Biomedical subjects

Zvonimir Krajcer

Publications and source records attributed to Zvonimir Krajcer.

At least 19 recordsLinked to original sources

PubMed2006

Aortic wrap as a novel technique of type I endoleak repair.

Type I endoleak after endovascular abdominal repair is associated with a high risk of aneurysm expansion and rupture. Though type I endoleak can frequently be managed with endovascular techniques, in this report we describe a patient whose endoleak was refractory to multiple attempts at endovascular repair. The patient ultimately underwent a novel minimally invasive surgical repair with placement of an aortic wrap around the infrarenal aortic neck, successfully abolishing the endoleak.

Aged, 80 and over↗

PubMed2006

Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent.

BACKGROUND: The safety and efficacy of endovascular treatment of arterial trauma using the Wallgraft Endoprosthesis was evaluated in a subgroup analysis of a prospective, multicenter, nonrandomized registry trial with a historical control to surgical management. Endpoints were exclusion success at procedure and at 12-months, primary patency and freedom-from-bypass at 12-months, and major adverse events. METHODS: Sixty-two patients were treated for arterial trauma from October 1997 to June 2003. The anatomic locations of the injuries were: iliac (33), subclavian (18), and femoral (11) arteries. Indication for treatment was perforation/rupture (33), acute pseudoaneurysm (10), AV fistula (16), and dissection (3). Exclusion and patency were assessed using arteriography, duplex ultrasound, CT, or MRA at postprocedure and 12-months. Major adverse event and mortality rates were compared with surgical intervention of arterial trauma using literature based objective performance criteria. RESULTS: The Wallgraft Endoprosthesis achieved postprocedure exclusion in 58 of 62 cases (93.5%). One-year exclusion rates were 91.3% iliac, 90.0% subclavian, and 62.3% femoral. One-year primary patency rates were 76.4% iliac, 85.7% subclavian, and 85.7% femoral. Freedom-from-bypass was achieved in 74.3% iliac and 100% femoral and subclavian injuries. The most common adverse events were stenosis (4.8%) and occlusion (6.5% early, 1.6% late). There were no device- or procedure-related deaths. Analysis of the literature revealed the rates and severity of complications are less than those associated with surgical repair. CONCLUSION: The Wallgraft Endoprosthesis for the treatment of traumatic arterial injuries offers a promising alternative to conventional operative repair with comparable patency and less major morbidity and mortality.

Angioplasty↗

PubMed2006

Aneurysm sac re-expansion after thrombolysis.

PURPOSE: To present a case of delayed abdominal aortic aneurysm (AAA) re-expansion after thrombolysis for endograft limb occlusion. CASE REPORT: A 68-year-old man underwent AAA exclusion with an AneuRx stent-graft in 1999. Five years later, he developed right limb thrombosis of the endograft. He underwent right limb thrombolysis and AngioJet thrombectomy. The patient experienced abdominal and back pain during the procedure, and the aneurysm sac, which had remained reduced in size for several years, acutely re-expanded. The patient was managed conservatively. The fluid that accumulated in the sac was reabsorbed, and the AAA returned to its previous dimensions at 1-month follow-up. CONCLUSION: Symptomatic re-expansion of the aneurysm sac after AngioJet rheolytic thrombectomy may occur when the graft is stripped of neointima by the "power-pulse" spray of lytic agent, allowing serum to seep into the sac. Based on this experience, we advise caution when delivering thrombolytics using the AngioJet "power-pulse" spray mode in patients with a thrombosed stent-graft.

Aged↗

PubMed2006

Combined endovascular and surgical treatment of infected carotid-carotid bypass graft.

