RESUMO
PURPOSE: To evaluate the safety and performance of Wrapsody™, a cell-impermeable endoprosthesis (CIE), for treating hemodialysis vascular access outflow stenosis. MATERIALS AND METHODS: Investigators retrospectively analyzed 113 hemodialysis patients treated with a CIE (11/2021-12/2022) across four centers in Brazil. De novo or restenotic lesions were treated. The primary efficacy outcome measure was target lesion primary patency (TLPP) at 1, 3, 6, and 12 months; the primary safety outcome measure was the absence of serious local or systemic adverse events within the first 30 days post-procedure. Secondary outcome measures included technical and procedural success, access circuit primary patency (ACPP), and secondary patency at 1, 3, 6, and 12 months post-procedure. RESULTS: Thirty-nine patients (34.5%) had thrombosed access at the initial presentation, and 38 patients (33.6%) presented with recurrent stenosis. TLPP rates at 1, 3, 6, and 12 months were 100%, 96.4%, 86.4%, and 69.7%, respectively. ACPP rates were 100% at 1 month, 89.2% at 3 months, 70.9% at 6 months, and 56.0% at 12 months. The target lesion secondary patency rates at 1, 3, 6, and 12 months were 100%, 97.3%, 93.6%, and 91.7%, respectively. In the adjusted multivariate Cox regression analysis, male sex and endoprosthesis with diameters of 10, 12, 14, and 16 mm were associated with improved primary patency rates. No localized or systemic serious adverse event was observed through the first 30 days post-procedure. CONCLUSION: The CIE evaluated in this study is safe and effective for treating peripheral and central outflow stenoses in hemodialysis vascular access. LEVEL OF EVIDENCE: Level 2b, cohort study.
Assuntos
Oclusão de Enxerto Vascular , Diálise Renal , Grau de Desobstrução Vascular , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Brasil , Idoso , Oclusão de Enxerto Vascular/terapia , Constrição Patológica , Resultado do Tratamento , Derivação Arteriovenosa Cirúrgica , Prótese Vascular , AdultoRESUMO
BACKGROUND: Vascular stenosis commonly leads to dysfunction in hemodialysis vascular access. Although percutaneous transluminal angioplasty is an established treatment, stent utilization has increased in the last decade as an alternative solution to extend the access function. This study evaluated the safety and initial results of a new impermeable covered stent for treating vascular access outflow stenosis. METHODS: Investigators retrospectively analyzed 114 hemodialysis patients treated with polytetrafluorethylene-covered stents from September 2018 to September 2022 across four centers. Lesions treated were de novo or restenotic and located in the venous graft anastomosis, outflow segment, cephalic arch, and basilic swing point. Patients were followed by in-person physical examination at 1, 3, and 6 months, and Duplex ultrasound was performed to evaluate the vascular access circuit and in-stent restenosis. The primary efficacy endpoint was target lesion primary patency at 1, 3, and 6 months. Secondary endpoints included access circuit primary patency and secondary patency at 1, 3, and 6 months. The primary safety endpoint was freedom from local or systemic serious adverse events through 30 days post-procedure. RESULTS: Forty-four patients had thrombosed access at the initial presentation, and 41 patients presented with recurrent stenosis. The target lesion primary patency rates at 1, 3, and 6 months were 100%, 89.4%, and 74%, respectively. The access circuit primary patency rates were 100% at 1 month, 85% at 3 months, and 62.7% at 6 months. The secondary patency rates at 1, 3, and 6 months were 100%, 96.4%, and 94.6%, respectively. In the adjusted multivariate Cox regression analysis, only recurrent lesions and female gender were associated with reduced primary patency rates. No serious adverse event was observed through the first 30 days post-procedure. CONCLUSION: In this retrospective analysis, a new covered stent was shown to be safe and effective for treating peripheral outflow stenosis in vascular access.
