RESUMEN
Thoracoabdominal aneurysms pose technical challenges for endovascular repair due to involvement of visceral and renal vessels. We report a case series of four patients diagnosed with thoracoabdominal aneurysm who underwent complex endovascular repair with Fenestrated Device and chimney grafts (FEVARCh). FEVARCh is a technically feasible approach for repair of thoracoabdominal aneurysms that involve renal, superior mesenteric, and celiac arteries for patients not appropriate for open surgical repair. Further studies are needed to understand the implications of resultant Type 1a endoleaks and strategies to minimize the displacement of the main body graft with adjunct chimneys.
Asunto(s)
Aneurisma de la Aorta Abdominal , Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Stents , Resultado del TratamientoRESUMEN
OBJECTIVES: We aim to describe real-world outcomes from multicenter data about the efficacy of adjunct Heli-FX EndoAnchor usage in preventing or repairing failures during infrarenal endovascular aneurysm repair (EVAR), so-called EndoSutured-aneurysm-repair (ESAR). METHODS: The current study has been assigned an identifier (NCT04100499) at the US National Library of Medicine (https://ClinicalTrials.gov). It is an observational retrospective study of prospectively collected data from seven vascular surgery departments between June 2010 and December 2019. Patients included in the ANCHOR registry were excluded from this analysis. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each center's practice. Follow-up imaging was scheduled according to each center's protocol, which necessarily included either abdominal ultrasound or radiography or computed tomographic scan imaging. The main outcomes analyzed were technical success, freedom from type Ia endoleaks (IaEL), all-cause and aneurysm-related mortality, and sac variation and trends evaluated for those with at least six months imaging follow-up. RESULTS: Two hundred and seventy-five patients underwent ESAR in participating centers during the study period. After exclusions, 221 patients (184 males, 37 females, mean age 75 ± 8.3 years) were finally included for analysis. Median follow-up for the cohort was 27 (interquartile range 12-48) months. A median 6 (interquartile range 3) EndoAnchors were deployed at ESAR, 175 (79%) procedures were primary and 46 (21%) revision cases, 40 associated with type IaEL. Technical success at operation (initial), 30-day, and overall success were 89, 95.5, and 96.8%, respectively; the 30-day success was higher due to those with subsequent spontaneous proximal endoleak seal. At two years, freedom from type IaEL was 94% for the whole series; 96% and 86% for the primary and revision groups, respectively; whereas freedom from all-cause mortality, aneurysm-related mortality, and reintervention was 89%, 98%, and 87%, respectively. Sac evolution pre-ESAR was 66 ± 15.1 vs. post ESAR 61 ± 17.5 (p < 0.001) and for 180 patients with at least six-month follow-up, 92.2% of them being in a stable (51%) or regression (41%) situation. CONCLUSIONS: This real-world registry demonstrates that adjunct EndoAnchor usage at EVAR achieves high rates of freedom from type IaEL at mid-term including in a high number of patients with hostile neck anatomy, with positive trends in sac-size evolution. Further data with longer follow-up may help to establish EndoAnchor usage as a routine adjunct to EVAR, especially in hostile necks.
Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Médicos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/prevención & control , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Masculino , Perú , Sistema de Registros , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Identifying fragile aortas that are more likely to lead to adverse clinical outcomes would provide surgeons with a better sense of how to balance the risks of surgical versus medical management in patients with type B dissections. We examine the progression of a type B dissection into a type A dissection in a patient and analyze changes in the Gaussian surface curvature distribution, as well as the response of the stress distribution at the lesser curve in response to pressurization. We hypothesize that examining the Gaussian curvature will provide us with a link between aortic surface geometry and the stress distribution, which is crucial to understanding the process driving aortic dissection. METHODS: Computed tomography scans of a patient before and after the type A dissection are obtained. These are segmented in Simpleware ScanIP. Centerline curvatures are calculated on segmented models in ScanIP. Models are then pressurized in the finite element analysis software Abaqus. The Gaussian curvature is calculated by exporting segmentations into the computational program Matlab and applying a modified previously published algorithm. RESULTS: The centerlines generated in ScanIP fail to capture the change in the acuity of the lesser curve before and after the type A dissection. Instead, Gaussian curvature analysis shows that the curvature distribution before the type A dissection is much wider compared with the distribution after the type A dissection. In addition, analyzing the stress distribution in response to pressurization reveals that before the type A dissection there is a large divergence in the principal stress vectors at the lesser curve but this transitions to a more uniform hoop stress after the type A dissection. CONCLUSIONS: Our analysis demonstrates that Gaussian surface curvature analysis captures changes in aortic geometry that are otherwise silent in centerline curvature analysis. Here, we show that as the aorta develops a type A dissection it is able to more smoothly handle the hoop stress at the lesser curve compared with the stress focusing seen in the before type A geometry. We propose that the geometric focusing before type A creates a higher energy stress state, which is relaxed on retrograde dissection. Thus, Gaussian curvature analysis may provide a window to capture underlying geometric instability in type B dissections.
