Basic Research
Aneurysm Pulsatility After Endovascular Exclusion - An Experimental Study Using Human Aortic Aneurysms
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elsevierViewall">Displacement <span class="elsevierStyleItalic">versus</span> three cycles of load curve.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sandra Umeda Sasaki, Roberto Freire da Mota e Albuquerque, César Augusto Martins Pereira, Guilherme Simões Gouveia, Júlio César Rodrigues Vilela, Fábio de Lima Alcarás" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Sandra Umeda" "apellidos" => "Sasaki" ] 1 => array:2 [ "nombre" => "Roberto Freire da Mota e" "apellidos" => "Albuquerque" ] 2 => array:2 [ "nombre" => "César Augusto Martins" "apellidos" => "Pereira" ] 3 => array:2 [ "nombre" => "Guilherme Simões" "apellidos" => "Gouveia" ] 4 => array:2 [ "nombre" => "Júlio César Rodrigues" "apellidos" => "Vilela" ] 5 => array:2 [ "nombre" => "Fábio" "apellidos" => "de Lima Alcarás" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222028460?idApp=UINPBA00004N" "url" => "/18075932/0000006300000001/v1_202212060857/S1807593222028460/v1_202212060857/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1807593222028447" "issn" => "18075932" "doi" => "10.1590/S1807-59322008000100011" "estado" => "S300" "fechaPublicacion" => "2008-02-01" "aid" => "2844" "copyright" => "CLINICS" "documento" => "article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "fla" "cita" => "Clinics. 2008;63:59-66" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Basic Research</span>" "titulo" => "Correlation Between Intrasac Pressure Measurements of a Pressure Sensor and an Angiographic Catheter During Endovascular Repair of Abdominal Aortic Aneurysm" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "66" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig6" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1151 "Ancho" => 1944 "Tamanyo" => 181413 ] ] "descripcion" => array:1 [ "en" => "<p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Scatterplots showing agreement between the Reading 2 pressure measurements of angiographic catheter and pressure sensor.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pierre Galvagni Silveira, Christopher William Teixeira Miller, Rafael Freygang Mendes, Gilberto Nascimento Galego" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pierre Galvagni" "apellidos" => "Silveira" ] 1 => array:2 [ "nombre" => "Christopher William Teixeira" "apellidos" => "Miller" ] 2 => array:2 [ "nombre" => "Rafael Freygang" "apellidos" => "Mendes" ] 3 => array:2 [ "nombre" => "Gilberto Nascimento" "apellidos" => "Galego" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222028447?idApp=UINPBA00004N" "url" => "/18075932/0000006300000001/v1_202212060857/S1807593222028447/v1_202212060857/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Basic Research</span>" "titulo" => "Aneurysm Pulsatility After Endovascular Exclusion - An Experimental Study Using Human Aortic Aneurysms" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "67" "paginaFinal" => "70" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Hussein Amin Orra, Pedro Puech-Leão, Erasmo Simão da Silva, Domingos Guerino Silva" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Hussein Amin" "apellidos" => "Orra" "email" => array:1 [ 0 => "drpuech@usp.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "af1" ] ] ] 1 => array:3 [ "nombre" => "Pedro" "apellidos" => "Puech-Leão" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "af1" ] ] ] 2 => array:3 [ "nombre" => "Erasmo Simão da" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "af1" ] ] ] 3 => array:3 [ "nombre" => "Domingos Guerino" "apellidos" => "Silva" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "af1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "af2" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cirurgia Vascular e Endovascular, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil" "etiqueta" => "a" "identificador" => "af1" ] 1 => array:3 [ "entidad" => "Cirurgia Vascular, Instituto Dante Pazzanese de Cardiologia - São Paulo/SP, Brazil" "etiqueta" => "b" "identificador" => "af2" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 548 "Ancho" => 993 "Tamanyo" => 91900 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Inspection of an aneurysm after an experiment, showing mural thrombus and recent clot around the device.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Endovascular aneurysm repair (EVAR) aims to prevent expansion and rupture, by completely excluding blood flow from contact with the aneurysm wall. Radiological demonstration of a type I or III endoleak is always taken as a failure of the procedure; however, several recent reports have shown that aneurysm enlargement can occur without demonstrated endoleak,<a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib2">2</a> leading to a search for non-radiological predictors of late failure<a class="elsevierStyleCrossRef" href="#bib3">3</a>. Some of these are sac pressurization (endotension), pulsatile wall motion, and aneurysm sac pulsatility.