Crushing of a bridging stent during follow-up of endovascular branched aortic arch repair:A novel mode of failure

A 68-year-old man developed aneurysmal degeneration of the aortic arch and proximal descending aorta after an open ascending graft for a type A aortic dissection. A three-branched endovascular aortic arch repair was performed with patency of all branches despite some degree of initial misalignment of the branches in relation to the target vessels. At 6 months postoperatively, an asymptomatic partial crushing of the left common carotid bridging grafts was observed on computed tomography angiography. This was treated by reinforcing the branch with a balloon-expandable endograft. The postoperative course was uneventful but a computed tomography angiography after 1 month showed recurrent asymptomatic compression. A left carotid-subclavian bypass was eventually performed. We have reported a new failure mode of an inner branch arch repair of residual type A chronic dissection. (J Vasc Surg Cases Innov Tech 2022;8:646-50.

The Use of Iliac Branched Devices in the Acute Endovascular Repair of Ruptured Aortoiliac AneurysmsThe Use of Iliac Branched Devices in the Acute Endovascular Repair of Ruptured Aortoiliac Aneurysms

BACKGROUND: The objective of this study was to evaluate the feasibility and midterm outcomes of iliac branch devices (IBDs) to preserve the internal iliac artery perfusion in emergent endovascular repair of ruptured aorto-iliac aneurysms.METHODS: Between December 2012 and July 2017, a total of 8 IBDs were implanted in 6 patients (the median age 65 years; all men) in a single tertiary referral center. The indication for IBD implantation was a ruptured abdominal aortic aneurysm with a concomitant common iliac artery aneurysm (n = 4) or isolated CIA aneurysms (n = 2). The main outcome measures were technical and clinical success. The secondary outcomes were primary and primary assisted patency, the occurrence of type I/III endoleaks, and reinterventions.RESULTS: All patients were hemodynamically stable during the procedures, which were performed under local anesthesia. Technical success was achieved in all cases (the median total procedure time of 188 min and the median IBD procedure time of 28 min). The median follow-up was 34 months (interquartile range 19-78). There were no deaths during the follow-up and no major complications unrelated to the IBD. Two (25%) secondary interventions were performed for IBD occlusion in patients with bilateral IBDs. The other reintervention was a type II endoleak embolization in 1 of these 2 patients. The freedom from reintervention estimate was 75% through 2 years. The overall primary assisted patency was 100% through 3 years.CONCLUSIONS: The use of IBDs in the acute setting is feasible to exclude ruptured aortoiliac aneurysms while maintaining pelvic circulation. The secondary intervention rate is considerable; however, the midterm assisted primary patency rates are promising. Further studies are needed to guide patient selection and to evaluate longer term outcomes

Reliability of Lupus Anticoagulant and Anti-phosphatidylserine/prothrombin Autoantibodies in Antiphospholipid Syndrome: A Multicenter Study

Background: Is it well-known that one of the major drawbacks of Lupus Anticoagulant (LA) test is their sensitivity to anticoagulant therapy, due to the coagulation based principle. In this study we aimed to assess the reproducibility of LA testing and to evaluate the performance of solid assay phosphatidylserine/prothrombin (aPS/PT) antibodies.Methods: We included 60 patients that fulfilled the following inclusion criteria: (I) diagnosis of thrombotic antiphospholipid syndrome (APS); (II) patients with thrombosis and (a) inconstant previous LA positivity and/or (b) positivity for antiphospholipid antibodies (aPL) at low-medium titers [defined as levels of anti-β2Glycoprotein-I or anticardiolipin (IgG/IgM) 10–30 GPL/MPL] with no previous evidence of LA positivity. aPL testing was performed blindly in 4 centers undertaking periodic external quality assessment.Results: The 60 patients enrolled were distributed as follows: 43 (71.7%) with thrombotic APS, 7 (11.7%) with thrombosis and inconstant LA positivity and 10 (16.7%) with low-medium aPL titers. Categorical agreement for LA among the centers ranged from 0.41 to 0.60 (Cohen's kappa coefficient; moderate agreement). The correlation determined at the 4 sites for aPS/PT was strong, both quantitatively (Spearman rho 0.84) and when dichotomized (Cohen's kappa coefficients = 0.81 to 1.0). Discordant (as defined by lack of agreement in ≥3 laboratories) or inconclusive LA results were observed in 27/60 (45%) cases; when limiting the analysis to those receiving vitamin K antagonist (VKA), the level of discordant LA results was as high as 75%(15/20). Conversely, aPS/PT testing showed an overall agreement of 83% (up to 90% in patients receiving VKA), providing an overall increase in test reproducibility of +28% when compared to LA, becoming even more evident (+65%) when analyzing patients on VKA. In patients treated with VKA, we observed a good correlation for aPS/PT IgG testing (Cohen's kappa coefficients = 0.81–1; Spearman rho 0.86).Conclusion: Despite the progress in the standardization of aPL testing, we observed up to 45% of overall discrepant results for LA, even higher in patients on VKA. The introduction of aPS/PT testing might represent a further diagnostic tool, especially when LA testing is not available or the results are uncertain

