Thoracic Stent Grafts with a Distal Fenestration for the Celiac Axis

Descending thoracic aneurysms can be treated with a stent graft provided that there is sufficient proximal and distal aortic neck length above the celiac axis. One of the options for the treatment of thoracic aneurysms with a too short distal neck is described in this report. For this purpose, a stent graft was constructed with a scallop for the celiac axis. Three cases are presented, and the technical details are described.

Emergency Endovascular Stent Grafting for Thoracic Aortic Pathology

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease.

From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm ( n = 13), pseudoaneurysm ( n = 6), aortic rupture ( n = 5), type B dissection ( n = 5), aortobronchial or aortoesophageal fistula ( n = 4), and intramural hematoma ( n = 1).

The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures.

The mean follow-up was 31 ± 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections.

Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft.

Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.

Circumference as an alternative for diameter measurement in endovascular aneurysm repair

Appropriate sizing of endografts for endovascular aneurysm repair has traditionally been performed by one standardized method. By measuring the average of the minor and major axes in the sealing zone, the endograft size is traditionally calculated. However, no adequate scientific evaluation has been performed to validate this method. The guidelines that were published are based on theories and experience, more than scientific evidence. In case the central lumen line artery cross-section is a circular disk, the vessel diameter is a reliable estimation. Yet the aortic neck cross-section may not always be geometrically a perfect circular disk. Application of the standardized method might therefore lead to inaccurate endograft sizing, potentially leading to endoleaks. We hypothesize that in these cases the circumference of the vessel is a mathematically correct reference to deduct the appropriate endograft diameter. The following formula was applied in this study: diameter of the corresponding circle (d) equals circumference (C) divided by πd=Cπ. This study provides a theoretical analysis of the mathematical implications of this method. Only in case of highly irregularly shaped cylinders, the circumference-based method was more accurate than the standardized method. Nonetheless, the circumferential method was a practical reference in case the aortic neck was irregularly shaped. Also, the circumference method was accurate in all cases in deducting the diameter of a matching circle. Therefore, the hypothesis that was raised in this study has a strong theoretical base. We predict that in case this hypothesis holds true in the clinical practice, application of the circumference method might lead to less endoleaks than the standardized method.

Suprarenal fixation resulting in intestinal ischemia after endovascular aortic aneurysm repair

Endovascular aneurysm repair (EVAR) may be associated with specific stent- and procedure-related complications. Hepatic artery anatomic variability may lead to dramatic consequences when unanticipated. A 64-year-old man presented with a 6-cm abdominal aortic aneurysm, suitable for an EVAR procedure. The EVAR procedure was uneventful and the patient was discharged after 2 days. After 2 weeks, he was readmitted for recurrent upper abdominal pain due to acute cholecystitis. The postoperative EVAR computed tomography scan was revisited and the suprarenal bare-metal stent of the Zenith device overlapped the highly calcified origin of both the superior mesenteric artery (SMA) and the celiac trunk. Moreover, the patient appeared to have a right replaced hepatic artery originating from the SMA. He developed diffuse, patchy ischemia of both the large and the entire small bowel, and quickly became unresponsive to vasopressor drugs. He died shortly thereafter. An EVAR procedure may result in a highly complicated course when hepatic artery anatomic variability is present. Fenestrated EVAR or proximal graft scallops should be considered for cases in which the proximal sealing zone is diseased and flow to visceral vessels is compromised.

Iliac branched device implantation in tortuous iliac anatomy after previous open ruptured aortic aneurysm repair

The aim of this paper was to present iliac branched device (IBD) implantation in a fit 67-year-old man with tortuous iliac anatomy after previous emergent open abdominal aortic aneurysm (AAA) repair. The patient underwent open treatment for a ruptured abdominal aortic aneurysm in another hospital. The procedure was complicated by extreme blood loss which prevented concommitant treatment of two large iliac aneurysms. Later, the patient underwent stent-grafting of a right common iliac artery aneurysm (CIAA) with coil embolization of the internal iliac artery (IIA). He was then refferred to our institute for treatment of the left CIAA with preservation of the left IIA. An IBD was used to this purpose. The introduction system was inserted over a through-and-through wire, and the bridging stent-graft via a left axillary approach. An Excluder leg was used to mate the IBD with the surgical graft limb. Additional self-expanding stents were needed to keep the limbs of the surgical graft open. One year later the patient is doing well, without buttock claudication, and the aneurysm is well excluded. With challenging anatomy, endovascular repair with an IBD may require additional technical tricks but also back-up materials to achieve success.

