RESUMEN

PURPOSE: In arterial disease, the presence of two or more serial stenotic lesions is common. For mild lesions, it is difficult to predict whether their combined effect is hemodynamically significant. This study assessed the hemodynamic significance of idealized serial stenotic lesions by simulating their hemodynamic interaction in a computational flow model. MATERIALS AND METHODS: Flow was simulated with SimVascular software in 34 serial lesions, using moderate (15 mL/s) and high (30 mL/s) flow rates. Combinations of one concentric and two eccentric lesions, all 50% area reduction, were designed with variations in interstenotic distance and in relative direction of eccentricity. Fluid and fluid-structure simulations were performed to quantify the combined pressure gradient. RESULTS: At a moderate flow rate, the combined pressure gradient of two lesions ranged from 3.8 to 7.7 mmHg, which increased to a range of 12.5-24.3 mmHg for a high flow rate. Eccentricity caused an up to two-fold increase in pressure gradient relative to concentric lesions. At a high flow rate, the combined pressure gradient for serial eccentric lesions often exceeded the sum of the individual lesions. The relative direction of eccentricity altered the pressure gradient by 15-25%. The impact of flow pulsatility and wall deformability was minor. CONCLUSION: This flow simulation study revealed that lesion eccentricity is an adverse factor in the hemodynamic significance of isolated stenotic lesions and in serial stenotic lesions. Two 50% lesions that are individually non-significant can combine more often than thought to hemodynamic significance in hyperemic conditions.

Asunto(s)

Simulación por Computador , Hemodinámica , Humanos , Hemodinámica/fisiología , Modelos Cardiovasculares , Velocidad del Flujo Sanguíneo , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen

RESUMEN

We describe a patient with a fistula between small bowel and a polyester patch of the common iliac artery. After emergency treatment with an endograft, the patch was replaced by a venous patch. Within 3-week a symptomatic pseudoaneurysm developed. It was decided to embolize the pseudoaneurysm using autologous subcutaneous fat, followed by a femoro-femoral crossover bypass using an allograft. Using this technique, the pseudoaneurysm was successfully excluded. This case shows that subcutaneous fat tissue can be used as an autologous embolic material, also in larger vessel pathology and in cases of ongoing infection, where regular embolization material cannot be used.

Asunto(s)

Aneurisma Falso , Implantación de Prótesis Vascular , Humanos , Arteria Ilíaca/cirugía , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/terapia , Resultado del Tratamiento , Grasa Subcutánea/diagnóstico por imagen , Grasa Subcutánea/cirugía

RESUMEN

PURPOSE: The feasibility of using a compressed interwoven Supera stent as a flow diverting device for popliteal aneurysms was recently demonstrated in patients. It is unclear, however, what the optimal flow diverting strategy is, because of the fusiform shape of popliteal aneurysms and their exposure to triphasic flow. To assess this flow diverting strategy for popliteal aneurysms, flow profiles and thrombus formation likelihood were investigated in popliteal aneurysm models. MATERIALS AND METHODS: Six popliteal aneurysm models were created and integrated into a pulsatile flow set-up. These models covered a bent and a straight anatomy in three configurations: control, single-lined and dual-lined Supera stents. Two-dimensional flow velocities were visualized by laser particle image velocimetry. In addition, the efficacy of the stent configurations for promoting aneurysm thrombosis was assessed by simulations of residence time and platelet activation. RESULTS: On average for the two anatomies, the Supera stent led to a twofold reduction of velocities in the aneurysm for single-lined stents, and a fourfold reduction for dual-lined stents. Forward flow was optimally diverted, whereas backward flow was generally deflected into the aneurysm. The dual-lined configuration led to residence times of 15-20 s, compared to 5-15 s for the single stent configurations. Platelet activation potential was not increased by the flow diverting stents. CONCLUSION: A compressed Supera stent was successfully able to divert flow in a popliteal aneurysm phantom. A dual-lined configuration demonstrated superior hemodynamic characteristics compared to its single-lined counterpart.

