Use of a remotely steerable "robotic" catheter in a branched endovascular aortic graft

We report the use of a remotely steerable catheter to treat kinked renal bridging stents 8 months after branched endovascular repair of a type III thoracoabdominal aortic aneurysm. Conventional techniques using single, coaxial, and manually steerable sheaths proved too unstable to provide the support required to pass a wire against resistance through the kinked stent. A remotely steerable "robotic" catheter provided sufficient precision and stability to cross the kink and reline it with an additional stent, restoring renal perfusion. This technology can help achieve precise and stable introducer sheath position. Further evaluation is necessary to understand the wider applications.     

Homemade endovascular treatment of postoperativi aortobronchial fistulas

Successful treatments of aortobronchial fistulas were achieved in two cases using a homemade endovascular stent graft. In one, a 75-year-old man was operated on for a distal arch aneurysm 11 years previously. In the other, a 73-year-old woman was operated on for a ruptured type B aortic dissection 2 months previously. In both cases, the chief complaint was repeated hemoptysis, and the communiation between the aorta and the airway tract was at the distal anastomotic site in the descending aorta. To minimize risks associated with reoperation, endovascular stent grafting was selected electively. Postoperative courses were uneventful and there were no recurrences of hemoptysis.     

Anaesthesia for endovascular aneurysm repair

The surgical management of an abdominal aortic aneurysm (AAA) can be undertaken via an open or endovascular approach. The use of an endovascular approach has benefits for the patient by being less invasive with initially lower mortality and morbidity and a shorter hospital stay, although the long-term outcomes match open techniques. The endovascular technique requires more specialist resources, including stents and imaging equipment. In the UK, endovascular techniques are usually performed in specialist hospitals with specialist teams of interventional radiologists, vascular surgeons and anaesthetists. Patients requiring endovascular repair of their AAA can present the anaesthetist with a range of complex comorbidities that require specific management and optimization preoperatively. The intraoperative management of the patient can vary, depending on patient, surgical and anaesthetic factors and from local, regional or general anaesthesia techniques. The postoperative complications are generally minimal, but patients require lifelong follow up making the procedure more expensive than an open operation.     

Guidewires, Catheters, and Sheaths Used for Thoracic Endografting Procedures

Abstract   Background: Endovascular repair represents an option becoming progressively more integral to the treatment of thoracic aortic pathology. Effective use by practitioners of the most appropriate endovascular equipment is essential to the continued growth of this treatment modality. This article aims to provide an overview of the guidewires, catheters, and sheaths employed in the practice of thoracic endovascular aortic repair (TEVAR). Methods: We reviewed our current utilization of guidewires, catheters, and sheaths in TEVAR. Concurrently, we conducted a survey of the present medical literature with regard to the materials and methods used in this procedure by other cardiothoracic surgeons, vascular surgeons, and interventional radiologists. Results: Fundamental principals of the guidewires, catheters, and sheaths used in TEVAR are consistent across the spectrum of specialists performing this procedure. However, considerable variation exists in the specific products used by practitioners. Conclusions: The importance of proper training and experience with the endovascular equipment used in TEVAR cannot be understated. We believe the endovascular tools discussed in this article offer a proper selection for safe and effective performance of these procedures.     

Anaesthesia for endovascular aneurysm repair

A patient with an abdominal aortic aneurysm can have surgical management through either an open or endovascular approach. The use of an endovascular approach has benefits for the patient by being a less invasive approach with initially lower mortality and morbidity and lower lengths of hospital stay, although longer term outcomes match open techniques. The endovascular technique requires more specialist equipment, including stents and imaging equipment. In the UK they are usually performed in specialist hospitals with teams of interventional radiologists, vascular surgeons and anaesthetists working together. Patients presenting for endovascular repair of their abdominal aortic aneurysm can present the anaesthetist with range of complex comorbidities which require specific management and optimization pre-operatively. The intraoperative management of the patient can vary, depending on patient, surgical and anaesthetic factors, from local anaesthetic, regional techniques or general anaesthesia. The postoperative complications are generally minimal, but the patients require lifelong follow up, making the procedure more expensive than an open procedure.     

