Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aortic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the procedure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities.……

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Objective To evaluate the early and mid-term results of endovascular repair for acute and chronic type B aortic dissection, and to compare the clinical outcomes between the 2 groups. Methods From May 2002 to December 2006, 50 patients with type B aortic dissection were treated by endovascular stent-graft. There were 23 patients in the acute aortic dissection (AAD) group and 27 patients in the chronic aortic dissection (CAD) group. All patients were followed up from 1 to 54 months (average, 17±16 months).The immediate and follow-up clinical outcomes were documented and compared between the 2 groups. Results Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 50 patients. Compared to the CAD group, the AAD group had a higher percentage of pleural effusion (17.4% vs. 0%, P=0.04) and visceral /leg ischemia (26.1% vs 3.7%, P=0.04). Procedure related complications, including endoleak and post-implantation syndrome, occurred more frequently in the AAD group than in the CAD group (21.7% vs 3.7% and 30.4% vs 11.1%, respectively; P=0.08 and P=0.04). Kaplan–Meier analysis showed no difference in the survival rate at 4 years between the 2 groups (86.4% vs 92.3%, P=0.42 by log-rank test). However, the event-free survival rate was higher in patients with chronic dissection than in patients with acute aortic dissection(96.2% vs 73.9%; P=0.02 by log-rank test). Conclu- sions Endovascular repair with stent-graft was safe and effective for the treatment of both acute and chronic type B aortic dissection. However, both immediate and long term major complications occurred more frequently in patients with acute dissection than in those with chronic dissection.

Endovascular stent-graft for type B aortic dissection in elderly patients

Objective To report the clinical outcome and complications ofendovascular stent-graft treatment for type B aortic dissection in elderly patients, as compared with younger patients in a single medical center. Methods From May 2002 to July 2008, endovascular stent-graft implantation was performed in 124 patients with type B aortic dissection at the Department of Cardiology, Shenyang Northern Hospital. Among them, 39 patients were 60 yrs or older （ranging ~om 68 to 81 years） while 85 patients were younger than 60 years old （ranging from 31 to 58 years）. Patients were followed up for a mean period of 26 months （ranging from 1 to 78 months）. Clinical data were analyzed between the two groups. Results Comparing with the younger group, the elderly group had higher prevalence of coronary artery disease （59.0% vs 24.7%, P=0.001）. There was no significant difference of complication rates between the 2 groups （38.5% vs 31.8%, P=0.54）. Kaplan-Meier analysis showed a similar 5-year survival rate（80.2% vs 89.6%; Log Rank, P=0.31） between the 2 groups. Conclusions Endovascular stent-graft implantation is safe and effective in the treatment of type B aortic dissection for both elderly and younger patients. The procedure-related complication rate seems independent of age .

Endovascular stent-graft treatment for aortoesophageal fistula induced by an esophageal fishbone:Two cases report

BACKGROUND Aortoesophageal fistula(AEF)induced by esophageal fishbones is a rare complication of esophageal foreign bodies and is very difficult to treat.Although the current view suggests that endovascular stent-graft treatment is useful for AEF,whether a subsequent thoracic operation is necessary remains controversial.The purpose of this report is to describe our experience using endovascular stentgraft treatment without combined thoracic operations for the treatment of AEF in two specific cases.CASE SUMMARY We presented two cases of patients complaining of retrosternal discomfort treated in our department for an aortoesophageal fistula caused by the accidental ingestion of a fishbone.The two patients were effectively managed with combined means of endoscopic,medical(broad-spectrum antibiotic therapy,fasting,gastrointestinal decompression,etc.)and endovascular stent-graft treatment.The main difference in treatment was that the first patient presented with hematemesis after endoscopic removal of the fishbone.Subsequently,the patient underwent endovascular stent-graft treatment.The second case was managed with endoscopic removal of the fishbone with simultaneous endovascular stent-graft treatment,without any signs of hematemesis or melena.Both patients had successful postoperative management and were discharged home.Long-term follow-up is ongoing.CONCLUSION The treatment decision-making process should depend on the patients’specific situations.Our practice indicates that endovascular stent-graft treatment without combined thoracic operations could be a valuable alternative in selected patients.

