Статті в журналах: "Vascular endograft"

1

Abatzis-Papadopoulos, Manolis, Konstantinos Tigkiropoulos, Spyridon Nikas, Katerina Sidiropoulou, Christina Alexou, Kyriakos Stavridis, Dimitrios Karamanos, Vasilios Kotsis, Ioannis Lazaridis, and Nikolaos Saratzis. "Study Protocol of a Prospective, Monocentric, Single-Arm Study Investigating the Correlation of Endograft Properties with Aortic Stiffness in Abdominal Aortic Aneurysm Patients Subjected to Endovascular Aortic Repair." Journal of Clinical Medicine 13, no. 8 (April 11, 2024): 2205. http://dx.doi.org/10.3390/jcm13082205.

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The number of endovascular aortic repairs (EVARs) has surpassed the number of open surgical repairs of abdominal aortic aneurysms (AAAs) worldwide. The available commercial endoprostheses are composed of materials that are stiffer than the native aortic wall. As a consequence, the implantation of stent–graft endoprostheses during EVAR increases aortic rigidity and thus aortic stiffness, resulting in a decrease in abdominal aorta compliance. EVAR has been found to have a possibly harmful effect not only on heart functions but also on other vascular beds, including kidney function, due to the decrease in aortic compliance that it causes. Aortic stiffness is measured by various hemodynamic indices like the pulse wave velocity (PWV), the central aortic pressure (CAP), and the augmentation index (AIx). In the literature, there are increasing numbers of studies investigating the properties of endografts, which are strongly related to increases in aortic stiffness. However, there is a lack of data on whether there is a correlation between the length of various endografts implanted during EVAR and the increase in the PWV, CAP, and AIx postoperatively compared to the preoperative values. The aim of this prospective, observational, monocentric, single-arm study is to investigate the correlation between endograft length and the postoperative increase in the PWV, CAP, and AIx in patients subjected to EVAR. Additionally, this study intends to identify other endograft properties related to increases in the PWV, CAP, and AIx. Other endpoints to be studied are the existence of immediate postoperative myocardial and kidney injury after EVAR. The prediction of cardiovascular events caused by endograft-related increased aortic stiffness could contribute to the improvement of various endograft properties so that the impact of endografts on the native aortic wall can be minimized.

2

de Niet, Arne, Esmé J. Donselaar, Suzanne Holewijn, Ignace F. J. Tielliu, Jan Willem H. P. Lardenoije, Clark J. Zeebregts, and Michel M. P. J. Reijnen. "Endograft Conformability in Fenestrated Endovascular Aneurysm Repair for Complex Abdominal Aortic Aneurysms." Journal of Endovascular Therapy 27, no. 5 (June 22, 2020): 848–56. http://dx.doi.org/10.1177/1526602820936185.

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Purpose: To compare the impact of 2 commercially available custom-made fenestrated endografts on patient anatomy. Materials and Methods: The records of 234 patients who underwent fenestrated endovascular aneurysm repair for abdominal aortic aneurysm from March 2002 to July 2016 in 2 hospitals were screened to identify those who had pre- and postoperative computed tomography angiography assessments with a slice thickness of ≤2 mm. The search identified 145 patients for further analysis: 110 patients (mean age 72.4±7.1 years; 94 men) who had been treated with the Zenith Fenestrated (ZF) endograft and 35 patients (mean age 72.3±7.3 years; 30 men) treated with the Fenestrated Anaconda (FA) endograft. Measurements included aortic diameters at the level of the superior mesenteric artery (SMA) and renal arteries, target vessel angles, target vessel clock positions, and the target vessel tortuosity index. Variables were tested for inter- and intraobserver agreement. Results: There was a good agreement between observers in all tested variables. The native anatomy changed in both groups after endograft implantation. In the ZF group, changes were seen in the angles of the celiac artery (p=0.012), SMA (p=0.022), left renal artery (LRA) (p<0.001), and the right renal artery (RRA) (p<0.001); the aortic diameter at the SMA level (p<0.001); and the LRA (p<0.001) and RRA (p<0.001) clock positions. In the FA group, changes were seen in the angles of the LRA (p=0.001) and RRA (p<0.001) and in the SMA tortuosity index (p=0.044). Between group differences in changes were seen for the aortic diameters at the SMA and renal artery levels (p<0.001 for both) and the LRA clock position (p=0.019). Conclusion: Both custom-made fenestrated endografts altered vascular anatomy. The data suggest a higher conformability of the Fenestrated Anaconda endograft compared with the Zenith Fenestrated.

3

May, James, Geoffrey H. White, Weiyun Yu, Richard Waugh, Michael S. Stephen, Kishore Sieunarine, Xavier Chaufour, and John P. Harris. "Endoluminal Repair of Abdominal Aortic Aneurysms: Strengths and Weaknesses of Various Prostheses Observed in a 4.5-Year Experience." Journal of Endovascular Therapy 4, no. 2 (May 1997): 147–51. http://dx.doi.org/10.1177/152660289700400206.

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Purpose: To summarize the results of endovascular abdominal aortic aneurysm (AAA) treatment using several endograft designs over a 4.5-year experience and offer comparisons on the various devices. Methods: From May 1992 to August 1996, 121 AAA patients meeting the criteria for an endoluminal repair were treated with 1 of 5 endograft designs in three configurations. The endografts were implanted in the operating room under fluoroscopic control. Follow-up included contrast-enhanced computed tomography within 10 days of operation, 6 months postoperatively, and annually thereafter. Results: Endografts were successfully deployed in 106 patients (88%). Fifteen cases were converted to open repair. Six procedure-related deaths occurred within 30 days owing to myocardial infarction (3), combined renal failure and septicemia (2), and multisystem failure (1). There were 36 local/vascular complications (30%) and 18 systemic/remote complications (15%). Of the 121 patients undergoing endoluminal AAA repair, 93 (77%) are currently alive and well with their AAAs excluded from the circulation. Conclusions: Trends in endoluminal AAA repair and prosthetic design point toward simpler devices and earlier treatment of smaller aneurysms once the long-term outcome of aortic endografting has been determined.

4

May, James, Geoffrey H. White, Weiyun Yu, Richard C. Waugh, Michael S. Stephen, Timothy J. McGahan, and John P. Harris. "Early Experience with the Sydney and EVT Prostheses for Endoluminal Treatment of Abdominal Aortic Aneurysms." Journal of Endovascular Therapy 2, no. 3 (August 1995): 240–47. http://dx.doi.org/10.1177/152660289500200302.

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Purpose: The aim of this study was to report early experiences with the Sydney and Endovascular Technologies (EVT) prostheses for the treatment of abdominal aortic aneurysms (AAA) deemed suitable for endoluminal tube graft repair. Methods: Consecutive endoluminal tube graft repairs were analyzed over the first 12 months in which the Sydney and EVT prostheses were used. Patients eligible for the EVT prosthesis had type I AAAs: a proximal neck length ≥ 2 cm, a distal cuff length ≥ 1.5 cm, and nontortuous iliac arteries ≥ 8 mm. Selection criteria for the Sydney device were more liberal and included AAAs that had distal cuffs < 1.5 cm. During the study period, 28 of 91 patients evaluated for AAA repair were thus selected for endoluminal grafting: 18 patients received the Sydney endograft and 10 the EVT device. Medical comorbidities were present in slightly less than one third of patients in both groups. Contrast-enhanced computerized tomography (CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure. Results: All endografts were successfully deployed in both groups. Postprocedural CT scans revealed incomplete aneurysm exclusion in four patients with the Sydney endograft. Subsequent deployment of a second endograft sealed these “leaks” in two cases; the other two were converted to open repair (89% clinical success). No leaks were seen with the EVT device. Local/vascular complications occurred in 33% of the Sydney group compared with 20% for the EVT device (p = 0.001); systemic sequelae were more common in the EVT group (30% versus 17% in the Sydney cohort, p = 0.002). There were no deaths within 30 days; three late deaths were not procedure related. Conclusion: AAAs that are suitable for endoluminal tube graft repair may be treated with a high rate of initial success with either the Sydney or EVT prostheses. More liberal selection criteria may increase the likelihood of local/vascular complications.

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White, Rodney A., Carlos E. Donayre, Christian deVirgilio, Eric Weinstein, Fermin Tio, and George Kopchok. "Deployment Technique and Histopathological Evaluation of an Endoluminal Vascular Prosthesis Used to Repair an Iliac Artery Aneurysm." Journal of Endovascular Therapy 3, no. 3 (August 1996): 262–69. http://dx.doi.org/10.1177/152660289600300302.

