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Evaluation Of Sources Of Polymer Embolization After Fenestrated Aortic Repair Mimicking Spinal Cord Ischemia
Kristin Markle, MD candidate, MS, BS, Pierce Massie, MD, Amos Zimmerman, MD, Hillary Elwood, MD, Muhammad Ali Rana, MD, Ross Clark, MD.
University of New Mexico, Albuquerque, NM, USA.
Objectives Hydrophilic polymer embolization (HPE) is a rare and underrecognized complication of endovascular procedures such as fenestrated endovascular aortic repair (FEVAR). While candidate sources have been postulated
in vitro, data implicating specific culprit devices from actual HPE cases have yet to be investigated. Following cases of biopsy-confirmed HPE that mimicked spinal cord ischemia after FEVAR, we attempted to further identify devices responsible for this phenomenon.
Methods Formalin-fixed, paraffin-embedded tissue blocks from histopathological specimens of a skin biopsy from a case of HPE were obtained, and 5 µm sections were deparaffinized, OsO
4 impregnated and carbon coated. Embolized material was present within dermal capillaries on hematoxylin and eosin staining consistent with HPE. Scanning electron microscopy (SEM) with backscatter detection and elemental composition analysis using energy dispersive x-ray (EDX) were performed on embolized material to characterize the ultrastructure and elemental content. A total of 18 endovascular devices used as the standard set of instrumentation during all complex aortic repairs at our institution were amassed and representative samples from each were identically prepared for SEM-EDX analysis for comparison to the HPE case results.
Results SEM of embolized material confirms a classic smooth serpiginous ultrastructure of 5.6 µm mean diameter. EDX of adjacent tissue revealed carbon to oxygen (C:O) ratio of 3.5 while the embolized material was significantly different with a C:O ratio of 1.5. No other analyzed areas of the tissue were as profoundly carbon-poor. The C:O ratio of 1.5 with a standard deviation of ±0.3 was applied to create a sensitive spectrum in filtering results of the device analysis. Using this method, 8 of the 18 devices were identified as potential sources of embolized material. Devices most closely approximating target C:O ratio were the Ansel Sheath (1.56), Lunderquist wire (1.62) and Glidewire (1.62). Cook stent graft components were also implicated with C:O ratio 1.29 for Zenith Fenestrated main body and 1.21 for ZSLE limbs.
Conclusions Our results reveal a short list of devices implicated in hydrophilic polymer embolization during complex aortic repair. Future studies to evaluate the rate of polymer shedding of these devices in an
in vitro setting may be warranted.
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