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      Is Open Access

      Type IIIB endoleak caused by fabric erosion after thoracic endovascular aneurysm repair

      , MD, , MD, PhD, , MD, PhD

      Journal of Vascular Surgery Cases and Innovative Techniques

      Elsevier

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          Abstract

          A 78-year-old man who had undergone coronary artery bypass grafting and thoracic endovascular aortic repair (TEVAR) for a descending aortic aneurysm 7 years ago (A) developed chest pain. At the initial TEVAR, two stent grafts (Talent; Medtronic, Santa Rosa, Calif) were used; the distal stent graft (34 × 115 mm) was deployed first, and the proximal stent graft (36 × 114 mm) was deployed inside the distal stent graft. Contrast-enhanced computed tomography (CT) revealed rupture of the descending aneurysm with weak enhancement of the thrombus outside the stent graft (B). The rupture was diagnosed to be due to type II endoleak, and emergent replacement of the descending aorta was indicated. The aneurysm was exposed through the fourth intercostal space, and femorofemoral partial cardiopulmonary bypass was established with systemic heparinization. Inside the aneurysm, blood flowing out through the hole of the upper stent graft was detected (C). Both stent grafts were partially removed, and 28-mm Gelweave (Vascutek Terumo, Inchinnan, Glasgow, United Kingdom) was anastomosed to the residual stent grafts and native aorta. His postoperative course was vuneventful except for refixation of the rib, and he was discharged home 3 weeks later. Postoperative CT revealed patency of the graft (A). Detailed review of the past CT scan revealed that the bare stent of the distal stent graft had dug into the fabric of the proximal stent graft on the minor curvature (C). At this portion, the erosion was not found 2 years and 5 years after TEVAR but was detected at 7 years with rupture (D). Consent for the publication of images was obtained from the patient in a written form. Discussion Type III endoleak after TEVAR is rare.1, 2, 3 In a controlled trial, it was encountered in 1 of 160 patients. 2  The leak through a defect in graft fabric due to the fractures or holes involving the endograft is defined as type IIIB. Ellozy et al 4 stated that the stiff longitudinal spine of the Talent stent graft can be disadvantageous in the severely angulated neck. In this patient, fabric erosion occurred because of the compression of the bare stent outside, which did not align with the minor curvature and stood straight against the curved proximal stent graft. Recent improvement of the flexibility of the stent graft might contribute to prevention of this complication after TEVAR.

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          Most cited references 4

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          International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results.

          This trial evaluated the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) with a contemporary endograft system compared with open surgical repair (open) of descending thoracic aortic aneurysms and large ulcers. Forty-two international trial sites enrolled 230 subjects with descending thoracic aortic aneurysms or ulcers. The study compared 160 TEVAR subjects treated with the Zenith TX2 Endovascular Graft (William Cook Europe, ApS, Bjaeverskov, Denmark) with 70 open subjects. Subjects were evaluated preprocedure, predischarge, 1, 6, and 12 months, and yearly through 5 years with medical examination, laboratory testing, chest radiographs, and computed tomography scans. Mortality rates, prespecified severe morbidity composite index, major morbidity, clinical utility, aneurysm rupture, and secondary interventions were compared. The TEVAR subjects were evaluated by a core laboratory for device performance, including change in aneurysm size, endoleak, migration, and device integrity. The 30-day survival rate was noninferior (P 10 mm) in 2.8% (3/107), and other device issues were rare. None of the patients with migration experienced endoleak, aneurysm growth, or required a secondary intervention. Thoracic endovascular aortic repair with the TX2 is a safer and effective alternative to open surgical repair for the treatment of anatomically suitable descending thoracic aortic aneurysms and ulcers at 1 year of follow-up. Device performance issues are infrequent, but careful planning and regular follow-up with imaging remain a necessity.
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            Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned.

            Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms. Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months). Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%). While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.
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              Thoracic aortic stent grafting: improving results with newer generation investigational devices.

              Six years ago an endovascular program for repair of descending thoracic aneurysms was established at the University of Pennsylvania. We report on the hypothesis that results are improving with new stent design iterations and describe our experience and lessons learned. From April 1999 to March 2005, 99 patients with descending thoracic aneurysms underwent repair with a first or second-generation commercially produced endograft; 24 patients had an early-generation device, and 75 patients had a late-generation device. Each patient was enrolled as part of 3 distinct Phase I or Phase II Food and Drug Administration-approved clinical trials in accordance with strict inclusion and exclusion criteria. Mean age was 73.1 years. Symptomatic aneurysms accounted for 42% of the cohort. Mean aneurysm size was 63.7 mm (range: 30-105 mm). Twenty percent of the patients underwent a subclavian carotid transposition or bypass preoperatively to obtain an adequate proximal landing zone. No procedures had to be aborted. In-hospital or 30-day mortality was 5.0%. The incidence of permanent spinal ischemia was 2%. Perioperative vascular complications requiring interposition graft, stent repair, or patch angioplasty occurred in 27% and seemed to be less frequent in the late-generation cohort than the early-generation cohort (22.7% vs 41.7%, respectively, P = .069). At the 30-day follow-up, 23 endoleaks were detected in 22 patients (14.7% in late-generation cohort vs 45.8% in early-generation cohort, P = .001). During the follow-up period, 3 new endoleaks were detected, 3 patients died of aortic rupture, and 10 patients underwent aneurysm-related reintervention. Kaplan-Meier estimated 1, 3, and 5-year survival was 84.5%, 70.5%, and 52.4%, respectively. Freedom from aneurysm-related event, defined as freedom from endoleak, aortic rupture, dissection, or any reintervention on the aorta, was 73%, 69%, and 64% at 1, 3, and 5 years, respectively. Thoracic aortic stent grafting is a safe procedure in selected patients with the added benefit of a low incidence of paraplegia. However, there is an incidence of late complications and reinterventions. This risk requires further quantification and must be balanced against the benefits of a minimally invasive approach with low perioperative morbidity and mortality. Results are improving as technology evolves and our level of experience increases. Radiologic follow-up is mandatory.
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                Author and article information

                Contributors
                Journal
                J Vasc Surg Cases Innov Tech
                J Vasc Surg Cases Innov Tech
                Journal of Vascular Surgery Cases and Innovative Techniques
                Elsevier
                2468-4287
                30 April 2018
                June 2018
                30 April 2018
                : 4
                : 2
                : 173-174
                Affiliations
                Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
                Article
                S2468-4287(18)30043-1
                10.1016/j.jvscit.2018.01.009
                6012986
                © 2018 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Vascular image

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