Endovascular treatment of ruptured lobulated anterior communicating artery aneurysms:A retrospective study of 24 patients

BACKGROUND Lobulated intracranial aneurysm is a special type of aneurysm with at least one additional cyst in the neck or body of the aneurysm.Lobulated intracranial aneurysm is a complex aneurysm with complex morphology and structure and weak tumor wall,which is an independent risk factor for rupture and hemorrhage.Lobular aneurysms located in the anterior communicating artery complex account for 36.9%of all intracranial lobular aneurysms.Due to its special anatomical structure,both craniotomy and endovascular treatment are more difficult.Compared with single-capsule aneurysms,craniotomy for lobular intracranial aneurysms has a higher risk and complication rate.AIM To investigate the efficacy and safety of endovascular treatment for ruptured lobulated anterior communicating artery aneurysm(ACoAA).METHODS Patients with ruptured lobulated ACoAA received endovascular treatment in Sanming First Hospital Affiliated to Fujian Medical University from June 2020 to June 2022 were retrospectively included.Their demographic,clinical and imaging characteristics,endovascular treatment methods and follow-up results were collected.RESULTS A total of 24 patients with ruptured lobulated ACoAA were included,including 9 males(37.5%)and 15 females(62.5%).Their age was 56.2±8.9 years old(range 39-74).The time from rupture to endovascular treatment was 10.9±12.5 h.The maximum diameter of the aneurysms was 5.1±1.0 mm and neck width were 3.0±0.7 mm.Nineteen patients(79.2%)were double-lobed and 5(20.8%)were multilobed.Fisher's grade:Grade 2 in 16 cases(66.7%),grade 3 in 6 cases(25%),and grade 4 in 2 cases(8.3%).Hunt-Hess grade:Grade 0-2 in 5 cases(20.8%),grade 3-5 in 19 cases(79.2%).Glasgow Coma Scale score:9-12 in 14 cases(58.3%),13-15 in 10 cases(41.7%).Immediately postprocedural Raymond-Roy grade:grade 1 in 23 cases(95.8%),grade 2 in 1 case(4.2%).Raymond-Roy grade in imaging follow-up for 2 wk to 3 months:grade 1 in 23 cases(95.8%),grade 2 in 1 case(4.2%).Followup for 2 to 12 months showed that 21 patients(87.5%)had good functional outcomes(modified Rankin Scale score≤2),and there were no deaths.CONCLUSION Endovascular treatment is a safe and effective treatment for ruptured lobulated AcoAA.

Effi cacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta(REBOA)can temporarily control traumatic bleeding.However,its prolonged use potentially leads to ischemia-reperfusion injury(IRI).Partial REBOA(pREBOA)can alleviate ischemic burden;however,its security and eff ectiveness prior to operative hemorrhage control remains unknown.Hence,we aimed to estimate the effi cacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun.METHODS:Twenty Landrace pigs were randomized into control(no aortic occlusion)(n=5),intervention with complete REBOA(cREBOA)(n=5),continuous pREBOA(C-pREBOA)(n=5),and sequential pREBOA(S-pREBOA)(n=5)groups.In the cREBOA and C-pREBOA groups,the balloon was inflated for 60 min.The hemodynamic and laboratory values were compared at various observation time points.Tissue samples immediately after animal euthanasia from the myocardium,liver,kidneys,and duodenum were collected for histological assessment using hematoxylin and eosin staining.RESULTS:Compared with the control group,the survival rate of the REBOA groups was prominently improved(all P<0.05).The total volume of blood loss was markedly lower in the cREBOA group(493.14±127.31 mL)compared with other groups(P<0.01).The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups(P<0.05).At 120 min,the S-pREBOA group showed higher alanine aminotransferase(P<0.05)but lower blood urea nitrogen compared with the cREBOA group(P<0.05).CONCLUSION:In this trauma model with liver injury,a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure,despite persistent hemorrhage.Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures,and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.

