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Background: Elective thoracic endovascular aortic repair in selected patients with suitable aortic anatomy is associated with low morbidity and mortality, and is gaining widespread acceptance. Its benefit in acute thoracic aorta diseases, however, has not yet been demonstrated in high-numbered studies. This report presents data of the Talent Thoracic Retrospective Registry (TTR) of all patients who underwent endovascular stent grafting for acute thoracic aorta pathology., Methods: Between December 1996 and July 2004 data were collected regarding 113 consecutive patients who underwent emergent endovascular stent grafting of the thoracic aorta using the Talent thoracic stent graft (Medtronic, Inc., Santa Rosa, California) in 7 European referral centers. Acute thoracic aorta pathology consisted of 41 (36.3 %) traumatic aortic injuries, 37 (32.7 %) Stanford type B dissections, 5 (4.4 %) intramural hematomas, 18 (15.9 %) thoracic aorta aneurysms, 4 (3.5 %) pseudoaneurysms and 8 (7.1 %) penetrating ulcers., Results: In all patients the stent graft system could be introduced via the common femoral artery. Conversion to open surgical repair was necessary in 2 patients, one in the early phase due to persistent bleeding via backflow in the false lumen from a distal entry tear, and another patient in a late phase due to retrograde dissection. Intraoperative mortality was 1.8%, one patient suffered a massive myocardial infarction, and another died of tamponade secondary to retrograde dissection. Overall hospital mortality was 8.0% (9 patients). In only 2 of them, it was considered a stent graft procedure related death. New neurological symptoms were seen in 6.2% (7 patients), with complete recovery in 5 patients. Mean follow-up was 15 months (range 1-69 months). Late mortality was 8.7% (9 patients). Only one late death was considered aorta related. Overall re-intervention rate was 8.9% (n=10) and was mainly for type I endoleak or persistent false lumen perfusion., Conclusion: Sub-analysis of the Talent Thoracic Retrospective Registry for endovascular stent grafting of acute thoracic aorta pathology in over 100 consecutive patients demonstrated its feasibility, with low morbidity and acceptable low mortality rates.

Objectives: This study sought to assess the safety and the effectiveness of endovascular stent grafting of chronic aortic dissection (AD) in Marfan patients., Background: The management of chronic AD of the descending thoracic aorta (DTA) is challenging. This is especially true in Marfan patients, who tend to exhibit poor short- and long-term results after conventional surgery., Methods: Fifteen patients with Marfan's syndrome and chronic AD of the DTA were identified among the 457 patients of the European Talent Registry. All patients underwent endovascular treatment., Results: No major adverse event was encountered during the procedure. Five patients experienced a primary endoleak (type 1, n = 4; type 2, n = 1). Three of them died, and 1 underwent successful conversion to open surgery. Five other patients experienced secondary endoleak (type 1, n = 4; type 3, n = 1). Four of them underwent successful conversion to either open or endovascular reintervention. Two other patients underwent successful conversion to open repair because of secondary aortic enlargement below the stent graft. After a mean follow-up of 2.1 +/- 1.4 years, 12 patients are alive. Of these 12, conversion to open repair was successfully performed in 5 patients. In the remaining 7 patients, complete thrombosis of the false lumen was achieved in 6 patients, with partial thrombosis in 1 patient., Conclusions: Endovascular stent grafting of the dissected DTA is feasible in selected Marfan patients with low mortality and morbidity rates. Nevertheless, the rate of primary and secondary endoleak is high. Close imaging surveillance is crucial to detect secondary aortic complications and to assess long-term results.