RESUMO
PURPOSE: To demonstrate the feasibility of the modification to preserve intercostal arteries of the t-Branch Endograft (Cook Medical, Bloomington, IN) in an urgent setting, associated with a less invasive approach for branch incorporation from percutaneous femoral access with steerable sheaths. TECHNIQUE: A 73-year-old female patient presented at our institution with intense abdominal pain. Angiotomography showed a 50-mm juxtarenal aortic aneurysm, with no signs of rupture. Urgent endovascular repair was indicated due to abdominal symptom with an off-the-shelf multi-branched endograft. To limit descending thoracic aortic coverage, we performed t-Branch modification to preserve intercostal arteries and minimize the risk of spinal cord injury, associated with a percutaneous transfemoral approach and branch incorporation with steerable sheaths to avoid the risks associated with a superior axillary or brachial access. Control angiotomography showed adequate aneurysm sac exclusion with patency of all four visceral vessels. CONCLUSION: t-Branch-modified endograft to limit aortic coverage is an alternative option in urgent cases to diminish the risk of spinal cord injury, and association of steerable sheaths with branch incorporation is leading complex aortic repairs to an even less invasive procedure. CLINICAL IMPACT: This paper highlights the possibility of performing complex endovascular aortic repair in an urgent setting with modification of an off-the-shelf multi branched endograft limiting intercostal arteries coverage, thereby diminishing the risk of spinal cord ischemia. This technical innovation provides an alternative for clinicians when treating large, rapidly expanding, or symptomatic juxtarenal, pararenal, paravisceral or type 4 thoracoabdominal aortic aneurysms that could not wait for a custom-made device and do not need extensive thoracic aortic coverage that an off-the-shelf device provides. In summary, expand the possibilities of an endovascular repair of complex aortic aneurysms.
RESUMO
Current guidelines and regulatory parameters for cardiothoracic surgery in the United States establish that open surgery is the first front line for treating ascending thoracic aortic aneurysms (ATAA). Despite advances in performing endovascular procedures in thoracic aortic aneurysms, there are no approved state-of-the-art techniques that allow endovascular procedures to be performed in ATAA. Thus, thoracic endovascular aortic repair (TEVAR) of the ascending aorta, as we will demonstrate, is a useful and effective technical opportunity for treating high-risk patients with type A dissections, intramural hematomas, and pseudoaneurysms. In this case, an 88-year-old female patient was consulted due to a preliminary diagnosed descending thoracic aortic aneurysm. As a result of uncertainty regarding the initial diagnosis, abdominal-pelvic and chest computed tomography scan tests contradicted the original conclusion and surprisingly yielded a different scenario; in fact, the patient had a dissected ATAA. Using the TEVAR procedure, the patient's ATAA was treated with a thoracic GORE TAG endograft stent (W. L. Gore & Associates, Inc., Newark, DE, USA). Four weeks later, the aneurysm was completely thrombosed, and the stent-graft was properly in place.
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Feminino , Humanos , Idoso de 80 Anos ou mais , Prótese Vascular , Implante de Prótese Vascular/métodos , Resultado do Tratamento , Stents , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/etiologia , Procedimentos Endovasculares/métodos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Desenho de PróteseRESUMO
Pseudoaneurysm and arteriovenous fistula can occur after iatrogenic trauma or penetrating injuries. Endovascular treatment is a minimally invasive method used to manage these complex vascular injuries. We have described the case of a 27-year-old male patient who had presented with progressively increasing pain and swelling of the left inguinal region after a gunshot injury 5 years earlier. The bell-bottom technique was used in a reversed fashion to exclude the pseudoaneurysm and treat the arteriovenous fistula, achieving symptom resolution without complications.
RESUMO
OBJECTIVES: The Iliac Sandwich is an off-label technique that uses parallel stent grafts to treat aortoiliac aneurysms. The purpose of this experimental study is to evaluate the conformability and juxtaposition of stent grafts combinations used in this technique through in-vitro mechanical evaluation, computed tomography (CT) analyses, and a controlled pulsatile flow system. METHODS: The combinations of two Viabahn® ("V-V") or Viabahn® and Excluder® iliac extension ("V-E") were analysed using CT imaging with measurement of the gutter area by two independent analysts before and after balloon angioplasty. In a second phase, the parallel stent combinations were also evaluated using CT imaging after being implanted in the aortic aneurysm model with a pulsatile flow system with controlled temperature, viscosity, and density. RESULTS: The "V-E" group had a better conformability when compared to the "V-V" group, ensuring smaller gutter areas (0.0064 cm2 ± 0.01 vs. 0.0228 cm2 ± 0.03, p < 0.001). Post dilatation with two non-compliant balloons resulted in enlargement of the gutter area (Area A, p 0.065; Area B, p 0.071). Conversely, post dilatation with a non-compliant balloon for the internal iliac component and a compliant balloon for the external iliac device reduced the gutter area (Area A, p 0.008; Area B, p 0.010). CONCLUSION: The combination of Viabahn® and Excluder® iliac extension device ("V-E") had a smaller gutter area compared to two Viabahn® parallel stents for the Iliac Sandwich Technique. Post dilatation using a non-compliant balloon for the internal iliac device and a compliant balloon for the external iliac provided superior conformability and juxtaposition.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma Ilíaco , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Humanos , Aneurisma Ilíaco/cirurgia , Desenho de Prótese , Stents , Resultado do TratamentoRESUMO
Endovascular aneurysm repair has dramatically changed the management of abdominal aortic aneurysms as an alternative to open repair. However, complications can occur, including stent graft migration, kinking, and occlusion, leading to compromise of the excluded aneurysm walls and acute limb ischemia. In the present report, we have described a case of migration and kinking of an abdominal aortic stent graft in the main body that led to occlusion of the abdominal aorta and bilateral acute limb ischemia. The patient required emergent explantation of the stent graft and open repair of the abdominal aneurysm with a rifampin-soaked Dacron graft, which achieved a favorable outcome.
