 and zone 0 with multiple parallel stent grafts (PSGs).Materials and MethodsFrom February 2011 to August 2018, 31 of 1,806 patients (1.7%) who underwent thoracic endovascular aortic repair (TEVAR) with double PSGs (DPSGs) (n = 20) or triple PSGs (TPSGs) (n = 11) were retrospectively reviewed. Procedures were performed in high-risk patients who had TAA or AD involving zone 1 or zone 0.ResultsFifteen patients (48.4%) who presented with symptomatic or impending rupture underwent urgent or emergent TEVAR with DPSGs or TPSGs. Nineteen patients (61.3%) were treated for zone 0 disease. Technical and clinical success rates were 70.0% for DPSG cohort and 45.5% for TPSG cohort. Intraoperative type Ia endoleak was observed in 30% of DPSG cohort and 45.5% of TPSG cohort. One patient in the DPSG cohort died of aortic sinus rupture intraoperatively. Minor stroke during the 30-day postoperative period was more frequent in the TPSG cohort (P = .042). Mean duration of follow-up was 28.9 months ± 17.7. The TPSG cohort had a higher incidence of major adverse events (72.7% vs 25.0%, P = .021). The most common adverse events were endoleaks (12.9%), endograft migration (9.7%), PSG stenosis or occlusion (6.5%), retrograde dissection (6.5%), and stroke (3.2%). Endograft migrations were more common in TPSG cohort (27.3%, P = .037). Overall mortality rate was 16.1% (5/31) perioperatively and during follow-up. There were no statistical differences in overall survival and reintervention-free survival.ConclusionsIn the context of TEVAR with multiple PSGs for aortic arch repair, TPSGs may have a high risk of major complications.     

Endovascular Lymphatic Decompression via Thoracic Duct Stent Placement for Refractory Ascites in Patients with Cirrhosis: A Pilot Study

PurposeTo evaluate the technical and clinical success of endovascular lymphatic decompression via thoracic duct (TD) stent placement in patients with cirrhosis with refractory ascites.Materials and MethodsNine patients (6 men and 3 women; median age, 66 [interquartile range {IQR}, 65–68] years; range, 62–78 years) who underwent TD stent placement for refractory ascites with contraindications for liver transplantation and transjugular intrahepatic portosystemic shunt creation were included in this retrospective study. TD stent placement was performed under local anesthesia using retrograde access from the venous system. Self-expanding stents from 5 to 8 mm in diameter were used and extended into the subclavian vein by approximately 1 cm. Technical (correct positioning of the stent) and clinical success (no more requirement of paracentesis) were evaluated. In addition, the safety of the procedure and TD pressure evolution were evaluated.ResultsThe technical success rate was 100%, and 3 (33%) patients reported clinical success. Five (56%) patients reported 7 minor adverse events (Grade I), among which 2 TD perforations were induced by stent angioplasty, with no clinical manifestation or treatment required. The median TD pressure decreased from 19 mm Hg (IQR, 11–24 mm Hg) at the beginning of the procedure to 6 mm Hg (IQR, 5–11 mm Hg) after TD stent placement. The median survival time after the procedure was 7.1 months.ConclusionsEndovascular lymphatic decompression via TD stent placement is feasible and safe and was effective on ascites in some patients with cirrhosis with refractory ascites.     