Surgery for aortic aneurysms

Aortic aneurysms, the majority of which affect the infrarenal abdominal portion of the aorta, are responsible for 1–2% of all deaths in men aged over 65 years in the Western world. The disease most commonly represents a multifactorial degenerative process involving both genetic and environmental risk factors and is characterized pathologically by a reduction in elastic lamellae within the aortic wall. The natural history of the condition is one of progressive enlargement with an associated increase risk of aneurysm rupture. Although aneurysm rupture remains a catastrophic event, with an overall mortality of approximately 80%, the majority of patients are asymptomatic. Asymptomatic aneurysms are usually diagnosed as an incidental finding and management relies on an assessment of the risks of future aneurysm rupture weighed against the risks associated with elective surgical repair. Aneurysm repair may be accomplished by traditional open surgery or minimally invasive endovascular repair. Although the latter confers a short-and medium-term survival advantage in selected patients, long-term follow-up data suggest this benefit may not persist. Thoracoabdominal aortic aneurysm disease is considerably more complex, with intervention, even in specialist centres, associated with significant morbidity and mortality. Best medical management of aortic aneurysm disease requires control of blood pressure, smoking cessation together with aspirin and statin therapy. Screening has been introduced in an effort to identify a largely silent killer although with better medical management the overall prevalence may be in decline.     

Using bilateral iliac branch devices for endovascular iliac aneurysm repair

Introduction: The endovascular repair of bilateral iliac aneurysms using bilateral Iliac Branch Devices (IBDs) has been infrequently performed and reported. We aim to describe this technique and report on the results of our case series. Methods: Three different device designs are available. The procedural options include a totally transfemoral approach, or a combined transfemoral and brachial approach. Clinical records for patients who have had this procedure were reviewed. Results: The indications for the technique include bilateral common iliac artery aneurysm repair, with or without concomitant abdominal aortic aneurysm repair. Considerations include the timing of main body endovascular aortic aneurysm repair (EVAR) device introduction, the use of a proximal access site and the type of IIA stent‐graft that is used. Between 2007 and 2010, six patients had bilateral IBD implantation. All patients required an EVAR main body device in addition to bilateral IBDs. Eighty‐three per cent were males, mean age was 73 years. Mean follow up was 15 months. Technical success was obtained in 100% of cases. There was one branch occlusion (8.3%). There were no type I endoleaks. One patient had a type II endoleak. Conclusions: Bilateral IBDs can be used safely and with excellent rates of technical success and branch patency in appropriately selected patients.     

B型主动脉夹层98例报告

目的探讨B型主动脉夹层的治疗效果,急、慢性主动脉夹层的治疗措施。方法 2001年7月～2011年6月98例B型主动脉夹层(胸主动脉夹层96例,腹主动脉夹层2例;急性主动脉夹层89例,慢性9例)行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)83例,外科手术修复1例,保守治疗10例,术前夹层动脉瘤突然破裂死亡4例。采用直型带膜支架修复80例,分支带膜支架修复3例。杂交手术7例,先行右腋动脉-左腋动脉人工血管旁路移植5例,行左颈动脉-左锁骨下动脉人工血管旁路移植2例。保守治疗的10例中,4例经1周治疗痊愈。9例慢性主动脉夹层发现夹层不断扩大,采取腔内修复治疗。结果 83例腔内修复手术围手术期死亡2例,病死率2.4%(2/83),死亡原因:1例术后1周因心包填塞(尸检结果),1例为不明原因于术后第2天死亡,考虑为其他位置再次破裂所致;余81例术后恢复良好,无脑卒中发生。腔内手术发生Ⅰ型内漏14例(16.9%);81例出院时夹层内血栓形成69例,12例夹层中仍可见部分血流。保守治疗的10例,6例显示夹层内血栓形成,其余变化不大。84例随访2～121个月,平均36.5月,随访率91.3%(84/92),其中TEVAR随访75例,保守治疗随访8例,外科手术随访1例:1例腔内修复术后3个月胸降主动脉再次破裂死亡,2例Ⅰ型内漏存在,夹层不断扩大,再次放置带膜支架后消失,其余病例情况良好。结论急性B型主动脉夹层的治疗要积极,TEVAR为首选,可以取得比较好的疗效;慢性B型主动脉夹层应注意随访,必要时采用TEVAR治疗。     