B-cell lymphoma related iliac vein occlusion treated by endovenous stent placement

Unilateral leg swelling is most often caused by deep vein thrombosis but other conditions may mimic this disorder. We describe the case of a patient with symptoms of unilateral lower extremity swelling caused by external compression of the iliac vein by a mass originating from the iliopsoas muscle. Initially this mass was diagnosed as an iliopsoas hematoma in a patient using anticoagulants. However, it proved to be B-cell non-Hodgkin lymphoma. Compression was relieved by placement of an endovenous stent in the left common iliac vein. Endovenous stenting is a relatively new treatment modality that is used to treat post-thrombotic venous occlusions and chronic venous insufficiency. Only a few case series have been described of stenting of compressed pelvic veins by adjacent structures such as gynecological malignancies. Although stent patency lasted only four weeks in this patient, venous stent placement quickly reliefs symptoms and should therefore be considered as an option to bridge time to allow development of sufficient venous collaterals.

Torsion of the gallbladder

INTRODUCTION

A 77-year-old woman was seen with progressive abdominal pain.

CASES

A CT scan was made and showed a large gallbladder extending into the right lower abdomen. Ultrasound was performed but demonstrated no gallstones. Laparoscopy showed a tordated, necrotic gallbladder that was attached to the liver only by the cystic artery and cystic duct. Cholecystectomy was performed.

CONCLUSIONS

Torsion of the gallbladder is a rare but clinically important condition in which the diagnosis seldom is made preoperatively. In radiological and clinical signs of cholecystitis without gallstones, this condition should be considered.

A new interventional technique for percutaneous treatment of drainage-resistant liver abscess

The objective of this case report is to describe a device that can be used as a minimally invasive alternative for the treatment of drainage-resistant liver abscess. The device uses pulse lavage to fragment and evacuate the semi-solid contents of a liver abscess. The treatment of liver abscesses consists of percutaneous drainage, antibiotics and treatment of the underlying cause. This approach can be ineffective if the contents of the abscess cavity are not liquid, and in those cases open surgery is often needed. Here, we describe for the first time a new minimally invasive technique for treating persistent liver abscesses. A patient developed a liver abscess after a hepatico-jejunostomy performed as a palliative treatment for an unresectable pancreatic head carcinoma. Simple drainage by a percutaneously placed pig-tail catheter was insufficient because of inadequate removal of the contents of the abscess cavity. After dilatation of the drain tract the persistent semi-solid necrotic contents were fragmented by a pulsed lavage device, after which the abscess healed uneventfully. The application of pulsed lavage for debridement of drainage-resistant liver abscesses proved to be an effective and minimally invasive alternative to open surgery.

Accuracy of FDG-PET-CT in the diagnostic work-up of vascular prosthetic graft infection

OBJECTIVES

To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET-CT in diagnosing vascular prosthetic graft infection.

DESIGN

Prospective cohort study with retrospective analysis.

MATERIALS

Twenty five patients with clinically suspected vascular prosthetic infection underwent CT and FDG-PET scanning.

METHODS

Two nuclear medicine physicians assessed the FDG-PET scans; all CT scans were assessed by two radiologists. Fused FDG-PET/CT were judged by the radiologist and the nuclear medicine physician. The concordance between CT and FDG-PET and the inter-observer agreement between the different readers were investigated.

RESULTS

Fifteen patients had a proven infection by culture. Single FDG-PET had the best results (sensitivity 93%, specificity 70%, positive predictive value 82% and negative predictive value 88%). For CT, these values were 56%, 57%, 60% and 58%, respectively. Fused CT and FDG-PET imaging also showed high sensitivity and specificity rates and high positive and negative values. Inter-observer agreement for FDG-PET analysis was excellent (kappa = 1.00) and moderate for CT and fused FDG-PET-CT analysis (0.63 and 0.66, respectively).

CONCLUSION

FDG-PET scanning showed a better diagnostic accuracy than CT for the detection of vascular prosthetic infection. This study suggests that FDG-PET provides a useful tool in the work-up for diagnosis of vascular prosthetic graft infection.

Fenestrated stent-grafting after previous endovascular abdominal aortic aneurysm repair

AIM

The aim of this study was to present their experience and highlight the technical difficulties associated with the use of fenestrated stent-grafts to treat juxta and pararenal abdominal aortic aneurysms (AAA) in patients having undergone a previous infrarenal endovascular aneurysm repair (EVAR).

METHODS

A prospectively held database maintained at the University Medical Center of Groningen including 162 patients who have undergone branched and fenestrated stent-grafting for AAA, was queried for patients treated with this technology after previous EVAR. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality and morbidity were evaluated.