Asunto(s)

Aneurisma , Arteria Poplítea , Aleaciones , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Humanos , Arteria Poplítea/diagnóstico por imagen , Diseño de Prótesis , Stents , Resultado del Tratamiento , Grado de Desobstrucción Vascular

RESUMEN

PURPOSE: The aim of this study was to investigate if non-invasive central pressure estimations are accurate in patients with an abdominal aortic aneurysm, before and after endovascular repair. Secondary evaluation was if measurement-accuracy was dependent on anatomical characteristics. METHODS: Procedural invasive and non-invasive pressure-measurements were performed simultaneously both before and after endovascular repair in 20 patients with an infrarenal abdominal aortic aneurysm. Invasive catheter measurements were performed in the abdominal aorta. A tonometric device was used to perform non-invasive pressure-wave-analysis at the radial artery. A generalized transfer-function was used to generate an ascending aortic waveform for both measurements, allowing for direct comparison. RESULTS: Pre-treatment the mean differences between methods were - 5.5 mmHg (p = .904), - 11.8 (p < .001), and - 7.2 mmHg (p = .124) for central systolic, diastolic, and mean pressure, respectively. The accuracy was dependent of aneurysm sac volume and intraluminal thrombus volume. Post-treatment limits of agreement were smaller for all pressure parameters compared to pre-treatment. The mean differences were 6.5 mmHg (p = .007), - 6.4 (p < .020), and 1.6 mmHg (p = .370) for central systolic, diastolic, and mean pressure, respectively. CONCLUSION: In untreated AAA's the accuracy of non-invasive central pressure estimation was acceptable (mean difference between 5 and 10 mmHg) when compared to invasive pressures, but dependent of AAA characteristics. After EVAR the accuracy of central pressure estimation improved (reduction of 75% of the mean difference between pre and post measurements) TRIAL REGISTRATION NUMBER: NCT03469388; 3-5-2018.

Asunto(s)

Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aorta Abdominal , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Asunto(s)

Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma Ilíaco , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/etiología , Aneurisma Ilíaco/cirugía , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/cirugía , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular

RESUMEN

OBJECTIVE/BACKGROUND: Mechanochemical endovenous ablation (MOCA) has been developed as a tumescentless technique to ablate saphenous veins and to avoid heat induced complications and post-procedural pain. The mechanism of action of MOCA is poorly understood. The present experiments were conducted to determine the effect of MOCA on vein wall injury and sclerosis in an animal model. METHODS: A total of 36 lateral saphenous veins (LSVs) were treated in 18 goats according to the human protocol. Veins from nine goats were evaluated 45 min after the procedure, while in the remaining nine, the treated veins were evaluated 6 weeks later. All treated veins were divided equally over three treatment groups: (i) MOCA, (ii) mechanical ablation without the sclerosant, and (iii) liquid sclerotherapy alone. The histological effects of treatment on the vein wall were systematically evaluated. RESULTS: The average diameter of the LSV was 4.0 ± 0.5 mm. Technical success was achieved in all but one LSV (35/36; 97%), with a median procedure time of 14 min (range 9-22 min). In the acute group, histological examination showed that mechanical ablation (alone or MOCA) induced severe injury to the endothelium in 82% but no damage to other layers of the vein wall. Mechanical ablation led to vasoconstriction. After 6 weeks follow-up, four of six MOCA treated veins were occluded. The occluded segments consisted mainly of fibrotic lesions probably evolved from organised thrombus. No occlusions were observed after sclerotherapy or mechanical treatment alone. No major complications occurred during procedures or follow-up. CONCLUSION: MOCA is associated with an increased occlusion rate compared with its separated components of mechanical ablation or sclerotherapy. The occlusion consists of cellular fibrotic material likely to be evolved from organised thrombus with fibrotic alterations to the surrounding media and adventitia. This study underlines the hypothesis that the additive use of MOCA increases the effectiveness of sclerosants alone by inducing endothelial damage and probably vasoconstriction.