Aortic arch aneurysm and Kommerell's diverticulum: Repair with a single‐stage hybrid approach

Kommerell's diverticulum is a rare congenital anomaly, consisting in aneurysmal dilatation at the origin of an aberrant subclavian artery. Depending on concomitant anatomical characteristics, different endovascular and open surgical procedures have been proposed. The following report describes the first single‐stage hybrid repair of a type I Kommerell's diverticulum associated with an aortic arch aneurysm and anomalous origin of the brachiocephalic vessels by total aortic arch replacement with a composite frozen elephant trunk prosthesis and endovascular treatment of the right subclavian artery. This hybrid procedure may represent an alternative to more challenging open repairs when totally endovascular approach is unfeasible.     

EVT® Endovascular graft for abdominal aortic anerysm

Background : A variety of prostheses are now available for the endovascular treatment of abdominal aortic aneurysm (AAA). Significant advantages of the EVT^® device are its unibody design, secure hook attachment system and graft fabric approximating that used in conventional surgery. Methods : Implantation of the EVT^® device was attempted in 60 patients who were studied prospectively with an analysis of subsequent problems encountered. Results : Conversion to open repair was required in four cases (6.7%). There were nine tube grafts inserted, 13 aorto‐unilateral iliac with crossover grafts and 34 aorto‐bi‐iliac grafts. There was one death (mortality 1.7%). Endoleaks were identified in eight patients (14%), none of which were proximal; three sealed spontaneously, two were treated with coil embolization, two are being observed and one patient had an iliac attachment converted to an open anastomosis. Access vessel problems were seen in 21 patients (35%); two‐thirds were corrected at the time of initial surgery. Seven patients (12%) had primary graft limb problems identified and treated before leaving the operating room. Nine patients (16%) developed secondary graft limb problems, which were diagnosed and treated after the initial surgery. Endovascular treatment was used in eight and was successful in six with surgical revision required in two. On review of these cases to assess if the problem could have been predicted at the time of initial surgery, it was felt that more aggressive treatment of intraoperatively diagnosed graft limb stenoses, even though considered mild, may have prevented 50% of subsequent secondary graft limb occlusions. Conclusion : Although the EVT^® device has significant advantages in the endovascular management of aortic aneurysm, potential graft limb problems need to be actively identified with the majority able to be successfully managed by supplementary endovascular techniques.     

Combined fenestrated-branched endovascular repair of the aortic arch and the thoracoabdominal aorta

ObjectiveThe aim of our study was to evaluate patients who underwent extensive endovascular aortic stent graft coverage (from the aortic arch to abdominal aorta) in terms of early and midterm clinical outcomes.MethodsA retrospective multicenter study was undertaken. All patients were treated with extensive endovascular aortic stent graft coverage with fenestrated and branched endografts at three experienced endovascular centers.ResultsBetween 2012 and 2017, there were 33 patients (22 male [67%]) treated with a combination of fenestrated-branched stent grafts in the aortic arch and the thoracoabdominal aorta. Most of the patients (20/33 [61%]) had fenestrated-branched endovascular aneurysm repair (fb-EVAR) of the thoracoabdominal aorta as a second-stage procedure after thoracic arch (fb-Arch) repair, 10 had fb-Arch repair as the first procedure, and three patients had a single-stage procedure. The mean age was 67 ± 13 years, and the mean interval between procedures was 13 ± 12 months. For fb-Arch repair, 20 fenestrated and 13 branched devices were used; for fb-EVAR, 23 fenestrated, 5 branched, and 5 composite devices were used. The use of spinal drainage was more common in fb-EVAR (20/33 [61%]). Technical success was 100%. Mean hospital stay was 15 ± 13 days for fb-Arch repair and 12 ± 9 days for fb-EVAR. Two patients died in the hospital after fb-EVAR, resulting in a 30-day mortality of 6% (2/33). No deaths occurred during the fb-Arch repair component or in the single-stage cases. Four patients developed spinal cord injury (12%), 1 had permanent paraplegia (3%), and 2 patients had a neurologic event (1 stroke [3%] and 1 transient ischemic attack [3%]). Six patients (18%) died during a mean follow-up of 23 ± 17 months. The survival at 12 months after the second procedure was 72%, and the freedom from any reintervention was 82%. The 12-month freedom from reintervention was 87% for fb-Arch repair and 81% for fb-EVAR.ConclusionsExtensive endovascular coverage of the aorta for aortic disease seems to be a feasible procedure in experienced centers, with acceptable perioperative morbidity and mortality. Spinal cord ischemia appears acceptable despite extensive aortic coverage.     