RESUMO
PURPOSE: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair. TECHNIQUE: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization. CONCLUSION: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Prótese Vascular , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Toracotomia , Resultado do Tratamento , Stents , Desenho de PróteseRESUMO
BACKGROUND: Proximal aortic neck dilatation (PND) affects a considerable proportion of patients undergoing endovascular aneurysm repair (EVAR) and is associated with increased rates of type I endoleak (EL1), migration, and reinterventions. Although there are numerous studies investigating PND following the placement of endografts that utilize self-expanding stent (SES) technology, there are few reports for patients treated with endografts that utilize polymer-filled rings. The purpose of this study is to examine PND and graft migration after EVAR with the Ovation stent graft. METHODS: The study comprised patients who underwent EVAR as part of the prospective, international, multicenter Ovation stent graft trial. A clinical events committee adjudicated adverse events through 1 year, an independent imaging core laboratory analyzed imaging through 5 years, and a data safety and monitoring board provided study oversight. Neck diameter was measured at the level of the lowest renal artery. PND was defined as neck enlargement of 3 mm or more. Graft migration was defined as distal movement >10 mm or movement ≤10 mm when resulting in secondary intervention. RESULTS: A total of 238 patients received this device during the study period. Patients were predominantly male (81%), with a mean age of 73 ± 8 years. Median follow-up was 58 months (IQR 36-60). Almost half the patients (110 patients, 46%) had challenging anatomy; defined as outside the instructions for use (IFU) with other commercially available stent grafts. 41 patients (17.2%) had a proximal neck length <10 mm and 93 (39%) had a minimum access vessel diameter <6 mm. The technical success rate was 100%. The 1-, 3- and 5-year overall survival rates were 96.6%, 86.2% and 74.9%, respectively. The immediate postoperative proximal neck diameter ranged from 16 mm to 31 mm with a mean of 22.4 ± 3 mm. During follow-up, ten patients (4.2%) developed PND. Freedom from PND estimates at 1, 3 and 5 years were 97.7%, 96%, and 93.6%, respectively. None of the patients developed endograft migration. CONCLUSIONS: The use of the Ovation stent graft was associated with low rates of PND despite challenging neck anatomy in 17% of patients. No graft migration was observed. The design of this endograft may explain its superiority to SES in preventing neck dilatation and migration even in patients with challenging neck anatomy. This is important, as we continue to see significant late failures of EVAR due to proximal neck degeneration.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Migração de Corpo Estranho/prevenção & controle , Polímeros , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Implante de Prótese Vascular/efeitos adversos , Chile , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Alemanha , Humanos , Masculino , Intervalo Livre de Progressão , Estudos Prospectivos , Desenho de Prótese , Falha de Prótese , Fatores de Risco , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Endovascular treatment in trauma is a promising strategy to reduce perioperative morbidity and mortality. We report the case of a gunshot wound causing an initially undiagnosed subclavian artery injury, with delayed progression to a complex, difficult-to-manage arteriovenous (AV) fistula. Placement of an encapsulated endovascular stent graft resolved the primary lesion, but persistent cervical arteriovenous communications were only repaired after multiple, sequential embolization procedures. REPORT: A 25-year-old male sustained a gunshot wound to the right neck. Initial treatment failed to identify any vascular injury, and the patient was discharged. Three weeks later, he presented to our facility with headache and a palpable right-sided cervical thrill. Arteriography showed contrast extravasation from the right subclavian artery and an AV fistula with the ipsilateral internal jugular vein. The arterial injury was repaired with an encapsulated stent graft, but residual contrast leak persisted on follow-up angiography. Three months after the first intervention, cervical thrill was still present; a right vertebral-right internal jugular AV fistula was identified and repaired by distal coil embolization. One month later, persistent symptoms prompted repeat arteriography, which again identified contrast extravasation, now involving the thyrocervical trunk. Selective thyrocervical embolization was ultimately successful, with resolution of symptoms and no further evidence of contrast leak. CONCLUSION: Delayed management of neck trauma can be challenging due to neovascularization, which hinders open repair in this delicate region. Post-traumatic arteriovenous fistulas are thus a particularly fearsome complication, and can be very difficult to approach; as in our patient, multiple interventions may be required. This case highlights the importance of detecting vascular trauma as early as possible, as a delay in diagnosis can hinder treatment and eventuate challenging late complications. Further studies are needed to demonstrate the long-term benefits of endovascular management of complex vascular injuries of the neck region.
