Endovascular aortic repair: First twenty years

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives – engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method

Percutaneous transluminal angioplasty and stenting of carotid arteries: Early results

INTRODUCTION Treatment of carotid stenosis could be surgical: eversion endarterectomy, conventional endarterectomy and patch-plasty, resection with graft interposition and bypass procedure or, in the past few years, carotid artery angioplasty (PTA) with stent implantation. OBJECTIVE The aim of this study is to present early results of carotid artery angioplasty and stenting, as well as to identify indications for this procedure. METHOD Twenty-three patients with stenosis of internal carotid artery were included in the prospective study which was performed in the period from July 2006 to July 2007. For PTA and stenting of the carotid artery we used Balloon dilatation catheter Ultra-softTM SV and Carotid WallstentTM MonorailTM. During the procedure, brain protection by embolic protection system Filter Wire EZ was essentially performed. Descriptive statistical methods were performed to present and describe the patient characteristics, risk factors and results. RESULTS 23 patients were examined. In four (17.39%) cases there was asymptomatic, while in 19 (82.61%) there was symptomatic homodynamic significant stenosis of the internal carotid artery. Four of these 19 patients (17.39%) had late restenosis following carotid endarterectomy, four (17.39%) important respiratory failure, and 11 (47.83%) important heart disease. Patients were followed up for the first 30 postopertive days. In that period, there were no mortality and no needs for surgical conversions. In one case (4.35%), residual stenosis of 30% remained. Two patients (8.70%) had TIA and one (4.35%) had CVI. CONCLUSION Main indications for PTA and stenting of carotid arteries are: surgically inaccessible lesions (at or above C2; or subclavial); radiation-induced carotid stenosis; prior ispilateral radical neck dissection; prior carotid endarterectomy (restenosis), severe cardiac and pulmonary conditions. Limitations and contraindications to carotid angioplasty and stentning include: significant peripheral occlusive diseases; unfavorable aortic arch anatomy; severe tortuosity of the common and internal carotid artery; severely calcified stenosis, lesions containing fresh thrombus; stenosis longer than 2 cm; critical (>99%) stenosis; associated carotid artery aneurysm; contrast-related issues and severe aortic valve stenosis

Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: Case report

Introduction. Treatment of thoracoabdominal aortic aneurysms is a major problem in vascular surgery. Conventional open repair is associated with significant rates of mortality and morbidity and therefore, there is a need for better solutions. One of them is a hybrid procedure that includes visceral debranching. This paper presents the first such case performed in Serbia, with a brief overview on all published procedures worldwide. Case Outline. A 57-year-old woman was admitted to the hospital because of thoracoabdominal aneurysms type V by Crawford-Safi classifications. Because of the significant comorbidities it was concluded that conventional treatment would bear unacceptably high perioperative risk, and that the possible alternative could be the hybrid procedure in two stages. In the first stage aortobiliacal reconstruction with bifurcated Dacron graft (16×8 mm) and visceral debranching with hand made tailored branched graft was done. In the second act, the thoracoabdominal aneurysm was excluded with implantation of the endovascular Valiant stent graft, 34×150 mm (Medtronic, Santa Rosa, CA). Control MSCT angiography showed a proper visceral branch patency and positioning of the stent graft without endoleaks. Nine months after the procedure the patient was symptom-free, with no aneurysm, diameter change and no graft-related complication. All visceral branches were patent. Conclusion. So far about 500 cases of visceral debranching have been published with the aim of treating thoracoabdominal aneurysms, and still we have no valid guidelines concerning this method. However, in carefully selected high-risk patients this is an excellent alternative to open surgery of thoracoabdominal aneurysms

Subclavian steal syndrome - surgical or endovascular treatment

Background/Aim. A phenomenon of subclavian steal is caused by occlusion or stenosis of the proximal subclavian artery with subsequent retrograde filling of the subclavian artery via the ipsilateral vertebral artery. The aim of this research was to compare surgical method [carotid-subclavian bypass grafts (CSBG)] and endovascular methods [percutaneous transluminal angioplasty (PTA) and stenting of subclavian artery] from the aspect of immediate and long-term results. Methods. Thirty patients [16 (53.33%) males], of average age between 60.1 ± 8.25 years were treated with CSBG and compared with a group of forty patients [18 (45%) males], of the average age between 57.75 ± 6.15 years treated by PTA and stenting of subclavian artery. Immediate and long-term results were determined clinically and confirmed by Doppler pressures and duplex ultrasound/angiography. All patients were followed-up after 1, 6 and 12 months post-procedure, and annually thereafter. Results. The average follow-up for both groups was 22.37 ± 11.95 months. There were 2 (6.67%) procedural complications in the CSBG group (transient ischemic attack in 2 patients) and 3 (7.5%) ones in the PTA/stent group (dissection and distal embolization in one patient and puncture site hematoma in one patient). Systolic blood pressure difference between the two brachial arteries in CSBG group was: 42.6 ± 14.5 mmHg vs 4.75 ± 12.94 mmHg (p 0.05). Conclusions. Both, the CSBG and PTA/stenting of subclavian artery are safe, efficacious and durable procedures. They have similar immediate and long-term results. PTA and stenting are the methods of choice for high grade stenosis, near total occlusions and segment occlusions of subclavian artery. CSBG is indicated in case of diffuse occlusive lesions and when the PTA and stenting do not succeed or cause complications