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Purpose: To describe the deployment technique, function, and gross healing of an endoluminal vascular prosthesis deployed in a high-risk patient for treatment of a common iliac artery (CIA) aneurysm. Methods: An 82-year-old, high-risk male with a 4-cm-diameter CIA aneurysm approximately 4.5 to 5 cm long was treated with endoluminal exclusion of the lesion using a 6-cm-long, 14-mm-internal diameter Dacron vascular prosthesis with Palmaz 308 stents sutured to either end of the graft. Intravascular ultrasound (IVUS) imaging facilitated sizing of the endograft and its accurate positioning so as to occlude both the aneurysm and the hypogastric artery, which was a potential source of retrograde flow to the aneurysm. Exclusion of the lesion and occlusion of the hypogastric artery were demonstrated on delayed angiographic images and contrast computed tomography scans obtained at 16 days postprocedure. Unfortunately, the patient died 67 days following implantation from a nonprocedure-related gastrointestinal complication. Results: At autopsy, the aortoiliac segment was excised and examined grossly and histologically; the evaluation confirmed complete isolation of the aneurysm by the fully expanded endoluminal prosthesis. The surface of the vascular graft was covered by a glistening, thin, fibrinous membrane. The graft material was filled with hypocellular compact fibrinous material with no evidence of endothelialization. These observations confirm preliminary sealing and isolation of the iliac artery aneurysm as healing of the endograft progressed. Conclusions: The data acquired from the analysis of this specimen provide information regarding the utility and early healing of an endograft used for iliac artery aneurysm exclusion. This case also exemplifies the utility of IVUS in endograft deployment.

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Goudeketting, Seline R., Jenske J. M. Vermeulen, Kim van Noort, Gerben te Riet o. g. Scholten, Henny Kuipers, Cornelis H. Slump, and Jean-Paul P. M. de Vries. "Effect of Different EndoAnchor Configurations on Aortic Endograft Displacement Resistance: An Experimental Study." Journal of Endovascular Therapy 26, no. 5 (July 18, 2019): 704–13. http://dx.doi.org/10.1177/1526602819857586.

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Purpose: This study investigated the effect of different EndoAnchor configurations on aortic endograft displacement resistance in an in vitro model. Materials and Methods: An in vitro model was developed and validated to perform displacement force measurements on different EndoAnchor configurations within an endograft and silicone tube. Five EndoAnchor configurations were created: (1) 6 circumferentially deployed EndoAnchors, (2) 5 EndoAnchors within 120° of the circumference and 1 additional, contralateral EndoAnchor, (3) 4 circumferentially deployed EndoAnchors, (4) 2 rows of 4 circumferentially deployed EndoAnchors, and (5) a configuration of 2 columns of 3 EndoAnchors. An experienced vascular surgeon deployed EndoAnchors under C-arm guidance at the proximal sealing zone of the endograft. A constant force with increments of 1 newton (N) was applied to the distal end of the endograft. The force necessary to displace a part of the endograft by 3 mm was defined as the endograft displacement force (EDF). Two video cameras recorded the measurements. Videos were examined to determine the exact moment 3-mm migration had occurred at part of the endograft. Five measurements were performed after each deployed EndoAnchor for each configuration. Measurements are given as the median and interquartile range (IQR) Q1, Q3. Results: Baseline displacement force measurement of the endograft without EndoAnchors resulted in a median EDF of 5.1 N (IQR 4.8, 5.2). The circumferential distribution of 6 EndoAnchors resulted in a median EDF of 53.7 N (IQR 49.0, 59.0), whereas configurations 2 through 5 demonstrated substantially lower EDFs of 29.0 N (IQR 28.5, 30.1), 24.6 N (IQR 21.9, 27.2), 36.7 N, and 9.6 N (IQR 9.4, 10.0), respectively. Decreasing the distance between the EndoAnchors over the circumference of the endograft increased the displacement resistance. Conclusion: This in vitro study demonstrates the influence EndoAnchor configurations have on the displacement resistance of an aortic endograft. Parts of the endograft where no EndoAnchor has been deployed remain sensitive to migration. In the current model, the only configuration that rivaled a hand-sewn anastomosis was the one with 6 EndoAnchors. A circumferential distribution of EndoAnchors with small distances between EndoAnchors should be pursued, if possible. This study provides a quantification of different EndoAnchor configurations that clinicians may have to adopt in clinical practice, which can help them make a measured decision on where to deploy EndoAnchors to ensure good endograft fixation.

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Goudeketting, Seline R., Richte C. L. Schuurmann, Cornelis H. Slump, and Jean-Paul P. M. de Vries. "Changes in Apposition of Endograft Limbs in the Iliac Arteries After Endovascular Aneurysm Repair: Determination With New Computed Tomography–Applied Software." Journal of Endovascular Therapy 26, no. 6 (August 12, 2019): 843–52. http://dx.doi.org/10.1177/1526602819867430.

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Purpose: To validate new computed tomography (CT)–applied software used to determine endograft limb position and apposition after endovascular aneurysm repair (EVAR). Materials and Methods: Twelve EVAR patients (mean age 81±6 years; 10 men) with distal stent-graft extensions for 15 (3 bilateral) type Ib endoleaks during follow-up were selected based on the availability of the following CT studies: pre-EVAR, 1 month, and the penultimate scan prior to the scan disclosing the type Ib endoleak. Twelve patients (mean age 82±7 years; 11 men) without endoleak and a similar interval between the primary EVAR procedure and the penultimate CT scan of the endoleak group were selected as controls using measurements from both endograft limbs (n=21, 3 excluded). Prototype Vascular Imaging Analysis software was adapted to calculate 6 parameters for the distal apposition zone: fabric distance, shortest apposition length, endograft diameter, iliac seal surface (ISS), iliac endograft apposition surface (IEAS), and percentage of iliac surface coverage (IEAS/ISS × 100). Measurements were performed on the preoperative, first postoperative, and penultimate/matched follow-up CT scans. Interobserver variability was assessed with the intraclass correlation coefficient (ICC). Continuous data are presented as the median [interquartile range (IQR) Q1, Q3]. Results: CTA follow-up was not significantly different between the endoleak and control groups [30 months (IQR 18, 58) vs 36 months (IQR 21, 59), p=0.843]. Interobserver agreement was good to excellent for all parameters (ICC 0.879–0.985). Preoperative anatomy and endograft dimensions on the first follow-up CTA scan did not differ significantly between the groups. When the penultimate CTA scan was compared with the first postoperative CT scan, endograft dimensions had significantly changed in the endoleak group; importantly, apposition was significantly decreased, and fabric distance was significantly increased, indicating limb retraction. Differences in changes in endograft dimensions were significant between the groups. Conclusion: New CT-applied software was introduced to visualize apposition and position changes of endograft limbs during follow-up. The software demonstrated good-to-excellent interobserver agreement and enabled accurate analysis of post-EVAR endograft dimensions. Significant changes in apposition and position were observed with the software on the penultimate CT scan prior to diagnosis of type Ib endoleak.

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van der Riet, Claire, Richte C. L. Schuurmann, Angelos Karelis, Mehmet A. Suludere, Meike J. van Harten, Björn Sonesson, Nuno V. Dias, Jean-Paul P. M. de Vries, and Martijn L. Dijkstra. "Supra- and Infra-Renal Aortic Neck Diameter Increase after Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm." Journal of Clinical Medicine 11, no. 5 (February 23, 2022): 1203. http://dx.doi.org/10.3390/jcm11051203.

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Hypovolemia-induced hypotension may lead to an aortic diameter decrease in patients with a ruptured abdominal aortic aneurysm (rAAA). This study investigates the changes in supra- and infra-renal aortic neck diameters before and after endovascular aortic aneurysm repair (EVAR) for rAAA and the possible association with endograft apposition. A retrospective cohort study was conducted including 74 patients treated between 2010 and 2019 in two large European vascular centers. Outer-to-outer wall diameters were measured at +40, +10, 0, −10, and −20 mm relative to the lowest renal artery baseline on the last pre- and first post-EVAR computed tomography angiography (CTA) scan in a vascular workstation. Endograft apposition was determined on the first post-EVAR CTA scan. The post-operative diameter was significantly (p < 0.001) larger than the preoperative diameter at all aortic levels. The aortic diameter at +40 mm (supra-renal) and −10 mm (infra-renal) increased by 6.2 ± 7.3% and 12.6 ± 9.8%, respectively. The aortic diameter at +40 mm increased significantly more in patients with low preoperative systolic blood pressure (<90 mmHg; p = 0.005). A shorter apposition length was associated with a higher aortic diameter increase (R = −0.255; p = 0.032). Hypovolemic-induced hypotension results in a significant decrease in the aortic diameter in patients with an rAAA, which should be taken into account when oversizing the endograft.

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Hagenaars, Tjebbe, Elma J. Gussenhoven, Petros Athanassopoulos, Peter M. T. Pattynama, and Marc R. H. M. van Sambeek. "Intravascular Ultrasound Evidence for Stabilization of Compensatory Enlargement of the Femoropopliteal Segment after Endograft Placement." Journal of Endovascular Therapy 8, no. 3 (June 2001): 308–14. http://dx.doi.org/10.1177/152660280100800311.