</p><p id="para20" class="elsevierStylePara elsevierViewall">Endotension is defined as continued sac pressurization without endoleak, after extensive investigation proving that endoleak is not present.<a class="elsevierStyleCrossRef" href="#bib4">4</a>,<a class="elsevierStyleCrossRef" href="#bib5">5</a> Pressure might be transmitted through the walls of the endograft, through pulsatile movements of the graft wall, through a thrombus lining the attachment site or through a thrombus sealing an endoleak.</p><p id="para30" class="elsevierStylePara elsevierViewall">Pulsatile wall motion (PWM) is an ultrasonographic concept that reflects the intraluminal systolic-diastolic pressure flutuations.<a class="elsevierStyleCrossRef" href="#bib6">6</a> PWM correlates with aneurismal pulse pressure (the difference between systolic and diastolic pressure), but not with mean pressure.<a class="elsevierStyleCrossRef" href="#bib7">7</a>,<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para40" class="elsevierStylePara elsevierViewall">Aneurysm sac pulsatility (ASP) is a clinical definition based on an expected reduction in aneurysm movement after EVAR.<a class="elsevierStyleCrossRef" href="#bib8">8</a> Pulsatility may be the result of sac pressurization, but not in all cases. Theoretically, a situation in which the pressure is high but constant results in no pulsatility. Conversely, low pressures with wide systolic-diastolic variation may cause wide pulsatility.<a class="elsevierStyleCrossRef" href="#bib6">6</a>,<a class="elsevierStyleCrossRef" href="#bib7">7</a>,<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para50" class="elsevierStylePara elsevierViewall">The importance of aneurysm pulsation after EVAR is still not clear. Some believe that it represents incomplete exclusion of the aneurysm,<a class="elsevierStyleCrossRef" href="#bib9">9</a> while others accept it as independent of endoleak or endotension. During a conference of experts in the field held in the year 2000, the following question was posed: “If an abdominal aortic aneurysm is pulsatile after endovascular abdominal aortic aneurysm repair, it is evidence of an endoleak?” Fifteen of the 26 respondents disagreed, nine agreed, and two were uncertain.<a class="elsevierStyleCrossRef" href="#bib10">10</a></p><p id="para60" class="elsevierStylePara elsevierViewall">Although there has been intense research in this field, based mainly in animal models or prosthetic aneurysms, there is a lack of important biomechanical analysis related to human aneurysm tissue and hemodynamic flow. This experimental study was designed to measure the pulsatility of human aneurysms before and after complete exclusion by EVAR, and was approved by the Institutional Ethics and Research Committee.</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">METHOD</span><p id="para70" class="elsevierStylePara elsevierViewall">Five infrarenal aortic aneurysms were obtained during human necropsies one to three hours post-mortem. None of them were ruptured nor were they the cause of death. The dimensions of each aneurysm are shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>.</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para80" class="elsevierStylePara elsevierViewall">A complete arterial segment, comprising the aorta from the renal arteries to the external iliacs, was harvested and dissected. The stumps of all branches were ligated and the aneurysms were not opened, thus preserving the intact mural thrombus. The specimens were conserved at temperatures lower than −4 ºC until the date of the experiment, a period that ranged from one to seven days. Prior to the experiment, the specimens were thawed to room temperature and used as soon as the process of thawing was completed.</p><p id="para90" class="elsevierStylePara elsevierViewall">The pulsatility of the aneurysms was measured using a flow simulator. This consists of a pump which promotes pulsatile flow with controlled pressures and frequency. These parameters were set at 120 X 60 mmHg and 80 pulses/minute, respectively. The specimens were tied to the pump at the aortic neck and the external iliacs, and the internal iliacs were ligated. The circulation fluid was an aqueous glycerol solution with a volume ratio of 40:60 water to glycerol, which has been shown to have a viscosity comparable to that of blood.