The impact of an interventional vascular specialty team on institutional endovascular aneurysm repair outcomes

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) is a technically demanding, resource-intensive procedure associated with a significant learning curve. In July 2002, the Department of Defense allocated nearly $5,000,000 for "Advances in Medical Practice" (AMP) and EVAR within the six major military medical centers in the United States Army. We sought to determine the impact of several institutional changes associated with the use of these funds. METHODS: We performed a single-institution, retrospective comparison of our early EVAR outcomes in physiologically similar patients before and after the use of AMP capital and the acquisition of a trained and equipped endovascular operative team. Morbidity, mortality, and operative variables were the main outcomes. Mean follow-up interval was 17.6 months. RESULTS: As of November 2004, a total of 114 conventional open and endovascular AAA repairs were performed at our institution since our first EVAR in May 2000. Ten of 51 (20%) total AAA patients were treated with EVAR by a general vascular surgical team before the addition of an endovascular specialty team to the service in July 2002. An additional 28 of 63 (44%) patients have been treated with EVAR since that time for a total of 38 repairs. During the first year evaluated, 20% of aneurysms were repaired with EVAR versus 83% during the most recent year. Devices from four different manufacturers were used during the study interval. Patients treated by the endovascular team had significantly less mean estimated blood loss (EBL), packed red blood cells (PRBCs) transfused, intravenous (IV) contrast used, and shorter operative times. Morbidity, mortality, endoleaks, and other variables were similar. In linear regression analysis adjusting for complex, time-consuming repairs that required adjunctive procedures outside the realm of normal EVAR, endovascular team EVAR was independently associated with decreased mean operative time, EBL, PRBCs transfused, and IV contrast used. CONCLUSIONS: At a major military medical center, EVAR has become the preferred technique for the repair of abdominal aortic aneurysms. EVAR by a dedicated endovascular surgical team favorably impacts several important operative variables and may improve overall outcomes. Some of these operative variables may be device specific.     

The iliac bifurcation device for endovascular iliac aneurysm repair: indications,deployment options and results at 1‐year follow‐up of 25 cases

Background: The iliac bifurcation device (William A Cook Australia, Brisbane, QLD, Australia) is a new endovascular device for iliac aneurysm repair. We review the indications for use, device characteristics, deployment options and the results of our case series. Methods: The most common indication for deployment is endovascular aortic aneurysm repair (EVAR) with common iliac aneurysm repair. The standard deployment sequence can be adapted to increase the utility of the device. Data were collected prospectively. Follow‐up was performed with plain X‐ray, ultrasound and computed tomography (CT) scan. Results: Between 2004 and 2007, 25 patients had their common iliac artery aneurysm repaired using the iliac bifurcation device. There were 23 male and 2 female patients. Median age was 75 years (range 60–85). The median follow‐up was 12 months (range 1–38). Twenty‐one procedures were combined with EVAR. The median abdominal aortic aneurysm diameter was 60 mm (range 31–97), and the median common iliac artery aneurysm diameter was 37 mm (range 24–71). Technical success was achieved in 100% of cases. There were no acute branch vessel occlusions. There was one early type I endoleak (4%). There was one death (4%) in the 30‐day period post‐procedure. There was one late type I endoleak (4%). Conclusions: The iliac bifurcation device achieves endovascular common iliac artery aneurysm repair with preservation of internal iliac artery flow. There are multiple different applications of the device and complementary deployment techniques. High rates of technical success and low rates of branch vessel occlusion are possible.     