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Purpose: To document whether the vasodilatory response seen at the anastomotic segment 6 months after placement of a balloon-expandable endograft in the femoropopliteal segment progresses between 6 and 24 months. Methods: Twelve patients (9 men; median age 65 years, range 47–75) treated with an investigational polytetrafluoroethylene (PTFE) endograft for obstructive disease of the femoropopliteal segment were studied with intravascular ultrasound (IVUS) immediately after placement and at 6 months (first follow-up period) and 24 months (second follow-up period). Matched IVUS cross sections derived from the endograft and the anastomotic segment were analyzed for changes in lumen (LA), vessel (VA), and plaque areas (PLA). Results: Five patients had complete IVUS surveillance at both the first (mean 8 months, range 7–9) and second (mean 25 months, range 23–26) follow-up periods; 1 patient was lost to follow-up during the second interval, and another 6 were excluded owing to graft occlusion (n = 4) or no IVUS surveillance available (n = 2) during the second follow-up period. Matched IVUS cross sections derived from the endograft showed no significant change in LA during both follow-up periods (–8% and +1%, respectively). There was no evidence for intimal hyperplasia or endograft recoil. During both follow-up periods, IVUS cross sections derived from the anastomotic segment revealed significant increases in LA (+37% and +8%, respectively) and VA (+26% and +6%, respectively) (both p < 0.05). The change in PLA during both follow-up periods was not significant (+13% and +3%, respectively). Conclusions: The PTFE endograft seems to inhibit both intimal hyperplasia and constrictive remodeling. The short-term (6-month) vascular dilatory response seen at the anastomotic segment tends to stabilize at 2 years. Therefore, this endovascular anastomosis acts as an “ideal” end-to-end anastomosis.

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McGahan, Timothy J., Gerald A. Berry, Sarah L. McGahan, Geoffrey H. White, Weiyun Yu, and James May. "Results of Autopsy 7 Months after Successful Endoluminal Treatment of an Infrarenal Abdominal Aortic Aneurysm." Journal of Endovascular Therapy 2, no. 4 (November 1995): 348–55. http://dx.doi.org/10.1177/152660289500200407.

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Purpose: To report the results of a postmortem examination in a patient who died of unrelated causes 7 months following endoluminal treatment of an infrarenal abdominal aortic aneurysm (AAA). Methods: As part of an FDA Phase I pilot study, a 73-year-old man underwent successful endoluminal exclusion of an infrarenal AAA using a 9-cm-long endograft (Endovascular Grafting System). Seven months later, he succumbed to complications of a spontaneous esophageal rupture. At autopsy, the aorta was dissected in situ by a vascular surgeon and pathologist before being explanted in order to examine the wound healing characteristics at the aorta-endograft interface. Particular attention was also directed to the hooks composing the attachment system at each end of the endograft. Results: Macroscopic and microscopic examination revealed that the graft had completely excluded the aneurysm sac from the circulation and was incorporated into the aortic wall at the proximal neck and distal cuff. A smooth pannus of endothelial cells covered the proximal end of the endograft at the areas of contact with the aorta, while microscopic examination of the distal end of the graft revealed poorly formed, fibrinous pannus. The neointima deep to the endothelium consisted of a collagenous matrix containing myofibroblasts and histiocytes, providing evidence of healing between the endograft and aorta. Both renal arteries were clear of the proximal end of the endograft, but a previously unrecognized right lower pole renal artery with an extremely caudal origin was excluded from the aortic lumen. Each hook of the attachment system was seen protruding through the adventitia of the aorta. There was no evidence of trauma to the aortic wall or the surrounding tissues caused by these hooks. Conclusion: There appears to be evidence that an endoluminally placed aortic graft may be incorporated by the host aortic tissue.

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Tanner-Steinmann, Beate, and Katia Boggian. "Vascular Endograft Infection withListeria monocytogenesreated with Surgical Debridement but without Graft Removal." Case Reports in Medicine 2011 (2011): 1–4. http://dx.doi.org/10.1155/2011/482815.

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The awareness ofListeria monocytogenesas a pathogen in meningitis and bacteremia in immunosuppressed patients is high. We report a case of vascular graft infection due to Listeria monocytogenes as an example of a less well-known manifestation of listeriosis and focus on the possible treatment procedures emphasizing a management with surgical debridement but preservation of the endograft, in contrast to the gold standard treatment of vascular graft infections which consists of a removal of the graft.

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Karthikesalingam, Alan, Mark Young, Sophie A. Powell, Golnaz Morshedian, Veni Ramachandran, Fabrizio D’Abate, Matthew M. Thompson, and Peter J. E. Holt. "The Impact of Endograft Surveillance on a Vascular Imaging Service." Vascular and Endovascular Surgery 47, no. 2 (January 20, 2013): 92–96. http://dx.doi.org/10.1177/1538574412474497.

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Costa, Davide, Michele Andreucci, Nicola Ielapi, Giuseppe Filiberto Serraino, Pasquale Mastroroberto, Umberto Marcello Bracale, and Raffaele Serra. "Infection of Vascular Prostheses: A Comprehensive Review." Prosthesis 5, no. 1 (February 2, 2023): 148–66. http://dx.doi.org/10.3390/prosthesis5010012.

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Vascular graft or endograft infection (VGEI) is a complex disease that complicates vascular-surgery and endovascular-surgery procedures and determines high morbidity and mortality. This review article provides the most updated general evidence on the pathogenesis, prevention, diagnosis, and treatment of VGEI. Several microorganisms are involved in VGEI development, but the most frequent one, responsible for over 75% of infections, is Staphylococcus aureus. Specific clinical, surgical, radiologic, and laboratory criteria are pivotal for the diagnosis of VGEI. Surgery and antimicrobial therapy are cornerstones in treatment for most patients with VGEI. For patients unfit for surgery, alternative treatment is available to improve the clinical course of VGEI.

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Gratl, Alexandra, Josef Klocker, Bernhard Glodny, Marius Wick, and Gustav Fraedrich. "Treatment options of crural pseudoaneurysms." Vasa 43, no. 3 (May 1, 2014): 209–15. http://dx.doi.org/10.1024/0301-1526/a000351.

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Background: Pseudoaneurysms (PAs) of crural arteries represent rare complications of vascular interventions or surgery. Management of crural PAs includes different treatment options, conservative treatment as well as open surgery or endovascular procedures. We reviewed our experience. Patients and methods: We retrospectively analysed all patients who were diagnosed with crural PAs since 2003. We evaluated etiology, treatment and outcome. Endpoints were target vessel patency, vascular re-intervention and limb loss. Results: A total of 30 patients were diagnosed with crural PAs. PA was caused by vascular intervention in 27 patients (90 %): open balloon thrombectomy (n = 25), subfascial endoscopic perforator vein surgery (n = 1) and transcutaneous catheter-assisted thrombus aspiration (n = 1). In 3 patients (10 %) it was caused by orthopaedic surgical procedures. Location of crural PAs were peroneal artery (n = 11; 36.7 %), posterior tibial artery (n = 10; 33.3 %), anterior tibial artery (n = 5; 16.7 %), and tibioperoneal trunk (n = 4; 13.3 %). Treatment of crural PAs included open surgery (n = 3; 10 %), endovascular procedures (n = 13; 43.3 %) such as endograft implantation (n = 9) or coil embolisation (n = 4), and conservative management (n = 14; 46.7 %). After a median follow-up period of 7 months (range: 0 - 46 months) 8 of 9 endografts were occluded, in none of these patients a minor or a major amputation was necessary. None of the surgically, endovascularly and conservatively treated patients needed a re-intervention for crural PA. A major amputation was necessary in 4 patients due to progression of peripheral arterial disease; none was a directly consequence of the crural PA. Conclusions: Crural PAs are mainly caused by vascular intervention, most frequently by catheter thrombectomy. As a consequence, we recommend fluoroscopic-assisted balloon thrombectomy over a guide wire as routine technique. In many cases of crural PAs, conservative management is sufficient. The choice of treatment of crural PAs depends on size, location and associated symptoms. Endovascular treatment using endografts is limited by poor long-term patency.

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Sengupta, Sampad, Mohamad Hamady, and Xiao-Yun Xu. "Haemodynamic Analysis of Branched Endografts for Complex Aortic Arch Repair." Bioengineering 9, no. 2 (January 18, 2022): 45. http://dx.doi.org/10.3390/bioengineering9020045.

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This study aims to investigate the haemodynamic response induced by implantation of a double-branched endograft used in thoracic endovascular aortic repair (TEVAR) of the aortic arch. Anatomically realistic models were reconstructed from CT images obtained from patients who underwent TEVAR using the RelayPlus double-branched endograft implanted in the aortic arch. Two cases (Patient 1, Patient 2) were included here, both patients presented with type A aortic dissection before TEVAR. To examine the influence of inner tunnel branch diameters on localised flow patterns, three tunnel branch diameters were tested using the geometric model reconstructed for Patient 1. Pulsatile blood flow through the models was simulated by numerically solving the Navier–Stokes equations along with a transitional flow model. The physiological boundary conditions were imposed at the model inlet and outlets, while the wall was assumed to be rigid. Our simulation results showed that the double-branched endograft allowed for the sufficient perfusion of blood to the supra-aortic branches and restored flow patterns expected in normal aortas. The diameter of tunnel branches in the device plays a crucial role in the development of flow downstream of the branches and thus must be selected carefully based on the overall geometry of the vessel. Given the importance of wall shear stress in vascular remodelling and thrombus formation, longitudinal studies should be performed in the future in order to elucidate the role of tunnel branch diameters in long-term patency of the supra-aortic branches following TEVAR with the double-branched endograft.

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Piacentino, Filippo, Federico Fontana, Camilla Micieli, Maria G. Angeretti, Larissa Nocchi Cardim, Andrea Coppola, Valeria Molinelli, Gabriele Piffaretti, Raffaele Novario, and Carlo Fugazzola. "Nonenhanced MRI Planning for Endovascular Repair of Abdominal Aortic Aneurysms: Comparison With Contrast-Enhanced CT Angiography." Vascular and Endovascular Surgery 52, no. 1 (November 21, 2017): 39–45. http://dx.doi.org/10.1177/1538574417740508.

