Total percutaneous access for endovascular aortic aneurysm repair ("Preclose" technique)

OBJECTIVE: Percutaneous access during endovascular aneurysm repair has been difficult owing to the large size of the delivery catheters. This study reports a single-center experience of totally percutaneous access during endovascular abdominal and thoracic aortic repairs using the Preclose Proglide device (Abbott Vascular, Redwood City, Calif). METHODS: Between December 2004 and August 2006, 262 endovascular aortic aneurysm repairs were performed. Percutaneous access was used for the introduction of 12F to 24F sheaths (4.4-mm to 8.6-mm outer diameter). The technique involved deployment of two Proglide devices before insertion of the sheath ("Preclose" technique) with the sutures left extracorporeally for closure after conclusion of the procedure. A prospectively maintained endovascular database and medical records were retrospectively reviewed. Rates of technical success, failure modes, and the overall duration of the endovascular repair compared with a similar cohort using open femoral exposures were examined. RESULTS: A total of 559 Proglide devices were used to close 279 femoral arteries, and 175 (63%) required the insertion of 18F to 24F sheaths. There were 16 failures, mainly due to obesity, device malfunction, severe calcific disease, and faulty arterial punctures, for a technical success rate of 94.3%. The success rates for 12F to 16F size sheaths were significantly higher than for the larger 18F to 24F sheaths (99.0% vs 91.4%, P<.01). For both endovascular abdominal (EVAR) and thoracic (TEVAR) aortic repairs, the Preclose technique resulted in shorter overall procedure times compared with a similar cohort in which open femoral exposures were used (EVAR, 115 vs 128 min, P<.001; TEVAR, 80 vs 112, P=.019). Despite this reduction of procedure time, the savings on the cost of operating room time was negated by the cost of the Proglide devices ($295 per device). CONCLUSIONS: Percutaneous access for endovascular aortic repair is safe and feasible using the Proglide device. Although the success rates are higher for smaller size sheaths, successful closures may be obtained for up to 24F sheaths. Percutaneous access may result in shorter overall procedure times and potentially lower operating room costs, but this appears to be offset by the cost of the closure devices.     

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??Comparation between blood vessel suture instrument and traditional surgical suture in EVAR surgery for abdominal aortic aneurysm: An analysis of 130 cases ZHANG Zheng, CHEN Zhong, TANG Xiao-bin, et al. Beijing Anzhen Hospital ??Capital Medical University, Beijing 100029, China
Corresponding author??CHEN Zhong, E-mail??chenzhong8658@vip.sina.com
Abstract Objective To investigate the application of the Perclose Proglide vascular closure devices in the endovascular abdominal aortic aneurysm repairing operation and its significance. Methods The clinical data of 130 cases of endovascular abdominal aortic aneurysm repairing operation performed between March 2013 and February 2015 in Department of Vascular Surgery??Beijing Anzhen Hospital of Capital Medical University were analyzed retrospectively. Among them, 69 cases were treated with Perclose Proglide vascular closure devices to suture the puncture site of the femoral arteries and 61 cases were treated with the traditional surgical suture to close the puncture site of the femoral arteries. The relationship between the two groups and various clinicopathological factors of patients with abdominal aortic aneurysm were analyzed by Chi-square using statistical software SPSS17.0. The clinicopathological factors include operation successful rate??operation time??intraoperative blood loss??hospital stay??cost of operation??wound healing??lower limb ischemia and so on. Results Analysis using chi-square showed that Perclose Proglide vascular closure devices group was obviously better than the other group in operative time, intraoperative blood loss and hospital stay (P<0.05). Conclusion Comparing with the traditional surgical suture method??Perclose Proglide vascular closure devices are safe and effective. The patients have less injury and can recover more quickly??The Perclose Proglide vascular closure devices are worthy of clinical popularization??     