PURPOSE: To present a complex case involving an infected carotid-carotid bypass graft that was successfully treated with a stent-graft and subsequent surgical removal of the infected graft. CASE REPORT: A 75-year-old woman presented with persistent purulent drainage of an infected and exposed carotid-carotid prosthetic bypass graft. Wound cultures revealed methicillin-resistant Staphylococcus aureus. She was treated with appropriate intravenous antibiotic therapy without improvement in wound drainage. Because of her comorbid conditions, a decision was made to pursue endovascular revascularization of her left and right common carotid arteries (CCA), with subsequent surgical removal of the infected prosthetic graft. The patient underwent balloon angioplasty; a 7x18-mm Omnilink stent was deployed in the innominate artery and a 7x18-mm Herculink stent in the ostial left CCA. During the same procedure, the carotid-carotid bypass graft was excluded with deployment of an 8x50-mm Viabahn stent-graft in the right CCA. Several days later, the infected and now thrombosed carotid-carotid bypass graft was surgically removed, and an area of adjacent muscle was used to patch the previously excluded connection of the bypass from the right CCA. A saphenous vein patch was used to repair the defect in the left CCA. Her postoperative course was uneventful. At 1 year, the clinical and duplex examinations revealed satisfactory wound healing and patent left and right CCAs. CONCLUSION: This case indicates that a combined endovascular and surgical approach may be a safe and effective option in the treatment of carotid-carotid bypass graft infection.

Aged↗

PubMed2006

Celiac artery aneurysm: a case report.

Aneurysm of the celiac artery is an uncommon clinical problem; fewer than 180 cases have been reported in the world medical literature. Most patients are symptomatic at the time of diagnosis. However, occasionally such aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 72-year-old man who had an asymptomatic celiac artery aneurysm detected by computed tomographic angiography after endoluminal exclusion of an infrarenal aortic aneurysm. The patient underwent successful resection of the aneurysm and revascularization of the aorta-common hepatic and splenic arteries with use of an autologous saphenous vein graft.

Aged↗

PubMed2005

Concomitant brachiocephalic and coronary artery disease: outcome and decision analysis.

BACKGROUND: In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit. METHODS: Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only. RESULTS: All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 +/- 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 +/- 10.5%, stroke 82.1 +/- 9.9%, redo coronary artery bypass grafting 95.8 +/- 4.1%, other vascular operation 82.2 +/- 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% +/- 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency. CONCLUSIONS: Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.

Adult↗

PubMed2005

Brachiocephalic reconstruction II: operative and endovascular management of single-vessel disease.

OBJECTIVE: Although the surgical management of brachiocephalic disease is well established, evolving endovascular techniques present new options for treatment. We explored the potential benefits and drawbacks of these interventions in terms of outcome. METHODS: From 1966 to 2004, 391 consecutive patients (43.7% male; mean age, 61.9 years) with single-vessel brachiocephalic disease were treated with either operative bypass (group A; n = 229) or percutaneous transluminal angioplasty and stenting (group B; n = 162). RESULTS: All patients were asymptomatic after surgery or endovascular intervention. Group A and group B had similar operative mortality (0.9% vs 0.6%) and stroke (1.3% vs 0%) rates. However, 5 years after the procedure, group A had significantly better freedom from graft or intervention failure (92.7% +/- 2.1%) than did group B (83.9% +/- 3.7%; P = .03, Kaplan-Meier analysis; P = .001, Cox regression analysis). At 10 years, group A had the following rates of actuarial freedom from specific events: death, 73.7% +/- 4.6%; myocardial infarction, 84.2% +/- 3.6%; stroke, 91.4% +/- 3.4%; graft failure, 88.1% +/- 3.3%; coronary revascularization, 69.8% +/- 5.1%; and other vascular operation, 70.7% +/- 4.6%. Endovascular intervention involved less initial cost (mean savings, $8787 per procedure), was less invasive, and did not necessitate general anesthesia. On satisfaction questionnaires, 96.5% of patients receiving an endovascular intervention and 95.1% of patients receiving operative bypass for single-vessel brachiocephalic disease subjectively rated their treatment as "good" or "very good." CONCLUSIONS: Operative bypass and endovascular intervention for single-vessel brachiocephalic disease are both associated with acceptably low operative morbidity and mortality. Operative bypass produces significantly better mid-term freedom from graft or intervention failure than endovascular intervention and produces excellent long-term freedom from failure. Endovascular intervention offers tangible benefits regarding cost, level of invasiveness, and subjective patient satisfaction. Undetermined are the differences between the procedures regarding long-term durability, patterns of failure, efficacy as an adjunct to coronary artery bypass grafting, need for anticoagulation, efficacy as treatment for complex (multivessel) disease, and long-term cost.

