Journal of Endovascular Therapy

To describe the predictability of an abdominal aortic aneurysm (AAA) rupture secondary to a type II endoleak following stent-graft exclusion.

An 81-year-old man with an enlarging AAA underwent endovascular repair using an AneuRx aortic stent-graft, but a type II endoleak fed by an accessory renal artery was detected at postprocedural computed tomography (CT). Surveillance CT scans at 6 and 16 months showed an increase in the aneurysm diameter and endoleak volume, but the patient refused advised treatment to close the leak. He suffered a fatal aneurysm rupture 24 months after endografting. Retrospective analysis of CT data documented progressive aneurysm enlargement that correctly predicted the rupture.

Type II endoleaks can lead to aneurysm rupture. Three-dimensional (3D) spiral CT angiography offers an opportunity to track endoleak volume and the effect of exposure to systemic pressure on the aneurysm sac.

To report intermediate results of a pilot study in which the glycoprotein IIb/IIIa receptor antagonist abciximab was given to patients during percutaneous carotid stenting for recurrent internal carotid artery (ICA) stenosis. The objective was to prevent procedure-related cerebral embolic events and decrease the incidence of recurrent stenosis.

Sixteen patients (9 women; mean age 66.5 years, range 39–78) with severe ICA recurrent stenosis (>80%) underwent balloon angioplasty and stenting. Before the procedure, abciximab was administered intravenously as a bolus (0.25 mg/kg) followed by a 12-hour continuous infusion (10 µg/min).

Fifteen patients received stents (14 Wallstent and 1 Strecker); 1 vessel was dilated with only 50% improvement in luminal diameter. Two stented arteries had residual stenosis (<30%) but satisfactory luminal diameter was achieved in the remaining 13 (81%) arteries. There were no neurological ischemic events during or following the procedure, nor were there any bleeding or peripheral vascular complications. Duplex surveillance studies up to 12 months revealed no significant recurrent stenosis in the treated vessels.

The administration of abciximab in conjunction with percutaneous revascularization procedures for postsurgical carotid artery stenosis may reduce cerebral ischemic episodes. It may also attenuate restenosis in the treated artery.

To examine the fate of the renal ostia following transrenal fixation of endovascular aortic stent-grafts.

Thirty-five patients (29 men; mean age 75 years) undergoing endovascular repair for abdominal aortic aneurysms (AAAs) had transrenal fixation of the uncovered proximal stent due to a short (<1.5 cm long) or conical neck or a periprocedural endoleak. Eighteen (51%) patients were hypertensive; 7 (20%) had renal artery stenoses (RAS). Outcome measures included blood pressure, serum creatinine, computed tomography, and renal artery duplex scans.

Two patients with ≥60% RAS had renal stents placed during the endograft procedure; the other 5 RAS patients were normotensive and their renal lesions were not treated. Overall technical success was 82.9% (29/35). One (2.9%) case was converted due to graft twisting. There were 5 (14.2%) early endoleaks. Transient postoperative creatinine elevations were observed in 5 (14.2%) cases.

Over a median 11-month period (range 2–24), no secondary endoleaks or silent renal artery occlusions were seen. One normotensive patient with an untreated ≥60% renal lesion developed hypertension and severe stenosis (99%) at 4 months; stenting through the interstices of the transrenal stent was performed. No disease progression was seen in the other 6 RAS patients.

In the intermediate period, transrenal fixation appears to have no adverse effects on renal blood flow. Moreover, in patients with no evidence of renal disease or preoperative RAS <60%, it does not precipitate or cause progression of renal stenosis. However, patients with preoperatively documented RAS ≥60% are a concern and mandate further study.

To study midterm changes in aortic aneurysm morphology after endovascular aneurysm repair.

Of 94 patients with abdominal aortic aneurysms (AAAs) treated with endografts between November 1993 and August 1998, 84 were available for follow-up. Patients were evaluated preoperatively by spiral computed tomography (CT) and aortography; in follow-up, spiral CT scanning was performed at 1, 3, and 6 months and semiannually thereafter. Measurements of the aneurysm neck diameter, maximum aneurysm diameter, and the distance from the lowermost renal artery to the aortic bifurcation were made preoperatively and in follow-up.