Steerable sheath for exclusively femoral bilateral extension of previous fenestrated endovascular aneurysm repair with iliac branch devices

We report the treatment of type Ib endoleak after fenestrated endovascular aneurysm repair (FEVAR) with iliac branch device (IBD) to allow exclusive transfemoral access without a femoral-to-femoral through-and-through wire. The patient was treated with fenestrated endovascular aneurysm repair and showed expansion of the aneurysm owing to a type Ib endoleak. An IBD was implanted by the use of a contralateral steerable sheath for internal iliac artery catheterizing. A computed tomography scan showed the patency of the target vessels and resolution of the endoleak. The use of a steerable sheath without femoral-to-femoral through-and-through wire to bridge the internal iliac artery in patients receiving an IBD after prior EVAR is feasible and avoids the risks associated with upper extremity access

The use of a novel short dilator tip on the distal bifurcated component during fenestrated aortic repair to avoid reno-visceral bridging stents

BACKGROUND: The aim of this study was to evaluate the feasibility and efficacy of a modified delivery system of the distal bifurcated FEVAR component where the dilator tip was shortened to prevent damage to the renovisceral bridging stents.METHODS: All consecutive patients from a tertiary referral center that underwent a FEVAR with a custom delivery system of the distal bifurcated endograft with a short tip between November 2017 and July 2019 were retrospectively analyzed. Only patients with complete fluoroscopic loops of the insertion and deployment of the distal endograft were included. The primary study endpoint was the degree of crossing of the fenestration bridging stentgrafts, that was graded as 'not crossing', 'partial crossing' and 'complete crossing' relative to the lowermost placed fenestration. Secondary endpoints included fenestration related adverse events, secondary interventions, changes in renal function, aneurysm related mortality and overall mortality.RESULTS: 23 patients were included (21 (91%) juxta-renal aneurysms, 2 TAAA type IV (9%)). The lowermost fenestration was crossed in 4 (17.3%), partially crossed in 9 (39.1%) and not crossed in 10 (43.4%) cases. Partial compression or inadequate flaring of a fenestration stentgraft was identified in the intraoperative cone beam CT in 6 (26.0%) patients and corrected perioperatively. Technical success was 100%. Median follow up was 34 (27 - 38) months with two non-aneurysm related deaths during this period. Four patients (17.3%) underwent a secondary intervention related to a fenestration bridging stentgraft.CONCLUSIONS: The use of a custom short dilator introducer tip on the bifurcated device during FEVAR reduces the need to cross the fenestration bridging stentgrafts and may result in less fenestration related adverse events. However, the reno-visceral segment is still frequently crossed by the iliac extension which may lead to adverse events. This could likely be avoided by a similar adaptation on the iliac extension delivery system

Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR

Background: Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events. Methods: All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range. Results: About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P = 0.33). Nine patients (2.2%) died within 30 days of the operation, whereas the remaining were followed up for 6.3 (4.7–8.4) years. The iliofemoral calcium score was 8348 (3830–14,179). Estimated overall survival at 5 years was 73 ± 2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5 years: 79 ± 4% vs. 71 ± 3%; P = 0.01) and cardiac event–free survival (5 years: 95 ± 2% vs. 91 ± 2%; P = 0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988–1.045]; P = 0.268) nor cardiac event–free survival (odds ratio, 1.024 [0.986–1.063]; P = 0.222). Conclusions: Low iliofemoral calcium score may be associated with lower incidence of fatal cardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further

Ilio-femoral calcium score may assist Glasgow Aneurysm Score prediction of long-term survival of low-risk patients after infrarenal EVAR

