Use of dynamic computed tomography to evaluate pre- and postoperative aortic changes in AAA patients undergoing endovascular aneurysm repair.

PURPOSE: To utilize dynamic computed tomographic angiography (CTA) on pre- and postoperative endovascular aneurysm repair (EVAR) patients to characterize cardiac-induced aortic motion within the aneurysm neck, an essential EVAR sealing zone. METHODS: Electrocardiographically-gated CTA datasets were acquired utilizing a 64-slice Philips Brilliance CT scanner on 15 consecutive pre- and postoperative AAA patients. Axial pulsatility measurements were taken at 2 clinically relevant levels within the aneurysm neck: 2 cm above the highest renal artery and 1 cm below the lowest renal artery. Changes in aortic area and diameter were determined. RESULTS: Significant aortic pulsatility exists within the aneurysm neck during the cardiac cycle. Preoperative aortic area increased significantly, with a maximum increase of up to 12.5%. The presence of an endograft did not affect aortic pulsatility (p=NS). Postoperative area also changed significantly during a heart cycle, with a maximum increase of up to 14.5%. Diameter measurements demonstrated an identical pattern, with significant pre- and postoperative intracardiac pulsatility within and above the aneurysm neck (p<0.05). An increase in maximum diameter change up to 15% was evident. CONCLUSION: Patients undergoing EVAR experience aortic diameter changes within and above the aneurysm neck. The presence of an endograft does not abrogate this response to intracardiac pressure changes. Static CT imaging may not adequately identify patients with large aortic pulsatility, potentially resulting in endograft undersizing, stent-graft migration, intermittent type I endoleaks, and poor patient outcomes. The current standard regime of 10% to 15% oversizing based on static CT may be inadequate for some patients.     

“三文治技术”在腹主动脉瘤腔内修复中保留髂内动脉血流的应用

目的探讨“三文治技术”在合并髂总动脉瘤的腹主动脉瘤患者腔内修复中保留髂内动脉血流的可行性及安全性。方法我们对1例合并双侧髂总动脉瘤的肾下性腹主动脉瘤患者行腔内修复术。该患者由于腹主动脉瘤合并双侧髂总动脉严重扩张,覆膜支架覆盖腹主动脉及髂总动脉瘤的时需覆盖双侧髂内动脉开口,可能造成髂内动脉血流受阻而引起盆腔缺血。我们在进行左髂总动脉腔内修复时应用了“三文治技术”,以覆盖病变血管同时保留一侧髂内动脉血供。结果手术成功地对腹主动脉瘤及双侧髂总动脉瘤进行了覆膜支架的腔内修复,同时保留了髂内动脉血供。结论在复杂腹主动脉瘤髂内修复时,使用“三文治技术”可能是一种有效的保留分支血管血供的方法。     

Intra- and Interobserver Variability of Aortic Aneurysm Volume Measurement With Fast CTA Postprocessing Software

Purpose: To study inter- and intraobserver variability of volume measurements with a new, fast semi-automatic method and compare the results to a previously validated standard manual method for volume measurement. Methods: Twenty abdominal computed tomographic angiography (CTA) datasets of patients with abdominal aortic aneurysms undergoing endovascular aneurysm repair (EVAR) were randomly selected from a clinical database (10 pre and 10 post EVAR). Aneurysm sac volume was measured by 2 independent observers using both the standard and semi-automatic methods. Intra- and interobserver variabilities and variability between the 2 methods were studied. Differences of each pair of measurements were plotted against their mean, and the repeatability coefficient (RC) was calculated according to Bland and Altman. Results: For the standard method, the intraobserver mean difference was 0.9 mL (0.4% of the first measurement), with an RC of 8.4 mL (4.2%); the interobserver mean difference was 0.0 mL (0.0%), with a RC of 11.8 mL (5.9%). For the semi-automatic method, the intraobserver mean difference was 1.4 mL (0.7%), with an RC of 7.8 mL (4.1%); the interobserver mean difference was -1.8 mL (-1.0%), with an RC of 10.8 mL (5.7%). The mean difference between the methods was 8.3 mL (4.2%), with an RC of 25.1 mL (12.6%) for observer 1, and a mean difference of 6.4 mL (3.2%) and an RC of 21.3 mL (10.7%) for observer 2. Conclusion: The semi-automatic method showed good intra- and interobserver variability for volume measurements of aortic aneurysms before and after EVAR. Volume measurements with the semi-automatic method correspond to measurements with the standard method. Sophisticated and fast postprocessing software may facilitate acceptance and clinical application of volume measurements in daily practice. The cutoff of 5% for relevant volume changes during follow-up, as advised in the reporting standards for EVAR, is sustained.     