Asunto(s)

Técnicas de Ablación/instrumentación , Procedimientos Endovasculares/instrumentación , Vena Safena/cirugía , Soluciones Esclerosantes/administración & dosificación , Técnicas de Ablación/efectos adversos , Animales , Endotelio Vascular/patología , Procedimientos Endovasculares/efectos adversos , Femenino , Fibrosis , Cabras , Hiperplasia , Modelos Animales , Músculo Liso Vascular/patología , Vena Safena/patología , Vena Safena/fisiopatología , Soluciones Esclerosantes/efectos adversos , Escleroterapia/efectos adversos , Factores de Tiempo , Vasoconstricción

RESUMEN

Over the years, various vascular injection products have been developed to facilitate anatomical dissections. This study aimed to compare the most commonly used vascular injection products in fresh-frozen and formalin-embalmed cadaver specimens. An overview of the properties, advantages and limitations of each substance was given, and a comparison of vascular infusion procedures in both preservation methods was made. A literature search was performed in order to identify the most commonly used vascular injection products. Acrylic paint, latex, gelatin, silicone, Araldite F and Batson's No. 17 were selected for the study. One fresh-frozen and one embalmed cadaver forearm were infused with each injection product according to a uniform protocol. The curing time, skin- and subcutaneous tissue penetration, degree of filling of the arterial tree, extravasations, consistency of the injected vessels during dissection, and the costs of each injection fluid were noted. There was a large variation between the injection fluids in processing- and curing time, colour intensity, flexibility, fragility, elasticity, strength, toxicity and costs. All fluids were suitable for infusion. The penetration of injection fluid into the skin and subcutaneous tissue was significantly better in fresh-frozen specimens (P = 0.002 and P = 0.009, respectively), with significantly smaller branches casted (P = 0.004). Vascular infusion of fresh-frozen cadaver specimens results in a significantly better filled coloured arterial tree, enabling more detail to be achieved and smaller branches casted. The biomechanical properties of fresh-frozen soft tissues are less affected compared with formalin fixation. All the injection fluids studied are suitable for vascular infusion, but their different properties ensure that certain products and procedures are more suitable for specific study purposes.

Asunto(s)

Anatomía/métodos , Vasos Sanguíneos/anatomía & histología , Cadáver , Disección , Embalsamiento , Resinas Epoxi , Antebrazo , Gelatina , Humanos , Látex , Pintura , Plásticos , Siliconas

RESUMEN

OBJECTIVE: The use of self-expanding stent grafts for treatment of popliteal artery aneurysms (PAA) is a matter of debate, although several studies have shown similar results compared with open surgery. In recent years, a new generation stent graft, with heparin-bonding technology, became available. The aim of this study is to present the results of endovascular PAA repair with heparin-bonded stent grafts. METHODS: Data on all patients with PAA treated with a heparin-bonded polytetrafluoroethylene (ePTFE) stent graft between April 2009 and March 2014 were gathered in a database and retrospectively analyzed. Data were collected from four participating hospitals. Standard follow-up consisted of clinical assessment, and duplex ultrasound at 6 weeks, 6 months, 12 months, and annually thereafter. The primary endpoint of the study was primary patency. Secondary endpoints were primary-assisted and secondary patency and limb salvage rate. RESULTS: A total of 72 PAA was treated in 70 patients. Mean age was 71.2 ± 8.5 years and 93% were male (n = 65). The majority of PAA were asymptomatic (78%). Sixteen cases (22%) had a symptomatic PAA, of which seven (44%) presented with acute ischemia. Early postoperative complications occurred in two patients (3%). Median follow-up was 13 months (range 0-63 months). Primary patency rate at 1 year was 83% and after 3 years 69%; primary assisted patency rate was 87% at 1 year and 74% after 3 years. Secondary patency rate was 88% and 76% at 1 and 3 years, respectively. There were no amputations during follow-up. CONCLUSION: Endovascular treatment of PAA with heparin-bonded stent grafts is a safe treatment option with good early and mid-term patency rates comparable with open repair using the great saphenous vein.

