Fiber Optic RealShape (FORS) Technology for Endovascular Navigation in Severe Tortuous Vessels

Purpose: The purpose of this study was to describe the use of a wire and catheters embedded with optical fiber (Fiber Optic RealShape [FORS]) to catheterize tortuous target vessels avoiding radiation. Technique: A virtual biplane vies was simulated coupling traditional x-ray system, preoperative CT scan, and FORS system to treat an isolated hypogastric aneurysm. Despite the complex anatomy, catheterization of all target vessels was possible in 12 minutes with 19 seconds of fluoroscopy time (Radiation Exposure 3.8 mGy×cm2). A minimal invasive endovascular exclusion of the aneurysm was achieved through selective coil-embolization of the iliolumbar artery and implantation of balloon expandable covered stents, thus preserving the perfusion of the superior gluteal artery. Conclusion: FORS guidance allowed catheterization of a target vessel with challenging anatomy with a low radiation exposure.

Management of Pancreatico-duodenal arterio-venous malformation

Purpose To describe the interventional management and clinical outcome of pancreatico-duodenal arterio-venous malformations (PDAVMs). Material and Methods Seven patients presenting a PDAVM (6 women, 1 male; mean age: 61) were retrospectively reviewed. Technical, clinical success and complications of embolization and surgical management of symptomatic PDAVMs were assessed. Technical success was defined as a complete occlusion of the PDAVM and clinical success as no clinical symptom or recurrence during follow-up. Patients with asymptomatic PDAVMs were followed clinically, by Doppler ultrasound and CT-angiography. Results Mean follow-up time was 69 months (15-180). Five symptomatic patients presented with upper gastrointestinal bleeding (n=3), ascites (n=1), and abdominal pain (n=1). Two patients were asymptomatic. The PDAVMs were classified as follow: Yakes I (1), IIIa (2), IIIb (3) and IV (1). Five symptomatic patients were treated with 9 embolization sessions with arterial approach (onyx®, glue, coils) in 7 and venous approach in 2 (plugs, coils, covered stents, STS foam and onyx®). Technical success of embolization was 60% (3/5). Devascularization was incomplete for 2 Yakes IIIB patients. Clinical success of embolization was estimated at 80% (4/5) as one patient required additional surgery (Whipple) because of persistent bleeding. One splenic vein thrombosis was treated successfully by mechanical thrombectomy and heparin. No recurrence occurred during follow-up. No progression was documented in asymptomatic patients. Conclusion Embolization of symptomatic PDAVMs is effective and surgery should be performed in second intention. Complete devascularization is more difficult to obtain in Yakes III PDAVM.

Spot Stenting Combined With False Lumen Endovascular Occlusive Repair for Post-dissection Abdominal Aortic Aneurysm

Purpose: To introduce a new spot stenting, combined with a false lumen endovascular occlusive repair (SS-FLEVOR) technique for treating post-dissection abdominal aortic aneurysms. Technique: This technique is demonstrated in a 74-year-old man who received an initial thoracic endovascular aortic repair 7 years ago and suffered from distal aortic expansion during the follow-up session. All the tears located more than 15 mm away from the orifice of visceral arteries were excluded by spot stenting in the aortic true lumen. Then, a compliant stent-graft was implanted in the false lumen to seal the tears near the visceral arteries orifice from the outside. In addition, coils were deployed to block the potential backflow from the intercostal arteries and to induce false lumen thrombosis. Moreover, visceral arteries originated from false lumen were repaired by covered-stents implanted from the true lumen. The distal iliac arteries were sealed either with iliac extensions or cover-stents. This new technique has been applied in 5 patients, resulting in 100% technical success and encouraging intermediate outcomes. Conclusion: SS-FLEVOR is a feasible and safe technique to promote false lumen thrombosis in selected cases.

680 Peripheral intravascular lithotripsy of ILEO-femoral arteries to facilitate transfemoral TAVI: a multicentric prospective registry

Aims The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve implantation (TAVI) by transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium and increases vessel compliance allowing TF-TAVI in selected patients with peripheral artery disease (PAD). To report on the safety and efficacy of IVL-assisted TF-TAVI in an all-comers population. Methods and results Clinical, imaging and procedural data on all consecutive patients treated by IVL-assisted TF-TAVI in six high-volume European centres (2018–2020) were collected in this prospective, real-world, multicentre registry. IVL-assisted TF-TAVI was performed in 108 patients, increasing from 2.4% to 6.5% of all TAVI in 2018 to 2020, respectively. The target lesion was most often localized at the common and/or external iliac artery (93.5% of cases; average TL-MLD 4.6 ± 0.9 mm with 318 degrees of calcium arc). Transfemoral aortic valve delivery was successful in 100% of cases; final procedural success in 98.2% (two conversion to cardiac open surgery for annular rupture and valve migration). Complications of the IVL-treated segments consisted of one perforation and three major dissections requiring stent implantation (two covered stents and two BMS). Access site related complication included three major bleedings. Three in-hospital deaths were recorded (2.8%, one failed surgical conversion after annular rupture, one cardiac arrest after initial valvuloplasty, one late hyperkalaemia in renal dysfunction). Conclusions IVL-assisted TF-TAVI proved to be a safe and effective approach, which helps expanding the indications for TF-TAVI in patients with severe calcific PAD. Still, these patients maintain a higher than average incidence of peri-procedural complication.