Objectives: Endovascular repair of descending thoracic aortic lesions is associated with a substantial risk of perioperative spinal cord ischaemia (SCI) which may lead to permanent paraplegia. We performed a retrospective analysis of our experience in the endovascular treatment of descending thoracic aortic lesions to define the incidence of SCI and to identify factors that contributed to its development., Methods: 67 consecutive patients underwent stent graft repair for descending thoracic aortic lesions including degenerative aneurysm (n=19), type B dissection (acute n=2, chronic n=15), traumatic rupture (acute n=14, chronic n=4), penetrating aortic ulcer (n=5), anastomotic false aneurysm (n=4), mycotic aneurysm (n=3) and embolic aortic lesion (n=1) between June 2000 and June 2005. All procedures were performed with the patient under general anaesthesia and strict blood pressure monitoring. No patient had intra-operative monitoring of spinal evoked potential or cerebrospinal fluid (CSF) drainage to prevent SCI. Neurological evaluation was realized after recovery from general anaesthesia. Fifteen factors, including nature of aortic disease, length of aortic coverage, number of stent-grafts, coverage of the distal third of the thoracic aorta and subclavian artery coverage, were investigated as possible predictors of postoperative SCI., Results: Five patients (7.5%) had postoperative neurological deficits (immediate n=2, delayed n=3) referable to SCI. Univariate analysis showed that length of aortic coverage (p<0.001) and number of stent-grafts deployed (p=0.02) were significant predictors of SCI. Multivariate logistic regression analysis showed that length of aortic coverage was the only independent significant predictor of SCI. ROC curve analysis revealed 205mm of aortic length coverage as the threshold for increased risk of postoperative SCI (p=0.001), with specificity and sensitivity of 95.2 and 80% respectively., Conclusion: In our study, length of aortic coverage is the only independent predictive factor of SCI after endovascular treatment with 205mm as a threshold for increased risk. Hence, methods to prevent SCI, especially those aimed at restoration of an adequate spinal cord perfusion pressure, should be offered to patients requiring extensive coverage of the descending thoracic aorta.

Open surgical management of acute rupture of the descending thoracic aorta (DTA) is associated with high mortality and morbidity. Endovascular stent-grafts (ESGs) could provide a less invasive treatment alternative to conventional open surgery. The purpose of this report detailing our experience using ESG for treatment of acute rupture of the DTA is to determine the indications for endovascular repair. From June 2000 to April 2005, 17 patients presenting rupture of the DTA were treated using commercially available ESGs at our institution. There were two women and 15 men, with a mean age of 41.9 +/- 20.5 years. The cause of aortic rupture was traumatic in 13 cases and nontraumatic in four. Treatment was undertaken immediately in 10 cases and delayed in seven (range 5-68 days, mean 23.5). In one patient, the proximal neck landing zone was prepared prior to endovascular repair. No patients died during the postoperative period. The technical success rate was 84%. One patient developed a proximal type 1 endoleak at the end of the procedure. Three complications, i.e., two iliac dissections and one femoral artery rupture, occurred during the procedure. No paraplegia was observed. Mean follow-up was 13.3 months (range 1-41). One patient treated for traumatic rupture was lost from follow-up 21 months after initial treatment. No procedure-related complication was observed in this traumatic rupture group. Control computed tomographic scan at 13 months following the procedure demonstrated no evidence of periprosthetic leak or false aneurysm. In the nontraumatic rupture group, two patients died of aortic rupture and one treated for aortobronchial fistula developed recurrent hemoptysis 23 months after initial treatment and required placement of two additional ESGs. The immediate outcome of covered stent-graft placement for management of acute aortic rupture of the DTA is good. However, long-term surveillance is mandatory, especially in patients treated for nontraumatic aortic rupture that is associated with a high late complication rate. Further study will be needed to determine the exact utility of endovascular therapy for aortic rupture: final treatment or bridge to conventional open-chest repair when the patient's condition has stabilized.

Objective: Prospective analysis of endovascular management of traumatic isthmic rupture with second generation stent grafts., Study Design: Prospective analysis and follow-up., Patients: Ten consecutive multiple injured patients presenting an acute isthmic traumatic rupture who underwent an endovascular repair with second generation stent grafts., Methods and Results: The aortic injury was diagnosed by spiral computed tomography scan. The appropriate time to repair was decided according to multidisciplinary decision after analysis of associated injuries status and mediastinal lesions evolution. Endovascular repair was successfully completed in all patients under general anaesthesia without requirement of haemodynamic manipulations. Despite a prolonged length of stay related to associated injuries, all patients were discharged from hospital without migration of devices or complication related to the endovascular procedure. After a 20 months follow-up (range 6 - 38 months), all patients were alive with a satisfactory CT scan analysis., Conclusion: The immediate availability of the second generation of stents-grafts allowed the endovascular treatment of isthmic rupture without haemodynamic manipulations or massive heparinization. The analysis of this selected series reinforces the interest of this non-invasive technique for anaesthetists especially in polytraumatized patients.

The authors report the clinical and imaging features of a patient with rupture of an aortoiliac graft successfully treated by endovascular approach. The endovascular treatment is easy to perform and effective. The main pitfall of this technique is the limited availability of stent-grafts.