RESULTS

A total of 9 patients underwent repair with a fenestrated endograft after previous EVAR. All patients had aneurysmal degeneration of the juxta- and pararenal aorta not suitable to standard endovascular techniques. We encountered various intraoperative complications including iliac and renal artery access problems, intraoperative previous graft migration, and dislocation of previous graft limb. In one patient, immediate conversion was needed because a twisted graft limb prevented retrieval of the top cap of the fenestrated graft. The remaining eight patients were successfully treated by endovascular means. For these patients, target vessel success rate was 100% (20/20) and mean hospital stay 6.0 days (range 3-12 days). Thirty-day and one-year mortality were 0%. Mean follow up was 31 months (range 1-76 months). No aneurysm related death occurred during follow-up.

CONCLUSION

Fenestrated endovascular stent-grafts can be used to repair juxta- and pararenal AAA after previous EVAR. However, several technical challenges have to be overcome due to the presence of a previous stent-graft.

Results of endovascular abdominal aortic aneurysm repair with selective use of the Gore Excluder

AIM

To evaluate single center results with selective use of the Gore Excluder stent-graft for elective abdominal aortic aneurysm repair.

METHODS

Retrospective analysis of a prospective data base. Primary endpoints were technical success, all-cause and aneurysm-related mortality and aneurysm rupture. Secondary endpoints were late complications including migration, endoleak, aneurysm growth, limb occlusion, and re-intervention.

RESULTS

The Gore Excluder stent-graft was used in 92 elective cases, mainly in cases with difficult iliac anatomy. There were 81 (88%) male patients. Mean age was 70.4+/-7.5 (range, 53-87). Primary assisted technical success rate was 98.9% (91/92 patients). Thirty-day mortality was 0%. Median follow-up was 35.7 months (range, 2-99). Overall survival was 95.2+/-2.4% at 1 year, 89.2+/-3.7% at 2 years, 83.9+/-4.5% at 3 years and 70.2+/-6.8% at 5 years. During follow-up there were 3 (3.3%) Type I endoleaks and 20 (21.7%) Type II endoleaks. Proximal migration of more than 5 mm without endoleak occurred in two patients. In total 13 re-interventions were performed in 12 (13%) patients. No graft limb occlusion occurred. No aneurysm ruptured during follow-up.

CONCLUSIONS

Selective use of the Gore Excluder demonstrates excellent short- and long-term results. Despite being used in challenging iliac anatomy no graft limbs occluded.

The role of branched endografts in preserving internal iliac arteries

AIM

The aim of this study was to report our treatment algorithm and early results with the use of an iliac branched device (IBD) to preserve the internal iliac artery (IIA) in the treatment of aortoiliac and solitary common iliac artery (CIA) aneurysms.

METHODS

From September 2004 on, all patients with aorto-iliac aneurysms with a suitable proximal neck or CIA aneurysms were evaluated. Selection for treatment with an IBD was done based on activity level of the patient and anatomical criteria of the aneurysm. Absolute exclusion criteria included aneurysmal IIA, severe atherosclerosis of the IIA, and small residual CIA lumen. Patients who were at risk of losing one out of two patent IIA were only considered for IBD if they were physically active. Follow-up was performed with computed tomography scanning at six weeks and one year, and thereafter yearly.

RESULTS

Fifty-nine patients (39 aorto-iliac, 20 CIA) were evaluated for treatment with an IBD. Seven patients were not considered for IBD for low activity level. Twenty-five patients were not suitable because of adverse anatomy. In total, 27 patients (20 aorto-iliac, 7 CIA) were treated with 30 IBDs. Technical success was achieved in 96.3% of patients. There was no 30-day mortality. Mean follow-up period was 16+/-14 months. In three patients the IIA side branch occluded, resulting in buttock claudication in only one patient. No external iliac artery occlusion or device component disconnection was observed.

CONCLUSIONS

An IBD provides a totally endovascular option to preserve the IIA in selected aortoiliac and isolated CIA aneurysms. Anatomical application rate for the use of an IBD was 52.5% in our series. Further studies are needed to determine the indications for use of this device.

Radiofrequency ablation of hepatic metastases from thyroid carcinoma

BACKGROUND

Radiofrequency ablation (RFA) is performed for various types of liver tumors. It might also have a role in the palliative treatment of liver metastases from thyroid carcinoma.

SUMMARY

Three patients with liver metastases of thyroid carcinoma were retrieved from our database of 125 patients who had been treated with RFA for liver tumors. In all three patients, the metastases were a sign of widespread disease, and several other treatment modalities had been performed earlier. Two patients had metastases from medullary thyroid carcinoma and had severe diarrhea. The third patient had a rapidly progressive metastasis of a follicular thyroid carcinoma. The aim of the treatment was cytoreduction with amelioration of symptoms (n = 2) and debulking with increased sensitivity for subsequent (131)I treatment. The ablation was performed via laparotomy (n = 1), laparoscopically (n = 1), or percutaneously (n = 1). One patient experienced superficial burn wounds after a long-lasting RFA procedure. Severity of symptoms was reduced significantly after RFA for a prolonged period of time. RFA induced partial tumor necrosis because of hypervascularization of the tumor in one patient. After arterial embolization the second RFA treatment induced total tumor necrosis. Local recurrences at the site of the ablated liver metastases were not encountered during follow-up.