Adult↗

PubMed2005

Brachiocephalic reconstruction I: operative and long-term results for complex disease.

OBJECTIVES: Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit. METHODS: Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%). RESULTS: No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%. CONCLUSIONS: Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.

Adult↗

PubMed2005

Carotid stenting.

From my point of view, carotid artery stenting, in 2005, is clearly here to stay. "Houston, the Eagle has landed." The rest is up to you and me as we encourage our surgical colleagues and our various medical Societies to embrace this safe, effective, and durable technology and make it available to the patients who will really benefit from it.

Blood Vessel Prosthesis↗

PubMed2005

Endovascular exclusion of a thoracoabdominal aortic aneurysm after retrograde visceral artery revascularization.

Historically, open surgical repair of thoracoabdominal aortic aneurysms has been associated with high morbidity and mortality rates. Furthermore, endovascular exclusion alone can restrict blood flow to visceral arteries. We report a case of thoracoabdominal aortic aneurysm that was repaired using a hybrid approach: surgery followed by an endovascular procedure. A 53-year-old woman was admitted to our hospital for endovascular exclusion of a thoracoabdominal aortic aneurysm that included the superior mesenteric artery and the celiac artery. Aorto-mesenteric and aorto-celiac artery bypass grafting was performed to create a landing zone for subsequent endovascular exclusion of the aneurysm, which was completed successfully 6 weeks after the bypass procedure. For thoracoabdominal aortic aneurysms that extend beyond the superior mesenteric artery and the celiac or renal arteries, a hybrid approach, consisting of limited surgical treatment followed by endovascular exclusion of the aneurysm, may yield optimal results in selected patients with serious preoperative comorbidities.

Aortic Aneurysm, Abdominal↗

PubMed2005

Mathematical Model analysis of Wallstent and Aneurx: dynamic responses of bare-metal endoprosthesis compared with those of stent-graft.

We performed this study in order to analyze the mechanical properties of bare-metal Wallstent endoprostheses and of AneuRx stent-grafts and to compare their responses to hemodynamic forces. Mathematical modeling, numerical simulations, and experimental measurements were used to study the 2 structurally different types of endoprostheses. Our findings revealed that a single bare-metal Wallstent endoprosthesis is 10 times more flexible (elastic) than is the wall of the aneurysmal abdominal aorta. Graphs showing the changes in the diameter and length of the stent when exposed to a range of internal and external pressures were obtained. If the aorta is axially stiff and resists length change, a force as large as 1 kg can act in the axial direction on the aortic wall. If the stent is not firmly anchored, it will migrate. In contrast, a fabric-covered, fully supported, stent-graft such as the AneuRx is significantly less compliant than the aorta or the bare-metal stent. During each cardiac cycle, the stent frame tends to move due to its higher elasticity, while the fabric resists movement, which might break the sutures that join the fabric to the frame. Elevated local transmural pressure, detected along the prosthesis graft, can contribute to material fatigue.

Alloys↗

PubMed2004

Endovascular repair of a giant carotid pseudoaneurysm with the use of Viabahn stent graft.

A 72-year-old woman presented with a large pulsatile anterior right neck mass with compressive symptoms of dysphagia and hoarseness. This was due to a large (6 cm by 4 cm) postcarotid endarterectomy pseudoaneurysm of the right common carotid artery. Successful endovascular exclusion of the pseudoaneurysm was performed with a Viabahn stent graft with significant decrease in the size on follow-up. Other endovascular options such as coil embolization and thrombin injection are also discussed. It is important to exclude infection as the cause of postendarterectomy pseudoaneurysm before considering endovascular repair over surgical repair.

Aged↗

PubMed2003

Percutaneous intervention for the treatment of hypoplastic aortoiliac syndrome.