<a class="elsevierStyleCrossRef" href="#bib11">11</a></p><p id="para100" class="elsevierStylePara elsevierViewall">The aneurysm and the pump terminals were contained in a transparent cylinder made of acrylic, totally closed except for a hole in the upper edge where a graduated glass tube was attached (<a class="elsevierStyleCrossRefs" href="#fig1">Fig. 1 and Fig. 2</a>). This cylinder was completely filled with saline in order to allow for quantitative measurement of the volume dislodged in each pulsation by observing the rise and fall of the level in the graduated tube and the qualitative behavior (movements) of the aneurysm sac. The variation in the column level at each cycle of the pump was registered and used to calculate the volume dislodged by the aneurysm pulsation, hereafter called V. Thus, pulsatility was measured using volumetric variations rather than changes in diameter.</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">After recording the pulsatility, each aneurysm was removed from the system, and a bifurcated endograft was implanted. The device used in all cases was the Vanguard II (Boston Scientific, Natick, MA), a nitinol-polyester endograft already discontinued due to failures, but with a short-term behavior similar to other devices made of the same components.<a class="elsevierStyleCrossRef" href="#bib12">12</a></p><p id="para120" class="elsevierStylePara elsevierViewall">The implant was carried out under direct observation through the sectioned aortic neck, with the non-covered stents over the ostia of the renal arteries. The branches were extended to the common iliacs. For the contralateral limb, passage of the guidewire through the stump in the device was performed in a reverse direction – from the aortic neck to the iliac, with the stump visible through the neck. In four cases, angioscopy was used as an aid to check for correct positioning. In all cases, banding of the aortic neck and common iliacs was performed to avoid any possibility of leakage at those sites. In cases #1 and #3, the banding created a neck in the large iliacs.</p><p id="para130" class="elsevierStylePara elsevierViewall">The space remaining between the device and the mural thrombus was filled with human blood obtained from the blood bank and not usable for transfusion due to excessive storage time. Calcium citrate was added to reverse anticoagulation, and the infusion was made through a cannula inserted between the device and the aortic wall until blood stopped passing to the graft lumen, confirming clotting of the fabric. This was done intentionally to reproduce the clinical situation, where the endograft is surrounded by recent clot and by the mural thrombus, and also to promote sealing of the fabric mesh.</p><p id="para140" class="elsevierStylePara elsevierViewall">After the implant, the aneurysms were replaced in the simulator in the same position as before, and submitted to perfusion at the same pressures and pulse rates. After these procedures, the aneurysm sac was completely excluded from the circulatory circuit by an endovascular graft.</p><p id="para150" class="elsevierStylePara elsevierViewall">The variation in the level of the column of saline in the graduated tube was recorded, and the volume dislodged was compared with the previous data for the same specimen. A Wilcoxon Signed-Rank Sum test was performed with the data, assuming 0.05 as α.</p><p id="para160" class="elsevierStylePara elsevierViewall">At the end of each experiment, the aneurysm was opened to check for the correct positioning of the endograft.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">RESULTS</span><p id="para170" class="elsevierStylePara elsevierViewall">The rise and fall of the saline level for each experiment was constant, indicating that all branches were ligated and no communication occurred between the perfusion media and the liquid around the aneurysm.</p><p id="para180" class="elsevierStylePara elsevierViewall">The values of V for each experiment are shown in <a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>. Although there is a tendency toward a reduction in pulsatility after EVAR, no statistical significance was found.</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p id="para190" class="elsevierStylePara elsevierViewall">Besides the volumetric variation, it was possible to observe that all the aneurysm specimens displayed movements before and after implant of the endovascular graft.</p><p id="para200" class="elsevierStylePara elsevierViewall">During the post-experimental examination of all of the specimens, the device was found to be well adapted and positioned. A recent thrombus was found around the device, and the mural thrombus was intact (<a class="elsevierStyleCrossRef" href="#fig3">Fig. 3</a>). No evidence of leakage or detachment was encountered. The space between the endograft and the mural thrombus was found to be filled only with the recent clot; no glycerin was present, indicating that the perfusion solution did not pass through the clotted fabric of the graft.