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Background: To assess whether noncontrast-enhanced magnetic resonance imaging (NC-MRI) is an alternative to contrast-enhanced computed tomography angiography (CTA) for aortoiliac measurements before endovascular abdominal aortic aneurysm repair (EVAR). Methods: This study encompasses 30 patients admitted for elective EVAR (27 men and 3 women). Two expert readers (vascular radiologist and vascular surgeon) reviewed CTA images in consensus and chose the proper endograft for each patient. Subsequently, a vascular radiologist and a resident radiologist (observer 1 and 2) reviewed CTA and NC-MRI examinations in a double-blind way and completed standard measurements. The interobserver and intermodality agreement was calculated by intraclass correlation coefficients (ICCs). Furthermore, the correlation between the endograft size chosen by the first pair and the second pair of observers was evaluated. Results: Concerning all measurements, no significant difference was found. Both CTA and NC-MRI angiographic measurements showed strong correlation. Interobserver ICCs for CTA and NC-MRI showed ranges of 0.62 to 0.99 (mean: 0.92) and 0.56 to 0.99 (mean: 0.91); intermodality ICCs for observer 1 and 2 showed ranges of 0.64 to 0.99 (mean: 0.92) and 0.56 to 0.99 (mean: 0.92). The CTA and NC-MRI vascular measurements correlated strongly, except for both external iliac artery diameters. The choice of stent size was always the same between the 2 observers; furthermore, graft size was always in agreement with that selected prospectively. Conclusion: Computed tomography angiography remains the standard of reference for EVAR planning; NC-MRI can be an option for patients with contraindications for CTA, in particular those with renal impairment.

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Molinari, Alessandro C. L., Enrico Leo, Lorenzo Muzzarelli, and Giovanni Rossi. "Vascular plug oversizing to treat an endoleak after hybrid surgery of the aortic arch." Interactive CardioVascular and Thoracic Surgery 31, no. 6 (November 1, 2020): 906–8. http://dx.doi.org/10.1093/icvts/ivaa197.

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Abstract A patient with prior ascending aortic replacement for a type A acute dissection and a bovine arch presented with an asymptomatic chronic dissecting innominate artery aneurysm extending to both carotid arteries. As the patient refused redo open surgery, we performed a hybrid procedure with reverse extra-anatomic aortic arch debranching and a fenestrated endograft. The aneurysm was still partially perfused due to an endoleak and corrected 1 week later with vascular plugs.

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Schroeder, Martin, Konstantinos P. Donas, Konstantinos Stavroulakis, Arne Stachmann, Giovanni Torsello, and Theodosios Bisdas. "Anatomical Suitability of the Zenith Off-the-Shelf (p-Branch) Endograft in Juxtarenal Aortic Aneurysms Previously Treated Using the Chimney Technique." Journal of Endovascular Therapy 24, no. 2 (January 1, 2017): 223–29. http://dx.doi.org/10.1177/1526602816684628.

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Purpose: To examine the suitability of the Zenith off-the-shelf (p-branch) endograft in patients with juxta- or pararenal abdominal aortic aneurysms (J/PRAA) previously treated with endovascular aneurysm repair incorporating the chimney technique (chEVAR). Methods: Between January 2012 and December 2014, high-resolution computed tomography angiograms and clinical data from 50 patients (mean age 79 years; 45 men) with J/PRAAs treated with chEVAR were retrospectively reviewed. Primary anatomical suitability was evaluated according to the Investigational Device Exemption protocol for the Zenith p-branch endograft in a dedicated 3-dimensional vascular workstation. Secondary suitability was defined as any additional intervention needed to overcome adverse anatomical conditions at the access vessels. The Zenith p-branch endograft is available in 2 configurations (A and B), with the main difference being the distance between the superior mesenteric artery (SMA) and the renal fenestrations. Results: The p-branch endograft showed a primary suitability of 54% (n=27). Each configuration was suitable in 18 (36%) patients. Main anatomical limitations were the clock position of the left renal artery (LRA; n=7, 14%), the distance between the SMA and LRA (A: n=16, 32%; B: n=16, 32%), and significantly narrowed or calcified iliac arteries. If additional interventions at the access vessels were employed, a secondary suitability of 64% (n=32) could be achieved. Conclusion: In this specific group of patients treated with chEVAR, the Zenith p-branch system would be suitable in about half of the patients, which could be raised to two-thirds with ancillary access vessel procedures. A prospective clinical study is warranted to evaluate these results.

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Patel, Tarak H., John Eggleston, Clifford R. Weiss, and Lawrence V. Hofmann. "Extracorporeal Expulsion of a Vascular Endograft Used to Treat a Mycotic Aneurysm." Journal of Vascular and Interventional Radiology 15, no. 10 (October 2004): 1157–60. http://dx.doi.org/10.1097/01.rvi.0000137403.06053.75.

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Harris, Peter L., and Jacob Buth. "An Update on the Important Findings from the EUROSTAR EVAR Registry." Vascular 12, no. 1 (January 2004): 33–38. http://dx.doi.org/10.1258/rsmvasc.12.1.33.

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This article summarizes the important findings to emerge from the European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) Registry since its inception in 1996. The Registry is an open observational study of the outcomes from endovascular aneurysm repair (EVAR). Data have been contributed, on a voluntary basis, by 135 vascular centers from 18 European countries. Patients are registered prospectively, and data analysis is on an intention-to-treat basis. Results from the first generations of endograft were characterized by excellent early results but poor durability of abdominal aortic aneurysm repair. EUROSTAR data have played a vital role in informing the technical evolution of subsequent generations of endograft and their clinical application. The latest data from EUROSTAR show significant improvements in all outcome measures, most importantly, those relating to durability. EUROSTAR has tracked and informed the evolution of EVAR. Improving results confirm that substantial progress has been made since 1996. EUROSTAR continues to contribute to this ongoing process.

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Tsang, Julian S., Yiu Che Chan, Yuk Law, and Stephen W. Cheng. "Clinical experience of positron-emission tomography in infective aortic disease." Asian Cardiovascular and Thoracic Annals 26, no. 1 (December 14, 2017): 11–18. http://dx.doi.org/10.1177/0218492317749054.

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Background Fluorine-18-fluorodeoxyglucose positron-emission tomography with computed tomography has revolutionized medical diagnosis by adding functional activity to anatomic imaging. We report our experience with this technique in patients with mycotic aortic pathology and aortic vascular graft infection. Methods We conducted a retrospective review of a prospective database of patients who underwent 18F-fluorodeoxyglucose positron-emission tomography with computed tomography for suspected infective aortic disease. From 2012 to 2016, 13 patients underwent 18F-fluorodeoxyglucose positron-emission tomography. Of these, 9 (69%) had a vascular graft infection (5 infrarenal aorta, 1 para-visceral, 2 descending, and 1 arch; 2 had previous open surgery and 7 had endovascular interventions) and 4 (31%) had a mycotic aneurysm (2 aortic arch, 1 infrarenal aorta, and 1 distal aorta and common iliac; 3 had endografts). The indications for imaging, location of pathology, 18F uptake, and clinical outcomes were analyzed. Results Eight (62%) patients had a single scan and 5 (38%) had serial scans performed. Among the 5 patients who had serial imaging, 3 showed decreased 18F uptake and 2 had increased uptake. Only one patient underwent subsequent endograft removal; the others were treated with lifelong antibiotics. There were 5 (38%) deaths on follow-up. Conclusion 18F-fluorodeoxyglucose positron-emission tomography with computed tomography could be a valuable adjunct in the diagnosis and surveillance of patients with aortic infection. Serial scans may be useful for monitoring disease activity and response to antibiotic therapy.

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Zimmerman, Pamela M., Gregory S. Cherr, George C. Angelos, Jayakumari Gona, and Hasan H. Dosluoglu. "Is F 18 Fluorodeoxyglucose Positron Emission Tomography Too Sensitive for the Diagnosis of Vascular Endograft Infection?" Vascular 16, no. 6 (December 1, 2008): 346–49. http://dx.doi.org/10.2310/6670.2008.00049.

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We report a case of a false positive fluorodeoxyglucose positron emission tomography (FDG-PET) scan in a patient who presented with abdominal pain, and gastrointestinal bleeding accompanied by elevation of inflammatory markers, seven weeks after a proximal type I endoleak repair with a cuff extension. Aortoenteric fistula and endograft infection was ruled out by laparotomy. FDG-PET image may have a role in diagnosis of infection, but false positive results are possible and caution is necessary if other data are non-confirmatory.

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Panuccio, Giuseppe, Fiona Rohlffs, Vladimir Makaloski, Ahmed Eleshra, Nikolaos Tsilimparis, and Tilo Kölbel. "Through-and-Through Suture Technique to Stabilize a Sheath in Branched Endovascular Aortic Repair." Journal of Endovascular Therapy 26, no. 6 (August 28, 2019): 805–9. http://dx.doi.org/10.1177/1526602819871931.