评估Perclose Proglide血管缝合器在胸主动脉夹层腔内修复术中的应用

目的探讨Perclose Proglide血管缝合器在胸主动脉夹层腔内修复术(TEVAR)中的应用价值。方法回顾性分析在我科采用TEVAR治疗Standford B型主动脉夹层患者106例,术后1个月、1年行CTA复查,分别测量术前、术后1个月、术后1年穿刺区股动脉直径大小。结果 106例患者均顺利完成覆膜支架腔内隔绝术,共使用223把缝合器,其中97例患者2把缝合器,7例患者3把缝合器,2例患者4把缝合器。术前、术后1个月、术后1年CTA测量穿刺区股动脉直径比较差异无统计学意义(P均0.05)。结论 Perclose Proglide血管缝合器在TEVAR中封闭股动脉穿刺道安全、可靠,且对股动脉管径无明显影响,值得推广。     

完全穿刺技术在腹主动脉瘤腔内修复术中的应用

目的 探讨应用Perclose ProGlide缝合器完全穿刺技术行腹主动脉瘤腔内修复术的安全性和有效性.方法 2008年5月至2010年4月,36例腹主动脉瘤患者完全穿刺下行腔内修复术治疗.其中男性30例,女性6例;平均年龄68岁.所应用的支架型血管包括:3例Endurant,13例Talent,20例Zenith.18～24 F的鞘管预置两把ProGlide,14～16 F的鞘管预置单把ProGlide.缝合动脉切口时取出鞘管并将线结下滑收紧.统计技术成功率、相关并发症及手术操作时间.术后3、6、9、12个月及其后每年进行CT血管造影随访.结果 20例局部麻醉,16例全身麻醉.68条股动脉共应用128把ProGlide,其中38条股动脉各应用2把,8条各应用3把,2条各应用4把,20条各应用1把.63条股动脉(63/68,92.6%)技术操作成功,2条中转切开缝合,3条出现血肿,无需手术处理.平均随访时间(12±3)个月.1例于术后3个月出现无症状的动脉夹层.结论 完全穿刺技术在腹主动脉瘤腔内修复术中的应用是安全和有效的.由于可能需要切开缝合,建议在杂交手术室中操作.     

From puncture to closure of the common femoral artery in endovascular aortic repair

In all fields of surgery there is a trend towards less invasive procedures reducing hospital stay, complications and mortality. Open surgery in the treatment of aortic diseases is gradually less applied, and instead endovascular aortic repair - EVAR - is a widely accepted treatment modality of today. The traditional approach in EVAR involves surgical exposure of the femoral arteries with bilateral groin incisions. Through the groin access, and under fluoroscopy, a special insertion sheath introducer is used to position a stent graft in the desired location with the patient in general or epidural anesthesia. The evolving stent-technology with smaller sheath sizes has broadened the scenario for alternative approaches for access and closure of the common femoral arteries. The following review presents an introduction on technical aspects of puncture of the femoral artery and closure of the arterial wall using percutaneous closure devices. We also aim to discuss three important approaches to expose and close the femoral arteries during endovascular aortic repair: The cut down approach, the true percutaneous technique, and the femoral fascial closure. Finally, factors important in the choice of techniques will be discussed in relation to early and late complications. We suggest that a percutaneous femoral approach should initially be considered for all endovascular aortic procedures, but with a low threshold to convert to traditional cut-down technique when complications such as bleeding, stenosis, ischemia, or femoral artery injury occur. The choice of the optimal femoral approach depends on the unique anatomy of each patient.     

Percutaneous thoracic and abdominal aortic aneurysm repair: techniques and outcomes

Endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become a widely accepted treatment modality. The conventional approach of an EVAR involves bilateral groin incisions to expose the femoral arteries followed by introducer sheath placement, which is typically performed with the use of general or epidural anesthesia. As technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. In this review, we present a brief history of percutaneous closure devices for common femoral artery access, factors important in patient selection, the technique of performing a percutaneous EVAR procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.     