CONCLUSIONS

RFA is a useful treatment modality in patients with liver metastases from thyroid carcinoma. It should be considered an adjunct to other types of treatment or for those patients in whom more regular treatment modalities are not effective or possible or are associated with increased risks.

Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?

AIM

Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort.

METHODS

Between June 1998 and February 2007, 73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel.

RESULTS

Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016).

CONCLUSION

Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.

Treatment of a ruptured thoracoabdominal aneurysm with a stent-graft covering the celiac axis

PURPOSE

To present a case of successful emergency endovascular repair of a ruptured, probably mycotic, thoracoabdominal aortic aneurysm (TAAA) with a stent-graft deliberately covering the celiac axis.

CASE REPORT

A 79-year-old woman with significant pulmonary comorbidity presented with a ruptured mycotic TAAA extending to the celiac axis. The aneurysm was excluded with a stent-graft soaked in rifampicin and deployed to deliberately occlude the celiac axis for effective distal sealing and fixation. The patient recovered well and was prescribed antibiotic treatment for up to 6 months.

CONCLUSION

Endovascular repair of a ruptured TAAA may be a life-saving option. In emergency situations when poor distal anatomy is present, covering the celiac artery with the stent-graft should be considered.

Fenestrated and Branched Stent-grafting After Previous Surgery Provides a Good Alternative to Open Redo Surgery

OBJECTIVE

To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak.

METHODS

Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n=4), suprarenal aneurysm after open AAA (n=4), distal type I endoleak after endovascular TAA (n=1), proximal anastomotic aneurysm after open AAA (n=1), and an aborted open AAA repair due to bleeding around a short infrarenal neck.

RESULTS

The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period.

CONCLUSIONS

Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.

Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up?

OBJECTIVE

The study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions.

METHODS

Between May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions.

RESULTS

Mortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 +/- 26 months. In the ruptured aneurysm group, survival was 67.8% +/- 8.6% at 1 year and 62.1% +/- 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% +/- 5.1% at 1 year and 16.2% +/- 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% +/- 6.1% at 1 year, 84.8% +/- 8.2% at 2 years, and 76.4% +/- 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% +/- 6.5% at 1 and 2 years and 20.9% +/- 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% +/- 1.2% at 1 year, 89.9% +/- 1.8% at 2 years, and 86.2% +/- 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% +/- 1.1% at 1 year, 7.6% +/- 1.6% at 2 years, and 12.9% +/- 2.2% at 3 years.

CONCLUSIONS

To our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up.

Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts

PURPOSE

The technique of fenestrated and branched endovascular aneurysm repair (EVAR) has been used for the treatment a variety of aortic aneurysms. Although technically successful, longer-term results have been lacking. This article reports on the mid-term results of aneurysm repair with fenestrated and branched endografts from a European center with a large endovascular experience.

METHODS

Between 2001 and 2005, 38 patients were prospectively enrolled in a single institution, investigational device protocol database. Indications for fenestrated or branched EVAR included unfavorable anatomy for traditional EVAR and an abdominal aortic aneurysm >5.5 cm in maximum diameter. Customized stent-grafts were either fenestrated or branched and based on the Zenith system. Data were analyzed on an intention-to-treat basis. Differences between groups were determined using analysis of variance with P < .05 considered significant.

RESULTS

The mean (SD) follow-up was 25.8 +/- 12.7 months (median, 25.0 months; range, 9 to 46 months), and no patients were lost to follow-up. All cause mortality was 13% (5/38), with all deaths occurring within the first postoperative year; 30-day mortality was 2.6%. No patient died during the operation. Completion angiography demonstrated successful sealing in 37 of 38 patients and an overall operative visceral vessel perfusion rate of 94% (82/87). Cumulative visceral branch patency was 92% at 46 months. Stent occlusions, when they did occur, all happened within the first postoperative year. All postoperative occlusions occurred in unstented fenestrations or scallops. No occlusions occurred in stented vessels. The difference in serum creatinine preoperatively and postoperatively at 6 months, 1, 2, and 3 years was not significant (P = NS). No patient required dialysis. The aneurysm sac size decreased significantly during the first year and then remained stable (P < .05). Limb perfusion as assessed by the ankle/brachial index was not affected by the presence of a fenestrated or branched endograft.

CONCLUSIONS

The intermediate-term results of fenestrated and branched endografts support their continued use in patients with anatomic contraindications for standard EVAR. Close surveillance is mandatory for early identification of visceral or branched vessel stenosis and preocclusion. All cases of failure appear to occur during the first year and then level off in subsequent longer-term follow-up. This includes death, secondary interventions, branch vessel patency, and complications. As the procedure matures, long-term results and randomized clinical trials will ultimately be required to determine the safety, efficacy, and stability of this system.