</p><elsevierMultimedia ident="fig3"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">DISCUSSION</span><p id="para210" class="elsevierStylePara elsevierViewall">This is the first bench top experiment on EVAR carried out with human aortic aneurysm tissue. The biological soft tissue is a heterogeneous material consisting of a complex arrangement of many individual components, each with a unique biomechanical behavior.<a class="elsevierStyleCrossRef" href="#bib13">13</a> A striking contrast between human aneurysm tissue and prosthetic tissue or even animal models of aneurysms<a class="elsevierStyleCrossRef" href="#bib8">8</a>,<a class="elsevierStyleCrossRef" href="#bib14">14</a>,<a class="elsevierStyleCrossRef" href="#bib15">15</a>,<a class="elsevierStyleCrossRef" href="#bib16">16</a> should be expected.</p><p id="para220" class="elsevierStylePara elsevierViewall">We chose to use glycerin as a perfusate instead of blood in order to keep the conditions constant before and after implantation. Blood tends to change viscosity when the machine is stopped, even when anticoagulation is used, and would require the system to be washed between the two phases. In addition, different blood samples do not have the same physical characteristics.</p><p id="para230" class="elsevierStylePara elsevierViewall">Despite the care taken in pre-clotting of the fabric, a slight type 4 endoleak may have contributed to the results. If this was an important factor, however, we should expect to have found a considerable amount of glycerin in the aneurismal sacs when they were opened after each experiment; however, the aneurysms were found filled only with clotted blood (no glycerin), showing that the fabric clotting was effective.</p><p id="para240" class="elsevierStylePara elsevierViewall">Unlike in open surgery, endografts for aortic aneurysms are implanted without opening the aneurysm sac. This results in the graft pulsating inside a closed chamber, and a pulsatile wave being transmitted to the aortic wall through the thrombus.</p><p id="para250" class="elsevierStylePara elsevierViewall">Our work is difficult to compare with other experimental data. First, we found greater aneurysm pulsatility because the aneurysms were tested without the constraint forces normally attached to them. Second, we used human aortic aneurysms, which clearly have different compliance and elasticity from animal aortas and artificial aneurysms sacs made of latex.</p><p id="para260" class="elsevierStylePara elsevierViewall">Our simulation indicates that transmission of pulsatility from the device to the aneurysm wall does occur. It may vary according to the material used in each particular graft, and should be a concern for manufacturers.<a class="elsevierStyleCrossRef" href="#bib2">2</a>,<a class="elsevierStyleCrossRef" href="#bib17">17</a>,<a class="elsevierStyleCrossRef" href="#bib18">18</a> Pulsatility may theoretically prevent aneurysm shrinking, and even promote enlargement, because the motion can lead to the rupture of wall fibers. However, it does not compromise the success of treatment, since there is no flow inside the sac in the absence of an endoleak, but rather a transmission of a pulsatile wave through static layers of clot. Even in the case of an aneurysm rupture, hemorrhage may not occur.</p><p id="para270" class="elsevierStylePara elsevierViewall">In conclusion, pulsatility of an aortic aneurysm after EVAR does not always indicate the existence of an endoleak. It may be caused by wave transmission and should not be interpreted as failure of the procedure, provided that the existence of an endoleak is ruled out.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "xpalclavsec1585147" "titulo" => "KEYWORDS" ] 1 => array:2 [ "identificador" => "cesec10" "titulo" => "METHOD" ] 2 => array:2 [ "identificador" => "cesec20" "titulo" => "RESULTS" ] 3 => array:2 [ "identificador" => "cesec30" "titulo" => "DISCUSSION" ] 4 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2007-08-28" "fechaAceptado" => "2007-09-19" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "KEYWORDS" "identificador" => "xpalclavsec1585147" "palabras" => array:6 [ 0 => "Aorta" 1 => "abdominal" 2 => "Aortic neurysm" 3 => "Endoluminal repair" 4 => "Pulsatile flow" 5 => "Vascular surgery" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVE</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">To measure the pulsatility of human aneurysms before and after complete exclusion with an endograft.