Technique for safe removal of an aortic endograft with suprarenal fixation

Complete removal of an aortic endograft with suprarenal fixation is difficult. We report the use of a simple device to extract a Zenith endograft. This device is made by cutting off the tip of the cylinder of a 20-mL syringe and rounding off the edges. The main body of the graft is resheathed by advancing the cylinder cranially while keeping the graft in a stable position. This way, the graft collapses and the hooks are withdrawn without tearing the wall of the aorta. The supraceliac clamping time in our patient was less than 2 minutes. This technique offers a safe and fast solution to the potentially hazardous removal of an aortic endograft with suprarenal fixation.     

A stand-up collar around the saphenous vein graft

We present a technique of a stand-up collar around the saphenous vein graft using a pedicled fat pad flap. This procedure is simple and effective to avoid kinking in a graft that was proximally anastomosed with an automatic device and to maintain the graft in its natural position.     

Mechanical failure of prosthetic human implants: a 10-year experience with aortic stent graft devices

OBJECTIVE: The first endovascular stent graft was implanted to treat an abdominal aortic aneurysm more than a decade ago. This technique has evolved dramatically with the growing understanding of metallurgic and fabric sciences and improved device designs. However the potential for stent graft material failure remains. This investigation describes the incidence of material failure, potential modes of device fatigue, and the clinical significance of these failures. METHODS: Six hundred eighty-six endovascular stent grafts were used to treat patients with aortic aneurysms. Device fatigue in the form of stent, suture fracture, or graft wear was identified with an analysis of follow-up radiographs and explanted stent grafts. A review of patient clinical histories, spiral computed tomographic scan studies, scanning electron microscopy, and energy dispersion spectroscopy of explanted devices was conducted to evaluate the modes and consequences of failure. RESULTS: Sixty patients were identified with device fatigue, 49 of whom had abdominal endovascular repairs and 11 of whom had thoracic repairs. Of the 60 patients with stent graft fatigue, 43 patients had metallic stent fractures, 14 had suture disruptions, and three had graft holes. These material failures occurred within seven distinct stent graft designs. The average time to the recognition of failure was 19 months, with a mean follow-up period of 8 months since the event was identified. Eleven patients died, and one was lost to follow-up 2 years after identification of a stent fracture. The remaining patients are presently being followed eoyj physical examination, plain film radiograph, and computed tomographic scans for clinical sequelae of device fatigue. CONCLUSION: Endovascular stent graft fatigue has been recognized in numerous devices after aortic implantation. Fatigue may take the form of stent, graft, or suture failure, with certain modes unique to specific stent graft devices. The clinical significance of stent graft material failure remains uncertain.     

Aortoceliac Artery Bypass Using an Anastomosis Device with a Saphenous Vein Graft from the Supraceliac Aorta

We describe the clinical experience of application of an aortic anastomotic device for aortoceliac artery bypass with a saphenous vein graft from the supraceliac aorta.A 53-year-old female with celiac artery occlusion and multiple superior pancreaticoduodenal artery aneurysms had an aortoceliac artery bypass surgery using the aortic anastomosis device. Coil embolization of the aneurysms was performed via the superior mesenteric artery. The postoperative angiogram revealed good graft patency and complete aneurysm embolization. This device can be considered for application in various anastomotic situations.     

Stapled explant of the Jarvik 2000 left ventricular assist device

Currently the most common indication for placement of a left ventricular assist device is as a bridge to heart transplantation. One of the new generation axial flow left ventricular assist devices is the Jarvik 2000. This device is placed in the apex of the left ventricle and the outflow graft passes through the left pleural space and is anastomosed to the descending thoracic aorta. The course of the outflow graft presents technical challenges during explant for heart transplantation. Opening the posterior pericardium and use of a vascular stapler to control the outflow graft at the level of the descending thoracic aorta facilitates easy explantation.     

Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology. Technical note

Cerebrospinal fluid (CSF) leakage following endoscopic endonasal skull base resection can be a significant problem. A method for securing tissue grafts is needed. In this paper the authors used an endonasal suturing device to secure the graft reconstruction following endonasal tumor resection. The U-Clip anastomotic device (Medtronic), developed for cardiovascular anastomoses, was used to secure the tissue graft to native dura. A specialized needle driver and hemoclip applier were used for the application and deployment of this device. No suture tying was necessary, facilitating its endonasal application. The graft was successfully secured in its desired position to native dura by using the U-Clip anastomotic device. The patient did not suffer a postoperative CSF leak, and postoperative imaging and endoscopy revealed that the graft was in a good position. There was no complication from the use of the device. The U-Clip anastomotic device can be used as a suture device during endonasal surgery. It may prevent tissue graft migration and help prevent CSF leakage.     

Endovascular repair of left ventricular assist device outflow graft defect

Outflow graft complications after left ventricular assist device placement are infrequent but highly morbid. In this case report, we describe endovascular repair of multiple outflow graft defects with external hemorrhage in a complex patient using overlapping stent grafts. This approach successfully stopped the outflow graft hemorrhage and temporized the patient for subsequent cardiac transplantation.     

The use of right ventricular pacing to facilitate stent graft deployment in the distal aortic arch: a case report

Stent graft repair of aortic pathology involving the distal aortic arch requires precise device deployment based on excellent imaging and stable hemodynamics. An inadequate proximal seal may result in a type I endoleak, which may require an additional device or even conversion to open surgery to control. This case report describes transvenous rapid pacing, a safe and reproducible technique to allow precise deployment or balloon dilation of a stent graft in the distal arch or proximal thoracic aorta.     

Anterior cruciate ligament reconstruction with a multistrand hamstring graft fixed with a Ligament Tension Screw: a new device that can be used to readjust graft tension after fixation

We developed a new fixation device for reconstruction of the anterior cruciate ligament with a multistrand hamstring graft. This device allows the graft tension to be readjusted after fixation. This device, called a Ligament Tension Screw, consists of three parts, a screw, a washer, and a post. To create the graft, the tendons were formed into a loop. The device was hung from one end of the loop of the graft and a Kennedy-ligament augmentation device (LAD) artificial ligament was hung at the other end. The Kennedy-LAD artificial ligament was used extraarticularly for fixation at the tibia with double staples. Graft tension was increased by turning the screw, which pulls on the post suspending the graft. Fifty-two patients were evaluated after a minimum 2-year follow-up. The evaluation included physical examination, stability measurement with a KT2000 arthrometer, a Cybex muscle strength measurement, a functional test, and scoring of the knee according to the International Knee Documentation Committee (IKDC). Pivot test was negative in 47 patients (91%), but glide occurred in 5 patients (9%). No patient had a "clunk" or markedly poor result on the pivot test. All patients recovered full extension. Seven patients lost full flexion, but the loss of flexion was less than 5° in all seven. The KT 2000 arthrometer measurement with 133 N anterior drawer force indicated that 46 patients (88%) had less than 3-mm side-to-side difference. The mean muscle strength of the quadriceps and hamstrings was 91% and 94%, respectively, compared with the findings in the contralateral limb. The functional test showed a one-leg hop distance equal to 94% of that the opposite side. According to the final IKDC evaluation, 48 patients were graded as normal or nearly normal, and 4 patients as abnormal; none was severely abnormal. This study demonstrated satisfactory results for the reconstruction with a multistrand hamstring graft fixed with the new Ligament Tension Screw. Received: February 15, 2001 / Accepted: July 30, 2001     

Thrombectomy of a Hemasite graft

Hemasite is a new device incorporated in a graft that is used for hemodialysis. A technique of thrombectomizing this device incorporated graft is described.     

An innovative exclusion technique for ductus arteriosus with a novel stent graft

A 72-year-old woman who had a patent ductus arteriosus that was anatomically unsuitable for catheter coiling was treated with a pre-curved fenestrated stent graft. This graft was custom-made to configure the patient's whole aortic arch, and was capable of accurately adjusting its fenestrations to the arch branch orifices. The advantage of this fenestrated stent graft is close sealing, especially on the lesser curvature of the arch. This device could be an excellent option to treat an otherwise normal aortic arch with such a localized lesion.     