False Lumen Stent-Grafts for Repair of Postdissection Aortic Aneurysms

PurposeTo evaluate the safety and efficacy of false lumen (FL) stent-grafts in the treatment of postdissection aortic aneurysms.Materials and MethodsEleven patients who underwent endovascular repair using FL stent-grafts from January 2016 to June 2019 were included. Among them, 2 patients had a prior history of type A aortic dissection, whereas 9 had undergone a prior endovascular repair for type B aortic dissection. Computed tomography angiography was performed to evaluate the reintervention and technical success rate, aortic remodeling, and other related aortic complications.ResultsThe mean age of patients was 55.6 ± 10.4 years. Technical success was achieved in all patients, and neither early mortality nor paralysis occurred. In total, 8 visceral branch arteries originating from the FL were reconstructed. The true lumen areas at the celiac axis, superior mesenteric artery, renal artery, and abdominal aortic bifurcation were significantly increased from 230.1 mm² to 312.3 mm², 212.1 mm² to 277.5 mm², 209.1 mm² to 291.6 mm², and 214.4 mm² to 300.6 mm², respectively (P < .05). The total diameter of the aorta at the 4 designated levels was stable or had shrunk in all patients. At a mean follow-up of 18.9 ± 7.6 months, 1 patient received re-intervention owing to iliac stent-graft occlusion. No aortic-related mortality occurred.ConclusionsFL stent-grafts can safely and effectively treat patients with postdissection aortic aneurysms. This strategy can be used to promote thrombosis of the FL and aortic remodeling. A larger sample and an extended follow-up period are needed to produce more conclusive results.     

Monopolar Radiofrequency Energy Delivered by a Conductive Endovascular Basket or Guidewire Leads to Thermal Occlusion in a Swine Model

PurposeTo assess the feasibility of inducing vascular occlusion by application of radiofrequency (RF) energy via conductive endovascular wires or baskets.Materials and MethodsA retrievable nitinol basket and stainless steel guidewire with a platinum tip were evaluated as conductors for endovascular application of RF energy. Tissue-mimicking thermochromic gel phantoms that change color with heating were cast with 2-, 5-, and 7-mm-diameter lumens and filled with 37 ^oC saline. After ablation, the phantoms were sectioned, and the thermal footprints were evaluated. Six castrated male domestic swine underwent endovascular ablation using the basket in iliac arteries and guidewires in renal arteries. Post-procedural angiography was performed, and postmortem arterial segments were resected for histopathologic analysis.ResultsIn the phantom, the depth of thermal change in the 5- and 7-mm lumens averaged 6.3 and 6.0 mm along the basket, respectively, and in the 2- and 5-mm lumens, the depth of thermal change averaged 1.9 and 0.5 mm along the wire, respectively. In the swine, RF energy delivery led to angiographic occlusion at 12 of 13 sites. Thermal injury and occlusion were similar at the proximal, middle, and distal basket treatment zone, whereas injury and occlusion decreased from the proximal to the distal end of the 5-cm wire treatment zone.ConclusionsEndovascular delivery of RF energy via a conductive basket in medium-sized arteries or a guidewire in small arteries led to acute angiographic and histologic occlusion. The potential to induce stasis might be useful in settings where rapid occlusion is desirable.     

Parallel Covered Stents Technique in the Treatment of Abdominal Aortic Diseases

PurposeTo investigate the safety and efficacy of the parallel covered stents technique in the treatment of anatomically challenging aortic aneurysms, pseudoaneurysms, and dissections.Materials and MethodsData were retrospectively collected from 16 patients with abdominal aortic diseases who were treated with parallel covered stents (Gore Excluder, n = 14; Medtronic Endurant, n = 2) between January 2016 and July 2018. Patients were treated with this technique if they were unsuitable for either open repair or standard endovascular aortic repair with bifurcated stents. Such unfavorable anatomy included narrow aortic necks (≤18 mm), small vascular access (occluded or ≤6.0 mm), or compressed aortic lumens (≤18 mm). All patients were male, with a mean age of 64.7 ± 13.3 years. For true aneurysms (n = 4) and pseudoaneurysms (n = 4), the mean diameter and length of the proximal necks were 17.5 ± 2.6 mm (range, 14–21 mm) and 51.0 ± 12.5 mm (range, 39–75 mm), respectively. The minimal diameter of true lumen in cases with aortic dissection and penetrating ulcers (n = 8) was 14.8 ± 3.1 mm. Small or occluded femoral access was found in 3 patients.ResultsTechnical success was 100%. Minor type I endoleaks, which were seen on completion angiography in 5 patients, had all resolved within 3 months. There were no perioperative deaths. Postoperative complications included supraventricular tachycardia in 1 patient and pneumonia combined with heart failure in 1 patient. Patency of all stents was observed at a mean follow-up of 21.8 ± 10.1 months.ConclusionsThe parallel covered stents technique appears to offer a feasible solution for abdominal aortic diseases with unfavorable anatomy. Long-term follow-up is needed to further evaluate the safety and efficacy of this technique.     