腹主动脉瘤腔内修复术中血管缝合器与手术切开缝合临床应用对比研究

目的 探讨Perclose Proglide血管缝合器在腹主动脉瘤腔内修复手术中的应用及意义。方法 回顾性分析2013年3月至2015年2月,首都医科大学附属安贞医院血管外科临床确诊腹主动脉瘤并实施腔内修复术的130例病人资料。术中采用穿刺股动脉方法建立入路并使用Perclose Proglide 血管缝合器缝合69例（A组）,手术切开股动脉并缝合61例（B组）。分析两组在缝合成功率、手术时间、术中出血量、住院时间、手术费用、伤口愈合情况、有无下肢缺血等因素,探讨Perclose Proglide 血管缝合器在腹主动脉瘤腔内修复手术中的应用效果。结果 在130例病人中,与手术切开组（B组）相比,使用缝合器组（A组）手术时间更短、术中出血量少、且住院时间较短,且差异均有统计学意义（P<0.05）。结论 在腹主动脉瘤腔内修复手术中,经皮穿刺建立股动脉入路并使用Perclose Proglide 血管缝合器处理穿刺点,该方法安全有效,且创伤小,病人术后恢复更快,值得推广使用。     

A novel access method for endovascular procedures in the porcine model

Objective To evaluate the use of the saphenous artery as an alternative access for endovascular procedures in the porcine model. Methods Fourteen adult pigs (25-35kg) were used in this study, 3 pigs from an acute study and 11 from chronic studies. A 2-3 cm incision was made and a saphenous artery cutdown was performed in 24 sides. Micropunc ture sets (Boston Scientific) or 18 G puncture needles were used to access the artery. Different sizes of introducers (4-7F) were used to establish endovascular access. Angiographic catheters were then used to confirm if the access was usable. Four saphenous arteries were explanted in the pigs from a chronic study 4 to 28 days after surgical procedure. Results The saphenous artery was very easy to expose and 4-5 F introducer sheaths were able to be inserted to establish access for endovascular procedures in the pigs. The saphenous artery was unable to accomodate an introducer with a size larger than 6 F. Four saphenous arteries were injured when 5 and 6 F introducers were used, but angiographic procedures could still be performed. Morphologic evaluation of the explanted arteries demonstrated occlusion of the saphenous arteries without injury or disruption of the adjacent femoral arteries. Conclusion The saphenous artery can be used as an access site in pigs for angiographic and interventional procedures if the catheter size is less than 6 F. This vessel is easier to access and can preserve the femoral artery for repeat procedures in the future.     

Chronically impaired endothelial vasoreactivity following oversized endovascular introducer sheath placement in porcine iliac arteries: implications for endovascular therapy

The conventional endovascular aortic aneurysm procedure entails the placement of oversized introducer sheaths in relatively normal ileofemoral arteries to allow the delivery and deployment of endovascular prosthesis. Endoluminal manipulation with passage of oversized endoluminal devices can lead to endothelial denudation, resulting in impaired cellular function. The purpose of this study was to assess the time course of endothelial function with vasoreactivity following oversized endovascular sheath insertion ranging from 1 day to 16 weeks in normal porcine iliac arteries. Following oversized introducer sheath placement in bilateral iliac arteries, vasoreactivity was tested using both endothelium-dependent and -independent vasodilators. Intravascular ultrasonography showed a significant reduction in the luminal area at 12 and 16 weeks. This was similarly supported by morphometric analysis, which showed increased medial thickness with an elevated intima to media ratio at the same time course. Endothelium-dependent relaxation to bradykinin, calcium ionophore A23187, serotonin, and adenosine diphosphate all uniformly displayed attenuated endothelial dysfunction at all time points when compared with the control group. In contrast, endothelium-independent relaxation showed a decreased vasoresponsiveness at 4 weeks. In conclusion, this study underscored the detrimental and chronic endothelial dysfunction in a normal artery caused by oversized introducer sheath placement. Chronically impaired endothelial function may play a role leading to iliofemoral artery thrombosis or late occlusion, which were well-recognized adverse events following endovascular aneurysm procedures. Our study underscores the importance of appropriate patient selection to minimize potential sheath oversize and endograft device miniaturization to avoid vessel wall injury and maintain vasoreactivity.     