Pilot study of dynamic cine CT angiography for the evaluation of abdominal aortic aneurysms: implications for endograft treatment.

PURPOSE: To utilize 40-slice electrocardiographically (ECG)-gated cine computed tomographic angiography (CTA) to characterize normal aortic motion during the cardiac cycle at relevant anatomical landmarks in preoperative abdominal aortic aneurysm (AAA) patients. METHODS: In 10 consecutive preoperative AAA patients (10 men; mean age 78.8 years, range 69-86), an ECG-gated CTA dataset was acquired on a 40-slice CT scanner using a standard radiation dose. CTA quality was graded and scan time was measured. Pulsatility measurements at multiple relevant anatomical levels were performed in the axial plane. Changes in aortic circumference were determined for both the aortic wall and the luminal diameter. RESULTS: All 10 CT scans were of good quality. All patients could be scanned in 14 to 33 seconds (mean 21). At each anatomical level measured, there was a 2.2- to 3.4-mm increase in the aortic wall circumference per cardiac cycle. A similar increase was observed in luminal circumference, with a 2.4- to 3.6-mm increase per cycle. CONCLUSION: This study introduces the concept of dynamic cine CTA imaging of aortic motion, providing insight into the pathophysiology of abdominal aortic and iliac pulsations. Patients with AAAs selected for EVAR demonstrate changes in aortic circumference with each cardiac cycle that may have consequences for endograft sizing and future design. The potential for graft migration, intermittent type I endoleak, and poor patient outcome following EVAR can be anticipated. Complex aortic dynamics deserve increased scrutiny in an effort to prevent potential complications.     

Natural history of the iliac arteries after endovascular abdominal aortic aneurysm repair and suitability of ectatic iliac arteries as a distal sealing zone.

PURPOSE: To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. METHODS: Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs < or =16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). RESULTS: The mean CIA diameter increased by 1.0+/-1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5+/-1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6+/-18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed. CONCLUSION: Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.     

Automated software supported versus manual aorto-iliac diameter measurements in CT angiography of patients with abdominal aortic aneurysms: assessment of inter- and intraobserver variation

BACKGROUND: Open surgical or endovascular abdominal aortic aneurysm (AAA) relies on precise preprocedual imaging. Purpose of this study was to assess inter- and intraobserver variation of software-supported automated and manual multi row detector CT angiography (MDCTA) in aortoiliac diameter measurements before AAA repair. PATIENTS AND METHODS: Thirty original MDCTA data sets (4 x 2mm collimation) of patients scheduled for endovascular AAA repair were studied on a dedicated software capable of creating two-dimensional reformatted planes orthogonal to the aortoiliac center-line. Measurements were performed twice with afour-week interval between readings. Data were analysed by two blinded readers at random order Two different measurement methods were performed: reader-assisted freehand wall-to-wall measurement and semi-automatic measurement. RESULTS: Aortoiliac diameters were significantly underestimated by the semi-automatic method as compared to reader-assisted measurements (p < 0.0031). Intraobserver variability of AAA diameter calculation was not significant (p > 0. 15) for reader-assisted measurements except for the diameter of the left common iliac artery in reader 2 (p = 0.0045) and it was not significant (p > 0. 14) using the semi-automatic method. Interobserver variability was not significant for AAA diameter measurements using the reader-assisted method and for proximal neck analysis with the semiautomatic method (p > 0.27). Relevant interobserver variation was observed for semi-automatic measurement of maximum AAA (p = 0.0007) and iliac artery diameters (p = 0.024). CONCLUSIONS: Dedicated MDCTA software provides a useful tool to minimize aortoiliac diameter measurement variation and to improve imaging precision before AAA repair. For reliable AAA diameter analysis the reader-assisted freehand measurement method is recommended to be applied to a set of reformatted CT data as provided by the software used in this study.     