Objectives: Blunt traumatic thoracic aortic rupture is a life-threatening surgical emergency associated with high mortality and morbidity. The recent development of endovascular stent-graft prostheses offers a potentially less invasive alternative to open chest surgery, especially in patients with associated injuries. We sought to compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture in a single center., Methods: From July 1998 to January 2004, 20 patients with acute blunt traumatic aortic rupture underwent treatment at our institution. All patients had a lesion limited to the isthmus, and associated injuries. Initial management included fluid resuscitation, treatment of other severe associated lesions, and strict monitoring of blood pressure. Eleven patients (9 men, 2 women; mean age, 32 years) underwent surgical repair, including direct suturing in 6 patients and graft interposition in 5 patients. Ten patients were operated on with cardiopulmonary support (left bypass with centrifugal pump, n = 2; extracorporeal circulation, n = 8). The delay between trauma and surgery was 2.6 days (range, 0-21 days). Nine patients (8 men, 1 woman; mean age, 32 years) underwent endovascular treatment with commercially available devices (Excluder, n = 2; Talent, n = 7). In all patients 1 stent graft was deployed. In 2 patients the left subclavian artery was intentionally covered with the device. The delay between trauma and endovascular treatment was 17.8 days (range, 1-68 days)., Results: One patient in the surgical group (9.1%) died during the intervention. Three surgical complications occurred in 3 patients (27%), including left phrenic nerve palsy (n = 1), left-sided recurrent nerve palsy (n = 1), and hemopericardium 16 days after surgery that required a repeat intervention (n = 1). No patient in this group had paraplegia. In the endovascular group successful stent-graft deployment was achieved in all patients, with no conversion to open repair. No patient died, and no procedure-related complications, including paraplegia, occurred in this group. Control computed tomography scans obtained within 7 days after endovascular treatment showed exclusion of pseudoaneurysm in all cases. Length of follow-up for endovascular treatment ranged from 3 to 41 months (mean, 15.1 months). Computed tomography scans obtained 3 months after endovascular treatment showed complete disappearance of pseudoaneurysm in all patients., Conclusion: In the treatment of blunt traumatic thoracic aortic rupture, the immediate outcome in patients who receive endovascular stent grafts appears to be at least as good as observed after conventional surgical repair. Long-term follow-up is necessary to assess long-term effectiveness of such management.

Objectives: We assessed the value of a gradient-compliant stent in an animal model., Methods: Bilateral carotid arteries were stented with nitinol stents having variable-oversizing, variable-stiffness, and with (CMS, 10 animals) and without (SMART, four animals) compliance-matching endings. Angiography, hemodynamic, scanning-electron-microscopic and histological analyses were performed at 3-month. The protocol was completed in 14 among 19 swines., Results: Transient (1-month) exaggerated recoil, attributable to stress-induced phasic inhibition of vasorelaxation, developed at CMS endings. At mid-term, all stents were endothelialized; CMS-stents, but not SMART-stents, were incorporated into walls (one-strut-thickness). Restenosis developed outside SMART-stents (cell migration+wall-compensatory enlargement) whereas CMS-stents elicited no or focalized cell-accumulations at endings that bulged vascular walls radially outward. SMART-stents were blood-flow neutral, whereas CMS-stents favored (higher-stiffness, higher-oversizing) or opposed (lower-stiffness, less-oversizing) carotid blood flow., Conclusions: Direct carotid stenting with stents having compliance-matched endings and specific requirements of stiffness and oversizing can optimize blood flow to the brain and restrict local restenosis.

Purpose: In order to decrease complications and improve postoperative recovery, we have developed a minimally invasive retroperitoneal approach (MIRPA) for the treatment of infrarenal aortic disease. This study was carried out to define the limitations and applicability of this technique in the treatment of aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysms (AAAs)., Methods: From November 2000 to February 2004, 150 patients with AAA (n = 130) or AIOD (n = 20) were prospectively included in the study. The procedure consisted in a standard aneurysmorrhaphy or bypass procedure performed through a video assisted left minilombotomy.The main outcomes measured were mortality, complications, operative time, aortic cross-clamp time, time to solid diet, and length of intensive care unit and hospital stay., Results: Operative mortality was 0.7 %. Nonfatal postoperative complications occurred in 12 patients (8%). Conversion to a standard procedure was necessary in 3 patients. Mean operative time was 207 +/- 57 minutes (AAA) and 224 +/- 55 minutes (AIOD). Mean aortic cross-clamp time was 76 +/- 26 minutes (AAA) and 48 +/- 21 minutes (AIOD). Median resumption of regular diet was 2 days. Median length of stay in the intensive care unit was 1 day and in the hospital 8 days., Conclusion: Our results suggest that MIRPA is a safe and effective minimally invasive procedure in the treatment of infrarenal aortic disease.

