Comparison of the Snare Loop Technique and the Hungaroring Reinforcement for Physician-Modified Endograft Fenestrations-An In Vitro Study

BACKGROUND

We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation.

MATERIALS AND METHODS

The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration.

RESULTS

Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010-1090) compared to 760 s (IQR:685-784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8-27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3-20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm.

CONCLUSION

Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.

The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses-a randomized controlled trial

Background

Air embolism is a known risk during thoracic endovascular aortic repair (TEVAR) and is associated with an incomplete deairing of the delivery system despite the saline lavage recommended by the instructions for use (IFU). As the delivery systems are identical and residual air remains frequently in the abdominal aortic aneurysm sac, endovascular aortic repair (EVAR) can be used to examine the effectiveness of deairing maneuvers. We aimed to evaluate whether increasing the flush volume can result in a more complete deairing.

Methods

Patients undergoing EVAR were randomly assigned according to flushing volume (Group A, 1× IFU; Group B, 4× IFU). The Terumo Aortic Anaconda and Treo and Cook Zenith Alpha Abdominal stent grafts were randomly implanted in equal distribution (10-10-10). The quantity of air trapped in the aneurysm sac was measured using a pre-discharge computed tomography angiography (CTA). Thirty patients were enrolled and equally distributed between the two groups, with no differences observed in any demographic or anatomical factors.

Results

The presence of air was less frequent in Group A compared to that in Group B [7 (47%) vs. 13 (87%), p = .02], and the air volume was less in Group A compared to that in Group B (103.5 ± 210.4 vs. 175.5 ± 175.0 mm3, p = .04). Additionally, the volume of trapped air was higher with the Anaconda graft type (p = .025).

Discussion

These findings suggest that increased flushing volume is associated with a higher amount of trapped air; thus, following the IFU might be associated with a reduced risk of air embolization. Furthermore, significant differences were identified between devices in terms of the amount of trapped air.

Clinical trial registration

[NCT04909190], [ClinicalTrials.gov].

[Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]

Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.

[Complex endovascular repairs of the aortic arch.]

Thoracic endovascular aneurysm repair (TEVAR) of the aortic arch has started to spread in recent years. We present our initial experience with TEVAR involving supra-aortic branches using parallel and branched grafts. Parallel grafts are typically used in emergency cases. In the case of Z0 proximal fixation, we can perform a combined hybrid surgery with Z1 debranching and securing of the innominate artery with chimney graft, which can also be used instead of Z0 debranching when the patient is unfit for sternotomy. In the case of TEVAR with planned Z2 position with inadvertent covering of the left common carotid artery, we can perform chimney conversion to rapidly recover the circulation of the left common carotid artery (LCCA). Instead of prior revascularization of the left subclavian artery, chimney graft can be used to recover the lumen, in the case of left upper limb ischemia after Z2 TEVAR. Exclusion of penetrating aortic ulcers located in the lesser curvature can be facilitated by use of a custom-made graft, where a scallop is placed around the origin of the supra-aortic vessel, thus increasing the length of the proximal neck. For elective interventions, custom-made branching grafts can be allowed to save all three branches with Z0 fixation. Technical success was obtained in all cases. Orv Hetil. 2023; 164(11): 426-431.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

BACKGROUND

Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS.

METHODS

A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up.

RESULTS

There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04).

CONCLUSION

The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

The prognostic value of serum MMP-7 levels in prostate cancer patients who received docetaxel, abiraterone, or enzalutamide therapy

OBJECTIVES

The rapidly changing treatment landscape in metastatic castration-resistant prostate cancer (mCRPC) calls for biomarkers to guide treatment decisions. We recently identified MMP-7 as a potential serum marker for the prediction of response and survival in mCRPC patients who received docetaxel (DOC) chemotherapy. Here, we aimed to test this finding in an independent patient cohort and in addition to explore the prognostic potential of serum MMP-7 in abiraterone (ABI) or enzalutamide (ENZA) treated patients.

METHODS AND MATERIALS

MMP-7 levels were measured in 836 serum samples from 320 mCRPC patients collected before and during DOC (n = 95), ABI (n = 140), or ENZA (n = 85) treatment by using the ELISA method. Results were correlated with clinical and follow-up data.

RESULTS

MMP-7 baseline levels were similar between the 3 treatment groups. In the ABI and ENZA cohorts, baseline MMP-7 levels were lower in patients with prior radical prostatectomy (P = 0.058 and P = 0.041, respectively). Baseline MMP-7 levels above the median were associated with shorter overall survival for the DOC (P = 0.001) and ENZA (P = 0.006) cohorts. Multivariable analyses in the DOC and ENZA cohorts revealed that high pretreatment MMP-7 level is an independent risk factor for patients' survival. In addition, in DOC-treated patients with high baseline MMP-7 level, marker decrease at the third DOC cycle was associated with improved survival. Patients with high baseline MMP-7 levels had better survival when treated with ABI compared to DOC or ENZA.