Feeding arteries of the spinal cord at CT angiography before and after thoracic aortic endografting.

PURPOSE: To study the visualization of spinal cord feeding arteries in patients with complex thoracic aortic pathology undergoing endovascular aortic repair (EVAR) using an optimized protocol for multislice computed tomographic angiography (MSCTA). METHODS: Eighteen consecutive patients (13 men; mean age 63 years, range 45-79) with aortic type B dissections (n=5), chronic expanding aortic dissections (n=5), thoracic aortic aneurysms (n=6), or penetrating aortic ulcers (n=2) underwent 16-slice CTA before and after (mean interval 9 days) EVAR. Pulse rate and neurological status were documented. Quantitative density measurements were taken at regions of interest (ROI) in the ascending thoracic aorta and at the level of the diaphragm. Two experienced radiologists qualitatively assessed the posterior intercostal arteries (PIA; fully visible, partially visible, non-visible), dorsal branches (DB; visible/non-visible), and artery of Adamkiewicz (AKA; visible/non-visible) on multiplanar reformations and maximum intensity projection reconstructions. RESULTS: MSCTA was performed successfully in 17/18 patients before and after EVAR (1 patient was excluded after EVAR owing to rising creatinine levels). Before EVAR, MSCTA revealed 197/203 PIAs within the stented area, of which 179 were fully and 18 partially visible. No significant (p=0.37) difference was noted for overall PIA detection within the stented area on post-EVAR MSCTA (185/203 PIA), although only 124 were fully and 61 partially visible. Similar results were obtained for DB visualization. The AKA were seen in 10/17 patients pre EVAR and 9/17 post EVAR. In 2 patients, the AKA was localized within the stented aortic segment. ROI analysis revealed contrast densities of 427+/-89 HU and 398+/-84 HU on pre- and post-EVAR MSCTA, respectively. No neurological events were observed. CONCLUSION: The majority of posterior intercostal arteries and dorsal branches remain open after EVAR due to retrograde perfusion. High-resolution MSCTA permits accurate pre- and post-EVAR visualization of spinal cord feeding arteries in patients with thoracic aortic pathology.     

Absence of buttock claudication following stent-graft coverage of the hypogastric artery without coil embolization in endovascular aneurysm repair.

PURPOSE: To evaluate the safety and efficacy of stent-graft coverage of the hypogastric artery origin without coil embolization during endovascular treatment of aortoiliac or iliac aneurysms. METHODS: A retrospective study was conducted of patients who underwent endovascular aneurysm repair with endograft coverage of the hypogastric artery between September 2001 and September 2005. Among the 88 patients who underwent EVAR during the study period, 21 patients (19 men; mean age 77+/-6 years, range 67-86) had unilateral hypogastric artery coverage without coil embolization. Aneurysmal arteries included 11 aortoiliac, 8 isolated common iliac arteries (CIA), and 2 isolated hypogastric arteries. Preoperative AAA size was a mean 57 mm (range 46-73), and mean CIA aneurysm diameter was 36 mm (range 17-50). All covered hypogastric arteries were patent prior to the procedure. The stent-grafts implanted were 10 Excluder, 10 AneuRx, and 1 Zenith. Clinical outcome focused on mortality and morbidity, including the occurrence and duration of new-onset buttock claudication, which was further correlated with superior gluteal and profunda femoris artery patency. RESULTS: Immediate seal was achieved in all patients. Mean follow-up was 16 months (range 1-54). No type I endoleaks developed from the aortic or external iliac artery, and no type II endoleaks were found from the origin of the hypogastric artery. New-onset buttock claudication occurred in 2 (9.5%) patients, but resolved in both within 4 months. No additional secondary procedures, aneurysm rupture, or aneurysm-related death occurred. CONCLUSION: Stent-graft coverage of the orifice of the hypogastric artery without coil embolization is a safe and effective adjunct during the treatment of aortoiliac or iliac aneurysm, with a low incidence of buttock claudication.     