Asunto(s)

Prótesis Vascular , Stents Liberadores de Fármacos , Arteria Poplítea/cirugía , Injerto Vascular/métodos , Anciano , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/métodos , Femenino , Heparina/administración & dosificación , Heparina/uso terapéutico , Humanos , Masculino , Resultado del Tratamiento , Injerto Vascular/instrumentación , Grado de Desobstrucción Vascular

RESUMEN

OBJECTIVE/BACKGROUND: Aorto-bifemoral bypass remains the gold standard for treatment of aortoiliac occlusive disease (AIOD) in patients with advanced (TASC D) lesions, but has significant associated morbidity and mortality. Treatment with a unibody stent-graft positioned at the aortic bifurcation is a potential endovascular option for the treatment of AIOD. The current study examines the safety, efficacy, and early patency rates of the Endologix AFX unibody stent-graft for treatment of AIOD. METHODS: A multicenter retrospective review was conducted of patients treated exclusively for AIOD with the AFX device. Primary, assisted primary, and secondary patency rates were noted. Clinical improvement was assessed using Rutherford classification and ankle brachial index. Mean duration of follow-up was 22.2 ± 11.2 months. Ninety-one patients (56 males [62%]) were studied. RESULTS: Sixty-seven patients (74%) presented with lifestyle-limiting intermittent claudication and the remaining 24 (26%) had critical limb ischemia. Technical success was 100%. Complications included groin infection (n = 4 [4%]), groin hematoma (n = 4 [4%]), common iliac rupture (n = 4 [4%]), iliac dissection (n = 4 [4%]), and thromboembolic event (n = 3 [3%]; one femoral, one internal iliac artery, and one internal iliac with bilateral popliteal/tibial thromboemboli). Thirty-day mortality was 1% (1/91) resulting from a case of extensive pelvic thromboembolism. At 1 year, 73% of patients experienced improvement in Rutherford stage of -3 or greater compared with baseline. Nine patients (10%) required 16 secondary interventions. At all time points, primary patency rates were > 90%, assisted patency rates were > 98%, and secondary patency rates were 100%. CONCLUSION: This is the largest study to examine the use of the Endologix AFX unibody stent-graft for the treatment of AIOD. Use of the AFX stent-graft appears to be a safe and effective endovascular treatment for complex AIOD.

Asunto(s)

Enfermedades de la Aorta/cirugía , Prótesis Vascular , Arteria Ilíaca/cirugía , Stents , Injerto Vascular/métodos , Anciano , Índice Tobillo Braquial , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Extremidades/irrigación sanguínea , Femenino , Humanos , Claudicación Intermitente/etiología , Isquemia/etiología , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/instrumentación , Grado de Desobstrucción Vascular

RESUMEN

OBJECTIVE: Endovascular aortic sealing (EVAS) with the Nellix endosystem (Endologix, Irvine, CA, USA) is a new concept to treat infrarenal abdominal aortic aneurysms (AAAs). By sealing the aneurysm, potential endoleaks may be avoided. Early results of EVAS are good, but no data have been published regarding peri-procedural changes in aortoiliac anatomy. In this study, 27 consecutive patients who underwent elective EVAS repair of an AAA were reviewed. METHOD: Specific AAA (diameter, length from renal arteries to aortic bifurcation, supra- and infrarenal neck angulation, AAA volume, thrombus volume, and flow lumen volume), and iliac artery characteristics (length, angulation, location of most severe angulation with reference to the origin of the common iliac artery) were determined from pre- and post-procedural reconstructed computed tomography angiograms. RESULTS: No type I or II endoleaks were seen at 30 day follow up. Total AAA volume, suprarenal and infrarenal angulation, as well as aortic neck diameter did not change significantly post-EVAS. AAA flow lumen increased significantly (mean difference -4.4 mL, 95% CI 2.0 to -8.6 mL) and AAA thrombus volume decreased (mean difference 3.2 mL, 95% CI 2.0 to -1.1 mL). AAA length (125.7 mm vs. 123.1 mm), left common iliac artery length (57.6 mm vs. 55.3 mm), and right and left maximum iliac artery angulation (right 37.4° vs. 32.2°; left: 43.9° vs. 38.4°) were reduced significantly and the location of maximum angulation was further from the iliac artery origin post-EVAS, suggesting slight straightening of the aortoiliac anatomy. CONCLUSION: Most aortoiliac anatomic characteristics remained unchanged post-EVAS. Filling of the endobags to a pressure of 180 mmHg may lead to lost thrombus volume in some patients, probably because liquid is squeezed into lumbar or the inferior mesenteric artery. The absolute differences in pre- and post-EVAS aortoiliac lengths were small, so pre-operative sizing is accurate for determining stent length.