Percutaneous In Situ Microneedle Puncture Fenestration via the Left Subclavian Artery for branched Thoracic Endovascular Aortic Repair

This study explored the feasibility of a totally percutaneous approach to perform in situ microneedle puncture fenestration during thoracic endovascular aortic repair (TEVAR) via access from the left subclavian artery (LSA). In total, 23 patients with either thoracic aortic dissection or thoracic aortic aneurysm were treated with in situ LSA fenestration during TEVAR. The procedure was technically successful in all the patients. No serious complications occurred during a mean 9-month follow-up period. In situ microneedle puncture fenestration during TEVAR via the LSA is a feasible and effective method for LSA reconstruction.     

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries

PurposeTo evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR).Materials and MethodsAll patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery.ResultsFifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001).ConclusionsA potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.     

Outpatient Percutaneous Endovascular Abdominal Aortic Aneurysm Repair: A Single-Center Experience

PurposeTo evaluate the safety of outpatient percutaneous endovascular abdominal aortic repair (PEVAR) versus inpatient PEVAR without or with adjunct procedures.Materials and MethodsBetween January 2012 and June 2019, a cohort of 359 patients comprising 168 (46.8%) outpatients and 191 (53.2%) inpatients who had undergone PEVAR were enrolled. All the patients were asymptomatic but had indications for endovascular aortic repair, ie, fit for intravenous anesthesia and anatomically feasible with standard devices. Patient sex, age, comorbidities, smoking status, type of anesthesia, adjunct procedures, type of graft device, operative times, mortality, complications, and readmissions were analyzed.ResultsMedian follow-up period was 16.5 months (interquartile range, 9–31 months). Except for a higher percentage of tobacco use (42.6% vs 28.8%; P = .04), dyslipidemia (39.7% vs 19.2%; P < .01), and use of local anesthesia (99.4% vs 82.2%; P < .01) in the outpatients, there was no significant difference in the type of graft and adjunct procedures used. No outpatient mortality occurred. There was no difference in the number, severity, and onset of complications (all P > .05). Outpatient unexpected same-day admission, 30-day readmission, and emergency department visit rates were 4.8%, 2.4% (P = .13), and 10% (P < .01), respectively. Operative times for outpatient PEVAR without adjunct procedures were shorter (P < .01).ConclusionsOutpatient PEVAR can be performed with a safety profile similar to that of inpatient PEVAR. The unexpected same-day admission, 30-day readmission, and emergency department visit rates were low. The outpatient PEVARs without adjunct procedures took less time.     

Preintervention Computed Tomography Improves the Performance of Endovascular Intervention in Patients with Abdominopelvic Trauma