Aging and Cardiovascular Disease: The Potential of AFX Iliac Extension in Abdominal Aortic Aneurysms with High Iliac Tortuosity

Recently, endovascular aortic aneurysm repair (EVAR) is the most common surgery for abdominal aortic aneurysm (AAA). However, iliac limb complications of EVAR often cause problems in patients with high iliac tortuosity. There is no difference of rate of iliac limb complication among EVAR devices, such as Excluder, Endurant, and Zenith in high iliac tortuosity. But there has been not reported about AFX. We studied AFX iliac extension as it is the only stent graft with an endoskeletal framework. This study aimed to evaluate the AFX iliac extension patency in a case in vitro and to use it in seven cases of AAA with high iliac tortuosity. The silicon tube inserted in the AFX iliac extension was flexed at 30, 60, 90, and 120 degrees, and the lumen of the iliac extension was monitored using an underwater camera in the circulatory system. During the experiment, the Iwaki Bellows Pump (IWAKI CO., LTD., Tokyo, Japan) produced a pulsating flow. We used this in seven patients with AAA high iliac tortuosity cases between November 2018 and May 2019. If the silicon tube inserted in the AFX iliac extension was flexed at 60 and 120 degrees, the stent protruded into the lumen. However, the graft was dilated at all degrees. All seven patients with AFX iliac extension had no complications and a patent iliac artery. The AFX iliac extension can reduce iliac limb complications in cases of high iliac tortuosity.     

A novel 14F endograft for abdominal aortic aneurysm: First in man

Objective : This study evaluated the feasibility of percutaneous endovascular treatment of infra‐renal abdominal aortic aneurysm (AAA) using the novel low profile modular Tripelay system (Tripelay, France). Background : Endovascular aortic aneurysm treatment (EVAR) has become more widely used as early mortality has been significantly reduced. Also, percutaneous access has become possible with the introduction of vascular closure devices and with the initial reduction in size of delivery catheters. However, percutaneous access is not commonly used and anatomical considerations, such as access vessel size and tortuousities, preclude a number of patients from being efficiently treated with EVAR. Methods : The novel Tripelay system enables two semicircular preshaped self‐expandable stentgrafts to be positioned side by side on the aneurysm neck extending into the iliac arteries. Each stentgraft being smaller than the target vessel diameter, the delivery catheter is reduced in size (14F) and accommodates with smaller and more tortuous access vessels than conventional devices. This device was used to treat a 57‐year‐old male patient with significant comorbidities (previous coronary artery bypass grafting (CABG) and abdominal surgeries, smoking, hypertension, obesity, hyperlipidemia). Percutaneous access was made on both femoral arteries. The device was inserted, positioned, and deployed as planned. Iliac extensions were used bilaterally. Results : The EVAR procedure was performed successfully, and the patient was discharged on day 6. Follow‐up computed tomography scans at 1, 6, and 12 months revealed perfect exclusion of the aneurysm sac, patent stentgraft, and vessels, and no prosthesis migration, endoleaks or stent fracture were observed. The patient remained asymptomatic and reported no adverse events during that period. Conclusion : The Tripelay system seemed as an effective and user friendly tool for treatment of AAAs. Of course, this procedure still needs further clinical evaluation with more cases and longer follow‐up to confirm long‐term efficacy and safety of this device. © 2010 Wiley‐Liss, Inc.     

Long-Term Results of Aortic Banding for Complex Infrarenal Neck Anatomy and Type I Endoleak after Endovascular Abdominal Aortic Aneurysm Repair