The Cook Zenith endovascular graft

From its early release in 1994, the Zenith endovascular graft presented with a more complex but very controlled deployment mechanism. It was loaded into small and flexible introduction systems. The main difference with most early grafts was the intended suprarenal fixation with a bare stent including hooks and barbs. This suprarenal fixation proved to be both safe and efficient. Several improvements were made over the years, resulting in the Zenith Tri-Fab stent-graft. Major advantages of the Tri-Fab include availability of stock products and the versatility with regard to distal diameter and lengths. Finally, the Zenith graft acted as the platform in the development of fenestrated and branched grafts.

Fenestrated and branched stent-grafting: a 5-years experience

Fenestrated stent-grafts aim at treating short-necked aneurysms. As a result of customized fenestrations, patency of vital side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft over these aortic side branches. Over the years, the technique has been refined. Results in a few experienced centers are good, with excellent patency rates of targeted side branches. Suprarenal and thoraco-abdominal aneurysms can only be treated by endovascular means with branched grafts. This can be achieved with fenestrated grafts, but with the use of covered stents through the fenestrations, or by fully branched grafts. Both options are feasible and present with specific advantages and disadvantages. This report gives an overview of our 5-years experience with fenestrated and branched grafts, and discusses the following aspects of the technique: indications, technical principles, results, and limitations.

Endovascular treatment of iliac artery aneurysms with a tubular stent-graft: mid-term results

OBJECTIVE

To report the mid term results of a prospective cohort of iliac artery aneurysms (IAAs) treated with endovascular tubular stent-grafts.

METHODS

All IAAs referred to the University Medical Center Groningen between June 1998 and June 2005 were evaluated for endovascular repair. Criteria for repair were a diameter of > or = 30 mm for anastomotic aneurysms and > or = 35 mm for true aneurysms. Preferentially, tubular grafts were used. Follow-up included both radiographs of the abdomen and duplex examination.

RESULTS

In 35 patients, 40 IAAs were treated endovascularly with a tubular stent-graft. Elective repair was performed in 30 patients (86%) and emergent repair in five patients (14%). Aneurysms were false in 26 cases (65%) and true in 14 cases (35%). Local anesthesia was used in 74% of the cases. The stent-grafts that were used included the Excluder contralateral limb (n = 28, 70%), Passager (n = 9, 22.5%), Hemobahn (n = 2, 5%), and Wallgraft (n = 1, 2.5%). The mean operation time was 83 +/- 28 minutes (range, 50 to 150 minutes). Mean hospital stay was 3.3 +/- 2.3 days (range, 1 to 12 days). There was no 30-day mortality. Patients were followed up for a mean of 31.2 +/- 20.7 months (range, 3 to 83 months). Complications occurred in two patients during follow-up, including migration with a proximal type I endoleak in one, and occlusion of the stent-graft in the other. The internal iliac artery was intentionally sacrificed in 28 patients (70%), and this led to gluteal claudication in three patients.

CONCLUSION

Endovascular repair of iliac artery aneurysms with flexible stent-grafts is a minimally invasive technique and is associated with low mortality and morbidity. Follow-up results up to 5 years suggest that the technique is durable. It should be regarded as a first choice treatment option for suitable aneurysms.

Abdominal angina in patients with a midgut carcinoid, a sign of severe pathology

In 36 consecutive patients with a foregut carcinoid with extensive local tumor growth and liver metastases with a carcinoid syndrome, six patients had complaints of postprandial abdominal pain and attacks of subileus based on segmental intestinal ischemia. A diagnosis of abdominal angina was supported by a positive response to nitroglycerin in two and ischemia of the ileum demonstrated by angiography in two other patients. Complaints were reduced in all patients after surgery. Histopathology of the resected small bowel specimens showed elastic vascular sclerosis in three patients and ischemic changes in three other patients, confirming the clinical diagnosis. Resection of ischemic bowel can provide relief in patients with segmental intestinal ischemia caused by carcinoid-induced vascular sclerosis.

Local anesthesia for endovascular abdominal aortic aneurysm repair

OBJECTIVES

This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications.

METHODS

All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation).

RESULTS

A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001).

CONCLUSIONS

A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.

Endovascular Treatment of Acute Abdominal Aortic Aneurysm with a Bifurcated Stentgraft

OBJECTIVES

To analyse the results of emergency endovascular aneurysm repair (eEVAR) for acute abdominal aortic aneurysms (AAA), in comparison to open repair, and to evaluate suitability and application rate.

