Multimodality Imaging Showing Pathology of Endovascular Aortic Graft for Abdominal Aortic Aneurysm

HomeCirculation: Cardiovascular ImagingVol. 12, No. 7Multimodality Imaging Showing Pathology of Endovascular Aortic Graft for Abdominal Aortic Aneurysm Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBMultimodality Imaging Showing Pathology of Endovascular Aortic Graft for Abdominal Aortic AneurysmCorrelation of Histological and Micro-Computed Tomographical Findings Salomé H. Kuntz, MD, Dipti Surve, MD, Matthew Kutyna, MS, Hiroyuki Jinnouchi, MD, Russell M. Jones, Erik K. Mont, MD, Maria E. Romero, MD, Nabil Chakfé, MD, Aloke V. Finn, MD and Renu Virmani, MD Salomé H. KuntzSalomé H. Kuntz CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France (S.H.K., N.C.). GEPROVAS, Strasbourg, France (S.H.K., N.C.). Search for more papers by this author , Dipti SurveDipti Surve CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author , Matthew KutynaMatthew Kutyna CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author , Hiroyuki JinnouchiHiroyuki Jinnouchi CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author , Russell M. JonesRussell M. Jones CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author , Erik K. MontErik K. Mont Nova Scotia Medical Examiner Service, Dartmouth, Nova Scotia, Canada (E.K.M.). Search for more papers by this author , Maria E. RomeroMaria E. Romero CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author , Nabil ChakféNabil Chakfé Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France (S.H.K., N.C.). GEPROVAS, Strasbourg, France (S.H.K., N.C.). Search for more papers by this author , Aloke V. FinnAloke V. Finn CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). School of Medicine, University of Maryland, Baltimore (A.V.F.). Search for more papers by this author and Renu VirmaniRenu Virmani Renu Virmani, MD, CVPath Institute Inc, 19 Firstfield Rd, Gaithersburg, MD 20878. Email E-mail Address: [email protected] CVPath Institute, Gaithersburg, MD (S.H.K., D.S., M.K., H.J., R.M.J., M.E.R., A.V.F., R.V.). Search for more papers by this author Originally published24 Jun 2019https://doi.org/10.1161/CIRCIMAGING.119.009183Circulation: Cardiovascular Imaging. 2019;12:e009183Traditionally, conventional open surgical repair was considered as the first-choice treatment for abdominal aortic aneurysm (AAA). However, over the past 2 decades endovascular aneurysm repair (EVAR) procedures have gained popularity.1 Reinterventions in EVAR are mostly related to late complications, such as endoleaks, kinks, or dislodgements of the stent graft.2 However, there is little information available about the pathological changes that occur in the arterial wall following EVAR.3 We report a unique case using multimodality imaging (Figure) of an AAA in a patient treated with both surgical and endovascular repair, with 20 years and almost 7-year survival, respectively.Download figureDownload PowerPointFigure. Multimodality imaging of an abdominal aortic aneurysm (AAA) from an 88-year-old man treated with both open surgery for ruptured AAA 20 years earlier, and endovascular repairs for enlarging AAA almost 7-years before death.A, Gross appearance of AAA starting below the superior mesenteric artery (SMA) and renal arteries extending to the level of the bifurcation of the common iliac arteries (CIA) (right [RCIA] and left [LCIA]). Radiograph of the AAA, the green and yellow lines are levels where histological sections (following embedding in Spurr and sections stained with H&E) were taken to illustrate the extent of healing, thrombus, calcification, and presence of grafts. Histological cross-sections of the endograft (EG) are illustrated in images B1 to B4. B1 shows the proximal suprarenal stent with focal healing and coverage by minimal neointimal growth. B2 corresponds to the infrarenal stent graft with mild fibrin deposition and infolding of the EG. B3 is the histological section from the middle of the AAA. Note the outer woven polyethylene terephthalate (PET) graft (blue arrowheads) that was placed during surgical intervention. The well expanded endovascular stent graft (black and yellow arrowheads) is seen within the surgically placed PET graft, and there is fibrin clot separating the two. B4 is a cross-section of the RCIA (larger) and internal iliac artery (smaller) with the latter showing total occlusion from the placement of the Amplatzer device. The right common iliac EG extension is seen with well-apposed stent struts and infolding of the graft and focal neointimal coverage. C, Micrco computed tomography (Micro-CT) image of the AAA with 3 lines showing regions where cross-sections (C1 and C2) and longitudinal sections (C3) are illustrated on the right. C1 and C1a are cross-sections at the level of the surgically placed PET graft sutured to the aortic wall (blue), shown in matched micro-CT and Spurr embedded specimen, respectively. C2 is the micro-CT image that is coregistered with the B3 histological section of the AAA, note corresponding stent graft within the surgically placed PET graft. C3 and C3a are longitudinal sections of the micro-CT and coregistered Spurr embedded aortic specimen. Note the enlarged aortic aneurysm from the leak that resulted from the discontinuity in the suture line (yellow arrow) that occurred years after the surgical placement of the graft. The EG main body effectively sealed the leak within the PET graft.The AAA specimen underwent micro-computed tomography (CT) and was embedded in methyl methacrylate for optimal histological correlation. The patient was an 88-year-old male patient with ruptured AAA who had undergone