Asunto(s)

Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Arteria Ilíaca/cirugía , Stents , Anciano , Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/diagnóstico , Aortografía/métodos , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Masculino , Diseño de Prótesis , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

RESUMEN

OBJECTIVE: In this study the first results are presented of a new endovascular technique using covered stents to reconstruct the aortic bifurcation in patients with aortoiliac occlusive disease. With the "Covered Endovascular Reconstruction of the Aortic Bifurcation" (CERAB) technique, the anatomy and physiology of the aortic bifurcation is mimicked. MATERIAL AND METHODS: Between 2009 and March 2014, 103 patients (51 male, 52 female) suffering from obstructive lesions at the level of the aortic bifurcation were treated with CERAB in two clinics. The median age was 61 years (range 36-85 years). Lesion morphology was evaluated by CT angiography. Six TASC-II B lesions, nine TASC-II C lesions, and 88 TASC-II D lesions were treated. Follow up was a median 12 months (range 0-49 months) and consisted of clinical examination, ankle brachial indices, and duplex ultrasound examination. RESULTS: Technical success was obtained in 98 procedures (95.1%). In five cases lesions could not be recanalized. Primary patency was 87.3% at 1 year and 82.3% at 2 years, while secondary patency was 95.0% at 1 year and 95.0% at 2 years. Mean ankle brachial indices improved significantly from 0.64 ± 0.21 before to 0.91 ± 014, after the procedure (p < .001). The overall 30 day complication rate was 23.3%, including 22 minor complications and two major complications (1.9%). There was no 30 day mortality. Median hospital stay was 2 days (range 1-16 days). CONCLUSIONS: The CERAB technique appears to be a safe and feasible alternative to open surgical reconstruction of the aortic bifurcation in complex occlusive disease. Comparative studies with the current gold standards are indicated.

Asunto(s)

Aorta Abdominal/cirugía , Arteriopatías Oclusivas/cirugía , Procedimientos Endovasculares/métodos , Arteria Ilíaca/cirugía , Stents , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos

RESUMEN

BACKGROUND: Arterial insufficiency is rarely caused by isolated infrarenal aortic occlusive lesions. Endovascular treatment options include plain balloon angioplasty and bare metal stent placement. In this study the feasibility and efficacy of polytetrafluoroethylene (PTFE) covered balloon expandable stents were evaluated. MATERIAL AND METHODS: Consecutive patients from two centers were prospectively collected in a database and retrospectively analyzed. Results were evaluated by clinical examination, ankle-brachial indices (ABI), duplex ultrasound, and plain abdominal radiography. RESULTS: Thirty-six consecutive patients were treated between November 2008 and June 2013. Indication for treatment was Rutherford 3 (n = 29), 4 (n = 3), and 5 (n = 4). Technical success was always achieved and there were no distal embolizations or vessel wall ruptures. The median follow-up was 22 months (range 0-60). All patients improved clinically and the ABI increased significantly from 0.73 ± 0.18 to 1.01 ± 0.14 (p < .01). One patent covered stent was removed surgically because of infection. Primary patency rates were 100% at 1 and 2 years without stent fractures. CONCLUSION: The use of PTFE covered stents for the treatment of isolated infrarenal aortic occlusive disease is safe and very effective. Patency rates are excellent and complications including distal embolization and vessel wall rupture are extremely rare.

Asunto(s)

Aorta Abdominal/cirugía , Arteriopatías Oclusivas/cirugía , Riñón/irrigación sanguínea , Politetrafluoroetileno/uso terapéutico , Stents , Grado de Desobstrucción Vascular/fisiología , Implantación de Prótesis Vascular/métodos , Femenino , Humanos , Masculino , Politetrafluoroetileno/efectos adversos , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