Application of multi-planar reconstruction technique in endovascular repair of aortic dissection

BACKGROUND Endovascular repair of aortic dissection is an effective method commonly used in the treatment of Stanford type B aortic dissection.Stent placement during the operation was one-time and could not be repeatedly adjusted during the operation.Therefore,it is of great significance for cardiovascular physicians to fully understand the branch status,position,angle,and other information regarding aortic arch dissection before surgery.AIM To provide more references for clinical cardiovascular physicians to develop treatment plans.METHODS Data from 153 patients who underwent endovascular repair of aortic dissection at our hospital between January 2021 and December 2022 were retrospectively collected.All patients underwent multi-slice spiral computed tomography angiography.Based on distinct post-image processing techniques,the patients were categorized into three groups:Multiplanar reconstruction(MPR)(n=55),volume reconstruction(VR)(n=46),and maximum intensity projection(MIP)(n=52).The detection rate of aortic rupture,accuracy of the DeBakey classification,rotation,and tilt angles of the C-arm during the procedure,dispersion after stent release,and the incidence of late complications were recorded and compared.RESULTS The detection rates of interlayer rupture in the MPR and VR groups were significantly higher than that in the MIP group(P<0.05).The detection rates of De-Bakey subtypesⅠ,Ⅱ,andⅢin the MPR group were higher than those in the MIP group,and the detection rate of typeⅢin the MPR group was significantly higher than that in the VR group(P<0.05).There was no statistically significant difference in the detection rates of typesⅠandⅡcompared to the VR group(P>0.05).The scatter rate of markers and the incidence of complications in the MPR group were significantly lower than those in the VR and MIP groups(P<0.05).CONCLUSION The application of MPR in the endovascular repair of aortic dissection has improved the detection rate of dissection rupture,the accuracy of anatomical classification,and safety.

Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Opportunities of endovascular treatment for cerebral venous thrombosis

Cerebral venous thrombosis(CVT)is a rare condition that can be fatal in severe cases.The limited occurrence of CVT poses challenges in conducting randomized controlled trials,leading to uncertainty regarding the effectiveness of endovascular thrombectomy(EVT)in specific subgroups of patients with CVT.Currently,a growing body of new evidence has been published on various aspects of CVT diagnosis and treatment,including studies on prognosis assessment scales and EVT therapy.Anticoagulation remains the primary treatment during the acute phase of CVT,as demonstrated by the thrombolysis or anticoagulation for cerebral venous thrombosis(TOACT)clinical trial.This study revealed that EVT combined with standard medical care did not improve functional outcomes for patients with severe CVT.Several risk screening scores have been developed to predict CVT prognosis,and some of these scales have been shown to perform adequately.The question of whether EVT is beneficial for patients with CVT,and to which subgroups of patients it should be offered,still remains unsettled.Large global research collaborations should be established to address current challenges and facilitate the execution of clinical trials.

Endovascular stent-grafts for acute and chronic type B aortic dissection： comparison of clinical outcomes

Background Endovascular stent-graff treatment has emerged as an alternative for patients with type B aortic dissection （AD）, either at acute or chronic phase, in selected patients. This study aimed to investigate the results of endovascular stent-graft repair for acute and chronic type BAD. Methods From May 2002 to July 2007, 67 patients with type BAD were treated by endovascular stent-graft placement. There were 32 patients in the acute phase （AAD group） and 35 patients in the chronic phase （CAD group）. The patients were followed up from 1 to 65 months （average, 17_＋16 months）. The immediate and follow-up clinical outcomes were documented and compared between the 2 groups. Results Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 67 patients. Compared with patients in the CAD group, those in the AAD group had higher percentages of pleural effusion （15.6% vs 0, P=-0.02） and visceral/leg ischemia （21.9% vs 2.9%, P=0.02）. Procedure related complications, including endoleak and post-implantation syndrome occurred more frequently in AAD group than in CAD group （21.9% vs 2.9% and 31.3% vs 8.6%, respectively; P=0.02 and P=0.02）. Kaplan-Meier analysis showed no significant difference in survival rate at 4 years between the 2 groups （86.4% vs 92.3%, P=0.42 by Log-rank test）. But the 4-year event-free survival rate was higher in patients with chronic dissection than in patients with acute dissection （96.2% vs 73.9%; P=0.02 by Log-rank test）. Conclusions Endovascular repair with stent-graff was safe and effective for the treatment of both acute and chronic type BAD. However, both immediate and long term major complications occurred more frequently in patients with acute dissection than in those with chronic dissection.

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.

Total endovascular repair of aberrant right subclavian artery using caster branched stent-graft

A 57-year-old man has 20-year history of hypertension presented with intermittent chronic pain in the chest area and shoulder blades over the last three months.Computed tomographic angiography(CTA)on admission revealed a chronic type B aortic dissection(TBAD)with an aberrant right subclavian artery(ARSA)crossed behind the trachea and bovine aortic arch(Figure IB).

New nitinol endovascular stent-graft system for abdominal aortic aneurysm with finite element analysis and experimental verification

Abdominal aortic aneurysm(AAA) is one of the most common and catastrophic manifestations of the acute aortic syndrome that can be treated with endovascular aneurysm repair(EVAR) which requires a specially designed stent-graft system.In this work, a self-expanding nickel–titanium(nitinol) stent-graft system is aiming at AAA using finite element analysis(FEA) methods to analyze both fatigue behaviors and radial forces.Based on the systematic analysis of the parametric variations, a final stent-graft system was developed by the selection and arrangement of the individual stent components, targeting an optimal performance for the treatment of AAA.Experimental tests, animal tests and clinical trials were carried out to confirm the results.Both animal trials and clinical trials showed comparable curative effects with Medtronic Endurant stent-graft(SG) systems.

Development of new endovascular stent-graft system for type B thoracic aortic dissection with finite element analysis and experimental verification

Endovascular repair of the thoracic aorta with self-expanding stent-grafts has been emerging as a less invasive alternative treatment compared with conventional open surgeries.Despite the promising efficacy and safety of endovascular stent grafting,the stent-graft failure remains a major concern in terms of stent migration,device fatigue,and the risk of endoleaks.Challenges associated with the stent-grafts involve optimized geometrical structure,lifetime fatigue resistance,and adequate radial support.In this work,a novel endovascular stent-graft system is developed specially for the treatment of Stanford type B thoracic aortic dissections(TAD).Numerical study with finite element analysis(FEA)was utilized to evaluate the mechanical behaviors of the individual stent component.Results of the simulation were validated by experimental tests.Based on the systematic analysis of the parametric variations,a final stent-graft system was developed by the selection and arrangement of the individual stent components,targeting an optimal performance for treatment of TAD.The optimized solution of the stent-graft system was tested in clinical trials,showing advantageous therapeutic efficacy.

Comprehensive classifications for the endovascular recanalization of vertebral artery stump syndrome

Background:and purpose:To share our single-center vertebral artery stump syndrome(VASS)treatment experience and assess the role of comprehensive classification based on anatomic development,proximal conditions,and distal conditions(PAD).Materials and methods:Data were retrospectively collected from patients who underwent endovascular thrombectomy(EVT)at the Stroke Center of the First Hospital of Jilin University between January 2016 and December2021.Among patients with acute ischemic stroke in the posterior circulation,those with acute occlusion of the intracranial arteries and occlusion at the origin of the vertebral artery confirmed by digital subtraction angiography were selected.The clinical data were summarized and analyzed.Results:Fifteen patients with VASS were enrolled in the study.The overall success rate of surgical recanalization was 80%.The successful proximal recanalization rate was 70.6%,and the recanalization rates for P1,P2,P3,and P4 were 100%,71.4%,50%,and 66.67%,respectively.The mean operation times for the A1 and A2 types were124 and 120 min,respectively.The successful distal recanalization rate was 91.7%,and the recanalization rates for types D1,D2,D3,and D4 were 100%,83.3%,100%,and 100%,respectively.Five patients experienced perioperative complications(incidence rate:33.3%).Distal embolism occurred in three patients(incidence rate:20%).No dissection or subarachnoid hemorrhage occurred in any patient.Conclusion:EVT is a technically feasible treatment for VASS,and comprehensive PAD classification can,to a certain extent,help initially estimate the difficulty of surgery and provide guidance for interventional procedures.