RESUMO
Purpose: To demonstrate an off-the-shelf multibranched (t-Branch) modification to allow intercostal arteries preservation during juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aortic aneurysm repair. Technique: The t-Branch is an off-the-shelf device not customized for specific patient anatomy and may be offered for urgent endovascular repair for patients with complex aortic aneurysms. However, a concern when treating patients who do not aneurysms extending above the celiac axis is that the more proximal extension which is required with this device may render patients at high risk for spinal cord injury. We report a novel technique with t-Branch modification performing a 180° fabric back windows at the first 2 sealing stents that allow perfusion to the intercostal arteries. Conclusion: T-Branch-PIA (preserving intercostal arteries) modification limits intercostal arteries coverage while optimizing proximal seal zone in juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aneurysms, thereby may decrease the risk of spinal cord injury.
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aorta Torácica , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Desenho de Prótese , Stents , Resultado do TratamentoRESUMO
PURPOSE: This technical note aims to show a challenging endovascular treatment approach of a giant and tortuous ruptured popliteal artery aneurism. MATERIALS AND METHODS: An 86-year-old male patient was admitted for acute lower right limb ischemia. Angio-MSCT showed highly calcified superficial femoral artery, with a 180° bend in distal portion, followed by a large popliteal aneurism (63 × 61 mm) with a large extent hematoma (142 × 112 × 104 mm). Endovascular approach was chosen due to high morbidity. RESULTS: Anterior puncture of right superficial femoral artery was performed under ultrasound guidance. Despite various intents, the 0.035 hydrophilic coated wire could not be crossed distally through the aneurism. Retrograde access was performed via tibio-peroneal trunk under fluoroscopic guidance with a micropuncture set. A stiff 0.035â³ Glidewire® was successfully advanced into the proximal portion of the aneurism through a 5F vertebral catheter externalized with a snare from the femoral sheath obtaining a "through-and-through wire" technique. Tightening of both ends of the wire helped gain support and straightened curves. Two stent grafts were implanted with no residual leak at 1 month follow-up. CONCLUSION: Anterograde and retrograde approach was useful to perform a through-and-through wire technique in a challenging case of a tortuous ruptured popliteal artery aneurism.
Assuntos
Aneurisma Roto/terapia , Cateterismo Periférico , Procedimentos Endovasculares , Artéria Poplítea , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico por imagem , Cateterismo Periférico/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Artéria Poplítea/diagnóstico por imagem , Resultado do Tratamento , Dispositivos de Acesso VascularRESUMO
BACKGROUND: Although endovascular treatment of the thoracic aorta (TEVAR) has become an elective procedure for treatment of complicated type B aortic dissection, its role in treating post dissection thoraco-abdominal aortic aneurysm (TAAA), is still limited. This is a case of aortic vascular disease, which reports the use of a new endovascular device. CASE PRESENTATION: We present the case of a 62 year old male patient with a history of hypertension, active smoker, who presented penetrating descending thoracic aortic ulcer in the setting of a chronic abdominal aortic dissection. The patient was treated using a new stent graft capable of in situ fenestration that allowed crossing the stent-graft membrane, implanting a covered stent to exclude the re-entry at the level of the left renal artery and redirecting the blood flow through the true lumen. CONCLUSIONS: This case report demonstrates the feasibility of a novel stent-graft concept. Larger studies with longer follow-up are essential to fully evaluate the safety and effectiveness of this new design.
RESUMO
Postendarterectomy carotid pseudoaneurysms are infrequent. The endovascular treatment is less invasive, with a minor risk of complications. However, the presence of a highly angulated aortic arch (type III) is a challenge, since the navigation of endovascular devices is not favorable. Through transcervical access, it is possible to deliver the devices directly into the carotid artery. We herein present a case of a postendarterectomy carotid pseudoaneurysm in a patient with type III aortic arch that was successfully treated with transcervical endograft exclusion.