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Purpose: To describe a technique to catheterize antegrade branches of a branched thoracoabdominal endograft from a femoral access with the help of standard sheaths and a vascular suture. Technique: The technique is demonstrated in a patient who underwent successful complex thoracoabdominal branched endovascular aortic repair. After the deployment of an aortic endograft with two antegrade branches for the targeted renovisceral vessels, a standard braided sheath was preloaded with a 3/0 polypropylene suture and introduced inside an additional sheath from the groin to the thoracic aorta. Simultaneous gentle traction on the suture as the preloaded sheath was advanced achieved a very stable 180° curve of the proximal end of the sheath. It was possible to selectively catheterize the antegrade branches and respective target vessels sequentially, as well as deploy the planned bridging stents for each branch. Conclusion: The through-and-through suture technique is a helpful tool in branched endovascular aortic repair. It saves time, radiation, and materials; no snare is needed, and it can be preloaded into a sheath.

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Allaria, P. M., E. Costantini, A. Lucatello, E. Gandini, F. Caligara, and A. Giangrande. "Aneurysm of Arteriovenous Fistula in Uremic Patients: Is Endograft a Viable Therapeutic Approach?" Journal of Vascular Access 3, no. 2 (April 2002): 85–88. http://dx.doi.org/10.1177/112972980200300207.

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One of the complications of arteriovenous fistulas in chronic hemodialyzed patients is the onset of an aneurysm which can be at risk of rupture. Traditional surgical repair is not always feasible and may not be successful in these cases, leading therefore to the loss of a functioning vascular access and requiring in any case the temporary use of a central venous catheter to allow regular hemodialysis sessions. We applied to this kind of aneurysm the same experience developed in the management of major arterial aneurysms and we considered endografting repair a good alternative in this case. In this paper we present the successful treatment of an arteriovenous fistula aneurysm using that technique. A distal radio-cephalic arteriovenous fistula in one of our patients presented an aneurysm with high risk of rupture. The endografting repair with percutaneous insertion of a Wallgraft™ endoprosthesis was well tolerated and the vascular access could be used the day after, without the need for a central venous catheter insertion.

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Fontanini, Daniele Mariastefano, Gábor Fazekas, Gábor Vallus, György Juhász, Rita Váradi, Zsolt Kövesi, Márton Kolossváry, and Zoltán Szeberin. "Mellkasiaortastentgraft-beültetések Magyarországon 2012 és 2016 között." Orvosi Hetilap 159, no. 2 (January 2018): 53–57. http://dx.doi.org/10.1556/650.2018.30960.

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Abstract: Thoracic aortic endograft implantation has become a widespread procedure in recent years, yet no report is available about Hungarian outcomes. Examination of our results is crucial to define further treatment strategies. Analysis of perioperative data from Hungarian thoracic endograft implantations based on the experience of 5 years is presented. Our retrospective, multicentric study analysed voluntarily reported data from all Hungarian institutions where thoracic endograft implantations are performed. Information was collected from every procedure performed in 5 years. Between 2012 and 2016, 131 thoracic stent graft implantations were performed in Hungary (67.18% male, mean age 62.80 years). 25.19% of the procedures were acute. 13.74% of the patients were diabetic. Indications for the procedure were aneurysm (64.89%), dissection (17.56%), aortic trauma (6.87%) and other conditions (10.69%). 73.91% of the dissection cases were acute. 16.47% of repaired aneurysms were ruptured. Additional preoperative revascularization (debranching) was performed in 26.72% of the cases. Postoperative stroke occured in 4.58%, temporary hemodialysis was needed in 1.53%, bowel ischaemia was present in 2.29% and reoperation within 30 days was needed in 5.34% of all cases. Thirty-day mortality of the procedure was 9.92%, 5-year long-term mortality reached 16.03%. Endovascular repair of the thoracic aorta is an effective procedure and our national data comfirmed its advantages compared to open thoracic surgery. Further use of the procedure in Hungary depends on the centralised care in vascular surgery and financial matters. Multidisciplinary cooperation and proper logistics are needed to provide patients with optimal treatment. Orv Hetil. 2018; 159(2): 53–57.

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Ljungquist, Oskar, Nuno Dias, Sven Haidl, Björn Sonesson, Karl Sörelius, and Jonas Ahl. "Guided Aspiration for Determining the Microbiological Aetiology of Aortic Vascular Graft and Endograft Infections." European Journal of Vascular and Endovascular Surgery 62, no. 6 (December 2021): 935–43. http://dx.doi.org/10.1016/j.ejvs.2021.08.006.

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Shayan, Mahdis, Sungyeun Yang, WonHyoung Ryu, and Youngjae Chun. "A novel low-profile thin-film nitinol/silk endograft for treating small vascular diseases." Journal of Biomedical Materials Research Part B: Applied Biomaterials 105, no. 3 (December 10, 2015): 575–84. http://dx.doi.org/10.1002/jbm.b.33548.

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Coppi, Gioacchino, Roberto Pacchioni, Roberto Moratto, Stefano Gennai, Gianantonio A. Farello, Gastone Bergamaschi, Claudio Rabbia, et al. "Experience with the Stentor Endograft at Four Italian Centers." Journal of Endovascular Therapy 5, no. 3 (August 1998): 206–15. http://dx.doi.org/10.1177/152660289800500304.

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Purpose: To report the outcome of an Italian multicenter trial of endovascular abdominal aortic aneurysm (AAA) exclusion using the Stentor device. Methods: Between April 1995 and July 1996, 66 patients (63 men; average age 69 years, range 53 to 84) with infrarenal AAAs meeting the inclusion criteria were enrolled. The average diameter of the aneurysm was 4.6 cm (range 4.2 to 7). Three (4.5%) of the 66 AAAs were anastomotic aneurysms. Results: Sixteen (25%) tubular and 50 (76%) bifurcated endograft procedures were attempted; 4 (6.1%) were converted and 1 terminated owing to technical faults with the bifurcated graft's second limb. One tube graft was too short and failed to exclude an anastomotic aneurysm. Sixty (91%) endograft procedures were completed successfully. Six (9.1%) vascular complications occurred, three in one patient who subsequently died of pulmonary embolism 72 hours postoperatively (1.5% mortality). There were four (6.1%) proximal endoleaks; two sealed spontaneously in < 1 month, and a third was converted (7.6% conversion rate). The fourth is being observed. Clinical success (aneurysm exclusion with no death or endoleak) at 30 days was 86.3% (57/66). In the 23-month follow-up of 57 eligible patients, 2 patients died of unrelated causes and 1 graft limb thrombosed, requiring a crossover femoral bypass. One patient was converted to surgical repair at 5 months postoperatively when increasing aneurysm size signaled an undisclosed endoleak (1.8% late conversion rate). Five other secondary endoleaks were treated with endovascular techniques. Conclusions: The Stentor was technically feasible in 10% to 40% of AAA candidates in this study, although deployment of the second limb was problematic in the bifurcated device. Introduction of the second-generation Vanguard endograft brought this study to an end.

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Criado, Frank J. "Mapping the Aorta: A New Look at Vascular Anatomy in the Era of Endograft Repair." Journal of Endovascular Therapy 17, no. 1 (February 26, 2010): 68–72. http://dx.doi.org/10.1583/09-2967.1.

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Chakfé, Nabil, Holger Diener, Anne Lejay, Ojan Assadian, Xavier Berard, Jocelyne Caillon, Inge Fourneau, et al. "Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections." European Journal of Vascular and Endovascular Surgery 59, no. 3 (March 2020): 339–84. http://dx.doi.org/10.1016/j.ejvs.2019.10.016.

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White, Rodney A., Carlos Donayre, George Kopchok, Irwin Walot, Eric Wilson, and Christian deVirgilio. "Intravascular Ultrasound: The Ultimate Tool for Abdominal Aortic Aneurysm Assessment and Endovascular Graft Delivery." Journal of Endovascular Therapy 4, no. 1 (February 1997): 45–55. http://dx.doi.org/10.1177/152660289700400109.

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Intravascular ultrasound (IVUS) imaging is a relatively new, rapidly evolving technology that enables precise catheter-based assessment of the dimensions and morphology of vascular structures and lesions. In extensive preclinical laboratory developmental studies and in clinical cases of endograft deployment for treatment of abdominal aortic aneurysms, we have found IVUS invaluable for determining key parameters of aortic morphology before and during interventions and for assessing the accuracy of deployment after device placement. By combining the IVUS data with information obtained from angiography, magnetic resonance imaging, and computed tomography (axial and three-dimensional reconstructions), we have been able to size devices and choose optimal fixation sites to prevent endoleaks and maintain luminal patency acutely and in the long term.

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Manta, Ringo, Chiara Lauri, Maurizio Taurino, and Alberto Signore. "Imaging of Vascular Graft/Endograft Infection with Radiolabeled White Blood Cell Scan and [18F]FDG PET/CT." Hemato 4, no. 4 (September 22, 2023): 285–300. http://dx.doi.org/10.3390/hemato4040023.

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Diagnosis of vascular graft/endograft infection (VGEI) is a challenge for clinicians due to the heterogeneity of clinical presentation and the complexity of its management. Microbiological culture is the gold standard, but it often fails to isolate the causative microorganism. A non-invasive imaging approach is therefore needed to assess VGEI. CTA is currently the first-choice imaging modality. Nuclear medicine techniques are recommended in case of negative or doubtful CTA results with persisting clinical suspicion. This review aims to summarize data from original studies published in the last decades regarding the role of both white blood cell (WBC) scans and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT), their respective diagnostic performances, and their integration into the diagnostic approach for patients with a suspicion of VGEI.

