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• W2092179218 abstract "The multilayer stents are occasionally used for the treatment of complicated aortic aneurysms, including thoracoabdominal aneurysms. No aneurysm-related mortality among patients treated with this technique has been described in the literature to date. We describe a case of rupture of an aortic aneurysm previously treated with a multilayer stent. The multilayer stents are occasionally used for the treatment of complicated aortic aneurysms, including thoracoabdominal aneurysms. No aneurysm-related mortality among patients treated with this technique has been described in the literature to date. We describe a case of rupture of an aortic aneurysm previously treated with a multilayer stent. The use of endografts for the treatment of aortic aneurysmal disease is limited to patients with suitable anatomy. When the aneurysm is adjacent to or involves a major arterial branch, available options include open repair and fenestrated/branched endografts.1Bakoyiannis C.N. Economopoulos K.P. Georgopoulos S. Klonaris C. Shialarou M. Kafeza M. et al.Fenestrated and branched endografts for the treatment of thoracoabdominal aortic aneurysms: a systematic review.J Endovasc Ther. 2010; 17: 201-209Crossref PubMed Scopus (85) Google Scholar Recently, a new type of multilayer self-expanding stent technology has been developed. The Multilayer Aneurysm Repair System (MARS) developed by Cardiatis, Isne, Belgium, consists of a three-dimensional braided-wire tube structured in several interlocked layers. This three-dimensional geometrical structure is supposed to give several hemodynamic and biologic effects that lead to exclusion of the aneurysm sac by leaving patent any side branches coming out of it.2Vaislic C. Fabiani J. Benjelloun A. Treatment of TAAAs using the multilayer non-covered flow modulator (MARS 3d): summary of a multicentric French and North African study.http://www.veithsymposium.org/pdf/vei/4641.pdfGoogle Scholar Its use is shown to be effective in occluding peripheral and visceral aneurysms.3Balderi A. Antonietti A. Ferro L. Peano E. Pedrazzini F. Fonio P. et al.Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience.Radiol Med. 2012; 117: 815-830Crossref PubMed Scopus (58) Google Scholar, 4Carrafiello G. Rivolta N. Annoni M. Fontana F. Piffaretti G. Endovascular repair of a celiac trunk aneurysm with a new multilayer stent.J Vasc Surg. 2011; 54: 1148-1150Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 5Ferrero E. Ferri M. Viazzo A. Nessi F. Endovascular treatment of hepatic artery aneurysm by multilayer stents: two cases and one-year follow-up.Interact Cardiovasc Thorac Surg. 2011; 13: 545-547Crossref PubMed Scopus (28) Google Scholar, 6Polydorou A. Henry M. Bellenis I. Kiskinis D. Bolos K. Athanasiadou K. et al.Endovascular treatment of arterial aneurysms with side-branches–a simple method Myth or reality?.Hosp Chronicles. 2010; 5: 88-94Google Scholar, 7Henry M. Polydorou A. Frid N. Gruffaz P. Cavet A. Henry I. et al.Treatment of renal artery aneurysm with the multilayer stent.J Endovasc Ther. 2008; 15: 231-236Crossref PubMed Scopus (91) Google Scholar, 8Mali W.P. Geyskes G.G. Thalman R. Dissecting renal artery aneurysm: treatment with an endovascular stent.AJR Am J Roentgenol. 1989; 153: 623-624Crossref PubMed Scopus (20) Google Scholar Recently, a few references and some anecdotal studies are proposing MARS as a therapeutic alternative for the treatment of complex aortic aneurysms.2Vaislic C. Fabiani J. Benjelloun A. Treatment of TAAAs using the multilayer non-covered flow modulator (MARS 3d): summary of a multicentric French and North African study.http://www.veithsymposium.org/pdf/vei/4641.pdfGoogle Scholar, 3Balderi A. Antonietti A. Ferro L. Peano E. Pedrazzini F. Fonio P. et al.Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience.Radiol Med. 2012; 117: 815-830Crossref PubMed Scopus (58) Google Scholar, 6Polydorou A. Henry M. Bellenis I. Kiskinis D. Bolos K. Athanasiadou K. et al.Endovascular treatment of arterial aneurysms with side-branches–a simple method Myth or reality?.Hosp Chronicles. 2010; 5: 88-94Google Scholar, 9Euringer W. Südkamp M. Rylski B. Blanke P. Endovascular treatment of multiple HIV-related aneurysms using multilayer stents.Cardiovasc Intervent Radiol. 