Assuntos
Falso Aneurisma/cirurgia , Aorta Torácica/anormalidades , Implante de Prótese Vascular , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Procedimentos Endovasculares , Idoso de 80 Anos ou mais , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Desenho de Prótese , Resultado do TratamentoRESUMO
The ascending aorta and arch have until recently been one of the last bastions of cardiovascular surgery, where life-threatening diseases impose the need for prompt correction and reversal of the impending adverse prognosis. Though a disease where dogmatic recommendations prevail, with upfront surgical intervention in the mind of every physician, type A acute aortic dissection (AAD) is a subject still blurred with many uncertainties. Endovascular intervention for the treatment of type A AAD is rapidly progressing and utilization of transcatheter therapies in the ascending aorta for treating type A AAD has demonstrated technical success in small studies, low early mortality rates, and relatively acceptable aorta-related mortality rates in the long term. These findings strengthen the preponderant role of the endovascular heart surgeon in the management of these procedures, where a combination of wire skill training and surgical proficiency encompassing all technical options available makes it distinctive and resourceful, which provides complete resolution to each multicomponent of this disease in one setting, besides the promptness to repair the inherent complications that will accompany these interventions. Transcatheter procedures and open surgery will coexist side by side and be regarded as complementary rather than competing. Substantial more refinement and technological innovation will be necessary before endovascular repair of type A AAD comes to widespread use, the ideal timespan for cardiovascular surgeons to be involved, and prepared to take on the challenges of leading this new enterprise.
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aorta/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Complicações Pós-Operatórias/cirurgia , StentsRESUMO
A ruptured abdominal aortic aneurysm after endovascular aneurysm repair with an arteriovenous fistula between the aneurysm sac and a retroaortic left renal vein is an extremely rare complication. This case describes an 81-year-old man who developed an aorto-left renal vein fistula owing to a type IB endoleak 2 years after endovascular aneurysm exclusion. The leak was repaired with a left endograft limb extension. Endovascular techniques are attractive and feasible alternatives and can play an essential role in reinterventions. This report is the first of an aorto-left renal vein fistula owing a type IB endoleak after an endovascular aneurysm repair.
RESUMO
Second-generation stent-grafts (SGs) have addressed many of the mechanical problems reported for first-generation endoprostheses, such as graft tear and stent rupture; however, suture wear and detachment due to pulsatile fatigue remains an issue. Numerical studies on the mechanical behavior of these endoprostheses usually model the attachment between stents and graft as a continuous ''tie'' constraint, which does not provide information on the mechanical loads acting on individual sutures. This paper presents a suitable approach for Finite Element (FE) simulations of SGs which allows for a qualitative evaluation of the loads acting on sutures. Attachment between stents and graft is modeled as rigid beams at discrete locations of the endoprostheses, and the reaction forces on the beams are analyzed. This modeling strategy is employed for four different SG models (two Z-stented commercial models and two circular-stented models) subjected to a severe 180° U-bend, followed by intraluminal pressurization. Results show that, for all models, the majority of sutures is experiencing fluctuating forces within a cardiac cycle (between 80 and 120 mmHg), which points to pulsatile fatigue as potential failure mode. In addition, the highest loads are concentrated in kinks and, for Z-stented models, at the apexes of stents. Moreover, suture loads for circular-stented models are lower than for Z-stented models, indicating better resistance to suture detachment. All these observations are in line with experimental results published in the literature, and, therefore, the procedure herein proposed may serve as a valuable tool in the development of new SG models with better suture resistance to pulsatile wear and fatigue.
Assuntos
Prótese Vascular , Stents , Fenômenos Mecânicos , SuturasRESUMO
Multivisceral transplantation is a life-saving treatment for many chronically ill patients with advanced abdominal pathologies. For such transplants, a complex arterial reconstruction is required, with numerous anastomoses on a composite donor graft and the native aorta. In these patients, anastomotic disruption or pseudoaneurysm formation, often in the setting of infection, are deadly complications. Open surgical repair is hazardous, because many of these patients have dense adhesions. Reported cases of disruption at the aortic anastomosis to date have resulted in patient demise. We report the case of a pediatric multivisceral transplant recipient with ruptured aortic pseudoaneurysm. He underwent an emergent endovascular parallel stent grafting technique, which successfully controlled bleeding and maintained graft perfusion.
RESUMO
Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Desenho de Prótese , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Brasil , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Ureteroarterial fistula (UAF) is a rare and life-threatening source of hematuria. A high index of suspicion is warranted for early diagnosis and timely intervention. Because of high perioperative risk and comorbidities in UAF patients, the endovascular approach has become preferred for repair. Infection can complicate this mode of therapy, and treatment with antibiotics is important. Herein we present five cases of secondary UAFs treated with stent graft alone or stent graft and embolization.