Abstract


Progressive peripheral artery disease, especially in the tibial and pedal vessels, can severely limit the interventions that vascular surgeons and interventionalists can provide to patients. End-stage peripheral arterial disease is often described as a disease where there are no distal targets available in the foot. Traditionally, amputation has been the only option for these patients. However with advancements in surgical and endovascular technology, surgical and now peripheral deep vein arterialization (pDVA) can be utilized. In pDVA, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts in order to increase distal limb perfusion and improve amputation-free survival. Many techniques have been described, but currently the only formal device marketed and under investigation for pDVA is the LimFlow System (LimFlow SA, Paris, France). Our institution has performed pDVA for multiple vascular patients with no other available surgical interventions. We describe the technique, postoperative care, and outcomes for these patients. Additionally, we will explore updated outcomes and applicability of the LimFlow System in the current vascular practice today.

Abstract


Pelvic Venous Disorder (PEVD) and May-Thurner syndrome (MTS) represent relatively understudied vascular issues that can significantly impact patients’ quality of life. This study aims to evaluate the efficacy of surgical treatment for PEVD and MTS, conduct a comparative analysis of outcomes, and determine the practical significance of different therapeutic approaches. The study was conducted from 2019 to 2022 in Moscow, Russia, encompassing two outpatient clinics. A total of 132 patients diagnosed with pelvic venous disorder and/or May-Thurner syndrome (MTS) participated in the research. Diagnostic confirmation relied on ultrasound, transrectal ultrasound, and magnetic resonance imaging. Surgical treatment methods included angioplasty and stenting of the iliac veins. Evaluation of outcomes was based on a comparison of symptoms and additional investigations before and after treatment. It was found that 36% of patients had a history of previous varicocelectomies, with 21% of them having undergone prior surgical interventions. Comorbidities included chronic prostatitis, sexual dysfunction, haemorrhoids, and the presence of varicose veins in the legs, with these pathologies observed in more than 50% of cases. Following the surgical intervention (placement of stents on the left common iliac vein, LCI), a significant improvement in condition was observed in 91% of cases. The obtained results confirm the high efficacy of surgical intervention in the case of PEVD and MTS. The research findings can assist physicians in making more informed decisions when choosing treatment methods for patients with these conditions.

Abstract


Introduction: The purpose of this article is to describe a standardized approach for creating a physician-modified endovascular graft (PMEG) based on the Zenith Flex® (Cook Medical Inc., Bloomington, Indiana) platform.
Technique: A sterile template is constructed based on computed tomography angiography (CTA) measurements. Once the Zenith Flex® bifurcated endograft is desheathed, the template is placed over the device and adjusted so that the planned fenestrations do not overlap with the struts. The fenestration locations are marked on the fabric of the endograft and created using high-temperature cautery. The distal part of a snare is obtained, braided around a modified angiometer with a diameter matching the fenestration, and secured around the corresponding fenestration with locking sutures. Diameter-reducing ties are added by first securing a suture loop at the 12 o’clock position of each Z-stent, then the trigger wire is repositioned to the outside of the endograft at the 6 o’clock position and threaded through each of the loops to constrain the Z-stents. The endograft is reloaded through the peel-away sheath and is ready for the procedure.
Conclusion: A PMEG with diameter-reducing ties and reinforced fenestrations can be constructed in a standardized fashion using the Zenith Flex® platform, providing an endovascular treatment option for complex abdominal aortic aneurysms when custom-made endografts are unavailable.
Clinical impact: Fenestrated endovascular aortic repair is an important treatment option for complex abdominal aortic aneurysms. However, custom-made fenestrated devices may not be available in all regions or medical centres, and their use is limited in urgent situations. Familiarity with constructing a physician-modified endovascular graft can provide patients with an endovascular treatment option in such situations. This step-by-step guide to constructing a physician-modified endovascular device based on the Zenith Flex® platform can help surgeons create a bespoke fenestrated device with diameter-reducing ties and reinforced fenestrations in a standardized fashion within a matter of hours.