AIM: Current commercially available modular stentgrafts are associated with relevant reintervention rates during follow-up. The Nellix Endovascular Aneurysm Sealing (EVAS) System is a potential device to overcome these limitations of EVAR. Device implantations outside of manufacturer instructions for use due to challenging neck anatomies are very common. This article presents very early experience in the treatment of patients with post EVAR complications and challenging neck anatomies. METHODS: EVAS with the Nellix System consists of bilateral PTFE-covered stentgrafts surrounded by endobags which are filled with biostable polymer which cures after 3-5 minutes. The device and concept is designed to seal the entire aneurysm lumen, to withstand lateral displacement forces and effectively seal lumbar or inferior mesenteric arteries. Potentially, device migration, type II endoleak, and subsequent reinterventions will be reduced in the longterm. Single case experience in four European vascular centers is reported using Nellix off-IFU (instructions for use), addressing technical aspects as well as patient selection criterias. RESULTS: Recent preliminary clinical experience using Nellix outide of the IFU in challenging neck anatomies prooves early feasibility and efficacy in patients being excluded for open repair (OR) and also for EVAR and FEVAR within OR. Short-term results are promising. Migration, renal artery occlusions or type II endoleaks were not observed. One type Ia endoleak was observed but was temporary and resolved. We also found that the chimney technique is feasible with Nellix, where secondary target vessel loss nor gutters were observed. The EVAS concept is a potential tool to treat post EVAR complications such as secondary type I endoleak or type IV material fatigue. Feasibility has been proven in single cases. CONCLUSION: EVAS is an innovative, intriguing concept in the treatment of abdominal aortic aneurysm (AAA). Short-term outcomes of the Nellix system is promising. Early experience of Nellix out of IFU when treating patients with challenging proximal infraenal necks, with post EVAR complications, short necks and chimney techniques show technical feasibility and promising short-term results. Mid- and long-term data are needed to validate device and procedure durability.

Asunto(s)

Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Endofuga/cirugía , Procedimientos Endovasculares/instrumentación , Falla de Prótesis , Stents , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Endofuga/diagnóstico , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Europa (Continente) , Estudios de Factibilidad , Femenino , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/prevención & control , Humanos , Masculino , Diseño de Prótesis , Reoperación , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

RESUMEN

Endovascular treatment of occlusive disease of the aortic bifurcation is challenging. We developed the Covered Endovascular Reconstruction of Aortic Bifurcation or CERAB-technique, as a new approach for extensive and/or recurrent aortoiliac occlusive disease using three covered balloon expandable stents to reconstruct the aortic bifurcation. This configuration provides the ability to deal with TransAtlantic Inter-Society Consensus (TASC II) C and D lesions, simulating a neo-bifurcation or flow divider in combination with the benefits of covered stents. The intervention can be performed percutaneously or as a hybrid procedure. Initial results are encouraging and further studies are indicated.

Asunto(s)

Aorta Abdominal/cirugía , Prótesis Vascular , Materiales Biocompatibles Revestidos , Procedimientos Endovasculares/métodos , Arteria Ilíaca/cirugía , Síndrome de Leriche/cirugía , Stents , Angiografía , Aorta Abdominal/diagnóstico por imagen , Humanos , Arteria Ilíaca/diagnóstico por imagen , Síndrome de Leriche/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Diseño de Prótesis

RESUMEN

OBJECTIVE: This study evaluated the feasibility, safety and 1-year results of mechanochemical endovenous ablation (MOCA™) of small saphenous vein (SSV) insufficiency. DESIGN: Prospective cohort study. MATERIALS AND METHODS: Fifty consecutive patients were treated for primary SSV insufficiency with MOCA™ using the ClariVein(®) device and polidocanol. Initial technical success, complications, patient satisfaction and visual analogue scale (VAS) pain score were assessed. Anatomic and clinical success was assessed at 6 weeks and at 1 year. RESULTS: Initial technical success of MOCA™ was 100%. At the 6-week assessment, all treated veins were occluded. The 1-year follow-up duplex showed anatomic success in 94% (95% confidence interval, 0.87-1). Venous clinical severity score (VCSS) decreased significantly from 3.0 (interquartile range (IQR) 2-5) before treatment to 1.0 (IQR 1-3, P < 0.001) at 6 weeks and to 1.0 (IQR 1-2, P < 0.001) at 1 year. Median procedural VAS score for pain was 2 (IQR 2-4). No major complications were observed, especially no nerve injury. CONCLUSIONS: MOCA™ is a safe, feasible and efficacious technique for treatment of SSV insufficiency. One-year follow-up shows a 94% anatomic success rate and no major complications.