The objective of this work was to develop a platform to evaluate and deliver putative therapeutic agents for in-stent restenosis. Arterial stenting is applied in more than 60% of balloon angioplasties for treating cardiovascular disease. However, stented arteries encounter accelerated rates of restenosis. No prior platform has allowed evaluation or local management of in-stent restenosis without perturbing the very system being examined. A stainless steel, balloon-expandable stent was modified to serve as an ablumenal drug delivery platform. Several combinations of bioerodible polymer microspheres and gels were evaluated for channel retention under in vitro flow and in vivo conditions. A stent-anchored hybrid system prevented material embolization under all conditions. Unlike prior platforms, these stents do not alter local inflammation or in-stent plaque formation relative to conventional Palmaz-Schatz stents after in vivo deployment. The system also proved sensitive enough to detect plaque reduction with an antirestenotic agent. We conclude that a platform to evaluate and deliver therapeutic agents for in-stent restenosis has been achieved.

Objectives: we investigated the therapeutic effect of angioplasty with local drug delivery (LDD) of the wall-accumulating NO-donor molsidomine (M) in the superficial femoral arteries (SFA) of atherosclerotic swine., Materials and Methods: atherosclerotic Pietrin swines (n=14) underwent PTA-LDD-M (4 mg/2 ml) vs contralateral PTA-LDD-Placebo in the SFA using a channelled balloon angioplasty catheter. Invasive and colour Doppler energy (CDE) assessments of haemodynamics and wall mechanics were performed at 24 h (n=4) and 5 months (n=10). Immuno-histolabelling of cell proliferation and histomorphometry were serially performed in perfusion fixed SFA samples., Results: at 24 h, PCNA-positive nuclei revealed 33+/-14 and 12+/-3 proliferating cells/mm2 at placebo and molsidomine PTA-LDD sites, respectively (p<0.001). At 5 months, PTA-LDD-M vessels, compared with PTA-LDD-P, had increased compliance (66+/-9 vs 11+/-4 ml/mmHg) and lowered impedance (0.11+/-0.05 vs 0.45+/-0.14 mmHg/ml x min(-1)) (p<0.05). CDE revealed low, middle and high velocity peaks at 7.5, 20 and 35, and 8, 15 and 22 cm x s(-1) in systolic and diastolic flows, respectively; and PTA-LDD-M prevented emergence of restenosis-associated increases in low blood velocities (p<0.01). PTA-LDD-M inhibited restenotic intimal thickening and medial thinning which decreased mean lumenal diameter in placebo-treated (2.6+/-0.3) as compared to molsidomine-treated (3.4+/-0.3 mm) vessels (p<0.05)., Conclusions: in the atherosclerotic porcine SFA model, PTA-LDD with molsidomine consistently improved haemodynamic wall mechanics, lowered cell proliferation and prevented late lumen loss observed with PTA-LDD with placebo., (Copyright 2002 Harcourt Publishers Limited.)

Purpose: Alpha-1-antitrypsin (AAT) is the major circulating elastase inhibitor. Deficiency of elastase inhibition leads to emphysema and vascular abnormalities including accelerated neointima. Because recent evidence suggests that tissue AAT levels determine inhibitory function, the authors hypothesize that local tissue-based expression of AAT limits elastase activity sufficiently to guide arterial response to injury., Materials and Methods: Rabbit common femoral arteries were injured by mechanical overdilation and treated with buffer, viral control, or an adenovirus expressing AAT (Ad/AAT). After 3 and 28 days, intima-to-media (I/M) ratios were evaluated. Additionally, early changes in elastase inhibition potential (3 d), extracellular elastin and collagen content (3 d), and local macrophage and neutrophil infiltration (7 d) were determined., Results: Ad/AAT significantly decreased neointima formation after mechanical dilation injury after 28 days: buffer controls exhibited mean I/M ratios of 0.76 +/- 0.06, whereas viral controls reached 0.77 +/- 0.09; in contrast, Ad/AAT reduced I/M ratios to 0.44 +/- 0.06. Both early elastin and collagen content were preserved in the Ad/AAT group relative to controls. The Ad/AAT group also reversed the local inflammation that characterized viral controls., Conclusions: This strategy demonstrates that local increases in elastase inhibition potential promote a neointima-resistant small-caliber artery, which may offer new promise in management of patients undergoing angioplasty.