For many patients with abdominal aortic aneurysm, unsuitable anatomy of the infrarenal aortic neck precludes endovascular aortic aneurysm repair or causes type I endoleak after the procedure. In an attempt to overcome these challenges, we retrospectively examined the usefulness of aortic banding as an adjunctive procedure to endovascular repair in 8 patients who had an abdominal aortic aneurysm with a complex infrarenal aortic neck. The procedures were performed with the patients under general anesthesia and involved making an 8-cm upper-midline laparotomy incision to expose the aneurysmal aorta. Three patients underwent aortic banding before endovascular repair; the other 5 underwent banding after the repair because of persistent type I endoleak. After banding, the abdominal aortic aneurysm was successfully excluded in all 8 patients. Long-term follow-up (mean, 38 ± 20 mo) revealed no type I endoleak and no procedure-related complications. In patients who have an abdominal aortic aneurysm with complex infrarenal neck anatomy or a refractory type I endoleak, performing aortic banding as an adjunctive procedure to endovascular aortic repair appears to be a safe strategy with good long-term results.Key words: Aortic aneurysm, abdominal/complications/surgery; blood vessel prosthesis implantation/adverse effects/methods; patient selection; postoperative complications; risk factors; stents; treatment outcome; vascular surgical procedures/instrumentationEndovascular abdominal aortic aneurysm repair (EVAR) is a rapidly expanding treatment method for abdominal aortic aneurysm (AAA).¹ Unsuitable anatomy of the infrarenal aortic neck precludes EVAR in many patients,^1–3 and this is the most common reason for EVAR ineligibility and subsequent surgical repair (in 106 of 165 patients in one study).⁴ In addition, investigators have reported that proximal attachment failure after EVAR frequently results in type IA endoleak. When left untreated, this sequela is associated with a high risk of AAA expansion and rupture.^2–5 Various endovascular methods of reinforcing the neck from the inside have yielded largely unsatisfactory results.^6,7 The failure of endovascular intervention often necessitates surgical repair and removal of the endograft, which increases the morbidity and mortality associated with EVAR.^2,3,5,7 We examined the feasibility of reinforcing the “outside” of the aorta with an external aortic band.^8,9 We report the cases of 5 men and 3 women who underwent EVAR, and in whom adjunctive external aortic banding was used to cinch and reinforce the proximal infrarenal aortic neck to treat or prevent type IA endoleak.     

主动脉夹层CTA的诊断及介入治疗

目的对主动脉夹层CTA的诊断及介入治疗进行探讨与分析。方法本研究共纳入研究对象60例,均为2012年6月到2014年1月我院收治的主动脉夹层患者,所有患者均经DSA抑或MR T1-FS确诊。对患者的内膜瓣、管壁增厚、夹层动脉瘤和双腔征等影像学征象进行回顾性分析。结果 60例患者中出现主动脉夹层病变的70处,其中30例前循环,40例后循环。在70处主动脉夹层病变当中,有27处内膜瓣,7处双腔征,36处血管狭窄。相比DSA诊断,通过CTA可以把23处内膜瓣显示出来,占85.2%(23/27),可把5处双腔征显示出来,占71.4%(5/7),可把34处血管狭窄显示出来,占94.4%(34/36)。而在显示主动脉夹层脉瘤和血管闭塞上差异不显著。CTA比MR T1-FS更容易把血管内膜增厚给显示出来。结论通过CTA诊断主动脉夹层,能够把多种影像学征象给清晰显示出来,包括管壁和血管腔在内的主动脉夹层,是一种有效的影像学方式,对临床上运用适当的介入治疗有着重要的指导作用。     

Endovascular treatment of an internal iliac artery aneurysm using a nitinol vascular occlusion plug.

PURPOSE: To report endovascular occlusion of an internal iliac artery (IIA) aneurysm with an Amplatz nitinol vascular occlusion plug. CASE REPORT: A 71-year-old asymptomatic man who had previously undergone open aortic aneurysm repair presented for annual follow-up. A bifurcated Dacron graft had been inserted 12 years ago from the infrarenal aorta to the left common femoral artery and the right common iliac artery. The left common iliac artery was ligated proximally, and the left external iliac artery (EIA) provided retrograde flow into the IIA. Magnetic resonance imaging (MRI) revealed a 7.4-cm aneurysm of the left IIA. After transfemoral calibrated catheter angiography was performed, the proximal EIA was occluded with an Amplatz nitinol vascular occlusion plug. In addition, microcoils were placed distal to the vascular plug to achieve complete thrombosis of the vessel. One day after treatment, the patient was discharged free of symptoms after MRI had shown complete obliteration of the IIA aneurysm. At 6 months, the patient was free from symptoms, and angiography confirmed exclusion of the IIA aneurysm. CONCLUSIONS: This case illustrates the technical feasibility and successful short-term follow-up of a novel embolization approach to IIA aneurysms in patients with an aortofemoral graft.     

Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm.

PURPOSE: To describe a technique of aortic clamping during endovascular aneurysm repair (EVAR) in patients with ruptured abdominal aortic aneurysms (AAA) and circulatory collapse. TECHNIQUE: A balloon catheter is inserted percutaneously from the femoral artery and inflated in the suprarenal aorta. An introducer sheath must support the balloon. The stent-graft is passed from the contralateral groin and deployed beneath the balloon. The sheath makes it possible to retrieve the balloon after the endograft has been deployed. Carbon dioxide facilitates angiography while the aortic blood flow is arrested. CONCLUSIONS: The aortic stent-graft can be deployed while the aorta is continuously "clamped" from a transfemoral approach. This may allow EVAR in patients with circulatory collapse due to aneurysm rupture.     

联合应用三维计算机断层和数字减影血管造影诊治颅内动脉瘤

目的 探讨联合应用三维计算机断层血管造影(CTA)和数字减影血管造影(DSA)诊治颅内动脉瘤的效果。方法 对60例怀疑颅内动脉瘤的患者行CTA和DSA检查，其中1例仅行CTA检查。所有病例再行CTA、DSA检查，将所有检查结果及术中发现做比较。结果 (1)CTA发现55例共56个动脉瘤，9例宽颈，1例多发动脉瘤；DSA发现52例共56个动脉瘤，9例宽颈，4例多发动脉瘤；共治疗53例。(2)9例宽颈动脉瘤，4例手术(2例分别球囊、支架辅助栓塞)，4例多发动脉瘤均行手术夹闭，1例载瘤动脉闭塞；43例窄颈动脉瘤，31例电解可脱微弹簧圈(GDC)栓塞，9例夹闭，3例转院。(3)2例仅依据CTA资料行急诊手术，术中发现与CTA检查结果相符。结论 CTA和DSA联合检查有助于颅内动脉瘤的诊断，对治疗方案的选择有重要的指导意义。     

Endovascular maneuvers for contralateral stent graft limb misplacement in endovascular aortic repair

Cannulation and placement of the contralateral stent graft limb during endovascular aortic repair (EVAR) procedure are crucial steps as mispositioning may lead to conversion to open aortic repair. Endovascular bail-out strategies for stent graft relocation in EVAR are underreported though detailed knowledge may facilitate application and prevent conversion. We present three endovascular bail-out strategies for repositioning of a mispositioned contralateral stent graft limb. (1) Retraction of the mispositioned component with an inflated reliant balloon and placement of an interposition stent graft after successful cannulation; (2) Push-maneuver of the mispositioned stent graft into the infrarenal aortic aneurysm with an inflated reliant balloon supported by a large lumen introducer sheath and (3) Parallel placement of a second contralateral stent graft limb displacing the mispositioned one against the atrial wall in cases with adequate vessel diameter. Prevention of stent graft mispositioning by applying recognized tests to ensure correct placement are essential, following the slogan: check twice, deploy once.     

Intraoperative intrasac thrombin injection to prevent type II endoleak after endovascular abdominal aortic aneurysm repair.

PURPOSE: To report a prospective, nonrandomized pilot study to determine whether fibrin glue aneurysm sac embolization at the time of endovascular aneurysm repair (EVAR) is a safe and effective procedure to primarily prevent type II endoleaks. METHODS: Between June 2003 and December 2005, 84 consecutive patients (79 men; mean age 73.8+/-7.8 years, range 64-86) with degenerative infrarenal abdominal aortic aneurysm underwent EVAR with bifurcated stent-grafts and fibrin glue injection into the aneurysm sac at the conclusion of the endovascular procedure. A total of 424 imaging studies and 348 visits were recorded during the study period and reviewed. RESULTS: Selective catheterization of the aneurysm sac and fibrin glue injection immediately after initial stent-graft deployment was successful in 83 (99%) of 84 cases; there was one failure to access the excluded aneurysm sac due to severe iliac artery calcification. The estimated primary and assisted clinical success rates at 2 years were 91.3% and 98.8%, respectively, but the major findings were the low rate of delayed type II endoleak (2.4%) and the statistically significant decrease in the maximum transverse aneurysm diameter (50.40+/-6.70 versus 42.03+/-6.50 mm, p = 0.0001) at follow-up. In addition, of 31 patients available for 24-month follow-up, 14 (45.2%) patients showed a reduction in maximum transverse aneurysm diameter by >or=5 mm; 16 (51.6%) patients had no significant changes, whereas only 1 patient showed a >5-mm enlargement. CONCLUSION: This clot engineering approach to aneurysm sac embolization at the time of endografting appears to be safe and may spare the patient a repeated catheter-based intervention or surgical procedure.     

