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In situ fenestration of stent-graft represents a potential option for the treatment of aortic diseases in patients unsuitable for standard endovascular repair. The best fenestration strategy to restore perfusion of collateral vessels after their coverage by an endograft depends mainly on the anatomical area. Several tools are employed as fenestration devices, including needles, radiofrequency probes, and laser systems, used in conjunction with other instrumentation to provide enough support and stability during the procedure. In this systematic review, the approaches to reach the correct fenestration site both in human, animal, and in in vitro environments are described and discussed, highlighting advantages and limitations. Both commercial and dedicated solutions for the intraoperative modification of the fabric material are reported as well. The clinical interest in this procedure has so far encouraged researchers to develop and refine both methods and tools to solve the current limitations of this technique, intending to extend the indications for endovascular treatment to a broader range of patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of the study is to evaluate the safety and effectiveness of common femoral endarterectomy (CFE) in critical limb ischemia (CLI) associated with proximal and distal endovascular (EV) revascularization in diabetic (type 1 and type 2) and non-diabetic patients. PATIENTS AND METHODS: We analyzed patients from January 2008 to December 2011 who underwent one-staged hybrid procedures. Patients were divided into three groups: group 1 = EV reconstruction proximal to the CFE, group 2 = EV procedures distal to the CFE, group 3 = both proximal and distal EV procedures. Patients were evaluated at 6 and 36 months after the procedures, and the mean follow-up was 42 ± 20.3 months. RESULTS: A total of 43 (79% men; aged 74.4 ± 8.6 years) out of 635 (5.5%) patients operated for CLI fulfilled the inclusion criteria; 23 (53.5%) had type 1 or type 2 diabetes mellitus (DM). DM patients were younger than controls (p = 0.048). The patient distribution was 14 in Group 1 (32.5%), 24 in Group 2 (55.8%) and 5 in Group 3 (11.7%). CFE was successful in all cases, while associated EV procedures were successful in 90.7% of patients. Peri-operative morbidity and mortality were 11.6% and 2.3%, respectively. Survival rates at 6 and 36 months were 93% and 71.9%, respectively. Three patients (6.98%) underwent a major amputation. The cumulative limb salvage was 95.2% at 6 months and 92.1% at 36 months. No recurrent CFE stenosis was observed. No differences in survival, amputation or patency rates emerged between DM and non-DM patients or among the three EV revascularization groups. CONCLUSIONS: Hybrid procedures are safe and effective both in CLI patients with or without DM, and they should be taken into consideration whenever indications are present. [ABSTRACT FROM AUTHOR]

Objective: This work aims at providing novel endovascular instrumentation to overcome current technical limitations of in situ endograft fenestration including challenges in targeting the fenestration site under fluoroscopic control and supplying mechanical support during endograft perforation. Technology: Novel electromagnetically trackable instruments were developed to facilitate the navigation of the fenestration device and its stabilization at the target site. In vitro trials were performed to preliminary evaluate the proposed instrumentation for the antegrade in situ fenestration of an aortic endograft, using a laser guidewire designed ad hoc and the sharp end of a commercial endovascular guidewire. Results: In situ fenestration was successfully performed in 22 trials. A total of two laser tools were employed since an over bending of laser guidewire tip, due to its manufacturing, caused the damage of the sensor in the first device used. Conclusions: Preliminary in vitro trials demonstrate the feasibility of the proposed instrumentation which could widespread the procedure for in situ fenestration. The results obtained should be validated performing animal studies. Clinical Impact: The proposed instrumentation has the potential to expand indications for standard endovascular aneurysm repair to cases of acute syndromes.

Objectives: The purpose of this in vitro study was to clinically assess the feasibility of a three-dimensional (3D) electromagnetic (EM) navigator, including sensorized catheters and guidewires, to determine any reduction in radiation dose and contrast medium injection., Methods: The study was performed using a navigator prototype developed at the EndoCAS center. The system includes catheters and guidewires simultaneously tracked with an EM localizer (Aurora, Northern Digital, Waterloo, Canada). Tests were performed on a commercial abdominal aortic aneurysm model. Fifteen operators were asked to cannulate renal arteries using the conventional fluoroscopic guidance and the EM navigator without fluoroscopic support. Each trial was video-recorded and analyzed for timing and success of completing the cannulation task by two blinded and independent observers. Performances were also qualitatively evaluated using the Imperial College Endovascular Cannulation Scoring Tool (IC3ST). Moreover, a questionnaire was administered to participants to evaluate the navigator potentialities., Results: Quantitative analysis results show no significant difference between the fluoroscopic and EM guidance regarding the total procedure time (median 2.36 minutes [interquartile range {IQR} = 1.26-4.7) vs. 2.95 min [IQR = 1.35-5.38], respectively; p = .93); number of total hits with catheter/guidewire tip to vessels wall (median 5.50 [IQR = 2.00-10.00] vs. 3.50 [IQR = 2.50-7.00], respectively; p = .65); and number of attempts at cannulation (median 4.0 [IQR = 2.00-5.00] vs. 4.0 [IQR = 2.00-5.00], respectively; p = .72]. Moreover, there was no significant difference between the IC3ST score obtained using the EM navigator and the traditional method (average 22.37 [STD = 7.95] vs. 21.58 [STD = 6.86]; p = .92). Finally, questionnaire results indicate a general agreement concerning the navigator usefulness, which clearly shows the positions of instruments inside the 3D model of the patient's anatomy. Participants also agreed that the navigator can reduce the amount of contrast media delivered to the patient, as well as fluoroscopy time., Conclusions: This work provides proof of concept that simultaneous EM navigation of guidewires and catheters is feasible without the use of live fluoroscopic images., (Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)