Endovascular foreign body retrieval

ObjectiveThe number of endovascular procedures performed is increasing exponentially as technology improves. A serious complication of endovascular therapy is loss of a foreign body in the vasculature. We reviewed our experience and evaluated the cause, management, and outcomes of intravascular foreign body (IVFB) misplacement.MethodsWe completed a retrospective review of patients who underwent endovascular retrieval of IVFBs between 2005 and 2010. Patients were identified by current procedural terminology code or by our hospital's risk management team. Patients undergoing routine endovascular retrieval of temporary vena cava filters were excluded.ResultsTwenty-seven IVFBs were identified in 26 patients. Twenty patients were asymptomatic (76.9%). Six patients were symptomatic (22.2%) with either pain (n = 4) or abnormal physical findings (n = 2). There were 13 (48.1%) catheter fragments, six (22.2%) guidewires, five (18.5%) inferior vena cava (IVC) filter (embolisms), two (7.4%) stents, and one (3.7%) sheath fragment. There were five (15.6%) embolizations of an IVFB into the right heart, three (9.4%) into a pulmonary artery, eight (25%) into the vena cava, eight (25%) into peripheral veins, five (15.6%) into peripheral arteries, one (3.1%) into a coronary artery, one (3.1%) into a hepatic vein, and one (3.1%) into adjacent soft tissue. The mechanism of endovascular loss was device fracture in 16 (59.3%) cases, loss of control in six cases (22.2%), migration in four (14.8%) cases, and incorrect device deployment in one case (3.7%). The probable cause of foreign body loss was technical error in eight (29.6%) cases. In three cases, IVFB retrieval was not attempted. The misplacement and retrieval were completed during the same procedure in 13 (48%) cases. Twenty-four endovascular retrievals were performed. Fifteen (62.5%) procedures used a snare to remove the IVFB and two (8.2%) used balloon catheters. Three IVFBs could not be removed and two cases were converted to open procedures. Technical success was achieved in 19/24 cases (79.2%). There were no immediate complications related to the retrieval of the IVFB; however, there was a single late complication of pulmonary embolism after failed endovascular retrieval (1/24, 4.2%). Thirty-day survival was 100%.ConclusionsIntravascular foreign bodies are a serious complication of endovascular therapy that can be minimized with proper device selection and deployment. When an intravascular foreign body is identified, endovascular retrieval should be attempted due to its high success rate and minimal morbidity

A systematic review of covered balloon-expandable stents for treating aortoiliac occlusive disease

Objective: To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease. Methods: A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis. Results: A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years. Conclusions: CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years

Sustainability of Individual EndoAnchor Implants in Therapeutic Use to Treat Type Ia Endoleak After Endovascular Aneurysm Repair

Purpose: To investigate changes in penetration depths and angles of EndoAnchor implants with initially good penetration after therapeutic use in endovascular aneurysm repair. Materials and Methods: Patients were selected from the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR; ClinicalTrials.gov identifier NCT01534819). Inclusion criteria were (1) EndoAnchor implantation to treat intraoperative or late type Ia endoleak and (2) at least 2 postoperative computed tomography angiography (CTA) scans. Exclusion criteria were the use of adjunct procedures. Based on these criteria, 54 patients (44 men) with 360 EndoAnchor implants were eligible for this analysis. Penetration depth of each EndoAnchor implant into the aortic wall was judged as (1) good (2-mm penetration), (2) borderline (</p

Subintimal angioplasty of chronic total occlusion in iliac arteries: A safe and durable option