Objectives: We studied enhancement of local gene delivery to the arterial wall by using an endovascular catheter ultrasound (US)., Background: Ultrasound exposure is standard for enhancement of in vitro gene delivery. We postulate that in vivo endovascular applications can be safely developed., Methods: We used a rabbit model of arterial mechanical overdilation injury. After arterial overdilation, US catheters were introduced in bilateral rabbit femoral arteries and perfused with plasmidor adenovirus-expressing blue fluorescent protein (BFP) or phosphate buffered saline. One side received endovascular US (2 MHz, 50 W/cm2, 16 min), and the contralateral artery did not., Results: Relative to controls, US exposure enhanced BFP expression measured via fluorescence 12-fold for plasmid (1,502.1+/-927.3 vs. 18,053.9+/-11,612 microm2, p < 0.05) and 19-fold for adenovirus (877.1+/-577.7 vs. 17,213.15+/-3,892 microm2, p < 0.05) while increasing cell death for the adenovirus group only (26+/-5.78% vs. 13+/-2.55%, p < 0.012)., Conclusions: Endovascular US enhanced vascular gene delivery and increased the efficiency of nonviral platforms to levels previously attained only by adenoviral strategies.

Vascular endothelial growth factor (VEGF) can promote angiogenesis but may also exert certain effects to alter the rate of atherosclerotic plaque development. To evaluate this potential impact on plaque progression, we treated cholesterol-fed mice doubly deficient in apolipoprotein E/apolipoprotein B100 with low doses of VEGF (2 microg/kg) or albumin. VEGF significantly increased macrophage levels in bone marrow and peripheral blood and increased plaque area 5-, 14- and 4-fold compared with controls at weeks 1, 2 and 3, respectively. Plaque macrophage and endothelial cell content also increased disproportionately over controls. In order to confirm that the VEGF-mediated plaque progression was not species-specific, the experiment was repeated in cholesterol-fed rabbits at the three-week timepoint, which showed comparable increases in plaque progression.

Purpose: Insulin-like growth factor-1 (IGF-1) is a potent chemoattractant to vascular smooth muscle cells (SMCs). The authors hypothesize that perivascular release of IGF-1 in vivo can direct migration of SMCs away from the lumen and reduce neointima formation in a rabbit model of arterial balloon injury., Materials and Methods: Balloon angioplasty of the common femoral arteries was performed in adult male New Zealand White rabbits (n = 8 per treatment group) and controlled release microspheres delivering either IGF-1 or blank control treatment were implanted perivascularly at the angioplasty site prior to surgical closure. At 7 days, five arteries per group were harvested and cross-sections were subjected to anti-PCNA (proliferating cell nuclear antigen) immunostaining to determine the number and distribution of proliferating SMCs. At 28 days, the remaining three arteries per group were harvested and sections were evaluated for intima-to-media (I/M) ratios by means of VVG-Masson staining. One-way analysis of variance with Fisher protected least significant difference post hoc testing was used to determine statistical significance at P < .05., Results: At 7 days, PCNA(+) medial SMCs assumed a significantly more peripheral (ie, further from lumen) distribution in the vessel wall with use of perivascular IGF-1 than with use of blank treatment (P < .05). Overall SMC proliferation was not significantly different, thus the change in distribution was likely due to directionally altered SMC migration. At 28 days, perivascular IGF-1 significantly decreased I/M ratios by 44% relative to control treatment (P < .05)., Conclusions: Perivascular release of IGF-1 can directionally guide SMC migration away from the lumen and reduce neointima in the balloon-injured artery. This novel strategy might have implications in the development of antirestenosis therapies.

Intravenous leiomyomatosis is a rare, histologically benign neoplasm that may be malignant in its specific tendency to intravascular extension. A case of intravenous leiomyomatosis with extension into the entire inferior vena cava in a 41-year-old woman is described. The patient was diagnosed with syncope 3 years after hysterectomy and was treated with a 1-stage procedure including venous replacement.