Mean follow-up was 17.5 ± 1.1 months; 56 (67%) patients were followed for 1 year and 28 (33%) for ≥2 years. There was a median 2-mm increase (interquartile range [IQR] 0 to 3) in neck diameter at 18 months. However, a ≥3-mm increase was seen in 18 (46%) of 39 patients examined at 18 months (median 4 mm, IQR 3 to 4, p = 0.0001). The maximum AAA diameter decreased by 9 mm (IQR 4 to 16, p = 0.0003) at 24 months, but after 18 months, no further interval decrease was seen. Aneurysms with a persistent endoleak showed either increasing or unchanged AAA diameters. There was no change in the renal artery to bifurcation distance.

The infrarenal aortic neck appears to dilate after AAA endografting, but only in a subset of patients. Shrinkage of aneurysms after successful stent-grafting seems to stop after 18 months, implying that the only indication of late failure in the absence of endoleak might be aneurysm enlargement. Graft-related endoleaks are often associated with an increase in aneurysm diameter.

To report the endovascular treatment of abdominal aortic aneurysms (AAA) in 2 patients with pelvic renal transplants.

Two men with multiple comorbidities and pelvic transplant kidneys underwent endovascular AAA repair using an aortomonoiliac system with femorofemoral bypass grafting. The arterial end-to-side anastomosis in both patients was to the external iliac artery. Tapered aortomonoiliac grafts were fashioned from Gianturco Z-stents covered with Dacron graft material and implanted with the distal attachment site in the iliac system ipsilateral to the transplant kidney arterial anastomosis. The body of the stent-graft was reinforcement with a Wallstent in each case before the contralateral common iliac artery was occluded and the cross-femoral bypass constructed. Both patients recovered uneventfully from the procedure and are free of endoleak or other complications related to their aneurysm repair at 7 and 34 months.

The presence of a pelvic renal transplant in a patient undergoing endovascular AAA repair increases the complexity of procedural planning and endograft implantation, but a good outcome can be achieved.

To assess the safety and efficacy of high-dose adenosine administration to increase the precision of endovascular abdominal aortic aneurysm (AAA) repair using a balloon deployed stent-graft.

From January 1997 to March 1999, 98 AAA patients (79 men; mean age 71 years, range 62–91) were treated with balloon-expandable stent-grafts under an approved protocol. After placing a temporary transvenous ventricular lead or an external transthoracic pacing electrode, adenosine (24 mg initially) was administered in an escalating dose fashion to induce at least 10 seconds of asystole, during which the proximal stent was expanded.

Adenosine dosages ranged from 24 to 90 mg (median 24 mg). Nine (9.2%) self-limiting cardiac events were observed: 2 (2.0%) episodes of transient myocardial ischemia, 2 (2.0%) cases of atrial fibrillation requiring cardioversion, 1 (1.0%) transient left bundle branch block lasting <10 seconds, and 4 (4.1%) prolonged periods of asystole requiring temporary pacemaker activation. There were no cases of bronchospasm or worsening obstructive pulmonary disease, and no patients required inotropic support after adenosine-induced asystole.

Cardiac events following adenosine-induced asystole are infrequent, mild, and easily treated. The perioperative use of high-dose adenosine to ensure precise stent-graft placement appears to be a safe method of inducing temporary asystole during endovascular aortic repair.

To evaluate the use of a superior mesenteric artery (SMA) approach to embolize type II endoleaks arising from the inferior mesenteric artery (IMA).

When reperfusion of the aneurysmal sac via the SMA occurs through the IMA, as shown by computed tomography (CT) and angiography, the IMA origin can be accessed via the marginal artery or the anastomosis of Riolan. The SMA is catheterized with a 5-F catheter, and a coaxial catheter is advanced to the leak to deliver 2- to 8-mm-diameter minicoils to embolize the IMA origin and entire aneurysmal sac. Embolization usually requires from 1 to 2 hours to complete. In our experience with this technique in 11 cases, complications have not occurred, and there has been only one very small residual leak that sealed the next day. Over a 24.5-month follow-up (range 12–39), the endoleaks have remained sealed according to serial color duplex scans.

Successful percutaneous treatment of type II endoleak due to IMA inflow can be accomplished using an SMA access via the Riolan anastomosis or marginal artery. The procedure appears to be safe and has no adverse effects.