BackgroundTraditionally, aortobifemoral bypass has been the intervention of choice for iliac artery chronic total occlusions (CTOs). However, it is associated with significant morbidity and mortality, limiting its use in high-risk patients. To reduce procedural risk, subintimal angioplasty (SIA) for femoropopliteal CTO has been utilized by many, but few have extended this endovascular technique to treating iliac artery CTOs. We present our experience with 101 successful SIAs for iliac artery CTOs.MethodsA retrospective review of consecutive patients with iliac artery CTOs treated with subintimal angioplasty from June 2000 to January 2009 was completed. Demographic and risk factor data were obtained, along with procedural data. Primary and secondary patency, survival, freedom from claudication, and limb salvage rates were determined by Kaplan-Meier survival analysis. Univariate and multivariate analyses were completed to identify factors adversely affecting primary patency.ResultsOne hundred twenty patients underwent an attempted SIA of an iliac artery CTO, and 101 iliac artery CTOs were successfully treated, giving a technical success rate of 84%. Technical failure was due to the inability to re-enter the lumen in all cases. Indications for intervention were lifestyle-altering claudication in 64 patients (63%) and critical limb ischemia (CLI), in 37 (37%). Eighty-five patients underwent percutaneous SIA, while 11 patients underwent a combined SIA with surgical outflow procedure. Lesions were classified as TransAtlantic InterSociety Consensus (TASC) B, 39 (39%); TASC C, 27 (27%); and TASC D, 35 (35%). In 82 (81%) lesions, stents were deployed with an average of 1.2 (range, 0-3) stents utilized. A re-entry device was used in 14 (14%) lesions. Major complication rate was 3.0%, with a 30-day mortality rate of 1.0%. Primary and secondary patency rates at 1, 2, and 3 years were 86% and 94%, 76% and 92%, and 68% and 80%, respectively. Survival rate was 67% at 5 years, reflecting the poor health of this cohort. Limb salvage for CLI patients at 1 and 5 years was 97% and 95%, respectively. Freedom from claudication at 1 and 3 years was 89% and 73%. Univariate analysis identified hyperlipidemia, coronary artery disease, and prior surgical bypass in treated limb as factors for loss of primary patency; however, on multivariate analysis, no factors remained statistically significant.ConclusionThis study demonstrates that SIA of iliac CTOs is feasible and can be performed safely and effectively, even in high-risk patients. Excellent patency and limb salvage rates can be achieved. In our experience, the safety and durability of SIA makes it an attractive first-line therapy for iliac artery occlusive disease

pivotal results for the valiant navion stent graft system in the valiant evo global clinical trial

Abstract Objective The Valiant Navion stent graft system (Medtronic, Santa Rosa, Calif) is a new iteration of a thoracic endograft for the treatment of descending thoracic aortic aneurysms. Herein, the 30-day primary safety and efficacy outcomes and secondary end points are presented. Methods The Valiant EVO global clinical trial is a prospective, nonrandomized, single-arm trial. Patient enrollment occurred from April 2016 to October 2017. The primary end point was defined as access and/or deployment failure and/or a major device effect (MDE), including device-related secondary procedures, device-related mortality, conversion to open surgery, or thoracic aortic aneurysm rupture within 30 days of the index procedure. Other measures of stent graft performance including procedural data, rates of secondary procedures, and frequency of endoleaks are also reported. Results Of the 87 consecutive patients undergoing thoracic endovascular aneurysm repair who were enrolled, 33 (37.9%) were female with 61 (70.9%) presenting with severe access artery tortuosity and 66 (85.7%) with high thoracic aortic tortuosity per core laboratory evaluation. The mean procedure duration was 88.7 ± 53.4 minutes and geographical differences existed such as percutaneous access (37/52 [71.2%]) in the United States and surgical cut down in the outside of the U.S. sites (28/35 [80.0%]). There were no access or deployment failures and only 2.3% of the patients (2/87; P Conclusions Access/deployment failures, MDEs, and endoleaks were rare in the first 30 days of the Valiant Evo clinical trial. The Valiant Navion thoracic stent graft system has shown encouraging 30-day results in this challenging cohort and trial patients will continue to be followed through 5 years

Early abdominal closure with mesh reduces multiple organ failure after ruptured abdominal aortic aneurysm repair: Guidelines from a 10-year case-control study