PATIENTS AND METHODS

All patients treated for an acute AAA between January 1998 and August 2004 were included. The primary outcome measure was in-hospital mortality. Secondary outcome measures were procedure time, intra-operative blood loss, transfusion requirement, intensive care unit, and hospital length of stay. Suitability and application rate for eEVAR were assessed in a subgroup of patients, from January 2003.

RESULTS

A total of 253 patients were treated. eEVAR was performed in 40 patients, 5 (13%) died in-hospital. Open repair was performed in 213 patients, 64 (30%) died in-hospital. Secondary outcome measures were all significantly improved in the eEVAR subgroup. From January 2003, 56 patients were treated. Of the 44 (79%) patients who were evaluated for eEVAR, 16 (36%) patients were anatomically suitable. Eventually, 15 out of the 56 (27%) patients were treated by eEVAR.

CONCLUSION

The results of eEVAR in a selected group of patients are promising, but suitability and application rate were low.

Fenestrated and branched endovascular techniques for thoraco-abdominal aneurysm repair

Since 1991, endovascular aortic aneurysm repair (EVAR) has been established as an alternative for open surgical repair of aortic aneurysms. One of the main limitations for EVAR is the need for a sufficient sealing zone below or above vital aortic side branches. Recently, efforts have been made to overcome these limitations by incorporating fenestrations or branches in customized stent-grafts. This paper reviews the technical and clinical possibilities, as well as the results with fenestrated and branched stent-grafts. All these techniques can be classified into 6 groups, including abdominal fenestrated, abdominal branched, thoraco-abdominal fenestrated, thoraco-abdominal branched, thoracic fenestrated, and thoracic branched stent-grafting. The only well-elaborated technique at this moment is abdominal fenestrated stent-grafting. Currently, branched stent-grafting must be regarded as experimental, but advancements are taking place rapidly. It is anticipated that wider adoption will take place in the near future. New developments include the further use of reinforced fenestrations, indwelling catheters and flexor sheaths, as well as the use of new type branches.

Frequency and Outcome of Re-interventions after Endovascular Repair for Abdominal Aortic Aneurysm: A Prospective Cohort Study

PURPOSE

To describe frequency, type, and outcome of re-intervention after endovascular aortic aneurysm repair (EVAR).

METHODS

Between September 1996 and December 2003, 308 patients were treated, with data collected prospectively. No patient was lost to follow up, but two were excluded (one primary conversion, and one post-operative death). Vanguard, Talent, Excluder, Zenith, and Quantum devices were used. Follow up required a CT scan before discharge. Initially, a CT scan was done at each follow up. Subsequently, we used duplex ultrasound and abdominal X-ray, with CT scan used selectively.

RESULTS

Mean follow-up was 36+/-22 months. Re-interventions were required in 47 (15%) patients, 31 (66%) elective and 16 (34%) emergency cases. In 32 patients, the primary re-intervention was successful; in 15 patients an additional 13 secondary and four tertiary re-interventions were required. A total of 72 adjunctive manoeuvres were performed: 49 endovascular (68%) and 23 open (32%). The success of endovascular re-interventions was 80%. The success of open re-interventions was 96%. Open conversions were required in nine patients (3%). There was no mortality.

CONCLUSION

EVAR was associated with a low burden of re-interventions, with only 15% patients requiring re-intervention. Our long-term follow up, without regular CT, was simple and effective.

[Massive haemoptysis: primary care, diagnosis and treatment]

Massive haemoptysis is life-threatening because of asphyxiation from flooding of the central airways with blood. The first step in treatment includes airway protection, usually managed by intubation. Imaging may be inconclusive, and bronchoscopy--rigid or flexible--is essential to establish the site and cause of the bleeding. Bronchoscopy may be therapeutic in that a balloon catheter may be inserted in the bleeding airway in order to tamponade the source of bleeding. Embolisation of pathological bronchial arterial vessels is the treatment of choice in most cases; surgery is limited to causes that cannot be managed by the endovascular treatment modality, or to cases that fail to respond to embolisation.

Treatment of short-necked infrarenal aortic aneurysms with fenestrated stent-grafts: short-term results

INTRODUCTION

A proximal neck of 15 mm length is usually required to allow endovascular repair of abdominal aortic aneurysms (EVAR). Many patients have been refused EVAR due to a short neck. By customising fenestrated grafts to the patients' anatomy, we can offer an endovascular solution, especially for patients who are unsuitable for open repair.

METHODS

Eighteen patients were selected for fenestrated stent-grafting if they presented with an abdominal aneurysm of at least 55 mm in diameter, a short neck (less than 15 mm), plus contra-indications for open repair (cardiopulmonary impairment or a hostile abdomen). The stent-graft used was a customised fenestrated model based on the Cook Zenith composite system. We used additional stents to ensure apposition of the fenestrations with the side branches.