2012; 35: 945-949Crossref PubMed Scopus (35) Google Scholar, 10Benjelloun A. Henry M. Ghannam A. Vaislic C. Azzouzi A. Maazouzi W. et al.Endovascular treatment of a tuberculous thoracoabdominal aneurysm with the multilayer stent.J Endovasc Ther. 2012; 19: 115-120Crossref PubMed Scopus (36) Google Scholar, 11Natrella M. Castagnola M. Navarretta F. Cristoferi M. Fanelli G. Meloni T. et al.Treatment of juxtarenal aortic aneurysm with the multilayer stent.J Endovasc Ther. 2012; 19: 121-124Crossref PubMed Scopus (39) Google Scholar, 12Chocron S. Vaislic C. Kaili D. Bonneville J.F. Multilayer stents in the treatment of thoraco-abdominal residual type B dissection.Interact Cardiovasc Thorac Surg. 2011; 12: 1057-1059Crossref PubMed Scopus (49) Google Scholar No failure of these devices, in term of aneurysm rupture, has been reported to date. We report a case of a patient with a suprarenal aortic aneurysm having been treated with MARS that finally developed an aneurysm rupture. An 82-year-old male patient was urgently transferred by a district hospital in our institution, with the diagnosis of abdominal aortic aneurysm rupture. The patient suffered severe abdominal pain and hemodynamic instability. His medical history included an open infrarenal abdominal aortic aneurysm repair about 10 years ago, and an endovascular repair of a suprarenal aortic aneurysm (probably a proximal para-anastomotic aneurysm), with MARS, 12 months ago. Both procedures had been performed in other institutions. The emergency computed tomography (CT) scan showed MARS extended well above and below the aneurysm area, with good and long landing zones. Although the stent permitted flow to all visceral arteries, the aneurysm sac was also filled by contrast. Additionally, a contained rupture had existed on the left retroperitoneal space (Fig 1, A). On an earlier CT scan 6 months before (about 6 months after the stent insertion), blood flow through the stent system into the aneurysm sac was also noted (Fig 1, B). The patient was treated with an emergency open repair through a left retroperitoneal approach (Fig 2, A). Because of the extended hematoma, the proximal aortic cross-clamping was achieved at the distal thoracic aorta through a separate left lateral thoracotomy. Although a tube polyester graft was anastomosed from the suprarenal aorta to the old aortic graft, the patient suffered a ventricular tachycardia that led to intraoperative demise. After its retrieval, the stent system was inspected and palpated for any technical defect, but nothing was found. The hypothesis of aneurysm thrombosis using a low porosity bare metal stent, a concept similar to MARS, was first described about two decades ago. Geremia et al13Geremia G. Haklin M. Brennecke L. Embolization of experimentally created aneurysms with intravascular stent devices.AJNR Am J Neuroradiol. 1994; 15: 1223-1231PubMed Google Scholar had observed that a metallic stent when bridging an aneurysmal sac might alter the flow pattern within the aneurysm, thereby promoting thrombus formation and aneurysmal occlusion. At the same time, Piquet et al14Piquet P. Rolland P.H. Bartoli J.M. Tranier P. Moulin G. Mercier C. Tantalum-Dacron coknit stent for endovascular treatment of aortic aneurysms: a preliminary experimental study.J Vasc Surg. 1994; 19: 698-706Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar described treatment of aneurysms utilizing a stent-like device that combined both metal and fabric, or so-called “coknit.” In patients treated with coknit, thrombosis of abdominal aortic aneurysms had been observed, keeping patent the inferior mesenteric artery and some lumbar arteries, similar to the way stents preserve collateral vessels when placed across the ostia. MARS is a bare stent system made of biocompatible cobalt alloy wire, structured in several superimposed layers, thus achieving low porosity.6Polydorou A. Henry M. Bellenis I. Kiskinis D. Bolos K. Athanasiadou K. et al.Endovascular treatment of arterial aneurysms with side-branches–a simple method Myth or reality?.Hosp Chronicles. 2010; 5: 88-94Google Scholar In an aneurysm with branches, the stent redirects the flow toward the ostium of the collaterals by creating a kind of suction effect. Consequently, the aneurysm gradually shrinks while keeping the collaterals patent.6Polydorou A. Henry M. Bellenis I. Kiskinis D. Bolos K. Athanasiadou K. et al.Endovascular treatment of arterial aneurysms with side-branches–a simple method Myth or reality?.Hosp Chronicles. 2010; 5: 88-94Google Scholar Sporadic recent reports refer to use of MARS in treating various types of aortic aneurysms.6Polydorou A. Henry M. Bellenis I. Kiskinis D. Bolos K. Athanasiadou K. et al.Endovascular treatment of arterial aneurysms with side-branches–a simple method Myth or reality?.Hosp Chronicles. 2010; 5: 88-94Google Scholar, 9Euringer W. Südkamp M. Rylski B. Blanke P. Endovascular treatment of multiple HIV-related aneurysms using multilayer stents.Cardiovasc Intervent Radiol. 