腔内修复术后腹主动脉瘤破裂对策

腔内修复（EVAR）术后腹主动脉瘤（AAA）破裂是严重的主动脉疾病，危及生命。随着EVAR手术的推广和病人预期生命延长，发现其术后远期发生率显著高于预期。提高EVAR术后长期随访率，同时重视动脉粥样硬化和系统性炎性疾病对EVAR手术远期预后的意义，有助于早期发现AAA破裂风险，降低发生率。该疾病须根据病人病情制定个体化的手术治疗方案，但总体的围手术期病死率高。腔内手术是首选的手术治疗方法，以“Cuff开窗技术”、“裙套技术”为代表的腔内手术能够快速、有效地隔绝内漏；开放手术是治疗复杂病变的重要手段，以“球囊阻断技术联合主动脉缩缝术”为代表的开放手术，能够迅速稳定血流动力学状态，彻底纠正主动脉破裂的病变，有较高的救治成功率。     

Endovascular Graft Limb Occlusion After an Anterior Resection for Rectal Cancer: Report of a Case

An endovascular aneurysm repair has become an important therapeutic option for the management of patients with aortic aneurysms. Early advantages of the endovascular technique have been well documented. Patients with aortic aneurysms undergoing these procedures are usually elderly, which increases the likelihood of comorbidities. With the increased use of vascular devices, potential complications such as graft limb occlusion need to be widely understood, so they can be recognized and treated early. We recently treated an 85-year-old man with acute endovascular graft limb occlusion after an elective anterior resection for rectal cancer, and we discuss some factors that may have contributed to this complication.     

Thorakoabdominelles Aortenaneurysma

Thoracoabdominal aortic aneurysms (TAAA) are rare events with an incidence of 5.9 cases per 100,000 persons per year. In Germany approximately 940 TAAA procedures are performed annually. The cause of TAAA is mostly degenerative but they can also occur on the basis of an aortic dissection or connective tissue disease (e. g. Marfan’s syndrome). Patients often have severe comorbidities and suffer from hypertension, coronary heart disease or chronic obstructive pulmonary disease, mostly as a result of smoking. Operative treatment is indicated when the maximum aortic diameter has reached 6 cm (>?5 cm in patients with connective tissue disease) or the aortic diameter rapidly increases (>?5 mm/year). Treatment options are open surgical aortic repair with extracorporeal circulation, endovascular repair with branched/fenestrated endografts and parallel grafts (chimneys) or a combination of open and endovascular procedures (hybrid procedures). Mortality rates after both open and endovascular procedures are approximately 8?% depending on the extent of the repair. Furthermore, there are relevant risks of complications, such as paraplegia (up to 20?%) and the necessity for dialysis. In recent years several approaches to minimize these risks have been proposed. Besides cardiopulmonary risk evaluation, clinical assessment of patients by the physician with respect to the patient-specific anatomy influences the allocation of patients to one treatment option or another. Surgery of TAAA should ideally be performed in high-volume centers in order to achieve better results.     

Thorakoabdominelles Aortenaneurysma

Thoracoabdominal aortic aneurysms (TAAA) are rare events with an incidence of 5.9 cases per 100,000 persons per year. In Germany approximately 940 TAAA procedures are performed annually. The cause of TAAA is mostly degenerative but they can also occur on the basis of an aortic dissection or connective tissue disease (e. g. Marfan’s syndrome). Patients often have severe comorbidities and suffer from hypertension, coronary heart disease or chronic obstructive pulmonary disease, mostly as a result of smoking. Operative treatment is indicated when the maximum aortic diameter has reached 6 cm (>?5 cm in patients with connective tissue disease) or the aortic diameter rapidly increases (>?5 mm/year). Treatment options are open surgical aortic repair with extracorporeal circulation, endovascular repair with branched/fenestrated endografts and parallel grafts (chimneys) or a combination of open and endovascular procedures (hybrid procedures). Mortality rates after both open and endovascular procedures are approximately 8?% depending on the extent of the repair. Furthermore, there are relevant risks of complications, such as paraplegia (up to 20?%) and the necessity for dialysis. In recent years several approaches to minimize these risks have been proposed. Besides cardiopulmonary risk evaluation, clinical assessment of patients by the physician with respect to the patient-specific anatomy influences the allocation of patients to one treatment option or another. Surgery of TAAA should ideally be performed in high-volume centers in order to achieve better results.     