</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHOD</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">Five aortic aneurysms obtained during necropsy were submitted to pulsatile perfusion before and after implantation of a bifurcated endograft. The specimens were contained in a closed chamber filled with saline solution. A vertical tube attached to the chamber was used to measure volume dislocation in each systole. Mural thrombus was kept intact, and the space around the device was filled with human blood. After each experiment, the aneurysm was opened to check for the correct positioning and attachment of the device.</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">The level of the saline column oscillated during pulsation in each case, with respective amplitudes of 17, 16, 13, 7, and 25 cm before the endograft insertion. After the insertion, the amplitudes dropped to 13, 12, 9, 3.5, and 23 cm, respectively. The differences were not significant. During the post-experimental examination, all devices were found to be in position and well attached to the neck and iliacs. No endoleak was detected during perfusion or by visual inspection.</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">Pulsation of an endograft is transmitted to the aneurysm wall even in the absence of endoleak, and should not be interpreted as procedural failure.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "ceabs10" "titulo" => "OBJECTIVE" ] 1 => array:2 [ "identificador" => "ceabs20" "titulo" => "METHOD" ] 2 => array:2 [ "identificador" => "ceabs30" "titulo" => "RESULTS" ] 3 => array:2 [ "identificador" => "ceabs40" "titulo" => "CONCLUSION" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 646 "Ancho" => 955 "Tamanyo" => 27415 ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of the perfusion system.</p>" ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 746 "Ancho" => 994 "Tamanyo" => 115982 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Aneurysm being submitted to pulsatile perfusion.</p>" ] ] 2 => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 548 "Ancho" => 993 "Tamanyo" => 91900 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Inspection of an aneurysm after an experiment, showing mural thrombus and recent clot around the device.</p>" ] ] 3 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Experiment # \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Proximal neck diameter (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Proximal neck length (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Maximum diameter (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Aneurysm length (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Right common iliac artery diameter (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Left common iliac artery diameter (cm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Diameters measured in the 5 specimens.</p>" ] ] 4 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Experiment # \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Volume variation before implant (ml) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Volume variation after implant (ml) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32,7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Pulsatility before and after endograft implantation in the 5 aneurysms, represented by volume variation. Variation was not significant at p<0.05.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delayed aortic aneurysm enlargement due to endotension after endovascular abdominal aortic aneurysm repair" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ PH Lin \n \t\t\t\t\t\t\t\t """ 1 => """ RL Bush \n \t\t\t\t\t\t\t\t """ 2 => """ JB Katzman \n \t\t\t\t\t\t\t\t """ 3 => """ G Zemel \n \t\t\t\t\t\t\t\t """ 4 => """ OA Puente \n \t\t\t\t\t\t\t\t """ 5 => """ BT Katzen \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0741-5214(03)00468-3" "Revista" => array:6 [ "tituloSerie" => "J Vasc Surg" "fecha" => "2003" "volumen" => "38" "paginaInicial" => "840" "paginaFinal" => "842" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14560240" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Late abdominal aortic aneurysm enlargement after endovascular repair with the Excluder device" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ JS Cho \n \t\t\t\t\t\t\t\t """ 1 => """ ED Dillavou \n \t\t\t\t\t\t\t\t """ 2 => """ RY Rhee \n \t\t\t\t\t\t\t\t """ 3 => """ MS Makaroun \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jvs.2004.02.038" "Revista" => array:6 [ "tituloSerie" => "J Vasc Surg" "fecha" => "2004" "volumen" => "39" "paginaInicial" => "1236" "paginaFinal" => "1242" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15192562" "web" => "Medline" ] ] ] ] ] ] ] 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