emergently open surgical repair using a polyethylene terephthalate graft placement 20 years before death from unrelated causes. EVAR was performed 13 years later because of enlarging AAA. A Zenith Flex aorto-uni-iliac AAA Endovascular Graft (Cook Medical, Bloomington, IN) was placed from the infrarenal abdominal aorta to the right external iliac artery with an Amplatzer Vascular Plug (Abbott, Lake Bluff, Ill) in the right internal iliac artery, and an Occluder Endovascular Graft iliac plug (Cook Medical, Bloomington, IN) in the left common iliac artery. In the same operative time, he underwent a femoro-femoral crossover bypass.Pathological examination revealed a good apposition between the stent graft and the atherosclerotic wall in the proximal neck and in the distal end. The suprarenal stent attachment was mostly well apposed with focal healing by neointimal tissue and fibrin clot. The stent graft in the aneurysm sac remained uncovered. The right common iliac artery shows an open stent graft lumen with similar healing as proximally, and the internal iliac artery was occluded by a vascular plug (Amplatzer device). The polyethylene terephthalate fabric showed discontinuity of the inferior anastomosis to the aortoiliac bifurcation where a leak occurred that lead to AAA enlargement.One of the challenges of effective treatment of AAA with EVAR is the necessity to establish a hemostatic seal between the stent graft ends and the arterial wall to prevent complications of endoleaks. We report that incorporation of a vascular prosthesis into surrounding tissue by fibrin and focal neointimal tissue may be sufficient for graft healing, for long-term functional patency. In addition, micro-CT provided near histological level resolution and was able to identify the different grafts and repairs. Micro-CT showed findings matched histological images as shown in the Figure. Use of micro-CT, in this case, demonstrates the advantages of high resolution imaging to better correlate large AAA with polyethylene terephthalate fabric and endovascular stent treatment that was embedded in plastic to allow appropriate sawing and histological sectioning to match the findings observed in micro-CT.This study also demonstrates the necessity of explant analysis program to better understand materials behaviors in humans.4DisclosuresCVPath Institute has received institutional research support from 480 Biomedical, Abbott Vascular, ART, BioSensors International, Biotronik, Boston Scientific, Celonova, Claret Medical, Cook Medical, Cordis, Edwards Lifesciences, Medtronic, MicroPort, MicroVention, Celonova, OrbusNeich, ReCore, SINO Medical Technology, Spectranetics, Surmodics, Terumo Corporation, W.L. Gore, and Xeltis. Dr Virmani has received honoraria from 480 Biomedical, Abbott Vascular, Boston Scientific, Cook Medical, Lutonix, Medtronic, Terumo Corporation, and W.L. Gore; and is a consultant for 480 Biomedical, Abbott Vascular, Medtronic, and W.L. Gore. Dr Finn has sponsored research agreements with Boston Scientific and Medtronic CardioVascular and is an advisory board member to Medtronic CardioVascular. The other authors report no conflicts.FootnotesRenu Virmani, MD, CVPath Institute Inc, 19 Firstfield Rd, Gaithersburg, MD 20878. Email [email protected]orgReferences1. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kolbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, Esvs Guidelines C, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document R, Bjorck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor’s choice - european society for vascular surgery (esvs) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57:8–93. doi: 10.1016/j.ejvs.2018.09.020CrossrefMedlineGoogle Scholar2. Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT, Kohler TR, Kougias P, Jean-Claude JM, Cikrit DF, Swanson KM; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.N Engl J Med. 2012; 367:1988–1997. doi: 10.1056/NEJMoa1207481CrossrefMedlineGoogle Scholar3. McArthur C, Teodorescu V, Eisen L, Morrissey N, Faries P, Hollier L, Marin ML. Histopathologic analysis of endovascular stent grafts from patients with aortic aneurysms: does healing occur?J Vasc Surg. 2001; 33:733–738. doi: 10.1067/mva.2001.113980CrossrefMedlineGoogle Scholar4. Lejay A, Colvard B, Magnus L, Dion D, Georg Y, Papillon J, Thaveau F, Geny B, Swanström L, Heim F, Chakfé N. Explanted vascular and endovascular graft analysis: where do we stand and what should we do?Eur J Vasc Endovasc Surg. 2018; 55:567–576. doi: 10.1016/j.ejvs.2018.01.022CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lin J, Nutley M, Li C, Douglas G, Du J, Zhang Z, Douville Y, Guidoin R and Wang L (2020) Innovative textile structures designed to prevent type III endoleaks in endovascular stent‐grafts, Artificial Organs, 10.1111/aor.13819, 45:3, (278-288), Online publication date: 1-Mar-2021. Kuntz S, Jinnouchi H, Kutyna M, Torii S, Cornelissen A, Sakamoto A, Sato Y, Fuller D, Schwein A, Ohana M, Gangloff H, Lejay A, Finn A, Chakfé N and Virmani R (2021) Co-Registration of Peripheral Atherosclerotic Plaques Assessed by Conventional CT Angiography, MicroCT and Histology in Patients with Chronic Limb Threatening Ischaemia, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2020.08.037, 61:1, (146-154), Online publication date: 1-Jan-2021. July 2019Vol 12, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.119.009183PMID: 31230459 Originally publishedJune 24, 2019 KeywordsX-ray microtomographyaortic aneurysmblood vessel prothesisvascular surgical procedurespathologyPDF download Advertisement SubjectsAneurysmCardiovascular SurgeryComputerized Tomography (CT)ImagingStent