RESULTS

All endovascular procedures were successful. Out of the 46 targeted side branches (10 superior mesenteric arteries, 36 renal arteries), 45 were patent at the end of the procedure. One accessory renal artery became occluded by the stent-graft. There was one possible proximal type I endoleak, which later proved to be a type II endoleak. There was no mortality, but complications occurred in six patients: two cardiac complications, three urinary complications and one occlusion of a renal artery. At follow-up (mean 9.4 months, range 1-18), there were no additional renal complications and all the remaining targeted vessels stayed patent.

DISCUSSION

By customizing fenestrated stent-grafts, it is possible to position the first covered stent completely inside the proximal neck, thus achieving a more stable position. The additional side-stents may also contribute to a better fixation. This technique may become a valuable alternative for patients who are at high risk from open surgery.

Treatment of popliteal artery aneurysms with the Hemobahn stent-graft

PURPOSE

To report a prospective study to ascertain the results of popliteal aneurysm treatment with a self-expanding stent-graft.

METHODS

In a recent 3-year period, 21 patients (18 men; median age 67 years, range 52-82) with 23 popliteal aneurysms were treated with Hemobahn stent-grafts. Follow-up evaluation included duplex scanning, ankle-brachial index (ABI) measurements, and radiographic examination of the knee. Outcome measures were occlusion of the stent-graft and limb loss.

RESULTS

Technical success in placing the stent-graft and excluding the aneurysm was 100%. An additional vascular intervention was performed in the same session in 5 (24%) cases. In the other 16 patients, local anesthesia was used in 10 (63%). During a median follow-up of 15 months (range 2-37), 5 (22%) of 23 stent-grafts occluded, resulting in a cumulative patency of 74%. All occlusions occurred within 6 months after the intervention; 2 were successfully recanalized, and none of the 3 patients with persisting occlusion required an amputation.

CONCLUSIONS

The results of this study suggest that endovascular stent-graft repair of popliteal artery aneurysms is feasible. Midterm patency rates are lower compared to traditional surgical repair.

Endovascular repair of acute AAAs under local anesthesia with bifurcated endografts: a feasibility study

PURPOSE

To evaluate endovascular repair of abdominal aortic aneurysms (AAA) under local anesthesia in the acute setting.

METHODS

Between 1998 and 2001, 47 patients with an acute AAA were evaluated for endovascular repair after informed consent, provided they were in a stable, albeit hypotensive condition. The patients underwent urgent computed tomography to assess suitability for endovascular repair; 16 were eligible for stent-graft repair: 9 were frank ruptures and 7 were symptomatic aneurysms. Complications and outcome of endovascular repair were evaluated; mortality was compared to a contemporaneous surgical cohort.

RESULTS

Seven (23%) of 31 patients having a standard surgical procedure died in the study period compared to 1 (6%) of 16 patients undergoing endovascular repair (following conversion to surgery because of calcified access vessels). Twelve (75%) of the endovascular repairs were performed under local anesthesia; no complications with this mode of anesthesia were encountered. The median duration of the endovascular procedures was 110 minutes (range 75-240); median blood loss was 250 mL (range 100-2800 mL). Only 4 patients required blood transfusion, and only 8 patients required admission to the intensive care unit. There were 3 postoperative complications (1 ischemic colitis, 1 renal failure, 1 groin hematoma). During follow-up, 3 endograft patients received stent-graft extensions in uneventful procedures. Two patients died at 9 and 16 months from cardiac causes.

CONCLUSIONS

This study demonstrates the feasibility and possible advantages of endovascular repair under local anesthesia in selected acute AAA patients. Further studies are needed to prove the advantages over open repair.

Stent-graft repair of a recurrent popliteal arteriovenous fistula

PURPOSE

To describe the successful endovascular treatment of a popliteal arteriovenous fistula with a stent-graft.

CASE REPORT

A 54-year-old man was referred to our hospital with a distal popliteal arteriovenous fistula following an arthroscopic meniscectomy 6 years earlier. Three surgical attempts to close the fistula were undertaken, but the fistula recurred. He now presented with symptoms of progressive venous hypertension with claudication, swelling of the leg, and ulceration at the ankle. The fistula was closed with a stent-graft deployed percutaneously. At 18 months, the patient is doing well; duplex evaluation has documented the patency of the popliteal artery and the stent-graft.

CONCLUSIONS

Endovascular treatment of a popliteal arteriovenous fistula is an alternative to open surgical reconstruction. In this situation, after multiple failed surgical closures and in a leg with extensive venous hypertension, it may be the best treatment option.

Arteriography and portal venography on routine follow-up after orthotopic liver transplantation

RATIONALE AND OBJECTIVES

To describe the findings of routinely performed angiographic examinations in patients at discharge 2 months after orthotopic liver transplantation (OLT) and at follow-up 1 year later.