397 Long-term follow-up after balloon expandable covered stents implantation for management of TAVI-related vascular access complications

Aims Despite increasing experience and device innovation with transcatheter aortic valve implantation (TAVI), vascular complications are still a major problem and endovascular management is generally the first option. When stent implantation is required, self expandable (SE) stents are generally preferred over balloon expandable (BE) stents as they are more elastic and less compressible. However, BE stents support higher radial outward force, adhere to the vase lumen with greater precision and are less expensive. As no large registry reported data about stents BE alone in this setting, we report our experience with BE stents implantation to manage a vascular complication after TAVI. We believe that our work could be useful and possibly serves as a starting point for future research. Methods and results We retrospectively collected baseline, procedural and follow-up data about 78 patients who were implanted with a BE stent to manage a vascular complication after TAVI. At a median clinical follow-up of 410 days (IQR: 66–1016 days), no percutaneous or surgical interventions were reported after discharge. No cases of symptomatic leg-ischaemia were reported and only one patient was symptomatic for claudication. Doppler follow-up (available for 25 patients; 32%) showed no cases of stent fracture or displacement. Conclusions Our experience showed good acute and long-term results of BE covered stent implantation to manage a vascular complication after TAVI. It is possible that a greater radial outward force is a good choice in terms of hemostasis without necessarily being associated with stent deformation/fracture resulting in restenosis or further interventions. While present data may not be generalized, they may be useful to critically re-evaluate (and eventually reduce) the need of SE stents when treating femoral arteries bleedings.

Endovascular Treatment of Innominate Artery Bifurcation Injury with Balloon-Expandable Covered Stents Utilizing Kissing Stent Technique

Major injury of the innominate artery is traditionally treated with an open repair which is technically challenging, associated with large volumes of blood loss and prolonged operative times. Endovascular treatment with covered stent placement across the injury is an attractive alternative. However, placement of a single covered stent across the innominate artery bifurcation into one of its distal branches will not prevent bleeding because of retrograde perfusion from the unstented branch distal to the bifurcation. Here, we report a case of successful endovascular repair of one such injury involving the innominate artery bifurcation with ongoing extravasation into the mediastinum. The injury was successfully treated by utilizing 2 balloon-expandable covered stents placed in kissing fashion from the innominate artery into both of its distal branches. This technique of parallel covered stent placement across a bifurcation could effectively repair bifurcation injuries while maintaining patency of both distal branches.

Clinical Outcomes Following Large Vessel Coronary Artery Perforation Treated with Covered Stent Implantation: Comparison between Polytetrafluoroethylene- and Polyurethane-Covered Stents (CRACK-II Registry)

Data on the clinical outcomes comparing synthetic fluorocarbon polymer polytetrafluoroethylene- (PTFE, GraftMaster) and polyurethane- (Papyrus) covered stents (CSs) to seal coronary artery perforations (CAPs) are limited. We aimed to evaluate 30-day and 1-year clinical outcomes after PCI complicated by CAP and treated with CS. We assessed 106 consecutive patients with successful CAP sealing (122 CSs): GraftMaster (51 patients, 57 CSs) or Papyrus CS (55 patients, 65 CSs). The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac death, target lesion revascularisation (TLR), and myocardial infarction (MI). The mean age of subjects was 69 ± 9.6 years (53.8% males). No significant differences were identified between the GraftMaster and Papyrus groups at the 30-day follow-up for MACE, cardiac death, MI and stent thrombosis (ST), while significantly lower rate of TLR and TVR (p = 0.02) were confirmed in the Papyrus group. At one year, differences remained similar between stents for MACE, a trend towards a lower rate of TLR (p = 0.07), MI (p = 0.08), and ST (p = 0.08), and higher for cardiac death (p = 0.07) was observed in the Papyrus group. This real-life registry of CAP illustrated that the use of Papyrus CS is associated with lower rates of TLR and TVR at 30-day follow-up in comparison to the GraftMaster CSs and no significant differences between both assessed CS at one year of follow-up.

Saphenous Vein Graft Aneurysm after Drug-Eluting Stent Implantation: Treatment by Covered Stent

Saphenous vein graft aneurysms (SVGAs) occur as a rare complication of coronary artery bypass graft but increases the risk of morbidity and mortality. Atherosclerosis is considered to be the most common cause of saphenous vein graft aneurysms. Other etiologies include infections, varicosities of vein grafts, and surgical technical issues. These aneurysms usually present as an incidental finding of a mediastinal or cardiac mass on chest radiograph. Symptomatic aneurysms may present with a wide variety of clinical manifestations such as chest pain/angina, shortness of breath, and myocardial infarction. Treatment options of SVG aneurysms include surgery, percutaneous intervention (including vascular plugs, covered stents, and embolization coils), and conservative management. Herein, we describe a case of a saphenous vein graft aneurysm that developed after percutaneous intervention, which has never been described, to our knowledge, in the previous literature. The aneurysm was treated with polytetrafluoroethylene covered stent implantation.