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Challenges and Opportunities in Endovascular Surgery

Challenges and Opportunities in Endovascular Surgery

Reinke, A., Schmid, G. L., Shiban, E., & Wild, A. (2021)



Aggressive Vertebral Hemangiomas (VH) are very rare lesions that may present with compression fractures or bony expansion and erosion into the epidural space resulting in neurological symptoms. Especially in these patients a surgical treatment is essential. We illustrate our institutional experience and discuss the relevant literature.


Our database was searched for cases with vertebral hemangioma and the appearance of a neurological deficit between 2015 and 2020. We were able to identify one very extraordinary case which showed a very aggressive nature and resulted in paraparesis twice in the patient. Furthermore a Medline analysis was performed to identify data of this rare illness (aggressive VH, Enneking stage 3, S3) to assess the incidence and therapeutic options for this so called benign vascular tumor.


One patient was identified in the database with an extraordinary course which resulted in paraparesis twice. A 54-year-old man presented with an acute onset of paraparesis of the legs. Contrast-enhanced magnetic resonance imaging (MRI) revealed a hypervascular tumor of the entire L3 vertebral body and the surrounding tissue with subtotal compression of the spinal canal (Enneking stage 3). After decompression and spinal stabilization a complete recovery of the paraparesis was seen. Two weeks after the initial presentation a recurrence of the paraparesis was noted. The subsequent MRI demonstrated a recurrent increase in the tumor size with spinal canal compression. After endovascular embolization, a gross total tumor resection with a vertebral replacement was performed. The patient was noted to have a complete recovery.


The number of cases with aggressive vertebral hemangiomas (Enneking Stage 3) is limited.  However, despite limited treatment algorithms for these rare cases due to the lack of data, surgical treatment should be recommended, especially in the presence of neurological symptoms. That can be underlined by our institutional experience.

Ali, A., Khwaja, S., Saavedra, J., Eckroth-Bernard, K., Javed, U., Venugopal, C., Reich, H., Hashimi, H., Araim, L., Stewart, R., Wilkins, L., Janday, N., Calkins, A., & Lin, J. C. (2022)


There have been significant advances in the technique and application of endovascular repair of thoracic aortic pathology over the past 20 years. The Stanford type A and the complicated type B dissection patients require urgent/emergent intervention.  In the last decade, earlier intervention has been pursued for uncomplicated type B dissections. The INvestigation of STent-grafts in Aortic Dissection (INSTEAD) Long term (XL) study showed that there was significant crossover from medical management to Thoracic EndoVascular Aortic Repair (TEVAR) at year 3, suggesting TEVAR might benefit this population long term.

Today, the application of TEVAR, which was initially designed to address aneurysmal disease, has become a standard and Food and Drug Administrative (FDA) approved management option in dissections.

Currently there are four FDA approved TEVAR devices in the United States for the treatment of the thoracic dissections, namely Gore, Medtronic, Cook, and Terumo.  With each iteration, there are increased opportunities for customization and widespread use in individualized patient’s pathology.  As the technology improves and the feasibility of the grafts expands, the complication rates continue to decline cementing the safety and efficacy of these thoracic aortic grafts. Two rare but catastrophic complications in spinal ischemia and retrograde Stanford type A aortic dissection are further discussed.  With the success of the TEVAR, a new frontier of hybrid aortic surgery has developed.  The debranching of the aortic arch vessels in order to advance the TEVAR proximal landing zones has been aggressively pursued.  With the widespread growth of TEVAR technology it is apparent that complex aortic pathology can be safely repaired endovascularly. 

DeRieux, J., Obed, D., & Casey, K. (2022)


Nutcracker Syndrome is a rare condition secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta, or rarely, when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. Left renal vein compression varies widely in presentation and severity, ranging from asymptomatic imaging findings, to chronic pelvic or flank pain. While left renal vein transposition remains the most common management modality, there is growing acceptance for other surgical interventions as well as endovascular treatments–particularly stenting. However, there remains a scarcity of evidence for these less invasive techniques. We conduct a review of the recent literature and discuss the diagnosis and current management strategies for nutcracker syndrome. We also revisit a unique case of nutcracker syndrome in a female patient with a history of chronic pelvic pain and venous congestion wherein transposition of the left renal vein resulted in complete resolution of her symptoms.

Danieli, G., Tinelli, G., De Rosa, S., Greco, P., Indolfi, C., Larocca, G., Massetti, M., & Tshomba, Y. (2023)


This paper describes the new version of RObotic System for Angioplasty (ROSA), which was developed from a simplified version of the RObotic System for Endovascular Surgery (ROSES). ROSES itself arose from the original ROSA device and has been tested for clinical use on patients.

The new version of ROSA offers several advantages over the previous versions. First, it allows the measurement of forces used to track catheters during the endovascular procedure. This process only requires standard mechanical disposables, since the measuring system is embedded in a special cart that controls the movement of various robotic actuators. Second, it uses a new hemostasis valve that rotates with the angioplasty disposable, making it easier to guide rotations. Finally, it offers the possibility of positioning the initial catheter using a system that includes two robotic actuators found on the cart. The first of these is simpler and has an internal disposable, whereas the second is new and contains two gear trains, which control five independent parameters (two rotations and three advancements). This makes it possible to control advancement and rotation of the initial catheter, while straightening its curvature using a movable core guidewire. Once the first catheter is correctly positioned, it is possible to perform all procedures without changing the position of the guiding catheter by replacing the disposable for the 0.035″ guidewire with movable core with the disposable for angioplasty, which drives both the angioplasty balloons or stents and the 0.016” wire, which instead needs to turn on its axis in order to ease penetration of the small guide wire which has to  penetrate the winding path of the coronaries. And this is allowed by the presence of the two independent gear trains of the recent robotic actuator, which can block rotations of the gear train on which the initial catheter is positioned, while allowing all rotations needed for the angioplasty disposable. However, in the near future it will also be possible to change the position of the guiding catheter using a special 6 French catheter with controlled tip curvature, for example, to perform an additional angioplasty on a different coronary artery, should this be required.

Lodi, Y., Bowen, A., Soltani, A., Khan, I., Polavarapu, H., & Hourani, A. (2023)


Background: Despite the advancement in acute ischemic stroke with large vessel occlusion (LVO), golden time is lost in assessment lengthy neurological examination and redundantly in the Emergency department, often after emergency medical service prehospital stroke scale evaluation indicating possible LVO. A simple acute ischemic stroke scale (AISS) of the cortical representations of the anterior circulation can rapidly predict LVO, saving precious time to initiate early intravenous tissue plasminogen activator and endovascular mechanical thrombectomy. We proposed an ASIS in the emergency department called Gaze Weakness Neglect Speech (GWNS) to evaluate its feasibility and predictability for the detection of LVO in anterior circulation in the emergency department. Additionally, to evaluate if time can be gained that has been lost in obtaining National Institute of Health stroke Scale (NIHSS) and computed tomographic angiography (CTA), avoiding unnecessary radiation.

Methods: This is a prospective observational study. An institutional review board permission was obtained, and patient enrollment started in January 2020 and ended in January 2021. Consecutive patients from January 2020 to September 2021 were selected from the database. The GWNS stroke scale was used by stroke and vascular neurologist during the emergency triage. The GWNS stroke scale scores range from 0 to 4 (1 for positive 0 for negative). The GWNS stroke scale assesses gaze deviation or gaze preference (G), presence of any weakness (W), neglect/disregard (N), and any speech impairment (S). Demographic data, CTA/cerebral angiographic data, and scores from NIHSS were also collected. The collected data was analyzed by a biostatistician to determine the association between the GWNS scale score and LVO.

Results: In our study,109 qualifying patients were selected. Fifty-eight patients had GWNS stroke scale score of 3 or 4, with 57 having confirmed LVO and 1 presenting after a seizure.  The GWNS stroke score ≥3 (0.86) correlated with LVO better than NIHSS (0.67), regardless of hemisphere side involvement. The GWNS stroke scale score of ≥3 also was effective in detection of proximal and distal blood vessels occlusion in the anterior circulation (Internal carotid artery, middle cerebral artery and its branches).  A GWNS stroke scale score of ≥3 with presence of gaze was the most predictive for LVO (0.9) followed by neglect/disregards (0.8). The time to obtain GWNS stroke scale was 1.5 minutes (range 1-3) and time to obtain/interpretation CTA was 41.3 +/- 7.4 minutes after emergency department arrival (range: 29-51 minutes).

Conclusions: Our Gaze Weakness Neglect Speech stroke scale can be performed rapidly in the emergency department and is highly predictive of LVO in the internal carotid artery, middle cerebral artery and middle cerebral branches. A GWNS stroke scale score of ≥3 is highly predictive of LVO, especially when gaze or neglect is present. Patients can potentially bypass CTA or advanced imaging in future studies, saving precious time and millions of brain cells for better outcome.

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