Hypoplastic aortoiliac syndrome (HAIS) occurs in young women and is characterized by a small infrarenal aorta with a hypoplastic iliofemoral arterial system and advanced atherosclerotic disease. Of 304 aortoiliac interventions (AoI), 30 female patients (mean age, 50 +/- 5 years) had HAIS. HAIS patients were less likely to have coronary disease (33% vs. 88%; P < 0.0001) or diabetes (10% vs. 42%; P < 0.001) compared to their AoI counterparts. Twenty-three patients (73%) had hyperlipidemia with mean cholesterol of 287 +/- 42 mg/dl. Twenty-eight patients (93%) were successfully treated with AoI. The ankle/brachial indices improved from pre-AoI ABI of 0.55 +/- 0.1 to post-AoI ABI of 0.99 +/- 0.1. Complications included one groin hematoma and one case of thrombosis. Follow-up averaged 31 months (range, 3-91 months) with an early (less than 12 months) restenosis rate of 7% and late (greater than 12 months) restenosis of 21%. One patient (3%) required surgical revascularization for persistent symptoms. Percutaneous treatment of HAIS is an alternative to surgical revascularization with satisfactory long-term results.

Aged↗

PubMed2002

Percutaneous repair of abdominal aortic aneurysms using the AneuRx stent graft and the percutaneous vascular surgery device.

Endovascular exclusion of abdominal aortic aneurysms (AAAs) was developed in an effort to treat patients who were at high risk for complications following standard surgical repair. Stent grafts used for endovascular repair of AAAs require the use of large-bore sheaths and surgical exposure of the common femoral arteries (CFAs). To decrease the invasiveness of AAA repair, we attempted to perform the procedure percutaneously utilizing the Prostar XL Percutaneous Vascular Surgery Device and the preclose technique. Thirty patients underwent an attempted percutaneous AAA repair. These patients were followed prospectively to assess the success of the procedure. Twenty-eight patients (93%) had successful percutaneous repair of both CFA access sites. One patient had inadequate hemostasis of the 22 Fr CFA entry site and one patient had inadequate hemostasis of the 16 Fr CFA entry site. Both of these CFA sites underwent open surgical repair. The rate of successful repair of the 22 Fr CFA access site was 29 of 30 (96%); for the 16 Fr CFA access site, 29 of 30 (96%). No in-hospital groin complications were seen. The procedure time was 105 +/- 21 min. The estimated blood loss was 90.6 +/- 50 cc. The hemoglobin loss was 1.54 +/- 0.89 mg/dL and the hematocrit loss was 5.04% +/- 2.8%. Complete percutaneous endoluminal AAA repair is feasible using the preclose technique. CFAs with sheaths up to 22 Fr can be safely and successfully accessed and repaired percutaneously using this technique. This method provides secure hemostasis and reduces the invasiveness of procedures requiring large-bore sheaths.

Aged↗

PubMed2002

Abciximab administration and clinical outcomes after percutaneous intervention for in-stent restenosis.

Abciximab therapy improves clinical outcomes after percutaneous interventions for de novo coronary artery disease. We sought to determine whether clinical outcomes after percutaneous intervention for in-stent restenosis are affected by abciximab administration. Between January 1996 and July 1999, 322 consecutive patients underwent percutaneous intervention for in-stent restenosis; 157 patients received abciximab and 165 patients were treated without abciximab based on operator discretion. Baseline clinical and angiographic variables and type of percutaneous intervention were recorded. Follow-up information was obtained and clinical endpoints were recorded. A multivariate analysis was performed to determine the independent variables associated with adverse clinical outcomes. Baseline clinical and angiographic variables were similar in both groups. Patients who received abciximab were more likely to be treated with rotational atherectomy and less likely to have only balloon angioplasty or repeat stenting. Mean follow-up duration was 19 +/- 12 months. There were no significant differences in the incidence of angina/myocardial infarction (29% vs. 30%; P = 0.9), target vessel revascularization (18% vs. 21%; P = 0.5), death (8% vs. 7%; P = 0.4), or major adverse cardiovascular events (38% vs. 39%; P = 0.9) in both groups. Abciximab administration was not an independent variable associated with adverse outcomes. In this observational study, clinical outcomes after percutaneous intervention for in-stent restenosis did not seem to be affected by abciximab administration. Randomized trials are needed to identify the role of platelet glycoprotein IIb/IIIa inhibitors in the management of in-stent restenosis.