Endovascular repair of aortic aneurysm: Preliminary results

Introduction. Endovascular aneurysm repair (EVAR) has been introduced into clinical practice at the beginning of the 90's of the last century. Because of economic, political and social problems during the last 25 years, the introduction of this procedure in Serbia was not possible. Objective. The aim of this study was to present preliminary experiences and results of the Clinic for Vascular Surgery of the Serbian Clinical Centre in Belgrade in endovascular treatment of thoracic and abdominal aortic aneurysms. Methods. The procedure was performed in 33 patients (3 female and 30 male), aged from 42 to 83 years. Ten patients had a descending thoracic aorta aneurysm (three atherosclerotic, four traumatic - three chronic and one acute as a part of polytrauma, one dissected, two penetrated atherosclerotic ulcers), while 23 patients had the abdominal aortic aneurysm, one ruptured and two isolated iliac artery aneurysms. The indications for EVAR were isthmic aneurismal localisation, aged over 80 years and associated comorbidity (cardiac, pulmonary and cerebrovasular diseases, previous thoracotomy or multiple laparotomies associated with abdominal infection, idiopatic thrombocitopaenia). All of these patients had three or more risk factors. The diagnosis was established using duplex ultrasonography, angiography and MSCT. In the case of thoracic aneurysm, a Medtronic-Valiant® endovascular stent graft was implanted, while for the abdominal aortic aneurysm Medtronic-Talent® endovascular stent grafts with delivery systems were used. In three patients, following EVAR a surgical repair of the femoral artery aneurysm was performed, and in another three patients femoro-femoral cross over bypass followed implantation of aortouniiliac stent graft. Results. During procedure and follow-up period (mean 1.6 years), there were: one death, one conversion, one endoleak type 1, six patients with endoleak type 2 that disappeared during the follow-up period, one early graft thrombosis. No other complications, including aneurysm expansion, collapse, deformity and migration of the endovascular stent grafts, were registered. Conclusion. According to all medical and economic aspects, we recommend EVAR to treat acute traumatic thoracic aortic aneurysm, as well as in elderly and high-risk patients with abdominal or thoracic aneurysms, when open surgery is related to a significantly higher mortality and morbidity

Treatment of traumatic rupture of the thoracic aorta

INTRODUCTION Interest for traumatic thoracic aorta rupture stems from the fact that its number continually increases, and it can be rapidly lethal. OBJECTIVE The aim of this study is to present early and long term results as well as experiences of our team in surgical treatment of traumatic thoracic aorta rupture. METHOD Our retrospective study includes 12 patients with traumatic thoracic aorta rupture treated between 1985 and 2007. There were 10 male and two female patients of average age 30.75 years (18-74). RESULTS In six cases, primary diagnosis was established during the first seven days days after trauma, while in 6 more than one month later. In 11 cases, classical open surgical procedure was performed, while endovascular treatment was used in one patient. Three (25%) patients died, while two (16.6%) had paraplegia. Nine patients (75%) were treated without complications, and are in good condition after a mean follow-up period of 9.7 years (from one month to 22 years). CONCLUSION Surgical treatment requires spinal cord protection to prevent paraplegia, using cardiopulmonary by-pass (three of our cases) or external heparin-bonded shunts (five of our cases). Cardiopulmonary by-pass is followed with lower incidence of paraplegia, however it is not such a good solution for patients with polytrauma because of hemorrhage. The endovascular repair is a safe and feasible procedure in the acute phase, especially because of traumatic shock and polytrauma which contributes to higher mortality rate after open surgery. On the other hand, in chronic postrauamatic aortic rupture, open surgical treatment is connected with a lower mortality rate and good long-term results. There have been no published data about long-term results of endovascular treatment in the chronic phase

Portal hypertension caused by postoperative superior mesenteric arteriovenous fistula

Introduction. Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery. Case report. We presented a 49-year-old man with cramplike abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension. Conclusion. Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications