Objective To determine the outcome of adjunctive renal artery stenting for renal artery coverage at the time of endovascular abdominal aortic aneurysm repair (EVAR). Methods Between 8/2000 to 8/2008, 29 patients underwent elective EVAR using bifurcated Zenith stent-grafts and simultaneous renal artery stenting. Renal artery stenting during EVAR was performed with endograft “encroachment” on the renal artery ostium (n = 23) or placement of a renal stent parallel to the main body of the endograft (“snorkel”, n = 8). Follow-up included routine contrast-enhanced computed tomography (CT), multi-view abdominal x-rays, and creatinine measurement at 1, 6, and 12 months, and then yearly thereafter. Results 31 renal arteries were stented successfully in 29 patients. All patients with planned renal artery stent placement (n=18) had a proximal neck length < 15mm. Mean proximal neck length was shorter in patients who underwent the “snorkel” technique (6.9 ± 3.1 mm) compared to those with planned endograft encroachment (9.9 ± 2.6 mm). None of the patients with unplanned endograft encroachment had neck lengths < 15mm (mean length: 26.3±10.2 mm). Mean proximal neck angulation was 42.8 ± 24.0 degrees and did not differ between the groups. One patient had a type I endoleak on completion angiography, and 2 additional patients had a type I endoleak on the first postoperative CT scan. All type I endoleaks resolved by the one-month postoperative CT scan. Primary-assisted patency of renal artery stents was 100% at a median follow-up of 12.5 months (range 2 days to 77.4 months). One patient had near occlusion of a renal artery stent noted on follow-up CT scan at 9 months; patency was restored by placement of an additional stent. One patient required dialysis following sustained hypotension from a right external iliac artery injury which resulted in prolonged post-operative bleeding. Mean creatinine at baseline was 1.1 ± 0.3 mg/dl, 1.2 ± 0.5 mg/dl at 1 month follow-up, and 1.2 ± 0.5 mg/dl at 2 years of follow-up. There were no cases of late type I endoleaks (>one month postoperatively) or stent-graft migration. Conclusions Adjunctive renal artery stenting during endovascular AAA repair using the “encroachment” and “snorkel” techniques is safe and effective. Short and medium term primary patency rates are excellent, but careful follow-up is needed to determine the durability of these techniques.

Background The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration. Methods A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality. Results Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1–74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1–72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5–312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13). One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%–88%) and 70% (range, 57%–80%), respectively. Survival at 1 and 5 years was 89% (range, 80%–94%) and 70% (range, 55%–81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3–17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3–31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9–73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05–0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2). Conclusions TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spin...

Objective Chimney” techniques used to extend landing zones for endovascular aortic repair(chEVAR) have been increasingly reported; however, concerns about durability and patency remain. The purpose of this analysis was to examine mid-term outcomes of chEVAR. Methods All patients at the University of Florida treated with chEVAR were reviewed. Major adverse events(MAEs) were recorded and defined as any chimney stent thrombosis, type 1a endoleak in follow-up, reintervention, 30-day/in-hospital death and/or ≥ 25% decrease in estimated glomerular filtration rate after discharge. Primary end-points included chimney stent patency and freedom from MAE. Secondary end-points included complications and long-term survival. Results From 2008–2012, 41 patients[age ± standard deviation(SD); 73±8; male 66%(N=27)] were treated with a total of 76 chimney stents(renal, N=51; superior mesenteric artery, N=16 celiac artery, N=9) for a variety of indications: juxtarenal, 42%(N=17, 1 rupture); suprarenal, 17%(N=7), and thoracoabdominal aneurysm, 17%(N=7); aortic anastomotic pseudoaneurysm, 15%(N=6; 3 ruptures), type 1a endoleak after EVAR, 7%(N=3), and atheromatous disease, 2%(N=1). Two patients had a single target vessel abandoned due to cannulation failure and one had a type 1a endoleak at case completion(technical success = 93%). Intraoperative complications occurred in 7 patients(17%), including graft maldeployment with unplanned mesenteric chimney(N=2) and access vessel injury requiring repair(N=5). Major postoperative complications developed in 20%(N=8). 30-day and in-hospital mortality were 5%(N=2) and 7%(N=3), respectively. At median follow-up of 18.2(range 1.4–41.5) months, 28 of 33(85%) patients with available postoperative imaging experienced stabilization or reduction of AAA sac diameters. Nine(32%) patients developed endoleak at some point during follow-up [type 1a, 7%(N=3); type 2, 10%(N=4); indeterminate, 7%(N=3)], and one patient underwent open, surgical conversion. The estimated probability of freedom from reintervention(±standard error mean) was 96±4% at both 1 and 3 years. Primary patency of all chimney stents was 88±5% and 85±5% at 1 and 3 years, respectively. Corresponding freedom from MAEs was 83±7% and 57±10% at 1 and 3 years. The 1 and 5-year actuarial estimated survival for all patients was 85±6% and 65±8%, respectively. Conclusions These results demonstrate that chEVAR can be completed with a high degree of success; however perioperative complications and MAEs during follow-up, including loss of chimney patency and endoleak may occur at a higher rate than previously reported. Elective use of chEVAR should be performed with caution and comparison to open and/or fenestrated EVAR is needed to determine long-term efficacy of this technique.

NMDA receptors have been implicated in activity-dependent synaptic plasticity in the developing visual cortex. We examined the distribution of immunocytochemically detectable NMDAR1 in visual cortex of cats and ferrets from late embryonic ages to adulthood. Cortical neurons are initially highly immunostained. This level declines gradually over development, with the notable exception of cortical layers 2/3, where levels of NMDAR1 immunostaining remain high into adulthood. Within layer 4, the decline in NMDAR1 immunostaining to adult levels coincides with the completion of ocular dominance column formation and the end of the critical period for layer 4. To determine whether NMDAR1 immunoreactivity is regulated by retinal activity, animals were dark-reared or retinal activity was completely blocked in one eye with tetrodotoxin (TTX). Dark-rearing does not cause detectable changes in NMDAR1 immunoreactivity. However, 2 weeks of monocular TTX administration decreases NMDAR1 immunoreactivity in layer 4 of the columns of the blocked eye. Thus, high levels of NMDAR1 immunostaining within the visual cortex are temporally correlated with ocular dominance column formation and developmental plasticity; the persistence of staining in layers 2/3 also correlates with the physiological plasticity present in these layers in the adult. In addition, visual experience is not required for the developmental changes in the laminar pattern of NMDAR1 levels, but the presence of high levels of NMDAR1 in layer 4 during the critical period does require retinal activity. These observations are consistent with a central role for NMDA receptors in promoting and ultimately limiting synaptic rearrangements in the developing neocortex.