CONCLUSIONS

We confirmed the prognostic value of pretreatment MMP-7 serum level and its changes as independent predictors of survival in DOC-treated mCRPC patients. In addition, high MMP-7 was a negative predictor in ENZA-treated but not in ABI-treated patients. These results warrant further research to confirm the predictive value of serum MMP-7 and to explore the potential mechanistic involvement of MMP-7 in DOC and ENZA resistance of mCRPC patients.

The presence of long and heavily calcified lesions predisposes for fracture in patients undergoing stenting of the first part of the subclavian artery

OBJECTIVE

To determine the prevalence and risk factors of subclavian artery stent fractures and to investigate their impact on in-stent restenosis development.

METHODS

One hundred eight patients (65 females; median age, 58.3 years [interquartile range, 53.4-65.5 years]) with steno-occlusive disease of the first part of the subclavian artery who underwent stenting (N = 108 stents; balloon-expandable, 83.3%; self-expandable, 16.7%) between 2005 and 2015 and returned for a fluoroscopic examination of the implanted stents in 2017 were included in our study. Fractures were type I (single strut fracture), type II (multiple strut fractures without deformation), type III (multiple strut fractures with deformation), type IV (multiple strut fractures with acquired transection but without gap), or type V (multiple strut fractures with acquired transection with gap in the stent body). Stent patency was monitored by duplex ultrasound imaging. The Mann-Whitney U and Fisher's exact tests; Kaplan-Meier, receiver operating characteristic, and logistic regression analyses; as well as a log-rank test were used as statistical methods.

RESULTS

The median follow-up was 73.8 months (interquartile range, 35.6-104.2 months). Thirty-eight fractures (35.2%) were detected; fractures were type I in 13, type II in 12, type III in 6, type IV in 4, and type V in 3 cases. Multivariable logistic regression analysis revealed the presence of long (≥20 mm) lesions (odds ratio, 3.3; 95% confidence interval, 1.3-8.4; P = .012) and heavy calcification (odds ratio, 4.7; 95% confidence interval, 1.7-12.7; P = .002) to be significant independent predictors of stent fracture. The primary patency rates were significantly worse (P = .035) in patients with stent fracture compared with those without stent fracture.

CONCLUSIONS

Stent fractures frequently occur. Patients with long and/or heavily calcified lesions require closer follow-up.

Stent Protrusion >20 mm Into the Aorta: A New Predictor for Restenosis After Kissing Stent Reconstruction of the Aortoiliac Bifurcation

Purpose: To determine the long-term patency of aortoiliac kissing stents and to identify predisposing factors for the development of in-stent restenosis (ISR). Methods: A retrospective analysis was conducted of 105 patients (median age 60.9 years; 64 women) with symptomatic aortoiliac occlusive disease who had kissing stents implanted between 2001 and 2015. The indication for kissing stents was severe claudication in 91 (86.7%) patients and critical limb ischemia in 14 (13.3%). Lesions were TASC A in 52 (49.5%), B in 29 (27.6%), C in 4 (3.8%), and D in 20 (19%) patients. Twenty-five (23.8%) patients had heavily calcified lesions. In all, 210 stents were deployed [180 (85.7%) self-expanding and 30 (14.3%) balloon-expandable]. Follow-up included clinical evaluation, ankle-brachial index measurement, and duplex ultrasonography. Results: The median follow-up was 45 months. The primary patency rates were 93%, 86%, and 77% at 12, 24, and 60 months, respectively. Significant ISR developed in 23 (21.9%) patients (12 unilateral and 11 bilateral). Univariate Cox regression analysis revealed older age [hazard ratio (HR) 0.5, 95% confidence interval (CI) 0.31 to 0.81, p=0.004] and larger aortic diameter (HR 0.42, 95% CI 0.25 to 0.7, p<0.001) to be variables favoring long-term patency, while a longer aortic stent segment (HR 1.56, 95% CI 1.16 to 2.09, p=0.003) and a larger discrepancy between the summed stent diameters and the aortic diameter (HR 1.64, 95% CI 1.01 to 2.65, p=0.043) were associated with ISR development. Multivariate analysis showed a longer aortic stent segment to be the only significant determinant of ISR (HR 1.44, 95% CI 1.02 to 2.01, p=0.035). Conclusion: The kissing stent technique can be performed with good long-term patency. Patients whose iliac stents protrude too far into the aorta need closer follow-up.