A review on the use of steerable sheaths in complex endovascular aortic repair

Complex aortic aneurysms are now more commonly treated endovascularly, and often require a fenestrated-branched endovascular aneurysm repair. The use of steerable sheaths can improve the technical success rate in catheterisation of target visceral vessels and reduce the surgical risks associated with these complicated procedures. There are several commercially available steerable sheaths in the market, but similar devices can be homemade using different endovascular instruments. Steerable sheaths allow catheterisation of downward orientated branches more easily through a transfemoral approach. The risks associated with a traditional upper extremity access can be minimalised. They are also described in the use of several other situations during endovascular aortic repairs. Limitations to this technique are the availability of the device, the stability of the sheath curvature, the difficulty to deliver instruments in a tight curve and the associated complications if large sheaths are used. Steerable sheaths can be used as a primary intent when challenging anatomy is anticipated or as an adjunct when standard procedures are not successful.     

Percutaneous Endovascular Abdominal Aortic Aneurysm Repair

In this prospective, nonrandomized study, we compared outcome with percutaneous femoral artery closure to that with open femoral arteriotomy in 95 patients who underwent endovascular AAA repair. Devices were introduced using 22 Fr and/or 16 Fr sheaths. The 8 Fr/10 Fr Perclose devices (Perclose Inc., Redwood City, CA) were used in an off-label "preclose technique." Thirty-three patients had bilateral open femoral arteriotomies, 44 patients had bilateral attempted percutaneous closure, and 18 patients had open femoral arteriotomy on one side and attempted percutaneous closure on the other side. Percutaneous closure was successful in 85% (47/55) of 16 Fr sheaths and 64% (29/45) of 22 Fr sheaths (p <0.027). BILATERAL PERCUTANEOUS CLOSURE WAS SUCCESSFUL IN 63% (28/44) OF PATIENTS. CONVERSION TO OPEN FEMORAL ARTERIOTOMY DUE TO BLEEDING OCCURRED IN 24 OF 106 PERCUTANEOUS ATTEMPTS. THERE WERE NO DISSECTIONS, ARTERIAL THROMBOSES, OR PSEUDOANEURYSMS ASSOCIATED WITH PERCUTANEOUS ARTERIAL CLOSURE. WOUND COMPLICATIONS WERE SEEN IN 3.6% (3/84) OF OPEN ARTERIOTOMIES AND 0.9% (1/106) OF ALL PERCUTANEOUS ATTEMPTS AND ARTERIAL CLOSURES (P > 0.05). Gender, previous femoral access, obesity, and iliac occlusive disease were not predictive of percutaneous failure. Procedural success for percutaneous AAA repair is affected by sheath size. Devices delivered through 16 Fr or smaller sheaths will have successful femoral artery closure rates of at least 85%.     

Percutaneous endovascular repair of infrarenal abdominal aortic aneurysms: a feasibility study

BACKGROUND: Endovascular grafting has markedly reduced the invasiveness of the treatment of abdominal aortic aneurysms. By using a modification of technique for available closure devices, we have been able to achieve percutaneous repair of aneurysms. This study reviewed our initial experience with this technique. METHODS: Demographics and background data from patients undergoing endovascular repair of abdominal aortic aneurysms were reviewed from prospectively collected registry data. Operative notes and angiographic and computed tomography scan data were retrospectively reviewed to assess the success of the percutaneous approach. RESULTS: Fourteen patients have undergone percutaneous placement of the AneuRx (Medtronic, Sunnyvale, Calif) endovascular graft, with a modification of the technique for the Prostar (Perclose, Redwood City, Calif) device for access site closure. Main graft body introduction with a 22F sheath proved successful in nine of 12 (75%) deployments. Contralateral limb deployment through a 16F sheath was successful in 10 of 14 deployments (71.4%). Reasons for conversion to open groin incisions include inadequate percutaneous hemostasis (six cases), iliofemoral dissection (four cases), device failure (one case), and compromised distal flow (one case). Percutaneous deployment success appears to be improved with larger iliac artery dimensions, decreased calcification, and limited tortuosity, because of the limitation of complications related to delivering a larger diameter sheath. Of the 13 percutaneous endograft insertions that were attempted, six (46.2%) were completely successful. CONCLUSION: Percutaneous deployment of available devices is technically feasible by using modifications of technique with percutaneous closure devices, despite large introducer sizes. Further experience with this technique offers the potential for identifying patients in whom this will prove successful and for even further reducing hospital stay and recovery times for aneurysm repair.     

Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels

We performed a one-stage hybrid surgical and endovascular procedure to manage a 6.5-cm right aortic arch aneurysm associated with anomalous origin of the supra-aortic vessels in a 70-year-old man. Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of the right aortic arch aneurysm with a Zenith TX2 stent graft (Cook, Bloomington, Ind) and Z-track plus introducer system. The procedure was successfully completed with exclusion of the aortic arch aneurysm, and the patient was discharged on postoperative day 7. Aortic arch aneurysms with complex anatomy may be successfully treated with a less invasive hybrid approach using new generation devices.     

主动脉腔内修复术双Perclose ProGlide交叉缝合与传统缝合穿刺点的疗效比较

目的通过与传统缝合比较,探讨主动脉腔内修复术采用双Perclose ProGlide交叉缝合修复20F或22F穿刺点的优缺点,为临床穿刺点修复方法选择提供参考。方法 2007年6月-2011年5月,103例115侧采用外径为20F或22F输送鞘行主动脉腔内修复术,其中采用双Perclose ProGlide交叉缝合修复穿刺点57例64侧(双Perclose组),传统缝合修复46例51侧(传统缝合组)。两组患者年龄、性别、病程等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。结果双Perclose组不同病种患者的手术时间、术中出血量、住院时间均明显优于传统缝合组(P<0.05)。术后双Perclose组5例(5侧)、传统缝合组2例(2侧)出现不同程度腹股沟区皮下瘀血;双Perclose组2例(2侧)皮肤穿刺点处淋巴漏,传统缝合组6例(8侧)切口发生淋巴漏。双Perclose组术后早期并发症发生率为7.8%(5/64),传统缝合组为15.7%(8/51),比较差异无统计学意义(χ2=1.76,P=0.19)。双Perclose组技术成功率为96.9%(62/64),传统缝合组为100%(51/51),差异无统计学意义(χ2=0.31,P=0.50)。两组患者术后均获随访,双Perclose组随访时间2～19个月,平均15个月;传统缝合组随访时间2～18个月,平均14个月。双Perclose组1例(1侧)术后3个月出现原穿刺点处假性动脉瘤,给予切开缝合;其余患者无缝合动脉狭窄、假性动脉瘤形成等中期并发症发生。双Perclose组中期并发症发生率为1.6%(1/64),传统缝合组为0,两组比较差异无统计学意义(P=1.000)。结论与传统缝合技术相比,双PercloseProGlide交叉缝合技术修复主动脉腔内修复术中20F或22F穿刺点疗效相似,但在控制手术时间、术中出血量及住院时间方面具有明显优势。     

Surgical strategies for organ malperfusions in acute type B aortic dissection

This study is retrospectively to evaluate strategies for organ malperfusion on the view point of two mechanisms (true lumen collapse in the aorta=Ao type, or branch dissection=Br type) in acute type B aortic dissection. There were 16 of Ao type and 4 of Br type in 20 patients with organ malperfusion. In Ao type, we performed entry closure in 12 patients, surgical bypass grafting in two to superior mesenteric artery (SMA) in one and femoral artery in two, and surgical fenestration in two. In Br type, we performed interventional non-covered stenting to the orifice of visceral arteries in two patients, surgical bypass to SMA with ileum resection in one, and surgical bypass to SAM and renal arteries in one. Five patients in 16 of Ao type died within 30 days that had two multiple organ failure after entry closure, one aortic injury during endovascular stent graft repair, two more multiple organ failure after femoral bypass, however, all four patients in Br type were rescued. Central aortic operation to true lumen collapse with entry closure for Ao type ischemia and organ reperfusion with extra-anatomical bypass or non-covered stent to ischemic arteries for Br type ischemia should be performed before catastrophic status.     