Asunto(s)

Técnicas de Ablación/instrumentación , Vena Safena/cirugía , Ultrasonografía Doppler Dúplex/instrumentación , Insuficiencia Venosa/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Estudios Prospectivos , Vena Safena/diagnóstico por imagen , Resultado del Tratamiento , Insuficiencia Venosa/diagnóstico por imagen

RESUMEN

AIM: Results of endovascular treatment for long de novo lesions of the superficial femoral artery (SFA) are limited by in-stent restenosis (ISR). Polytetrafluoroethylene (PTFE) covered stents are developed to reduce the incidence of ISR. This study was conducted to summarize available data on the use of endoprosthesis in the treatment of SFA occlusive disease and to evaluate their use in the treatment of ISR. METHODS: A systematic literature search was performed, using MEDLINE, EMBASE and Cochrane databases. Reports on the application of Hemobahn® and Viabahn® endoprosthesis in the treatment of long de-novo lesions and ISR of the SFA were included. RESULTS: A total of 19 articles were included. Technical success rates varied between 95-100%. Case series have shown 1-year primary patency rates varying between 44% and 86%, with secondary patency rates between 58% and 93%. Large differences in patient and lesion characteristics, medical therapy and developments in stent-graft design complicate comparisons between studies. Randomized studies have shown a superiority of the endoprosthesis above angioplasty only and similar patency rates with above-knee prosthetic femoro-popliteal bypass up to 48 months. Data on the use of endografts for ISR are scarce. CONCLUSION: The use of an endoprosthesis for SFA occlusive disease is an effective and safe treatment strategy for long de novo lesions. Patient selection and adequate medical support appear to be important in achieving long term patency. Data focusing on the effectiveness of endoprosthesis for ISR are still limited.

Asunto(s)

Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular/instrumentación , Procedimientos Endovasculares/instrumentación , Arteria Femoral/cirugía , Oclusión de Injerto Vascular/cirugía , Stents , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Constricción Patológica , Procedimientos Endovasculares/efectos adversos , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Diseño de Prótesis , Radiografía , Resultado del Tratamiento , Grado de Desobstrucción Vascular

RESUMEN

OBJECTIVE: Heparin is used worldwide by vascular surgeons as prophylaxis for arterial thrombo-embolic complications during open and endovascular arterial surgery. Possible harmful effect of heparin use is more perioperative blood loss, resulting in a higher morbidity and mortality. To evaluate the evidence for the use of heparin during aorto-iliac arterial surgery a review was performed. METHODS: A systematic review was performed of literature from MEDLINE, EMBASE and Cochrane databases, last search performed on March 8, 2012. RESULTS: For open surgery for abdominal aortic aneurysm (AAA), only 5 studies were eligible for review and for endovascular aneurysm repair (EVAR) only 1 study. Overall methodological quality of the included studies was poor. One randomised trial could be retrieved. Possible harmful effects of heparin were found of increasing operation time, more blood loss and more transfusion requirements when heparin was used for open AAA surgery in one study. No data were found comparing heparin to no intervention for EVAR. One study compared heparin to a direct thrombin antagonist during EVAR, showing no differences in clinical outcomes. CONCLUSION: Despite limitations this review showed no compelling evidence on the beneficiary effect of the prophylactic perioperative use of heparin during open surgery for (r)AAA. Authors will promote a randomised controlled multi-center trial on this topic for elective open surgical repair of AAA.

Asunto(s)

Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Fibrinolíticos/uso terapéutico , Complicaciones Intraoperatorias/prevención & control , Atención Perioperativa/métodos , Tromboembolia/prevención & control , Humanos