PurposeTo evaluate the role of computed tomography (CT) and CT angiography in guiding endovascular arteriography (EA) and embolization in hemodynamically (HD) stable and unstable patients with abdominal and/or pelvic (AP) trauma.Materials and MethodsA retrospective review was performed of patients with AP trauma who underwent EA with or without embolization (from January 2012 to August 2020) at an urban, level I trauma center. Patients aged <18 years or those undergoing EA outside of the abdomen and/or pelvis were excluded. Demographics, imaging findings, procedure length, contrast agent administration, laboratory values, and outcomes were compared on the basis of preprocedural imaging technique and hemodynamic status.ResultsA total of 190 patients with AP trauma underwent EA with or without embolization; among them, 123 were HD stable and underwent CT/CT angiography, whereas 67 were initially HD unstable and underwent operative management prior to EA. Of these patients, 38 underwent CT/CT angiography after hemodynamic stability was achieved prior to postoperative EA. The incidence of therapeutic embolization for arterial injury on EA was significantly higher in patients with preprocedural CT/CT angiography (65.8% vs 44.8%, P = .04). The positive and negative predictive values of CT angiography for arterial injury at the time of EA were 92.3% and 100%, respectively. Prior imaging was associated with a reduced contrast agent requirement at the time of EA and reduced transfusion requirement (P = .05 and P = .02). No significant differences were observed in adverse outcomes for patients undergoing preprocedural imaging.ConclusionsCT or CT angiography prior to EA for HD stable and unstable patients with AP trauma may improve the likelihood of therapeutic embolization and enable improved procedure metrics without increasing adverse outcomes.     

Comparison between Antegrade versus Retrograde Ureteral Stent Placement for Malignant Ureteral Obstruction

PurposeTo compare the technical success of antegrade uteral stent (AUS) and retrograde ureteral stent (RUS) placements in patients with malignant ureteral obstruction (MUO) and to determine the predictors of technical failure of RUS.Materials and MethodsThis study retrospectively included 61 AUS placements (44 patients) performed under fluoroscopic guidance and 76 RUS placements (55 patients) performed under cystoscopic guidance in patients with MUO from January 2019 to December 2020. Technical success rates of the 2 techniques were compared using inverse probability of treatment weighting (IPTW) analysis. Logistic regression was used to identify predictive factors for technical failures.ResultsTechnical success was achieved in 98.4% of the AUS group and 47.4% of the RUS group. After stabilized IPTW, the technical success rate was higher in the AUS group than in the RUS group (adjusted risk difference, 49.4%; 95% confidence interval [CI], 35.4%–63.1%). The independent predictors for technical failure of the RUS procedure were age of ≥65 years (odds ratio [OR], 5.56; 95% CI, 1.73–21.27), ureteral orifice invasion (OR, 4.21; 95% CI, 1.46–13.46), and extrinsic cancer (OR, 15.58; 95% CI, 2.92–111.81).ConclusionsThe technical success rate of AUS placement was higher than that of RUS placement in patients with MUO. RUS failure was associated with age of ≥65 years, cancer with ureteral orifice invasion, and extrinsic ureteral obstruction.     

Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes

PurposeTo evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries.Materials and MethodsPatients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency.ResultsThirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter–related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77–98). The median primary patency was 87 days (95% CI, 73–293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14–0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09–0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients.ConclusionsStent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.     

Predictive Factors for Restenosis Following Stent-Supported Endovascular Therapy with Intravascular Ultrasound Evaluation for Femoropopliteal Chronic Total Occlusion

PurposeTo determine the predictive factors for in-stent restenosis (ISR) following stent-supported endovascular therapy (EVT) with intravascular ultrasound (US) evaluation for femoropopliteal chronic total occlusion.Materials and MethodsThis was a single-center, retrospective, observational study. The study included 276 lesions in 251 patients who underwent stent-supported EVT with intravascular ultrasound evaluation for femoropopliteal chronic total occlusion from July 2012 to June 2019. The wire passage route was assessed using intravascular US, and lesions were classified accordingly into 2 groups: intraluminal and subintimal passage. In this study, the intraluminal group was further divided into 3 subgroups by severity of calcification: none, <180°, and ≥180° circumferential. The subintimal group was further divided into 2 subgroups: subintimal passage without or with calcification. The primary outcome measure was ISR. Cox proportional hazards regression was used to determine the association of clinical characteristics with ISR rates.ResultsThe mean follow-up period was 19 months ±16, during which time ISR was observed in 31% of lesions. After multivariate analysis, an increased degree of plaque burden (hazard ratio [HR] = 1.101) and subintimal passage with calcification (HR = 3.408) were associated with an increased risk of ISR; a larger distal external elastic membrane area (HR = 0.898) and use of a stent graft (HR = 0.130) were significantly associated with a reduced risk of ISR.ConclusionsThis study revealed that factors associated with ISR after stent-supported EVT with intravascular US evaluation were distal external elastic membrane area, plaque burden, subintimal passage with calcification, and use of a stent graft.     