Endovascular Therapy of Internal Carotid Artery Tandem Occlusions and Literature Review

Acute large vessel occlusion is a common cause of acute ischemic stroke (AIS), with high rates of disability and lethality. The incidence of tandem occlusion of the internal carotid artery accounts for about 20% of patients with large vessel occlusion of the anterior circulation in acute ischemic stroke. The low rate of recanalization by intravenous thrombolysis in AIS due to internal carotid artery tandem occlusion, the poor establishment of collateral circulation within a short time, and the complex pathogenesis often suggest a poor prognosis for patients. Mechanical thrombectomy (MT) is beneficial for the opening of intracranial large vessel occlusion with internal carotid artery tandem occlusion, there are many problems regarding the emergency management of carotid artery occlusion or stenosis after mechanical thrombectomy, and there are currently no standardized treatment recommendations;The sequential approach to the management of carotid tandem occlusion, the timing of carotid stenting, and the use of antiplatelet agents remain controversial. The current state of research on carotid tandem occlusion is analyzed in the literature to promote clinical understanding of endovascular treatment for patients with acute ischemic stroke due to carotid tandem occlusion.

Endovascular stent-graft placement for treatment of type B dissections

Objective To evaluate the safety and effectiveness of endovascular stent-graft placement for treatment of type B dissection. Methods From April 2002 to December 2005,180 patients with type B dissection underwent endovascular stent-graft placement. There were 158 men and 22 women with mean age of 50. 4±10. 9 years. All patients were diagnosed by computed tomography(CT) or magnetic resonance imaging (MRI) scans.

Endovascular Treatment of Ischemic Stroke due to Acute Carotid Dissection: A Report and Review of the Literature

The efficacy of endovascular therapy in patients with acute ischemic stroke due to tandem occlusion is comparable to that for isolated intracranial occlusion in the anterior circulation. Definitive treatment of carotid dissection-related strokes is currently unproved. The best endovascular technique in this setting remains to be established, but emergency carotid artery stenting (CAS) is frequently considered. We investigated the safety and efficacy of emergency CAS for carotid dissection in patients with acute stroke in current clinical practice.

Safety and Efficacy of Endovascular Aortic Repair for Abdominal Aortic Aneurysms with a Hostile Neck Anatomy

Objective This study aimed to investigate the safety and efficacy of endovascular aortic repair(EVAR)for the treatment of an abdominal aortic aneurysm(AAA)with a hostile neck anatomy(HNA).Methods From January 1,2015 to December 31,2019,a total of 259 patients diagnosed with an AAA who underwent EVAR were recruited into this study.Based on the morphological characteristics of the proximal neck anatomy,the patients were divided into the HNA group and the friendly neck anatomy(FNA)group.The patients were followed up for up to 4 years.Results The average follow-up time was 1056.1±535.5 days.Type I endoleak occurred in 4 patients in the HNA group,and 2 patients in the FNA group.Neither death nor intraoperative switch to open repair occurred in either group.The time of the operation was significantly longer in the HNA group(FNA vs.HNA,99.2±51.1 min vs.117.5±63.8 min,P=0.011).There were no significant differences in short-term clinical success rate(P=0.228)or midterm clinical success rate(P=0.889)between the two groups.The overall mortality rate was 10.4%,and Kaplan-Meier survival analysis indicated that the two groups had similar cumulative survival rates at the end of the follow-up period(P=0.889).Conclusion EVAR was feasible and safe in patients with an AAA with a proximal HNA.The early and midterm results were promising;however,further studies are needed to verify the long-term effectiveness of EVAR.

Morphological features and endovascular repair for type B multichanneled aortic dissection: A case report

BACKGROUND Among the various types of aortic dissection,multichanneled aortic dissection(MCAD)differs from classic double-channeled aortic dissection and involves the formation of an additional false lumen in the aortic wall or the flaps.It is considered a relatively rare condition with high perioperative mortality and morbidity.However,the morphological characteristic and the optimal therapeutic strategy for MCAD has not been fully determined.CASE SUMMARY A 64-year-old man presented to our hospital with severe epigastric abdominal pain radiating to the back that was associated with nausea without emesis.A computed tomography angiogram was performed that revealed a type B aortic dissection with multiple channels extending from the level of the left subclavian artery to the bilateral femoral arteries.We used a medical three-dimensional modeling(3D)modeling system to identify the location and extension of multiple lumens from different angles.It also precisely located the two primary entries leading to the false lumens,which helped us to exclude the two false lumens with one stent-graft.CONCLUSION By applying medical 3D modeling system,we discover the fragility of aortic wall and the collapse of true lumen caused by the multiple false lumens are the two morphological features of MCAD.