Experiences and results with the Endologix-bifurcated endovascular graft

Since the first endograft implantation for treatment of abdominal aneurysms the development of modern stentgrafts has progressed in many ways. In 1999 we started implantations using the PowerLink aortic stent graft by Endologix-company. The PowerLink aortic stent graft is a bifurcated, self-expanding, sutureless endovascular graft, covered with PTFE. This aortic stent graft facilitates the complete covering of the infrarenal aorta and the iliac arteries. The anatomical localization at the natural aortic bifurcation provides anti-gravitational supporting force, preventing distal migration of the device. From 1999 to 2005 we implanted 297 PowerLink aortic stent grafts. Our follow-up examinations showed a low rate of renal infarctions (3.0 %), a limb occlusion rate of 2.7 % and a total endoleakage rate of 16.8 %. Our conclusion is, that this is a very safe device for repair of abdominal aneurysms, associated with a low-risk of complications.     

Simple method of hemostasis in implantation and explantation of HeartMate left ventricular assist device.

We described a simple method of hemostasis in implantation and explantation of HeartMate left ventricular assist device. Wrapping of the inflow cannula, outflow conduit and outflow graft with Vascutek tube graft can localize the bleeding due to patient's coagulopathy, imperfect coating and device defect. During explantation, bivalving the tube graft, leaving the graft in place and no-touch of the adhesion between graft and soft tissue can minimize the dissection and prevent the potential bleeding.     

An improved method for deploying the polypropylene underlay patch of the PROLENE Hernia System

The PROLENE Hernia System (PHS) is a bilayer patch device providing an anterior approach to preperitoneal inguinal hernia repair. To provide improved expansion of the underlay patch of PHS, a modified device featuring a deploying "pocket" in the double-layered underlay graft was designed. The deploying "pocket" is flat in shape and harbors a perimeter that can act as a receiving unit for surgical force, which is exerted outward and backward to expand the underlying graft. Through a unique surgical technique using an angled metal pusher to facilitate access to intrapocket manipulation, the underlay graft not only can be fully deployed, but can be securely placed in the preperitoneal space to cover the entire myopectineal orifice. This allows effective treatment of inguinal/femoral herniation. Based on the encouraging clinical results obtained using a procedure that incorporates this strategy at our hospital, it can be concluded that this modified device/technique for PHS is one of the best inguinal/femoral hernia repair methods available.     

Sutureless coronary anastomoses: revival of old concepts.

Surgical environment is becoming increasingly challenging for the cardiac surgeon since off-pump coronary arteries bypass grafts and minimally invasive approach came up. The suture technique for coronary anastomosis construction is becoming inadequate to meet new surgeons' demand. Therefore, there is an increasing need for alternative ways to perform coronary bypasses. This article reviews the most recent devices developed for cardiac surgery (Q-Cab and distal connector from St. Jude Medical, CoreLink from Ethicon, GraftConnector from Jomed Int.), and demonstrates that the new anastomotic technologies are based on concepts expressed by Payr and other authors in the 19th century. We propose to consider three aspects to evaluate a sutureless anastomotic device: the device-vessel wall connection, the graft preparation and the anastomosis' biomechanical properties. Pins, wall eversion on an anvil and squeezing are the three systems used to anchor the connector to the graft and to the native artery. The graft preparation and anastomotic biomechanics are analysed with respect to the possibility of affecting graft patency rate. Finally, we trace the profile of the ideal anastomotic device: minimal graft manipulation, no limitation in anastomotic timing, no material in the vessel lumen and optimal anastomotic angle and compliance. The evidence of long-term graft patency is fundamental for any anastomotic device to become widely acceptable.     

Internal vascular access for hemodialysis in children weighing less than fifteen kilograms.

An arteroarterial femoral graft using expanded polytetrafluoroethylene is described which has been successfully for vascular access in young children having small peripheral vessels. This graft allows high flow and favorable patency for dialysis without the complications of arteriovenous shunting or the risks associated with an external hemodialysis device. This graft has been used successfully for outpatient dialysis in children weighing as little as 9 kg and may be a useful adjunct in long-term dialysis of patients for whom more conventional means of vascular access are not acceptable.     