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Xiong, Jiang, Meng Liu, Wei Guo, Xiaoping Liu, Tai Yin, Xin Jia, Lijun Wang, Xiaohui Ma, and Hongpeng Zhang. "A retrospective study on endovascular management of iatrogenic vascular injuries." Vascular 20, no. 2 (April 2012): 65–71. http://dx.doi.org/10.1258/vasc.2011.oa0327.

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The purpose of this study was to evaluate the outcome of endovascular management of iatrogenic vascular injuries (IVIs). We retrospectively reviewed the clinical records of 19 consecutive patients who underwent endovascular therapy of IVIs. Endograft implantation was conducted in 13 patients, intravascular embolization using coil was performed in four patients, combined treatment involving endovascular balloon intervention and percutaneous thrombin injection was done in one patient and the remaining one patient received balloon compression for hemostasis. There were no deaths after the operation. In the patients with vessel rupture ( n = 9) or perforation ( n = 4), cessation of bleeding and restoration of blood flow were achieved following the endovascular treatments. Four cases of pseudoaneurysm and one case of arteriovenous fistula were successfully eliminated. At a median follow-up of 23.8 months (range 4–84), one patient suffered a mild cerebral infarction secondary to covered stent placement and one patient developed a partial renal infarction secondary to coil embolization. Additionally, stent collapse was found in one patient with stenosis of the iliofemoral vein, accounting for the failure to resolve the lower limb edema. In conclusion, endovascular therapy is an effective technique in the management of different types of IVIs, but is associated with minor ischemic complications.

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Puttini, Ilaria, Marvin Kapalla, Anja Braune, Enrico Michler, Joselyn Kröger, Brigitta Lutz, Natzi Sakhalihasan, et al. "Aortic Vascular Graft and Endograft Infection–Patient Outcome Cannot Be Determined Based on Pre-Operative Characteristics." Journal of Clinical Medicine 13, no. 1 (January 3, 2024): 269. http://dx.doi.org/10.3390/jcm13010269.

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Vascular graft/endograft infection (VGEI) is a serious complication after aortic surgery. This study investigates VGEI and patient characteristics, PET/CT quantification before surgical or conservative management of VGEI and post-intervention outcomes in order to identify patients who might benefit from such a procedure. PET standard uptake values (SUV) were quantitatively assessed and compared to a non-VGEI cohort. The primary endpoints were in-hospital mortality and aortic reintervention-free survival at six months. Ninety-three patients (75% male, 65 ± 10 years, 82% operated) were included. The initial operation was mainly for aneurysm (67.7%: 31% EVAR, 12% TEVAR, 57% open aortic repair). Thirty-two patients presented with fistulae. PET SUVTLR (target-to-liver ratio) showed 94% sensitivity and 89% specificity. Replacement included silver-coated Dacron (21.3%), pericardium (61.3%) and femoral vein (17.3%), yet the material did not influence the overall survival (p = 0.745). In-hospital mortality did not differ between operative and conservative treatment (19.7% vs. 17.6%, p = 0.84). At six months, 50% of the operated cohort survived without aortic reintervention. Short- and midterm morbidity and mortality remained high after aortic graft removal. Neither preoperative characteristics nor the material used for reconstruction influenced the overall survival, and, with limitations, both the in-hospital and midterm survival were similar between the surgically and conservatively managed patients.

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Gilemkhanov, A. R., V. V. Plechev, A. A. Bakirov, R. F. Safin, R. E. Abdrakhmanov, S. I. Blagodarov, T. R. Ibragimov, and I. M. Gilemkhanova. "Surgical Treatment for Branched Endograft Thrombosis of the Abdominal Aorta." Creative surgery and oncology 13, no. 3 (October 5, 2023): 244–48. http://dx.doi.org/10.24060/2076-3093-2023-13-3-244-248.

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Introduction. Endovascular intervention was firstly introduced for repairing aortic aneurysms in the early 1990s. The greatest advantage of endovascular aneurysm repair (EVAR) is its minimally-invasive character, thus implying shorter post-operative period. The operative mortality rate comprises 3.3 % (95 % CI 2.9–3.6); however, according to recent studies, the rate has declined to 1.4 % due to a rapid improvement in outcomes. According to the DREAM-trial, the incidence of a branched endograft thrombosis accounts for 6.4% within the first 30 days. The EVAR trial reports an incidence of 2.6% after the first year of follow-up. Stent bending and small distal aortic diameters (less than 20 mm) are believed to be the most common causes of endograft thrombosis.Aim. To identify the causes of complications following the abdominal aortic stent-graft repair and to determine the optimal treatment strategy.Materials and methods. The paper presents a case of 71-year-old patient with late complication after endovascular abdominal aortic repair of an infrarenal aortic aneurysm. The patient was admitted to the hospital on January 05, 2020 as an emergency due to the pain in the left lower limb. On December 03, 2019 the patient underwent endovascular abdominal aortic repair. Angiography of January 06, 2020 revealed thrombosis of the left branch of the stent graft. Thrombectomy of the brunched left stent graft, left iliac artery and balloon dilatation of the brunched left stent-graft were performed.Results and discussion. Endovascular abdominal aortic repair stands as the first choice for patients with appropriate aortic anatomy and those with significant comorbidity. Despite the significant progress in endovascular abdominal aortic repairing, the EVAR procedure is followed by a nearly fivefold increase in the 30-day reintervention rate as compared to open surgery which comprises 9.8 % according to the EVAR-I, and 18 %, according to the EVAR-II trials.Conclusion. Our multidisciplinary team consisted of vascular and endovascular surgeons managed to perform hybrid surgery, thus eliminating the EVAR-associated complication together with its cause.

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Mansour, Wassim, Pasqualino Sirignano, Laura Capoccia, and Francesco Speziale. "Pressure injury to the chest wall caused by vascular graft and endograft after thoracic and thoraco-abdominal aortic repair." Interactive CardioVascular and Thoracic Surgery 29, no. 4 (June 10, 2019): 649–51. http://dx.doi.org/10.1093/icvts/ivz127.

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Abstract Thoracic and thoraco-abdominal aortic repair remains a challenging issue in vascular surgery, and long-term complications are well described. We report 2 cases of octogenarians with unusual long-term complications after open and endovascular thoracic aortic repair of chest wall pressure injury from the vascular prosthesis. In the first case, a computed tomographic scan of an 80-year-old man showed a pressure injury of the chest wall and rib erosion caused by a Dacron graft. The second case was an 81-year-old woman who presented with external bleeding from the left posterior chest wall. A computed tomographic scan showed a type IA endoleak and chest wall damage with rib erosion and thoracic cutaneous fistulae from the endovascular graft. Both patients were treated by relining the endovascular graft; debriding the surgical fistula was done only in the second case. In our experience, endovascular repair is a good option to avoid a complete open surgical repair.

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Nordanstig, Joakim, Kristina Törngren, Kristian Smidfelt, Håkan Roos, and Marcus Langenskiöld. "Deep Femoral Vein Reconstruction of the Abdominal Aorta and Adaptation of the Neo-Aortoiliac System Bypass Technique in an Endovascular Era." Vascular and Endovascular Surgery 53, no. 1 (September 19, 2018): 28–34. http://dx.doi.org/10.1177/1538574418801100.

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Background: Primary infection of the abdominal aorta is a rare pathology that may threaten the integrity of the aortic wall, while secondary aortic prosthesis infection represents a devastating complication to open surgical and endovascular aortic surgery. Curative treatment is achievable by removal of all infected prosthetic material followed by a vascular reconstruction. Design and Methods: Twelve consecutive patients treated with the neo-aortoiliac system bypass (NAIS) procedure were reviewed. Nine were treated for a secondary aortic prosthesis infection (tube graft n = 3, bifurcated graft n = 4, endovascular aortic repair (EVAR) stent graft n = 1, and fenestrated EVAR [FEVAR] stent graft n = 1), while 3 patients underwent NAIS repair due to an emergent primary mycotic aortoiliac aneurysm. Primary Results: Ten of 12 patients survived 30 days. Three patients were operated on acutely, and 9 patients had elective or subacute NAIS surgery. Two of 3 patients operated acutely died within 30 days, whereas no 30-day or 1-year mortality was observed in patients undergoing elective or subacute surgery. The median time from primary reconstruction to the NAIS procedure was 11 months (range: 0-201 months). Stent grafts (n = 5 of 12) were in 4 cases explanted using endovascular balloon clamping. Of the explanted endografts, 2 patients presented with a secondary graft infection after EVAR/FEVAR, while 3 patients had been emergently treated with endovascular cuffs as a “bridge-to-surgery” procedure due to aortoenteric fistula (AEF). Patients who received a “bridge-to-surgery” regimen were treated with the NAIS procedure within 8 weeks (median 27 days, range: 27-60) after receiving emergency stent grafting. Principal Conclusions: Aortic balloon-clamping during explantation of infected aortic prosthetic endografts is feasible and facilitates complete endograft removal. Endovascular bridging procedures could be beneficiary in the treatment of AEF or anastomotic dehiscence due to graft infection, offering a possibility to convert the acute setting to an elective definitive reconstructive procedure with a higher overall success rate.