Asunto(s)
Algoritmos , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Aortografía , Angiografía por Tomografía Computarizada , Imagenología Tridimensional , Interpretación de Imagen Radiográfica Asistida por Computador , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/fisiopatología , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/fisiopatología , Análisis de Elementos Finitos , Humanos , Masculino , Modelos Cardiovasculares , Modelación Específica para el Paciente , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Estudios de Casos Únicos como AsuntoRESUMEN
BACKGROUND: The Atrium iCAST balloon expandable stent is the traditional choice of stent for chimney and fenestrated endovascular aneurysm repair (ChEVAR and FEVAR respectively). Due to the iCAST's lack of flexibility, the Gore Viabahn balloon-expandable stent (VBX; W. L. Gore & Associates, Inc., Newark, DE, USA) has arisen as a flexible alternative for parallel or branch graft placement during complex EVAR. Our purpose was to analyze patients' outcomes after undergoing ChEVAR or FEVAR using VBX or iCAST stents with the major outcome of assessing stent graft patency. The secondary outcome was residual aneurysm sac behavior. METHODS: We retrospectively reviewed patients who were treated by ChEVAR or FEVAR with placement of iCAST or VBX stents from July 2012 to August 2018. Patients received follow-up CT scan and/or aortic duplex imaging. RESULTS: We examined 53 cases (70% ChEVAR and 30% FEVAR) with 15.6 months (0-76.5 months) mean follow-up period. Placement of stents included renal (65 iCAST and 38 VBX), superior mesenteric (12 iCAST and 13 VBX), celiac (4 iCAST and 5 VBX), and iliac arteries (1 iCAST and 5 VBX). A total of 143 stents (57% iCAST and 43% VBX) were successfully deployed with 100% initial patency. Follow-up patency was similar for both stent types (100% VBX vs 98.7% iCAST). VBX and iCAST had the same follow-up Type 1a endoleak occurrence (9%). Average aneurysm sac sizes for iCAST decreased more than VBX (9% iCAST and 4% VBX, P=0.21), however, the iCAST group had longer follow-up. CONCLUSIONS: Our experience demonstrates that the use of VBX stents for ChEVAR and FEVAR is a safe and effective alternative to iCAST stents with excellent mid-term patency without a negative impact on endoleak frequency.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Procedimientos Endovasculares/instrumentación , Stents Metálicos Autoexpandibles , Anciano , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Femenino , Humanos , Masculino , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler Dúplex , Grado de Desobstrucción VascularRESUMEN
We report the successful endovascular repair of a rare case of aortic rupture caused by axillary intra-aortic balloon pump (IABP) insertion failure. A 38-year-old Jehovah's Witness female with situs inversus totalis was referred to our hospital for acute decompensated heart failure. We placed an axillary IABP for circulatory support. However, an exchange was required due to balloon malfunction (kinked driveline). Unfortunately, the exchange was complicated by an iatrogenic aortic rupture along with a large hematoma compressing the trachea. Emergent endovascular repair was performed successfully without any blood transfusion. Postoperative computed tomography showed a successfully repaired aorta and resolving hematoma.