METHODS

The findings of 315 angiographic examinations performed in 190 patients 2 months and 1 year after OLT were reviewed, and the changes at the anastomotic site of the hepatic artery and portal vein were analyzed.

RESULTS

Routine angiography 2 months and 1 year after OLT demonstrated a normal anastomosis or low-grade stenosis in 82% and 84% of the patients (hepatic artery) and in 88% and 84% (portal vein), respectively. High-grade stenosis occurred in 9% and 5% of the patients (hepatic artery) and in 3% and 5% (portal vein). Hepatic artery occlusion and portal vein occlusion were observed in two and seven patients and in one and three patients, respectively. In 76% of patients, the anastomotic site of the hepatic artery did not change significantly. In eight patients, a normal anastomosis or a low- or medium-grade stenosis developed into high-grade stenosis or occlusion. Conversely, in nine patients, medium- or high-grade stenosis developed into a normal anastomosis or a low-grade stenosis. In all eight patients who initially had a high-grade stenosis, the hepatic artery proved to be patent at 1 year. In 98% of patients, the anastomotic site of the portal vein did not change significantly. In one patient who initially had a normal anastomosis, occlusion was found at I year.

CONCLUSIONS

In most patients, routine angiography 2 months and 1 year after OLT demonstrated normal findings or a low-grade stenotic anastomosis of the hepatic artery and portal vein. Significant changes occurred mainly at the anastomotic site of the hepatic artery and could not be predicted by previous angiograms.

Metachromatic leukodystrophy and coincidental finding of papillomatosis of the gallbladder. A case report

In this case report we describe the coincidental finding of polyps in the gallbladder by ultrasound investigation in a six-year-old girl, known to have metachromatic leukodystrophy. The investigation was carried out because of suspicion of abdominal trauma after falling down the stairs and finding elevated serum amylase.

Venography of the lower limbs. Pitfalls of the diagnostic standard. The ETTT Trial Investigators

RATIONALE AND OBJECTIVES

Phlebography is considered the diagnostic standard for suspected deep venous thrombosis. The authors studied the inter-observer variability of phlebogram interpretation in the setting of a multicenter therapeutic trial of the thrombolytic agent alteplase.

METHODS

The interpretation of 31 pairs of venograms (before and after thrombolytic therapy) was studied by comparing the quantitative Marder's scores which were computed by three experts and the qualitative assessment of phlebographic changes induced by thrombolysis by the panel of experts and by the investigators.

RESULTS

Although the scores of the three experts correlated fairly well (r = .67-.82; P < .001), they differed significantly from each other (P < .0001). Substantial differences also were found between local (by investigators) qualitative evaluation of the venographic changes induced by the treatment and central evaluation by the panel of experts (coefficient of agreement kappa = 0.19), local assessment being significantly more optimistic (P = .002) than central judgment.

CONCLUSION

Significant differences were observed between assessment of changes in venographic scores after thrombolytic treatment both among three expert radiologists, and between the panel of experts and the local investigators of the multicenter trial. This observation points to the need for an a priori definition of well-characterized decision criteria to allow a valid interpretation of the effects of the therapeutic intervention.

Vascular compromise prior to intestinal manifestations of Crohn's disease in a 14-year-old girl

Vascular manifestations as extraintestinal symptoms of Crohn's disease are rare and only occasionally reported in children. A 14-year-old girl with vascular compromise prior to intestinal manifestations of Crohn's disease is described. The vascular symptoms were due to segmental narrowing of several major arteries as shown by angiography. This kind of vascular involvement in our patient is different from the pattern described in Crohn's disease and resembles Takayasu's disease. Recently, it has been suggested that Crohn's disease could be mediated by multifocal gastrointestinal infarction due to chronic focal mesenteric arteritis at the level of the muscularis propria of the gut. In Takayasu's disease, a granulomatous inflammation of the vasa vasorum of affected vessels is frequently found. An intramural arteritis, granulomatous in nature, could be the common pathway in both Crohn's and Takayasu's diseases. Until the etiologies of both diseases are uncovered, the interrelation between them will remain subject to speculation.

Fusobacterium pyomyositis of the shoulder after tonsillitis. Report of a case of Lemierre's syndrome

A case of nontropical pyomyositis is reported in a young male without predisposing factors. The disease was preceded by a tonsillitis, and the presentation initially suggested a septic arthritis of the shoulder. Fusobacterium, a highly unusual pathogen in pyomyositis, was isolated from an abscess in the infraspinatus muscle. The increasing frequency of the disease in areas with a temperate climate and the pathogenesis are discussed. Our case had the classic features of Lemierre's syndrome: invasion of the bloodstream by Fusobacterium species from a tonsillitis.