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Ascoli Marchetti, Andrea, Fabio Massimo Oddi, Nicolò Diotallevi, Martina Battistini, and Arnaldo Ippoliti. "An unusual complication after endovascular aneurysm repair for giant abdominal aortic aneurysm with aortocaval fistula: High bilirubin levels." SAGE Open Medical Case Reports 8 (January 2020): 2050313X2098432. http://dx.doi.org/10.1177/2050313x20984322.

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Abdominal aortic aneurysm has among its rare complications the aortocaval fistula. It is observed in less than 1% of all abdominal aortic aneurysms and represents 3%–7% of clinical presentation in case of rupture. A male patient was presented to the emergency department with pulsating mass with continuous vascular systo-diastolic bruit, located in the lower part of abdomen with the back pain radiating anteriorly in lower abdomen. After diagnosis of abdominal aortic aneurysm with aortocaval fistula, a trimodular Endurant endograft was placed. Migration of the endoprosthesis was treated with Endoanchor and endovascular aneurysm sealing device. In the postoperative course, the patient had jaundice due to high bilirubin levels, cholestasis and increased hepatocyte cytolysis: aspartate aminotransferase and alanine aminotransferase. The treatment with appropriate continuous filtration rapidly reduced bilirubin values and the patient gradually improved.

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Ge, Shuxiong, Zhongyou Xu, and Jinlin Yan. "Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report." Medicine 103, no. 10 (March 8, 2024): e37410. http://dx.doi.org/10.1097/md.0000000000037410.

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Rationale: Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft. Patient concerns: A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours. Diagnoses: Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA. Interventions: Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery. Outcomes: The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery. Lessons: This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

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Taher, Fadi, Juergen Falkensammer, Joseph Nguyen, Miriam Uhlmann, Edda Skrinjar, and Afshin Assadian. "Assessing the institutional learning curve for pararenal aortic repair using the fenestrated Anaconda endograft." Vascular 27, no. 1 (September 11, 2018): 46–50. http://dx.doi.org/10.1177/1708538118799132.

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Objective Custom-made fenestrated aortic endografts allow exclusion of pararenal aortic aneurysms while maintaining blood flow to aortic branches. Meticulous device planning and precise deployment of the main body are essential to allow successful cannulation of the fenestrations. This study investigates whether a learning curve can be observed with more reliable cannulation and connection of fenestrations over time at a single department of vascular and endovascular surgery with multiple surgeons trained to use the device. Methods A retrospective analysis of data from all patients undergoing primary fenestrated endovascular aneurysm repair during the study period was performed. Outcome measures included case volume and average number of fenestrations over time, average fluoroscopy dose area product per calendar year and primary unconnected fenestration and 30-day mortality rates. Results Between 1 January 2013 and 31 December 2016, 89 patients with no history of endovascular aneurysm repair underwent fenestrated endovascular aneurysm repair at our institution. The number of fenestrations per case increased over time, averaging 2.6 in 2013 and 3.3 in 2016. Primary unconnected fenestration and 30-day mortality rates were 5.6%. Primary-assisted technical success was 93.3%, secondary-assisted technical success was 94.4%. Fluoroscopy dose area product declined over the study period. Thirty-day mortality and primary unconnected fenestration rates did not significantly change over the study period. Conclusion Albeit the reduction in lethal complications and primary technical success rates were not statistically significant, a lower percentage of unconnected fenestrations and 30-day mortality per calendar year were observed over time. At the same time, an increasing complexity of performed cases, as reflected by an increasing number of fenestrations per case, was observed. Complications associated with this complex endovascular procedure are potentially lethal and remain an unfortunate reality and may not be entirely dependent on overcoming a learning curve. A higher volume of cases performed over the study period and a reduction in fluoroscopy use can be considered a representation of the institutional development and learning curve for the Anaconda fenestrated endograft at a department with prior complex endovascular aortic repair experience, but due to limitations of the current retrospective observation, deserve further consideration in future trials, ideally designed in a prospective fashion.

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Lauri, Chiara, Alberto Signore, Giuseppe Campagna, Francesco Aloisi, Maurizio Taurino, and Pasqualino Sirignano. "[18F]FDG Uptake in Non-Infected Endovascular Grafts: A Retrospective Study." Diagnostics 13, no. 3 (January 23, 2023): 409. http://dx.doi.org/10.3390/diagnostics13030409.

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Purpose: After endovascular aneurysm repair (EVAR), an increased [18F]FDG uptake may be observed at PET/CT, being common to both vascular graft/endograft infection (VGEI) and sterile post-surgical inflammation. Increased non-specific metabolic activity, due to foreign body reaction, can persist for several years after surgery, thus complicating the interpretation of PET/CT studies. In this paper, we aimed to assess [18F]FDG distribution at different time-points after the implant of abdominal Endurant® endografts in patients without suspicion of infection. Methods: We retrospectively evaluated [18F]FDG/CT in 16 oncological patients who underwent abdominal aortic aneurysm exclusion with Endurant® grafts. Patients had no clinical suspicion of infection and were followed up for at least 24 months after scan. [18F]FDG PET/CT scans were interpreted using both visual and semi-quantitative analyses. Results: The time between the EVAR procedure and [18F]FDG PET/CT ranged between 1 and 36 months. All grafts showed mild and diffuse [18F]FDG uptake without a focal pattern. Mean values of SUVmax were 2.63 ± 0.48 (95% CI 2.38–2.88); for SUVmean 1.90 ± 0.33 (95% CI 1.72–2.08); for T/B ratios 1.43 ± 0.41 (95% CI 1.21–1.65). SUVmax and SUVmean were not correlated to the time elapsed from the procedure, but we observed a declining trend in T/B ratio over time. Conclusions: Endovascular implant of Endurant® grafts does not cause a significant inflammatory reaction. The evidence of faint and diffuse [18F]FDG uptake along the graft can reliably exclude an infection, even in early post-procedural phases. Therefore, in patients with a low probability of VGEI, [18F]FDG PET/CT can also be performed immediately after EVAR.

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Kragsterman, Björn, Martin Björck, and Anders Wanhainen. "EndoVAC, a Novel Hybrid Technique to Treat Infected Vascular Reconstructions With an Endograft and Vacuum-Assisted Wound Closure." Journal of Endovascular Therapy 18, no. 5 (October 2011): 666–73. http://dx.doi.org/10.1583/11-3465.1.

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Wiske, Clay, Jason T. Lee, Caron Rockman, Frank J. Veith, Neal Cayne, Mark Adelman, and Thomas Maldonado. "Practice Patterns of Fenestrated Aortic Aneurysm Repair: Nationwide Comparison of Z-Fen Adoption at Academic and Community Centers Since Commercial Availability." Vascular and Endovascular Surgery 52, no. 6 (May 29, 2018): 434–39. http://dx.doi.org/10.1177/1538574418776440.

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Context: Over the past decade, a number of endovascular approaches have evolved to treat aortic aneurysms with anatomy that is not amenable to traditional endovascular repair, although the optimal practice and referral patterns remain in question. The Zenith fenestrated (Z-Fen) endograft (Cook Medical) represents the first commercially available fenestrated graft product in the United States. Objective: We aim to quantify practice patterns in Z-Fen use during the first 5 years of commercial availability, and we identify predictors of high and low uptake. Design, Setting, and Patients: This is a retrospective review of complete order records for Z-Fen endografts since June 2012. We performed univariate and multivariate regressions of predictors that surgeons and centers would be in the top and bottom quartiles of annual Z-Fen use. Results: Since June 15, 2012, 744 surgeons have been trained to use Z-Fen, and 4133 cases have been performed at 409 trained centers. The average annual number of cases per trained surgeon was 4.46 [95% confidence interval (CI), 3.58-5.70]; however, many surgeons performed few or no cases following training, and there was a skew toward users with low average annual volumes (25th percentile 1.23, 50th percentile 2.35, 75th percentile 4.93, and 99th percentile 33.29). Predictors of high annual use in the years following training included academic center (aOR 5.87, P = .001) and training within the first 2 years of availability (aOR 46.23, P < .001). Conclusion: While there is literature supporting the safety and efficacy of Z-Fen, adoption has been relatively slow in an era when the vast majority of vascular surgeons have advanced endovascular skills. Given the training and resources required to use fenestrated or branched aortic endovascular devices, referral patterns should be determined and training should be focused on centers with high expected volumes.

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Reyes Valdivia, Andrés, Sara Busto Suárez, África Duque Santos, Ahmad Amer Zanabili Al-Sibbai, Claudio Gandarias Zúñiga, and Arindam Chaudhuri. "Evaluation of EndoAnchor Aortic Wall Penetration After Thoracic Endovascular Aortic Repair." Journal of Endovascular Therapy 27, no. 2 (March 18, 2020): 240–47. http://dx.doi.org/10.1177/1526602820907564.

