Uterine Fibroid Embolization

Uterine fibroids or leiomyomas are benign, hormone-dependent smooth muscle cell tumors that can be associated with menorrhagia, anemia, pelvic pain, urinary and/or intestinal symptoms, and dyspareunia. Traditionally, the mainstay of treatment has been surgical, consisting of hysterectomy or myomectomy. However, uterine artery embolization has become an increasingly utilized, minimally invasive treatment modality that can be offered as either sole therapy or as a staged, pre-operative measure to hysterectomy. A thorough knowledge of pelvic vascular anatomy and facility with specific embolotherapeutic techniques are required for safe and effective fibroid embolization

Endovascular Aortic Aneurysm Repair in Patients with Aortoiliac Occlusive Disease

Although endovascular aortic aneurysm repair (EVAR) has become an attractive, minimally invasive option for patients with abdominal aortic aneurysms (AAA), significant challenges in arterial access exist in patients with concomitant aortoiliac occlusive disease (AIOD), particularly for more advanced TASC C and D lesions. Under these circumstances, endograft delivery is possible but requires extensive preoperative planning and intraoperative techniques including but not limited to surgical conduit creation, plain balloon angioplasty, endoconduit placement, and subintimal recanalization. Newer generation aortic endografts have also shown promise in accommodating compromised access vessels. Concomitant AIOD and compromised access vessels complicate EVAR and increase operative time and complexity. Therefore, extreme caution, meticulous preoperative planning, familiarity and facility with the various surgical and endovascular options needed to circumvent these obstacles are essential for safe and effective delivery of EVAR in this high-risk subset of patients. The purpose of this chapter is to present standard approaches for access in patients undergoing EVAR; discuss how advanced AIOD precludes routine access; and present various methods to overcome difficult access in patients undergoing EVAR

Use of the Wallstent for infrapopliteal arterial disease and varying vessel diameters

There is little description of the Wallstent to treat infrapopliteal arterial disease. This may be a viable option due to its high conformability and ability to elongate in vessels of varying diameters. This case report highlights its use in this clinical situation

Iliac branch endoprosthesis for repair of a common iliac artery aneurysm in Loeys-Dietz syndrome type 3

The commercial availability of the iliac branch endoprosthesis (IBE) has permitted endovascular repair of iliac artery aneurysms with the preservation of pelvic circulation. However, the device instructions for use require certain anatomic criteria that can limit deployment in ≤30% of patients. Moreover, branched endovascular treatment of common iliac artery aneurysms with IBE in patients with connective tissue disorders such as Loeys-Dietz syndrome has not been described. In the present report, we have described our technique of alternative endograft aortoiliac reconstruction to overcome anatomic barriers to IBE placement in a patient with a giant common iliac artery aneurysm in the setting of a rare pathogenic variant in the SMAD3 gene

Inferior Mesenteric Artery Snorkel for Endovascular Treatment of a Large Degenerating Saccular Aneurysm

Objective: Preservation of the inferior mesenteric artery (IMA) during endovascular aortic aneurysm repair (EVAR) is necessary for prevention of mesenteric ischaemia in the case of chronically occluded coeliac and superior mesenteric arteries (SMA). This case report presents an approach in a complex patient. Methods: A 74 year old man with hepatitis C cirrhosis and recent non-ST elevation myocardial infarction presented with an infrarenal degenerating saccular aneurysm (58 mm), chronically occluded SMA and coeliac artery, and 9 mm IMA with high grade ostial stenosis. He also had concomitant atherosclerosis of the aorta with a narrow distal aortic lumen of 14 mm, which tapered to 11 mm at the aortic bifurcation. Endovascular attempts to cross long segment occlusions of the SMA and coeliac artery were unsuccessful. Thus, EVAR was performed using the unibody AFX2 endograft and chimney revascularisation of the IMA using a VBX stent graft. One year follow up demonstrated regression of the aneurysm sac to 53 mm with patent IMA graft and no endoleak. Conclusion: Few reports have described techniques for endovascular preservation of the IMA, which is a necessary consideration in the context of coeliac and SMA occlusion. Because open surgery was not a good option for this patient, available endovascular options had to be weighed up. An added challenge was the exceptionally narrow aortic lumen in the context of aortic and iliac atherosclerotic disease. It was decided that the anatomy was prohibitive for a fenestrated design and extensive calcification was too limiting for gate cannulation of a modular graft. Thus a bifurcated unibody aortic endograft with chimney stent grafting of the IMA was successfully used as a definitive solution

Renal vein stenting abates sickle cell trait mediated chronic refractory hematuria exacerbated by the Nutcracker phenomenon

Nutcracker syndrome (NCS) is a rare vascular anomaly involving left renal vein (LRV) outflow entrapment most commonly between the aorta and the superiormesenteric artery (SMA). This can lead to chronic LRV hypertension with resultant gonadal vein reflux, pelvic varicosity formation, hematuria, anemia, failure to thrive, and if severe enough, renal failure. Sickle cell trait (SCT) is a well-known and relatively common cause of hematuria causing damage to the renal microvasculature with subsequent renal papillary necrosis. In the rare setting of both conditions, LRV compression exacerbates upstream LRV sickling and exponentially augments hematuria. As is presented here, alleviation of LRV compression via a minimally endovascular approach can cease life-threatening hematuria

Trans-sternotomy, snare-assisted thoracic endovascular aortic repair for redirection of a migrated elephant trunk

The two-stage elephant trunk (ET) and thoracic endovascular aortic repair technique for type A and B aortic dissection can result in complications between the two stages. We have presented the case of a patient with an acute-on-chronic type B aortic dissection complicated by ET kinking and migration into the false lumen. We used a hybrid approach consisting of a first stage (retrograde thoracic endovascular aortic repair) and a second stage (“body floss” with antegrade thoracic endovascular aortic repair) to successfully reposition the ET back into the true lumen