椎-基底动脉夹层的临床特点和治疗

目的探讨椎-基底动脉夹层(VAD)的临床特征、治疗策略和疗效。方法选择经DSA或CT血管成像(CTA)确诊的VAD患者28例。25例表现为后循环缺血(PCI),3例为蛛网膜下腔出血(SAH)。对25例PCI中的21例患者给予氯吡格雷(75 mg/d)或阿司匹林(100mg/d)治疗,3例给予血管内治疗;3例SAH患者中,2例实施支架辅助弹簧圈栓塞动脉瘤及椎动脉闭塞术。分析患者的临床特点及治疗策略,并对疗效进行随访。结果①28例患者中,24例有明确的病因或诱因,分别为头颈部异常运动(15/24,53.6%)、动脉粥样硬化(4/24,16.7%)、上呼吸道感染(12.5%,3/24)、血小板增多症和酗酒(各4.2%,1/24),原因不明4例。②28例患者中,25例(89.3%)有PCI症状,其中21例为后循环急性脑梗死,4例为反复短暂性眩晕发作。3例(10.7%)为SAH。③DSA或CTA确诊30支椎动脉和1支基底动脉有VAD。16支(51.6%)表现为"线样征",9支(29.0%)为梭形或囊形动脉瘤,6支(19.4%)为"珠线征",2支(6.5%)为双腔征。夹层最多位于V4段(71.0%,22/31),其次为V2段(19.4%,6/31)。④25例PCI患者中,药物治疗的21例中19例预后良好,2例预后不良;9例复查CTA或DSA,4例血管狭窄程度减轻,4例狭窄程度无明显变化,1例椎动脉自行闭塞。血管内治疗的3例,预后均良好,复查CTA未发现血管再狭窄或动脉瘤复发。3例SAH患者中,2例行血管内治疗者的预后良好,复查CTA未发现动脉瘤复发;1例因家属拒绝手术而仅采用药物治疗,再发SAH后死亡。结论根据VAD患者的不同临床特征,选择不同的治疗方式,大部分患者的预后良好。     

Use of the IntuiTrak? Stent-Graft Delivery System for Percutaneous Abdominal Aortic Aneurysm Exclusion: Initial Single-Center Experience

The exclusion of abdominal aortic aneurysms by endovascular techniques has enabled the treatment of patients who have high-risk comorbidities that preclude safe surgical repair. Since the development of the unibody bifurcated endovascular stent-graft for abdominal aortic aneurysm exclusion, remarkable technological improvements have facilitated stent-graft delivery and reduced the required size of the access site. Our initial institutional experience with the use of the Endologix IntuiTrak® Express Delivery System for the Powerlink stent-graft (in 7 patients) shows that the device is suited for percutaneous use without sequelae. Herein, we describe the IntuiTrak system and the successful results of its use: we achieved percutaneous access and closure in all 7 patients, with no conversions to open repair or vascular exposure.Key words: Aneurysm, dissecting/percutaneous treatment; aortic aneurysm, abdominal/complications; blood vessel prosthesis; blood vessel prosthesis implantation/instrumentation/methods; catheterization, peripheral/instrumentation/methods; coronary disease/complications; prosthesis design; stents; survival analysis; treatment outcomeThe endovascular exclusion of abdominal aortic aneurysms (AAAs) has enabled the treatment of patients who have high-risk comorbidities that preclude safe surgical repair.^1,2 Since the introduction of the Powerlink unibody bifurcated endovascular graft (Endologix, Inc.; Irvine, Calif),³ the delivery system has undergone substantial improvement that facilitates its deliverability and deployment for the endovascular aneurysm repair (EVAR) of AAAs.The initial Powerlink stent-graft delivery system was approved for commercial use in the United States in 2004. The Powerlink endograft consists of a unibody cobalt chromium-alloy endostent that is sewn to the ends of a low-porosity, expanded-polytetrafluoroethylene (ePTFE) graft material. This design prevents device fatigue and erosion and allows the graft material to “float” in the aneurysmal portions of the aorta. In 2008, the Powerlink line of stent-grafts was updated to include a suprarenal-orientation design and to incorporate larger stent-graft sizes—enabling the treatment of aortic necks of up to 32 mm in diameter and iliac arteries of up to 23 mm in diameter. Currently, the Powerlink line has an integrated introducer sheath size of 19F—the smallest commercially available in the United States—for the delivery of the XL aortic extension that is 34 mm in diameter.Using a unibody delivery system precludes the need of a 2nd large-bore access site for delivery of the contralateral iliac limb in patients who have marked tortuosity or severe vascular disease in 1 iliac artery—a situation in which large sheaths can be occlusive. The unibody design affords the unique advantages of anatomic fixation: the deployed graft rests upon the aortoiliac bifurcation, which prevents distal migration and reduces excessive stress on the stent-graft.⁴ Six-year data from the Endologix clinical trial have revealed excellent long-term results of EVAR with use of the Powerlink endovascular graft.⁵Our center participated in a limited-release registry of the IntuiTrak® Delivery System (Endologix). The purpose of the registry was to evaluate the new IntuiTrak delivery system for possible clinical validation in percutaneous endovascular aneurysm repair (PEVAR). Here, we describe the IntuiTrak system and the results of its use in 7 patients.     

Aortoiliac angulation and the need for secondary procedures to secure stent graft fixation: which angle is important?

BACKGROUND: The purpose of this study was to quantify the degree of aortoiliac tortuosity and determine the relationship between aortoiliac angulation and the need for a secondary procedure following endovascular repair. METHODS: Among 206 patients treated with the AneuRx stent graft, 3-year follow up data were available in 71 patients. Twenty eight patients without duplex and CT angiograms (CT angiography) on follow-up were excluded. The anatomy of the preoperative proximal aortic neck was evaluated using 3D-CT angiography reconstructed images in: a) Group I: 15 patients who required secondary procedures and b) Group II: 18 patients without any endovascular leak during follow up. The groups did not differ in age (72.9+/-6.1 versus 73.3+/-9.1) or aneurysm diameter (60.1+/-9.1 versus 60.5+/-10.1). In order to determine the aortoiliac tortuosity, we measured: a) the suprarenal aorta-infrarenal aortic neck angle: angle of the aorta at the level of the renal arteries, b) infrarenal aortic neck-aneurysm angle: angle of the aorta at the start of aneurysm, c) right iliac angle, d) left iliac angle, e) aortic neck length, f) aortic neck diameter. RESULTS: Computer-based measurements on 3D-CT angiography reconstructed images were: a) suprarenal aorta-infrarenal aortic neck angle: group I: (22.6+/-16.2), group II: (11.9+/-6.9), p<0.05; b) infrarenal aortic neck-aneurysm angle: group I: 17.6+/-12.4, group II: 18.8+/-9.4, p=NS; c) right iliac angle: group I: 22.9+/-12.6, group II: 20.4+/-9.5, p=NS; d) left iliac angle: group I: 22.4+/-10.5, group II: 19.1+/-12.2, p=NS; e) aortic neck length: group I: 18.9+/-5.3 mm, group II: 20.4+/-5.3 mm, p=NS; f) aortic neck diameter: group I: 24.1+/-1.0 mm, group II: 23.3+/-1.6, p=NS. CONCLUSIONS: Aortoiliac angulation can be defined and quantified. In patients requiring secondary procedures, there is an increased angulation at the proximal aortic neck angle.