BACKGROUND: The aim of this study is to evaluate if ilio-femoral calcium score (CS) combined with Glasgow Aneurysm Score (GAS) can improve the prediction of long-term survival after EVAR.METHODS: All the patients who underwent infrarenal endovascular aortic repair (EVAR) for non-ruptured AAA between January 2004 and December 2012 at a tertiary referral center were retrospectively included if the preoperative imaging was of sufficient quality and they had survived for more than 30 days. Preoperative non-contrast enhanced CT were used to measure ilio-femoral calcium score using dedicated postprocessing software. GAS was calculated and patients were divided into low or high GAS by a cutoff of 80.RESULTS: Two hundred and eighty-eight out of 500 patients were included in the study with no difference in survival compared to excluded patients (P=0.529). Patients were followed-up for a median of 7 (range 4-9) years. GAS correlated positively with ilio-femoral calcium score (r=0.123; P=0.037). One hundred and thirty-five patients (46.9%) had low GAS, and 153 (53.1%) had high GAS. Patients with high GAS had lower survival compared to the ones with low GAS (P≤0.0001). GAS was associated with long-term mortality in a uni- and multivariate regression (P≤0.0001 and P≤0.0001). Ilio-femoral calcium score was significantly associated with mortality in the group with low GAS (P=0.028), but not in the group with high GAS (P=0.297). Significance retained in multivariate regression analysis (P=0.029). Moreover, in the low GAS group, ilio-femoral calcium score was further divided in high and low according to the median. Patients with high calcium score had lower survival compared to the ones with low calcium score (P=0.047).CONCLUSIONS: Long-term survival in patients who have had infrarenal EVAR can be predicted by the clinically based Glasgow Aneurysm Score. Measuring the ilio-femoral calcium score preoperatively may refine GAS assessment in low-risk patients

The optimal operative protocol to accomplish CO2-EVAR resulting from a prospective interventional multicenter study

Objectives: Carbon dioxide (CO2) angiography for endovascular aortic repair (CO2-EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO2-EVAR to create an operative standardized protocol. Methods: Patients undergoing CO2-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO2-EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO2 angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO2 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO2-related adverse events were also evaluated. χ2 and Wilcoxon tests were used for statistical analysis. Results: In the considered period, 65 patients undergoing CO2-EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO2 injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild. Conclusions: Preimplant CO2 angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO2. CHA can be satisfactorily visualized with CO2 alone. Completion CO2 angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO2-EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications

Reliability of Lupus Anticoagulant and Anti-phosphatidylserine/prothrombin Autoantibodies in Antiphospholipid Syndrome: A Multicenter Study

Background: Is it well-known that one of the major drawbacks of Lupus Anticoagulant (LA) test is their sensitivity to anticoagulant therapy, due to the coagulation based principle. In this study we aimed to assess the reproducibility of LA testing and to evaluate the performance of solid assay phosphatidylserine/prothrombin (aPS/PT) antibodies. Methods: We included 60 patients that fulfilled the following inclusion criteria: (I) diagnosis of thrombotic antiphospholipid syndrome (APS); (II) patients with thrombosis and (a) inconstant previous LA positivity and/or (b) positivity for antiphospholipid antibodies (aPL) at low-medium titers [defined as levels of anti-\u3b22Glycoprotein-I or anticardiolipin (IgG/IgM) 10-30 GPL/MPL] with no previous evidence of LA positivity. aPL testing was performed blindly in 4 centers undertaking periodic external quality assessment. Results: The 60 patients enrolled were distributed as follows: 43 (71.7%) with thrombotic APS, 7 (11.7%) with thrombosis and inconstant LA positivity and 10 (16.7%) with low-medium aPL titers. Categorical agreement for LA among the centers ranged from 0.41 to 0.60 (Cohen's kappa coefficient; moderate agreement). The correlation determined at the 4 sites for aPS/PT was strong, both quantitatively (Spearman rho 0.84) and when dichotomized (Cohen's kappa coefficients = 0.81 to 1.0). Discordant (as defined by lack of agreement in 653 laboratories) or inconclusive LA results were observed in 27/60 (45%) cases; when limiting the analysis to those receiving vitamin K antagonist (VKA), the level of discordant LA results was as high as 75%(15/20). Conversely, aPS/PT testing showed an overall agreement of 83% (up to 90% in patients receiving VKA), providing an overall increase in test reproducibility of +28% when compared to LA, becoming even more evident (+65%) when analyzing patients on VKA. In patients treated with VKA, we observed a good correlation for aPS/PT IgG testing (Cohen's kappa coefficients = 0.81-1; Spearman rho 0.86). Conclusion: Despite the progress in the standardization of aPL testing, we observed up to 45% of overall discrepant results for LA, even higher in patients on VKA. The introduction of aPS/PT testing might represent a further diagnostic tool, especially when LA testing is not available or the results are uncertain