Akutna ishemija lijeve ruke nakon TEVAR-a zbog anatomske varijante vertebralne arterije

Aim: In this case we report acute left arm ischemia after thoracic endovascular aortic repair of the saccular thoracic aortic aneurysm due to a rare anatomical variation of the left vertebral artery. Case report: Thoracic aortic stent-graft was deployed to cover the aneurysm, but six hours later acute left arm ischemia occurred due to a rare form of vertebral artery origin from the aortic arch instead of from the left subclavian artery. This hostile anatomy led to an iatrogenic acute ischemia which was the indication for an emergency left-common-carotid-to-subclavian-artery bypass grafting. Conclusion: Multidisciplinary approach and careful pre-procedural planning should always be the standard procedure in complex cases to avoid this complication.

Endovascular recanalization and remodeling of abdominal aorta stent graft chronic total occlusion after failed extra-anatomic bypass surgery

Objectives Chronic total occlusion (CTO) of the EVAR graft is a rare and serious complication. Traditionally, surgical intervention with prosthetic graft replacement or bypass graft implantation is performed. However, there are limited data in endovascular era. Methods We present a case of a 68-year-old male with a history of late EVAR graft occlusion treated with multiple surgical interventions (femorofemoral crossover, extra-anatomic bypass surgery, and thrombectomy) five years ago. Color Doppler ultrasound (CDUS) and computed tomography (CT) angiography revealed thrombosis of the entire bypass graft. Endovascular recanalization and remodeling of the abdominal stent graft CTO was performed with a combination of bare stents and stent grafts. Rupture of the stent graft occurred on the right limb. A second covered stent was placed. Results At 12-month follow-up, the patient was symptom free. Color Doppler ultrasound surveillance showed patent aortic stent graft and downstream arteries. Conclusions Endovascular recanalization of aortic stent graft CTO is a viable option in patients with failed bypass graft.

Multicenter Experience With Large Diameter Balloon-Expandable Stent-Grafts for the Treatment of Infrarenal Penetrating Aortic Ulcers

Purpose To describe the use of large-diameter balloon-expandable stent-grafts (BeGraft aortic stent-graft, Bentley InnoMed GmbH, Hechingen, Germany) in the treatment of infrarenal penetrating aortic ulcer (iPAU). Materials and Methods Retrospective analysis of patients undergoing endovascular treatment with the BeGraft aortic stent-graft in 8 European centers from January 2017 to October 2020. Demographics, perioperative data, and midterm outcomes were collected. Endpoints of the study were technical feasibility, early mortality, and morbidity. Results A total of 40 patients were included. The mean age was 73.9±7.05 years and 63.2% were male. Indications for treatment included size and morphology (65%), presence of symptoms (29.5%), and contained ruptures (5.5%). Urgent treatment was performed in 5% of cases. Technical success was 97.5%. Median operation time was 58 minutes (19–170 minutes), with 27.5% of patients having additional procedures during the main intervention (1 additional repair with a C-TAG (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) thoracic endoprosthesis, 5 covered endovascular reconstruction of aortic bifurcation procedures, 3 extensions with proximal cuffs, and 2 percutaneous angioplasties of the common iliac arteries). Percutaneous femoral access was used in 72.5%, while groin cut-down was performed in 27.5%. Repair was successful with only 1 stent in 45% of cases, while 37.5% required 2 stents and nearly 17.5% required 3/4 stent-grafts. The 30-day mortality was 0%, with a 2.5% reintervention rate (1 patient required evacuation of an intra-abdominal hematoma). Median follow-up was 13.9 months (2–39 months), during which no vascular-related reinterventions or deaths were reported. In 4 patients, a type II endoleak was observed. No cases of graft migration, thrombosis, or stent-fracture were observed. Conclusions The treatment of iPAU with the BeGraft aortic stent-graft in a selective patient group is feasible with low rate of perioperative morbidity and mortality. Balloon-expandable stent-grafts offer the option to repair iPAUs with a shorter coverage of the aorta using low-profile sheath, that enables treatment in the presence of calcified access vessels and small diameter aortic bifurcations.