Comparative Outcome Analysis of N-Butyl Cyanoacrylate Embolization of the False Lumen Versus Thoracic Endovascular Aortic Repair in Aortic Dissection

PurposeTo evaluate the feasibility, safety, and effectiveness of N-butyl cyanoacrylate (NBCA) embolization for the treatment of aortic dissection.Materials and MethodsIn this single-center retrospective study conducted from February 2003 to June 2019, NBCA embolization of an aortic false lumen was attempted in 12 patients (median age, 59 y; range, 41–68 y) and thoracic endovascular aortic repair (TEVAR) was performed in 53 patients (median age, 59 y; range, 37–70 y) for aortic dissection with one or more indications of persisting pain, malperfusion, rupture or impending rupture, maximal aortic diameter ≥ 55 mm, and/or rapid aortic enlargement. The main exclusion criterion for embolization was the presence of fast blood flow in the aortic false lumen on aortography. The efficacy of NBCA embolization and TEVAR was compared by evaluating technical and clinical outcomes, repeat intervention–free survival (RFS), and overall survival (OS).ResultsTechnical success was achieved in 11 of the 12 patients treated with NBCA embolization (91.7%), and clinical success was achieved in 9 of these 11 (81.8%). No significant difference was found between embolization and TEVAR in clinical success rates (embolization, 81.8%; TEVAR, 84.9%; P = .409) or procedure-related complications (embolization, 1 patient [8.3%]; TEVAR, 4 patients [7.5%]; P = .701). In addition, embolization showed comparable 5-y RFS (embolization, 82.5% ± 9.3; TEVAR, 85.5% ± 4.8; P = .641) and 5-y OS (embolization, 100%; TEVAR, 95.4% ± 3.2; P = .744) rates to TEVAR.ConclusionsNBCA embolization of the false lumen in aortic dissection seems to be a safe and effective treatment modality for the closure of false lumen in selected patients.     

Dynamic Indicators That Impact the Outcomes of Thoracic Endovascular Aortic Repair in Complicated Type B Aortic Dissection

PurposeTo investigate dynamic variables obtained from retrospective computed tomography angiography for ability to predict thoracic endovascular aortic repair (TEVAR) outcomes in patients with complicated type B aortic dissection (cTBAD).Materials and MethodsSeventy-nine patients with cTBAD who received TEVAR from March 2009 to June 2018 were retrospectively enrolled. Relative true lumen area (r-TLA) was computed at the level of tracheal bifurcation every 5% of all R-R intervals. Parameters that reflect the state of intimal motion were evaluated, including difference between maximum and minimum r-TLA (D-TLA) and true lumen collapse. The endpoints comprised early (≤ 30 days) and late (> 30 days) outcomes after intervention.ResultsOverall early mortality rate was 13.9% (11/79), and early adverse events rate was 24.1% (19/79). Patients who received TEVAR within 2 days of symptom onset demonstrated the worst outcomes. A longer time of r-TLA < 25% in 1 cardiac cycle (P = .049) and larger D-TLA (P < .001) were correlated to an increased early death. In addition, D-TLA was an independent predictor of early mortality. Area under the curve of D-TLA was 0.849 (95% confidence interval 0.730–0.967) for predicting early mortality and 0.742 (95% CI 0.611–0.873) for predicting early adverse events. Survival and event-free survival rates during follow-up were decreased in the D-TLA > 21.5% group compared with the D-TLA ≤ 21.5% group (all P < .001).ConclusionsLarger D-TLA is correlated with worse postoperative outcomes and might be a crucial parameter for future risk stratification in patients with cTBAD.