腹主动脉瘤腔内修复术后的并发症

腹主动脉瘤腔内修复术最早于1991年被报道,目前已经发展成为一项成熟可行的技术,但在术后并发症发病率及手术死亡率方面仍存在着相当高的风险。如果腹主动脉瘤腔内修复术欲在未来完全取代传统手术,降低围手术期死亡率并提高长期疗效势在必行。以下将围绕腹主动脉瘤腔内修复术并发症的产生机制、发病率及其带来的问题进行讨论。     

Outcomes of Oculomotor Nerve Palsy Caused by Internal Carotid Artery Aneurysm: Comparison between Microsurgical Clipping and Endovascular Coiling

The purpose of this study was to compare the clinical outcomes of microsurgical clipping and endovascular coiling in patients with oculomotor nerve palsy (ONP) caused by internal carotid artery (ICA) aneurysm. Among 17 patients with ICA aneurysms presented with ONP, 9 (52.9%) underwent microsurgical clipping and 8 (47.1%) underwent endovascular coiling. Outcomes of functional recovery of ONP were investigated and compared between surgical group and endovascular group. Mean intervals between the onset and treatment were significantly longer in microsurgical group (18.2 days) than in endovascular group (3.5 days). In microsurgical group, complete resolution (CR) of ONP was obtained in 7 of 9 patients (77.8%) and partial resolution (PR) was seen in 2 patients (22.2%). In endovascular group, CR was obtained in 5 of 8 patients (62.5%) and PR was seen in 3 patients (37.5%). The optimal treatment of aneurysm-induced ONP remains controversial; however, present study suggests both procedures are beneficial for achieving functional recovery of ONP. The treatment strategy should be decided primarily considering the general risks of the two procedures, and presence of ONP is not a disadvantageous factor for either procedure.     

The Incidence of Spinal Cord Ischaemia Following Thoracic and Thoracoabdominal Aortic Endovascular Intervention

ObjectivesTo determine the incidence and risk factors for spinal cord ischaemia (SCI) following thoracic and thoracoabdominal aortic intervention.MethodsA prospective database of all thoracic and thoracoabdominal aortic interventions between 2001 and 2009 was used to investigate the incidence of SCI. All elective and emergency cases for all indications were included. Logistic regression was used to investigate which factors were associated with SCI.Results235 patients underwent thoracic aortic stent grafting; 111(47%) thoracic aortic stent-grafts alone, with an additional 14(6%) branched or fenestrated thoracic grafts, 30(13%) arch hybrid procedures and 80(34%) visceral hybrid surgical and endovascular procedures. The global incidence of SCI for all procedures was 23/235 (9.8%) and this included emergency indications (ruptured TAAA and acute complex dissections) but the incidence varied considerably between types of procedures. Of the 23 cases, death occurred in 4 patients but recovery of function was seen in 6. Thus, permanent paraplegia occurred in 13/235 (5.5%) patients. Of the nine pre-specified factors investigated for association with SCI, only percentage of aortic coverage was significantly associated with the incidence of SCI; adjusted odds ratio per 10% increase in aorta covered = 1.78[95% CI 1.18–2.71], p = 0.007. The procedures in patients who developed SCI took longer (463.5 versus 307.2 minutes) and utilised more stents (4 versus 2).ConclusionSCI following thoracic and thoracoabdominal aortic endovascular intervention is associated with the proportion of aorta covered. The degree of risk varies between different types of procedure and this should be carefully considered in both selection and consenting of patients.