Abciximab↗

PubMed2002

Waligraft endoprosthesis for the percutaneous treatment of femoral and popliteal artery aneurysms.

PURPOSE: To evaluate the safety and efficacy of the Wallgraft Endoprosthesis for the treatment of femoropopliteal artery aneurysms. METHODS: From October 1997 to April 2000, 17 patients (13 men; mean age 73.5 +/- 7.1 years) with 7 femoral and 13 popliteal artery aneurysms underwent percutaneous aneurysm exclusion using the Wallgraft Endoprosthesis as part of a larger clinical trial. The mean aneurysm diameters were 37.6 +/- 12.9 mm and 22.3 +/- 8.7 mm, respectively. RESULTS: Acute procedural success was 100% for femoral aneurysms and 92.3% (12/13) in the popliteal artery owing to one endoleak that resolved after 1 month. There were no complications, and the mean length of stay was 2.2 +/- 3.8 days. Six-month and 1-year aneurysm exclusion rates were 100% for both locations, but 4 (31%) popliteal stent-grafts thrombosed in follow-up. Three were recanalized, but the fourth underwent bypass grafting after 3 thrombotic episodes. The 1-year primary and secondary patency rates were both 100% for the femoral aneurysms and 69% and 92%, respectively, for popliteal repairs. No procedure or device-related deaths occurred. CONCLUSIONS: Treatment of aneurysms in the femoropopliteal segment appears to be safe and effective with the Wallgraft Endoprosthesis, although longer follow-up in a larger patient group will be needed to determine this technique's potential versus surgical repair.

Aged↗

PubMed2002

Successful treatment of aortic endograft thrombosis with rheolytic thrombectomy.

PURPOSE: To report the benefits of rheolytic thrombectomy for treating aortic endograft thrombosis. METHODS: Of 40 patients who received the Ancure bifurcated endograft to treat abdominal aortic aneurysm (AAA) during a 9-month period, 6 (15%) patients (6 men; mean age 62.6 years, range 53-77) developed thrombosis of the endograft at an average of 9 weeks (range 1-20 months). Five patients were taking aspirin, and 3 were on warfarin therapy for atrial fibrillation. Immediately after angiography, rheolytic thrombectomy was used to remove the thrombus, followed by adjunctive procedures to treat the underlying pathology. RESULTS: Causes were kinking or extrinsic compression of the graft limb in 5 cases and thrombosis of the surgical closure site in a common femoral artery. Mechanical thrombectomy was successful in restoring circulation in all cases; thrombolysis was used in 1. All 6 patients had additional stents placed in the graft limbs, re-establishing patency. There was no mortality or recurrent thrombosis in a follow-up that has extended to 26 months, but 1 patient required additional stenting for subsequent focal kinking of a graft limb above the previously implanted stent. CONCLUSIONS: Rheolytic thrombectomy can safely and effectively treat endograft thrombosis after endovascular AAA repair. Additional thrombolytic agents, angioplasty, and stenting may be needed to correct the underlying causes of the thrombosis. Prophylactic stenting of iliac limbs at the time of implantation in patients with complex anatomy may prevent thrombosis of unsupported bifurcated endografts.

Aged↗

PubMed2002

Buttress technique to insure accurate placement of AneuRx stent-grafts in patients with complex anatomy.

PURPOSE: To describe a technique that prevents caudal displacement of the AneuRx stent-graft during removal of the nose cone and runners. TECHNIQUE: The buttress technique uses a 16-F sheath positioned from the contralateral femoral approach at the inferior edge of the endograft's main body to provide safe retraction of the runners and the nose cone and accurate endograft deployment. CONCLUSIONS: If accurate deployment of the stent-graft according to the manufacturer's directions is not possible, this buttress technique can insure proper positioning. It adds no additional time or equipment to the procedure, and it appears to be a safe and easily applied maneuver.

Blood Vessel Prosthesis Implantation↗