To analyze changes in the management of effort subclavian vein thrombosis at our institution.

Records of 23 patients with effort subclavian vein thrombosis treated over a 10-year period were analyzed to compare the results of conventional therapy (heparin/warfarin) used in the first half of this period to a multimodality treatment strategy (thrombolysis and other adjunctive treatment as indicated, e.g., first rib resection, angioplasty/stenting, and vein reconstruction). Diagnostic testing included duplex ultrasound and venography. All patients had at least 1-year follow-up.

Eight patients (7 men; mean age 34 years, range 15–54) had conventional treatment (group A) and 15 patients (14 men; mean age 36 years, range 17–55) had multimodality therapy (group B). Demographics and clinical characteristics were comparable for both groups. Initial thrombolysis was achieved in 14 (93%) group B patients; 10 received adjunctive treatment to relieve external compression or vein stenosis. Four patients had successful first or cervical rib resection and scalenectomy, and first rib resection followed by angioplasty/stenting was successful in 2. However, angioplasty and stenting alone failed in 2 patients, while venous reconstruction was successful in only 1 of 2 cases.

Mean follow-up was 72 months in group A patients and 59 months in group B. One (13%) group A patient and 12 (80%) group B patients demonstrated total venous recanalization and symptom resolution (p = 0.003). Overall, clinical resolution (total and partial symptom relief) was achieved in 3 (38%) group A patients and 13 (87%) group B patients (p = 0.026).

Initial lytic therapy followed by adjunctive treatment to relieve external venous compression or venous stenosis is effective in treating patients with effort subclavian vein thrombosis.

To report the early results of endovascular in situ saphenous vein bypass (EISVB) using side branch coil occlusion.

Between September 1997 and November 1998, 25 patients (15 men; mean age 70.9 years, range 53–85) with lower limb ischemia were treated with endovascular femorodistal bypass. The saphenous vein was prepared using retrograde valvulotomy and endoscopic cannulation with coil occlusion of the side branches. Duplex graft surveillance was performed at 1, 3, 6, and 12 months.

The 25 EISVB procedures consisted of 15 femorodistal popliteal, 7 femorotibial, 2 femoroperoneal, and 1 femorodorsalis pedis in situ saphenous vein reconstructions. Mean operative time was 202 ± 40 minutes, mean number of side branch coils per case was 5.1 ± 1.3, and mean number of incisions per case was 2.9 ± 0.6. Mean hospital length of stay (LOS) was 35 ± 13 hours (1.4 ± 0.6 days); 19 (76%) patients were discharged on the first postoperative day.

Short-term follow-up (mean 6.2 months, range 2–15) was notable for 2 graft thromboses and 1 graft stenosis; primary and secondary patency rates were 88% and 92%, respectively. Three asymptomatic, persistent arteriovenous fistulas discovered on routine duplex were ligated in the outpatient setting. Only 1 (4%) minor wound complication was encountered.

EISVB provides early patency comparable to conventional in situ infrainguinal bypass. Its distinct advantages, however, are the ability to minimize incision length with resultant reductions in wound-related complications, hospital LOS, and recovery time. EISVB promises to be a useful adjunct in the approach to peripheral vascular insufficiency.

To determine whether intravascular ultrasound (IVUS) is more sensitive in identifying incomplete stent deployment or mechanical disruption compared to angiography.

Over a 9-month period, 44 patients (25 men; mean age 63 years, range 36–88) treated for common or external iliac artery stenoses with balloon angioplasty and stenting underwent IVUS interrogation following completion arteriography.

One hundred nine stents were deployed in the 44 patients. Of these, 29 (27%) stents (in 45% of patients) were found by IVUS to be incompletely deployed or to have an associated mechanical disruption despite a normal completion arteriogram. Further treatment (repeat dilation or additional stenting) was performed in 28 cases; 1 hemodynamically insignificant dissection was not treated. Twenty-six (93%) of these interventions were successful as determined by IVUS; 2 underexpanded stents did not respond to redilation.

Incomplete stent deployment or mechanical problems associated with stenting were common in this study, occurring in nearly half of the patients. IVUS has clinical utility in identifying incomplete deployment or mechanical problems in stents with an increased sensitivity compared to contrast angiography.