AbstractObjective: The objectives of this study were the comparison of patients who needed mesh closure of the abdomen with patients who underwent standard abdominal closure after ruptured abdominal aortic aneurysm repair and the determination of the impact of timing of mesh closure on multiple organ failure (MOF) and mortality. Methods: We performed a case-control study of patients who needed mesh-based abdominal closure (n = 45) as compared with patients who underwent primary closure (n = 90) after ruptured abdominal aortic aneurysm repair. Results: Before surgery, the patients who needed mesh abdominal closure had more blood loss (8 g versus 12 g of hemoglobin; P <.05), had prolonged hypotension (18 minutes versus 3 minutes; P <.01), and more frequently needed cardiopulmonary resuscitation (31% versus 2%; P <.01) than did the patients who underwent primary closure. During surgery, the patients who needed mesh closure also had more severe acidosis (base deficit, 14 versus 7; P <.01), had profound hypothermia (32°C versus 35°C; P <.01), and needed more fluid resuscitation (4.0 L/h versus 2.7 L/h; P <.01). With this adverse clinical profile, the patients who needed mesh closure had a higher mortality rate than did the patients who underwent primary closure (56% versus 9%; P <.01). However, the patients who underwent mesh closure at the initial operation (n = 35) had lower MOF scores (P <.05), a lower mortality rate (51% versus 70%), and were less likely to die from MOF (11% versus 70%; P <.05) than the patients who underwent mesh closure after a second operation in the postoperative period for abdominal compartment syndrome (n = 10). Conclusion: This study reports the largest experience of mesh-based abdominal closure after ruptured abdominal aortic aneurysm repair and defines clinical predictors for patients who need to undergo this technique. Recognition of these predictors and initial use of mesh closure minimize abdominal compartment syndrome and reduce the rate of mortality as the result of MOF. (J Vasc Surg 2002;35:246-53.

Contemporary management of acute mesenteric ischemia: Factors associated with survival

AbstractPurpose: Acute mesenteric ischemia (AMI) is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the results of current management and the examination of factors associated with survival, we reviewed our experience. Methods: The clinical data of all the patients who underwent operation for AMI between January 1, 1990, and December 31, 1999, were retrospectively reviewed, clinical outcome was recorded, and factors associated with survival rate were analyzed. Results: Fifty-eight patients (22 men and 36 women; mean age, 67 years; age range, 35 to 96 years) underwent study. The cause of AMI was embolism in 16 patients (28%), thrombosis in 37 patients (64%), and nonocclusive mesenteric ischemia (NMI) in five patients (8.6%). Abdominal pain was the most frequent presenting symptom (95%). Twenty-five patients (43%) had previous symptoms of chronic mesenteric ischemia. All the patients underwent abdominal exploration, preceded with arteriography in 47 (81%) and with endovascular treatment in eight. Open mesenteric revascularization was performed in 43 patients (bypass grafting, n = 22; thromboembolectomy, n = 19; patch angioplasty, n = 11; endarterectomy, n = 5; reimplantation, n = 2). Thirty-one patients (53%) needed bowel resection at the first operation. Twenty-three patients underwent second-look procedures, 11 patients underwent bowel resections (repeat resection, n = 9), and three patients underwent exploration only. The 30-day mortality rate was 32%. The rate was 31% in patients with embolism, 32% in patients with thrombosis, and 80% in patients with NMI. Multiorgan failure (n = 18 patients) was the most frequent cause of death. The cumulative survival rates at 90 days, at 1 year, and at 3 years were 59%, 43%, and 32%, respectively, which was lower than the rate of a Midwestern white control population (P <.001). Six of the 16 late deaths (38%) occurred because of complications of mesenteric ischemia. Age less than 60 years (P <.003) and bowel resection (P =.03) were associated with improved survival rates. Conclusion: The contemporary management of AMI with revascularization with open surgical techniques, resection of nonviable bowel, and liberal use of second-look procedures results in the early survival of two thirds of the patients with embolism and thrombosis. Older patients, those who did not undergo bowel resection, and those with NMI have the highest mortality rates. The long-term survival rate remains dismal. Timely revascularization in patients who are symptomatic with chronic mesenteric ischemia should be considered to decrease the high mortality rate of AMI. (J Vasc Surg 2002;35:445-52.