RESUMEN

AIM: Bare metal stents have improved results of endovascular treatment of aortoiliac occlusive disease. Polytetrafluoroethylene covered stents may further improve patency rates by preventing tissue ingrowth, and might reduce complications. This study was conducted to assess possible assets or liabilities of covered stents used for aortoiliac occlusive disease and to conduct a comparison with bare metal stents. METHODS: A review was performed of literature published until March 2012 for infrarenal aortic lesions, iliac lesions and complex aortoiliac lesions. Outcomes were technical success, patency rates, clinical success and complication rates. Results were addressed to the three anatomic regions: the infrarenal aorta, the aortoiliac bifurcation and iliac arteries. RESULTS: A total of 51 articles were included in the study. Overall technical success varied between 73% and 100%. Randomized data have proven the superiority of covered stents in extensive iliac occlusive lesions. Case series of patients with iliac occlusive disease demonstrated a 1-year primary patency of bare metal stents between 76% and 100% with a 5-year primary patency rate of 63%-83%. One-year primary patency of covered stents varied between 70% and 100%, while no long term patency rates with covered stents have been reported so far. Reliable comparisons between groups cannot be made due to variances in patient and lesion characteristics. Covered stents seem to improve results of kissing stents and are related to excellent results in isolated aortic lesions. No difference in complication rate between bare metal and covered stents have been described, to date. CONCLUSION: Covered stents improve results of endovascular treatment of extensive iliac occlusive lesions and are related to excellent results in isolated aortic lesions. They may provide a valid alternative for surgery in patients with extensive aortoiliac disease.

Asunto(s)

Aorta Abdominal/cirugía , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular/métodos , Materiales Biocompatibles Revestidos , Arteria Ilíaca/cirugía , Pierna/irrigación sanguínea , Stents , Anastomosis Quirúrgica , Enfermedad Crónica , Humanos , Diseño de Prótesis

RESUMEN

Redo femoropopliteal bypass surgery is associated with increased morbidity and related to a poorer outcome than primary procedures. Endografts might provide an alternative, avoiding dissection of a previously operated groin. Patients treated with a polytetrafluoroethylene-covered stents for superficial femoral artery occlusive disease between February 2009 and September 2011 were prospectively gathered. Demographics, clinical status, procedural aspects, and follow-up were retrieved. Seventy-four patients were included of which 5 (7%) were treated before with a femoropopliteal bypass. Indication for intervention was Rutherford category 3 in all patients and the median ankle-brachial index (ABI) was 0.68. Technical success was achieved in all cases. The postoperative course was uneventful in all and the ABI increased to 0.95. After a follow-up period of 18 months, 4 of 5 endografts remained patent. The use of endografts after failed femoropopliteal bypass surgery is feasible and safe and could be used to avoid or minimize a difficult and hazardous dissection of a previously operated area.

Asunto(s)

Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Femoral/cirugía , Enfermedad Arterial Periférica/cirugía , Arteria Poplítea/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Índice Tobillo Braquial , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Constricción Patológica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Países Bajos , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Politetrafluoroetileno , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Estudios Prospectivos , Diseño de Prótesis , Radiografía , Reoperación , Stents , Factores de Tiempo , Insuficiencia del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos

RESUMEN

Treatment modalities for extensive chronic occlusive disease of the superficial femoral artery (SFA) have changed during the last decades. In this chapter we provide an overview of current treatment modalities for extensive chronic occlusive disease of the SFA. Although the autologous venous conduit is still considered the gold standard for treatment of long occlusive SFA lesions, endoluminal therapy is gaining territory. Its' minimal invasive character has great advantages in the frail vascular patient population. Percutaneous transluminal angioplasty is first choice in short SFA lesions, but patency rates decrease with longer lesions. When percutaneous transluminal angioplasty is combined with nitinol stent placement patency rates significantly improve. Patency rates of percutaneous transluminal angioplasty combined with covered stents are within reach of patency rates of prosthetic surgical bypasses. Drug-bonding in surgical PTFE bypasses increased patency rates significantly. In the near future drug-eluting and drug-bonded devices might further increase results of endovascular treatment.

Asunto(s)

Angioplastia de Balón/métodos , Arteriopatías Oclusivas/terapia , Implantación de Prótesis Vascular/métodos , Stents Liberadores de Fármacos , Arteria Femoral , Inhibidores de Agregación Plaquetaria/uso terapéutico , Guías de Práctica Clínica como Asunto , Angiografía , Arteriopatías Oclusivas/diagnóstico por imagen , Enfermedad Crónica , Humanos , Diseño de Prótesis , Índice de Severidad de la Enfermedad