To present a case of symptomatic mesenteric bypass graft stenosis treated with Palmaz stent implantation.

A 65-year-old man with a history of mesenteric ischemia and superior mesenteric artery (SMA) occlusion presented with recurrent symptoms 3 years after Dacron graft revision surgery for occlusion of a venous aorto-SMA bypass graft. Graft thrombectomy revealed a tortuous segment of narrowed graft proximally, and a Palmaz stent was deployed across the defect. Adequate flow was restored through the conduit, and the patient has remained asymptomatic for 2 years.

Mesenteric ischemia is a rare and potentially fatal condition requiring major vascular intervention. Revision surgery may be avoided by angioplasty and stent insertion across flow-limiting stenoses, even in prosthetic grafts.

To describe the use of a stent-graft for emergent repair of life-threatening hepatic artery hemorrhage.

A 57-year-old man with a 17-year history of myxoid liposarcoma underwent surgery for a recurrent abdominal mass. Multivisceral resection including a Kausch-Whipple procedure with an extended right hemicolectomy was performed. Three weeks later, an episode of gastrointestinal bleeding prompted surgical repair of the hepatic artery, which had been eroded by infection due to a leaking bilioenteric anastomosis. After 3 weeks of programmed abdominal lavage, bleeding recurred. Angiography documented another rupture of the proximal hepatic artery. After an unsuccessful attempt at coil embolization, a Hemobahn stent-graft was implanted percutaneously during simultaneous cardiopulmonary resuscitation. Hemostasis was secured, and the patient recovered. Over the 10-month follow-up, no bleeding or infection has been observed at the site of the repair, and flow through the hepatic artery endograft remains satisfactory.

Percutaneous stent-graft placement can be employed for emergent treatment of visceral artery rupture in patients at high risk for conventional surgical repair.

To demonstrate the utility of endovascular stent-graft repair for the management of an unusual aortoduodenal fistula.

A 23-year-old man with an aortoduodenal fistula secondary to tumor necrosis was treated with a Corvita endoluminal stent-graft after several failed surgical attempts to repair the defect. At 2-year follow-up, the patient was clinically and radiographically devoid of any evidence of occult stent-graft infection.

This case illustrates the usefulness of endovascular repair for the treatment of a primary aortoduodenal fistula. Endovascular repair should be included in the armamentarium for the management of difficult aortoduodenal fistulas.

To report the percutaneous endovascular repair of massive congenital arteriovenous malformations (AVMs) of the right arm complicated by tissue ischemia, severe edema, and life-threatening recurrent hemorrhagic episodes.

A 25-year-old man with a 3-year history of symptomatic upper right arm AVMs had been treated unsuccessfully with surgical ligation and coil embolization. The arm had become massively enlarged, disfigured, severely painful, and unusable, with extension of swelling to the upper chest. Under compassionate use as part of an investigational protocol, the AVMs were closed with 6 overlapping Wallgraft endoluminal prostheses deployed in the right brachial, axillary, and subclavian arteries, preserving the vertebral and distal circulations. Unfortunately, the patient suffered numerous pulmonary emboli and died 2 days after the procedure.

Percutaneous treatment of massive AVMs appears feasible with the Wallgraft endoprosthesis, but optimal postprocedural management of such large anomalies should include immediate venous filter placement and aggressive anticoagulation therapy with intravenous heparin.

To present a rare case of chronic total occlusion of the infrarenal aorta treated with a self-expanding endoluminal stent implanted without preliminary dilation.

A 68-year-old woman presented with severe bilateral buttock and thigh claudication. Angiography revealed total occlusion of the infrarenal abdominal aorta and relatively normal iliac vessels. Via a right groin puncture and a 9-F sheath, a 14-mm × 5-cm self-expanding Wallstent was deployed in the abdominal aorta and expanded with an angioplasty balloon. Completion angiography showed successful recanalization of the aorta with satisfactory distal flow. Palpable distal pulses were restored, and the patient's symptoms were alleviated. She remained asymptomatic until her death from a major stroke 11 months after aortic stent implantation.

Primary stenting may be considered a viable alternative to conventional surgery in selected patients with total infrarenal aortic occlusion.