Does a tensioning device pinned to the tibia improve knee anterior–posterior load‐displacement compared to manual tensioning of the graft following anterior cruciate ligament reconstruction? A cadaveric study of two tibial fixation devices

Devices that are pinned to the tibia to tension an anterior cruciate ligament (ACL) graft produce joint reaction loads that in turn can affect the maintenance of graft initial tension after tibial fixation and hence knee anterior-posterior (AP) load-displacement. However, the effect of these devices on AP load-displacement is unknown. Our objectives were to determine whether tensioning by device versus tensioning by hand causes differences in AP load-displacement and intraarticular graft tension for two commonly used tibial fixation devices: a bioresorbable interference screw and a WasherLoc. AP load-displacement and intraarticular graft tension were measured in 20 cadaveric knees using a custom arthrometer. An initial tension of 110 N was applied to a double-looped tendon graft with the knee at extension using a tensioning device pinned to the tibia and a simulated method of tensioning by hand. After inserting the tibial fixation device, the 134 N anterior limit (i.e., anterior position of the tibia with respect to the femur with a 134 N anterior force applied to the tibia) and 0 N posterior limit (i.e., AP position of the tibia relative to the femur with a 0 N force applied to the tibia) were measured with the knee in 25 degrees flexion. Intraarticular graft tension was measured at extension. These limits and intraarticular graft tension were also measured after cyclically loading the knee 300 times. Compared to a simulated method of tensioning by hand, tensioning with a device pinned to the tibia did not decrease the 134 N anterior limit and did not cause posterior tibial translation. However, intraarticular graft tension was maintained better with a tensioning device pinned to the tibia for the Washerloc, but not the interference screw. For two commonly used tibial fixation devices, a tensioning device pinned to the tibia does not improve AP load-displacement at 25 degrees flexion over tensioning by hand when the graft is tensioned at full extension, but does improve the maintenance of intraarticular graft tension for the Washerloc.     

Prediction of spinal cord ischemia with a retrievable stent graft on endovascular treatment for a case of thoracic aortic aneurysm

Multiple aortic aneurysms in Behçet’s disease were repaired with transluminaly placed endovascular stent grafts. Before deploying the stent graft device for permanent implantation for the saccular aneurysm located in the descending thoracic arota, from which feeding arteries for the spinal cord possibly branched, a retrievable stent graft was inserted and evoked spinal cord potential (ESP) were monitored in order to predict spinal cord ischemia. The original retrievable stent graft, constructed of a self-expandable Z-shaped stainless steel stent covered with e-PTFE, can be easily withdrawn into a 18 Fr. sheath after deployment. Blood flow into intercostal arteries branching from that part of the descending aorta where the permanent stent graft is planned to be implanted, is intercepted by the retrievable stent graft. A change of ESP during the temporary implantation of the device indicates that spinal cord ischemia would be caused by permanent implantation of the stent graft. In this case, no change of ESP was observed and the patient showed no postoperative paraplegia.The retrievable stent graft was useful for prediction of spinal cord ischemia before endoluminal stent graft repair of the descending aortic aneurysm. However, the device is not flexible enough to fit a severely tortuous aorta, therefore we are obliged to select patients to some extent. Further improvement of the device is required to make prediction of spinal cord ischemia with the retrievable stent graft possible in all cases.     

Hemi-replacement arthroplasty of the proximal humerus. A case report

A ten-year-old girl underwent excision of a chondrosarcoma of the right proximal humerus with subsequent insertion of a prosthesis. Failure of the device occurred six years after operation, requiring revision to an identical but shorter prosthesis. This device failed 1 1/2 years later and was replaced by a fibular graft inserted in the humeral medullary canal. The fibular graft was removed 18 months later, resulting in a flail right shoulder. The mode of failure in each instance was anterior and superior dislocation of the hemiarthroplasties. Currently, ten years after the initial procedure, the patient is tumor free with a shortened functional right upper extremity.     

A case of ostial stenosis with the PAS-Port proximal anastomosis system in off-pump coronary artery bypass grafting

The use of an automatic aortic connector device for proximal saphenous vein graft anastomoses eliminates the need for aortic clamping during off-pump coronary artery bypass grafting and may reduce the incidence of stroke in the elderly and in patients with severe aortic atherosclerosis. The PAS-Port proximal anastomotic system is a recently developed sutureless automatic saphenous vein graft anastomosis device. We used the system in thirteen patients. Overall handling, feasibility and safety of the device were satisfactory in our limited experience. However, one patient developed severe ostial and proximal graft stenosis in four months postoperative angiogram.