2012; 35: 945-949Crossref PubMed Scopus (35) Google Scholar, 10Benjelloun A. Henry M. Ghannam A. Vaislic C. Azzouzi A. Maazouzi W. et al.Endovascular treatment of a tuberculous thoracoabdominal aneurysm with the multilayer stent.J Endovasc Ther. 2012; 19: 115-120Crossref PubMed Scopus (36) Google Scholar, 11Natrella M. Castagnola M. Navarretta F. Cristoferi M. Fanelli G. Meloni T. et al.Treatment of juxtarenal aortic aneurysm with the multilayer stent.J Endovasc Ther. 2012; 19: 121-124Crossref PubMed Scopus (39) Google Scholar, 12Chocron S. Vaislic C. Kaili D. Bonneville J.F. Multilayer stents in the treatment of thoraco-abdominal residual type B dissection.Interact Cardiovasc Thorac Surg. 2011; 12: 1057-1059Crossref PubMed Scopus (49) Google Scholar In all cases, authors report a reduction but not a cessation of blood flow within the aneurysm sac, which, however, results in gradual aneurysm shrinkage. Despite the fact that blood flow may remain in the aneurysm sac for a variable period of time, no aneurysm-related death attributable to rupture has been reported to date. Recently, Vaislic et al2Vaislic C. Fabiani J. Benjelloun A. Treatment of TAAAs using the multilayer non-covered flow modulator (MARS 3d): summary of a multicentric French and North African study.http://www.veithsymposium.org/pdf/vei/4641.pdfGoogle Scholar reported their anecdotal experience in treating 29 patients with thoracoabdominal aneurysms using MARS. It regarded a multicenter prospective study that took place in France, in 22 patients suffering thoracoabdominal aortic aneurysms. The study preceded a pilot study performed in North Africa of seven similar patients. The total technical success of the method (defined as aneurysm thrombosis and shrinkage) was 40%, at 6 months after the procedure whereas in the pilot study group it was 67% and 83% at 6 and 12 months, respectively, but no rupture was stated. Failure of total sac thrombosis was also noted in our case. Although all splanchnic vessels remained patent, blood flow existed into the aneurysmal sac at 6 months and 12 months after system implantation. Unfortunately, this situation led to aneurysm enlargement and finally to rupture that proved to be lethal. We believe that when persisting flow into the sac is observed for a long time after MARS implantation, and especially if the aneurysm does not shrink, other measures should be undertaken as the situation may become dangerous. We believe that if our patient had an elective open repair of his endoleak earlier, he might have had a better outcome. Seeking an explanation of the type of endoleak through MARS that led to aneurysm rupture, we concluded that this was not a type I endoleak, as the stent had been deployed well above and below the aneurysm, with long proximal and distal necks (Fig 1, B). Additionally, no type III endoleak could be considered, as no defect of the stent system was noted either on the CT scan or on the stent itself after its retrieval, thereby leaving the only possible explanation of the leakage, the porosity throughout the metal mesh of the stent (type IV endoleak). Based on the operative findings of our case, we came to some technical observations: (1) MARS may be difficult to be removed in its entirety due to its rigid configuration, thereby needing to be divided and removed in pieces. (2) As the stent seems to strongly adhere at the aortic wall, if it needs to be removed, a safe option would be by leaving a part of it in place and suturing the new graft with both the remaining stent and the native aorta. This technique was used in our case, and we considered the result rewarding, as the construction of the anastomosis was feasible and relatively blood-tight. (3) Severe fibrosis seems to be created along the periaortic area above the aneurysm where MARS is extended. In this situation, to achieve proximal aortic control, it might be safer to dissect in a healthy proximal part of the aorta away from the stent, such as the distal descending thoracic aorta. MARS may be considered a promising solution for treating complex aortic aneurysms. However, the issue of blood flow persistence inside the aneurysmal sac has not completely been solved, keeping the aneurysm enlargement and rupture a probability. Further laboratory and in vivo animal studies might be needed before proceeding to applying the method in large-scale human populations. Regarding “A multilayer stent in the aorta may not seal the aneurysm, thereby leading to rupture”Journal of Vascular SurgeryVol. 57Issue 2PreviewLazaris and colleagues report the first case of aortic rupture after implantation of a flow-diverting stent (FDS) in abdominal aortic aneurysms (AAAs).1 There are now clinical, biological, and radiological data establishing that intraluminal thrombus (ILT) may be one of the driving forces in the evolution of dilation toward ruptures of AAAs. ILT is a main source of proteases and oxidation in AAAs as it is involved in the activation of plasmin and the retention of neutrophils. ILT is also a potential site of weak pathogen contamination. Full-Text PDF Open Archive" @default.
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