Totally percutaneous aortic aneurysm repair: experience and prudence

OBJECTIVE: Totally percutaneous aortic aneurysm repair has been shown to be technically feasible, with low morbidity. Complications from percutaneous arterial closure are not insignificant, however, and can be fatal. We sought to evaluate our experience with this technique, compare it with the published literature, and identify factors associated with conversion to open repair and complications. METHODS: A retrospective review of a prospectively collected database was performed. All patients who underwent percutaneous closure of large-bore-sheath (>12F) access sites with off-label use of a suture-mediated closure device (Prostar XL) between December 2002 and August 2005 were reviewed. Outcome measures evaluated were rates of technical success, conversion to open femoral arterial repair, and complications. Axial diameter measurements of the accessed vessels were assessed with computed tomographic (CT) angiography both before and after the procedure. Patient variables were compared by using chi2, Fisher exact, and paired and independent samples t tests where appropriate. The mean follow-up interval was 1.5 years. RESULTS: During the study period, 49 patients underwent percutaneous closure of 79 large-bore-sheath access sites after successful endovascular aneurysm repair. Seven patients (14%) were morbidly obese (body mass index >35 kg/m2). Successful closure was achieved in 74 access sites (93.7%). Percutaneous closure was unsuccessful in five access sites (6.3%), all of which required open femoral repair at the same setting. Two converted patients experienced complications (4.1%): one retroperitoneal hematoma requiring transfusion of blood products and one iliac artery injury leading to death from myocardial infarction. Both of these patients were morbidly obese. Both complications occurred after closure of larger than 20F sheath sites. Morbid obesity and sheath size greater than 20F were associated with a significantly increased complication rate (P = .02 and P = .01, respectively). No thrombotic or infectious complications occurred in this series. Upon comparison of preoperative and postoperative CT angiograms, one (1.3%) small pseudoaneurysm was detected. No arteriovenous fistulas or hematomas larger than 3 cm were detected. The pseudoaneurysm occurred after closure of a 20F sheath access site. There were no significant differences in minimum intraluminal (7.38 +/- 1.8 vs 7.48 +/- 1.8) or maximum extraluminal (11.25 +/- 2.8 vs 12.02 +/- 2.7) diameters between preoperative and postoperative CT angiograms, respectively. CONCLUSIONS: Totally percutaneous aortic aneurysm repair is technically feasible in most cases, with no effect on the luminal diameter of the accessed femoral artery. Complications occur more often in morbidly obese patients and with sheaths larger than 20F. These complications can be minimized with meticulous technique and good patient selection. The capability for expeditious open femoral arterial repair is mandatory with this approach.     

The use of the Angioseal device for femoral artery closure

BACKGROUND: As vascular surgeons perform increasing numbers of percutaneous catheter-based procedures, they will need to become familiar with varying methods of femoral artery closure. Few studies on closure devices have included significant numbers of patients with peripheral arterial disease. It is the purpose of this study to determine whether the Angioseal device (St. Jude Medical) is a satisfactory method of achieving femoral artery puncture site hemostasis in these patients. METHODS: The records of all patients undergoing Angioseal closure of femoral artery puncture by a single vascular surgeon were reviewed. Indication, type of intervention, and size of the vascular sheath employed were recorded. Times to mobilization and discharge were determined. Patients were seen before discharge and 1, 4, and 12 weeks after the procedure, and at 3- month intervals thereafter. Complications including hemorrhage, pseudoaneurysm, infection, and vessel occlusion were noted. RESULTS: Between February 1, 2002, and August 31, 2003, 220 Angioseal collagen plugs were deployed in 188 patients. Attempts were made to deploy Angioseal devices in 92% of patients undergoing percutaneous procedures during this time period. One hundred forty-four procedures were diagnostic and 74 procedures included 76 therapeutic interventions. One hundred forty-four 5F sheaths, 47 6F sheaths, and 29 7F sheaths were employed during the procedures. Time to mobilization and discharge was 58 +/- 19 minutes and 102 +/- 31 minutes in patients undergoing diagnostic studies, 68 +/- 22 minutes and 146 +/- 42 minutes following interventions using 6F sheaths, and 127 +/- 18 minutes and 219 +/- 37 minutes when interventions were performed using 7F sheaths. No patient developed a major hematoma or infection following the use of an Angioseal. There were 2 complications related to device deployment. One patient developed a 1.4-cm false aneurysm at the femoral artery puncture site that resolved spontaneously. A second patient required operation for vessel occlusion when an Angioseal was deployed in a markedly diseased femoral artery. These adverse events occurred early in our experience. CONCLUSIONS: The Angioseal provides a secure method of achieving hemostasis following femoral artery puncture. It is easy to deploy, has a high level of patient satisfaction, and allows for early ambulation and hospital discharge. When simple guidelines are observed, the device can be safely used in the great majority of patients with peripheral vascular disease. It offers considerable advantages over the traditional method of manual compression.     