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Purpose: To analyze aortic wall penetration of Heli-FX EndoAnchors after use in seal zones in the aortic arch or descending thoracic aorta during thoracic endovascular aortic repair (TEVAR). Materials and Methods: From May 2014 to May 2019, 25 patients (mean age 70.5±10 years; 16 women) were treated with TEVAR and adjunctive use of the Heli-FX device in 3 academic vascular surgery departments. Computed tomography scans were retrospectively reviewed to determine the location [arch or descending thoracic aorta (DTA)] of the EndoAnchors and the adequacy of aortic wall penetration, defined as adequate (≥2 mm), partial (<2 mm), or inadequate wall penetration (including loss). Endoleaks, reinterventions, and mortality were assessed. Results: A total of 161 EndoAnchors were deployed (median 7 per patient, range 4–9). Twenty-two EndoAnchors were place in the arch (zones 0–2) and 139 in the DTA (zones 3–5). A larger proportion of arch deployments (27%) had suboptimal penetration compared with the DTA (6.5%; p<0.005), resulting in a 91% adequate wall penetration rate for the series overall. Three EndoAnchors were lost (and only 1 retrieved) in 3 different patients, with no additional morbidity; thus, an overall deployment success rate of 88% was achieved. At a mean follow-up of 16.6±14 months, 4 patients required 5 (successful) reinterventions, including one for a type Ia endoleak treated with chimney TEVAR. One patient died 10 months after treatment due to endograft infection, without an opportunity for surgical correction. Conclusion: EndoAnchors have a higher risk of maldeployment in the arch, though this may be attributable to the small learning curve experience in this location. The best aortic wall penetration for this series was in the DTA, where EndoAnchors proved useful for distal endograft fixation during TEVAR.

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Krajcer, Zvonimir, and Edward B. Diethrich. "Successful Endoluminal Repair of Arterial Aneurysms by Wallstent Prosthesis and PTFE Graft: Preliminary Results with a New Technique." Journal of Endovascular Therapy 4, no. 1 (February 1997): 80–87. http://dx.doi.org/10.1177/152660289700400115.

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Purpose: To describe a new method of endovascular aneurysm exclusion using a Wallstent-PTFE vascular prosthesis in patients at high risk for surgery. Methods and Results: Two patients with significant comorbidities refused surgery in favor of endoluminal grafting for treatment of aneurysms in the abdominal aorta and popliteal artery, respectively. Both endovascular procedures were performed percutaneously with local anesthesia using a low-profile customized endograft constructed of thin-walled, predicted polytetrafluoroethylene (PTFE) graft mounted on a Wallstent. In both cases, the aneurysm was excluded from the arterial circulation; there were no postprocedural complications. Follow-up evaluation with appropriate imaging at 8 months (popliteal aneurysm) and 2 months (abdominal aneurysm) revealed no endoleaks. Conclusions: Our preliminary results indicate that the Wallstent-PTFE graft, with its smaller diameter and flexible design, offers significant advantages over currently available devices for repair of arterial aneurysms. This method obviates the need for general anesthesia or surgical exposure for arterial repair, which would increase the risk of the procedure in these patients.

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Jim, Jeffrey, Brian G. Rubin, Patrick J. Geraghty, and Luis A. Sanchez. "Long-term outcomes of endovascular aneurysm repair for challenging aortic necks using the Talent endograft." Vascular 19, no. 3 (June 2011): 132–40. http://dx.doi.org/10.1258/vasc.2011.oa0286.

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The aim of the present paper is to evaluate the long-term outcomes of endovascular aneurysm repair (EVAR) for challenging aortic necks. Subgroup analyses were performed on 156 patients from the prospective multicenter Talent eLPS (enhanced Low Profile Stent Graft System) trial. Patients with high-risk aortic necks (length < 15 mm or diameter ≥28 mm) were compared with the remaining patients. Patients with high-risk ( n = 86) and low-risk necks ( n = 70) had similar age and gender distribution. Despite similar prevalences of co-morbidities, the high-risk group had higher Society for Vascular Surgery scores. The high-risk group also had larger maximum aneurysm diameters (56.6 versus 53.0 mm, P < 0.02). There were lower freedoms from major adverse events (MAEs) for the high-risk group at 30 days (84.9 versus 95.7%; P < 0.04) and 365 days (73.4 versus 89.2%; P = 0.02). Effectiveness endpoints at 12 m showed no significant differences. Freedom from all-cause mortality at 30 days (96.5 versus 100%) and aneurysm-related mortality at 365 days (96.0 versus 100%) were similar. At five years, there were no differences in endoleaks or change in aneurysm diameter. All migrations occurred in the high-risk group. The five-year freedom from aneurysm-related mortality for the high- and low-risk groups was 93.2 and 100%, respectively. In conclusion, despite a higher rate of MAEs within the first year and higher migration rates at five years, EVAR in aneurysms with challenging aortic necks can be treated with acceptable long-term results.

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Anagnostopoulos, A., F. Mayer, B. Ledergerber, J. Bergadà-Pijuan, L. Husmann, C. A. Mestres, Z. Rancic, and B. Hasse. "Validation of the Management of Aortic Graft Infection Collaboration (MAGIC) Criteria for the Diagnosis of Vascular Graft/Endograft Infection: Results from the Prospective Vascular Graft Cohort Study." Journal of Vascular Surgery 74, no. 3 (September 2021): 1046. http://dx.doi.org/10.1016/j.jvs.2021.07.098.

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Hendricks, D. E., K. D. Hagspiel, J. F. Angle, B. Arslan, U. C. Turba, U. Bozlar, M. H. Alan, and M. D. Dake. "Abstract No. 279: Amplatzer® Vascular Plug Occlusion of the Left Subclavian or Celiac Artery Prior to Endograft Aneurysm Repair." Journal of Vascular and Interventional Radiology 19, no. 2 (February 2008): S104. http://dx.doi.org/10.1016/j.jvir.2007.12.316.

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van Rijsewijk, Nick D., Jasper H. G. Helthuis, Andor W. J. M. Glaudemans, Marjan Wouthuyzen-Bakker, Niek H. J. Prakken, David J. Liesker, Ben R. Saleem, and Riemer H. J. A. Slart. "Added Value of Abnormal Lymph Nodes Detected with FDG-PET/CT in Suspected Vascular Graft Infection." Biology 12, no. 2 (February 5, 2023): 251. http://dx.doi.org/10.3390/biology12020251.

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Vascular graft and endograft infections (VGEI) cause a serious morbidity and mortality burden. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is frequently used in the diagnostic workup, but the additional value of abnormal (18F-FDG active and/or enlarged) locoregional lymph nodes is unknown. In this retrospective study, the additional diagnostic value of abnormal locoregional lymph nodes on 18F-FDG PET/CT imaging for VGEI was evaluated, including 54 patients with a culture-proven VGEI (defined according to the Management of Aortic Graft Infection [MAGIC] group classification) and 25 patients without VGEI. 18F-FDG PET/CT was qualitatively and quantitatively assessed for tracer uptake and pattern at the location of the vascular graft, and locoregional lymph node uptake and enlargement (>10 mm). 18F-FDG uptake intensity and pattern independently predicted the presence of VGEI by logistic regression (Χ2: 46.19, p < 0.001), with an OR of 7.38 (95% CI [1.65, 32.92], p = 0.009) and 18.32 (95% CI [3.95, 84.88], p < 0.001), respectively. Single visual assessment of abnormal locoregional lymph nodes predicted the presence of VGEI with a sensitivity of 35%, specificity of 96%, PPV of 95%, and NPV of 41%. The visual assessment of abnormal lymph nodes after qualitative assessment of 18F-FDG uptake intensity and pattern at the vascular graft location did not independently predict the presence of VGEI by logistic regression (Χ2: 3.60, p = 0.058; OR: 8.25, 95% CI [0.74, 63.37], p = 0.096). In conclusion, detection of abnormal locoregional lymph nodes on 18F-FDG PET/CT has a high specificity (96%) and PPV (95%) for VGEI. However, it did not add to currently used 18F-FDG PET/CT interpretation criteria.

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van Dorp, Martijn, Martijn Gilbers, Patrick Lauwers, Paul Van Schil, and Jeroen M. H. Hendriks. "Local Anesthesia for Percutaneous Thoracic Endovascular Aortic Repair." AORTA 04, no. 03 (June 2016): 78–82. http://dx.doi.org/10.12945/j.aorta.2016.16.002.

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Background: Thoracic endovascular aortic repair (TEVAR) requires large-bore vascular access due to the considerable diameters of the endoprosthesis and delivery device. The preclose technique preceding endograft delivery has opened the door for an evolved access strategy. In addition, treatment under local anesthesia offers the advantage of optimal neuromonitoring. The goal of this study was to analyze the efficacy and safety of percutaneous TEVAR under local anesthesia. Methods: All patients undergoing TEVAR in an elective setting at the Antwerp University Hospital between June 2012 and June 2015 were prospectively entered into an endovascular database. This database was queried for demographics, procedural details, and access-related complications. All patients underwent a percutaneous approach with the Perclose Proglide under local anesthesia. Results: This review identified 34 patients in whom 37 percutaneous TEVAR procedures were completed under local anesthesia. All patients experienced adequate analgesia, and no conversions to general anesthesia were implemented. The mean size of the arteriotomy was 23.8 ± 1.3 French (F). The number of Proglide deployments was 80, with an 8% rate of failure on deployment. There were no conversions to surgical cutdown, and adequate hemostasis was obtained in all procedures. The incidence of postprocedural access-related complications was 3%. Conclusion: Local anesthesia for percutaneous TEVAR can be performed safely and effectively. The percutaneous approach facilitates local anesthesia, which provides the added benefit of early recognition of neurologic complications while maintaining a low risk of access-related complications despite the need for large-bore vascular access.

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