Endovascular repair for distal arch aneurysms

In the European and north American countries, stent grafts (SG) for endovascular repair of thoracic aortic aneurysms (TAA) have been commercially available for several years, whereas, in Japan, a manufactured SG had not been approved for this application until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices in most cases. Many researchers have continued to develop their homemade devices. We have participated in joint design and assessment efforts with a SG manufacturer, focusing primarily on fenestrated SG used in repairs at the distal arch, a site especially prone to aneurysm. For 15 years since 1995, over 1,120 patients of TAA have been treated with the endovascular technique using the SG in our hospital. The SG which was composed of several units of self-expanding Z stents covered with a polyester fabric or ePTFE, was individually designed for each patient. For distal arch aneurysms, SG should be so designed that it has scallop or fenestration on the graft to keep the blood flow into arch vessels. Exclusion of the aneurysms or closure of their entries without endoleak was achieved within 2 weeks postoperatively in over 96% of the cases. Endovascular stent grafting has the potential as a safe and useful treatment for thoracic aortic aneurysms, but further assessment is necessary of its efficacy over a longer postoperative period.     

Femoral-femoral stabilizing buddy wire for embolization of the internal iliac artery

Internal iliac artery (IIA) embolization is performed in a variety of clinical scenarios, most commonly in patients undergoing endovascular aneurysm repair (EVAR) with an iliac artery aneurysm or inadequate distal landing zone. In these patients, IIA embolization with iliac limb extension is often performed. While IIA embolization can be routinely performed with either ipsilateral or contralateral femoral arterial access, it can be challenging in some patients with an acutely angulated aortic or iliac bifurcation and in patients with short or ectatic common iliac arteries. In this select group of patients with difficult anatomy, IIA embolization can be challenging and may lead to increased radiation exposure and contrast administration. Having a sheath precisely positioned and stabilized at the internal iliac artery origin will facilitate embolization of the IIA. This report describes a novel technique in which crossover femoral-femoral artery buddy wire placement achieves stable positioning of large sheaths for concurrent IIA embolization at the time of EVAR.     

The Value of the Oblique Groin Incision for Femoral Artery Access during Endovascular Procedures

Groin incisions for access to femoral vessels are typically made in a vertical fashion extending across the groin crease. Significant morbidity can be associated with these incisions, including lymphoceles, lymph fistulae and infections, as documented in the infrainguinal revascularization literature. We have adopted an oblique groin incision for femoral artery access during endovascular graft reconstruction of the aorta because of the potential for reduced wound morbidity. In this study we report our experience with this technique and compare it with the existing literature to determine its usefulness. From June 1998 to May 1999, 98 consecutive patients received endovascular exclusion of aortic aneurysms at The Mount Sinai Medical Center, New York. Patients were treated with aortoaortic (24), aortouniiliac with femorofemoral crossover bypass (41), or bifurcated endografts (33) and were prospectively studied for wound complications. Aortoaortic procedures required one inguinal incision whereas aortouniiliac with femorofemoral crossover bypass and bifurcated procedures employed bilateral inguinal wounds. Wound complications were defined as cellulitis, subcutaneous purulence, femorofemoral graft infection, lymphocele, or lymphocutaneous fistulae. The oblique groin incision allows adequate exposure to the femoral arteries and is associated with low wound morbidity. We suggest that this approach may be the preferred technique for access to femoral arteries during endovascular procedures, and should be considered for infrainguinal arterial reconstructions.