Editor's Choice - Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair

OBJECTIVES

The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair.

METHODS

Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure.

RESULTS

The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years.

CONCLUSIONS

The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

OBJECTIVE

The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications.

METHODS

There were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter.

RESULTS

Mean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis.

CONCLUSIONS

Total endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.

Bridging stent grafts in fenestrated and branched endovascular aortic repair: current practice and possible complications

Fenestrated and branched endovascular aortic repair (F/B-EVAR) is associated with a high degree of technical and clinical success. Despite this, studies have also reported high reintervention rates, and these are often related to the bridging stent grafts. Often new devices appear on the market before they have been tested in the bridging stent graft position. This review aims to assess the current literature on bridging stent grafts and discuss complications, illustrated by case reports. Complications reported with bridging stent grafts include; endoleak, kink, fracture, migration, occlusion, stenosis and perforation. Some known risk factors for bridging stent occlusions are renal artery stent grafts vs. SMA and celiac artery stent grafts. Some device specific complications have also been reported such as type IIIc endoleak with the Lifestream stent graft (Bard Peripheral Vascular, Tempe, AZ, USA) fractures and type IIId endoleaks with the 1st generation of Begraft (BentleyInnoMed, Hechingen, Germany). In addition, this review also discusses some newer devices with possible relation to complications such as stenosis and target vessel perforation. In conclusion, bridging stent grafts in fenestrated and branched aortic repair have a good midterm patency. Despite this, remaining issues are often related to the bridging stent grafts. Thorough follow-up and attention are needed, especially when new devices are introduced. The endovascular community should work towards a common global feedback system.

Should endovascular approach be considered as the first option for thoraco-abdominal aortic aneurysms?

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique of open TAAA repair has evolved from the use of "island" patch incorporation to separate branch vessel bypass, from "clamp and go" to routine use of distal perfusion, and towards more extensive repair in patients with connective tissue disorders. Open TAAA repair can be done with excellent results in highly specialized centers. However, these operations continue to carry excessive risk when performed outside large aortic centers, with 30-day mortality estimated on 20% according to statewide and national databases. In octogenarians, the mortality of elective open TAAA repair can be up to 40%. Endovascular repair was introduced as an alternative to open surgical repair in the elderly or higher risk patients using hybrid reconstruction, parallel grafts or fenestrated and branched endografts. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular repair using patient-specific and off-the-shelf devices, offering a minimally invasive alternative to open repair allowing treatment of increasingly older and sicker TAAA patients. During the last decade, improvements in device design, patient selection, spinal cord injury protocols, and perioperative management have contributed to a continued decline in morbidity and mortality of fenestrated-branched endovascular aortic repair, challenging open surgical repair as the new "gold standard" for treatment of TAAAs. Despite the improved results, endovascular repair is a highly technical procedure that requires vast experience, involves a significant risk of complications, and also, has an impact on patients' physical quality of life. In this article, we review the current technical aspects of endovascular TAAA repair with the main focus on the evidence of open versus endovascular outcomes of TAAA repair.

Outcomes and complications after fenestrated-branched endovascular aortic repair

OBJECTIVE

To report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices.

METHODS

This study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications.

RESULTS

One -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively.

CONCLUSIONS

Endovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.

A novel all-retrograde approach for t-Branch implantation in ruptured thoracoabdominal aneurysm

The off-the-shelf t-Branch device (Cook Medical, Bloomington, Ind) significantly advanced the endovascular treatment of ruptured thoracoabdominal aortic aneurysms. Improved techniques for expeditious implantation of the t-Branch may improve clinical outcomes for this emergent procedure. Currently, implantation is described using axillary and femoral access. We describe the repair of a ruptured thoracoabdominal aortic aneurysm exclusively through femoral access aided by a steerable sheath and newer generation, low-profile bridging stents.

Treatment of Complex Aortic Aneurysms Using Combination of Renal and Visceral Bypass and Fenestrated/Branched Stent Grafts

BACKGROUND

The purpose of this study was to report our experience of treatment of aortic aneurysms using combination of renal and visceral arteries bypasses and fenestrated/branched stent graft in various complex anatomical situations.

METHODS

Between November 2005 and March 2017, 10 patients underwent a hybrid strategy combining bypasses for renal and/or visceral arteries and custom-made fenestrated/branched stent grafts. Two patients had abdominal aortic aneurysm (1 juxtarenal and 1 suprarenal), and 8 patients had thoracoabdominal aortic aneurysm (1 type I, 2 type II including one dissection, 2 type III, 1 type IV, and 2 type V). In total, 37 renal and visceral arteries were targeted, of which 23 were treated using fenestrated or branched stent graft and 14 were treated by bypass (11 to renal artery and 3 to celiac trunk).

RESULTS

Technical success was 100%, and no patient died during a mean follow-up of 24.3 ± 21 months. Six patients had 7 postoperative complications after bypass surgery, and 3 patients had 3 complications after fenestrated or branched endovascular aneurysm repair (FEVAR/BEVAR) procedure. Seven reinterventions were performed in 3 patients. No occlusion of target vessels occurred. Renal function was stable during follow-up in all patients except one who developed end-stage renal failure requiring permanent dialysis. On the last follow-up computed tomography scan, aneurysm diameter decreased for 6 patients, was stable for 3 patients, and increased for one patient, in which persistent type II endoleak was observed. Aneurysm exclusion was complete in the remaining 9 patients.

CONCLUSIONS

Combination of FEVAR/BEVAR procedures with renal and/or visceral artery bypass in patients with complex aortic aneurysms is feasible with acceptable results. Morbidity associated with bypass surgery has to be carefully balanced with the risk of catheterization difficulties in the setting of adverse anatomical features of the visceral/renal arteries or the aorta.

Performance of a feature-based algorithm for 3D-3D registration of CT angiography to cone-beam CT for endovascular repair of complex abdominal aortic aneurysms

BACKGROUND

A crucial step in image fusion for intraoperative guidance during endovascular procedures is the registration of preoperative computed tomography angiography (CTA) with intraoperative Cone Beam CT (CBCT). Automatic tools for image registration facilitate the 3D image guidance workflow. However their performance is not always satisfactory. The aim of this study is to assess the accuracy of a new fully automatic, feature-based algorithm for 3D3D registration of CTA to CBCT.

METHODS

The feature-based algorithm was tested on clinical image datasets from 14 patients undergoing complex endovascular aortic repair. Deviations in Euclidian distances between vascular as well as bony landmarks were measured and compared to an intensity-based, normalized mutual information algorithm.

RESULTS

The results for the feature-based algorithm showed that the median 3D registration error between the anatomical landmarks of CBCT and CT images was less than 3 mm. The feature-based algorithm showed significantly better accuracy compared to the intensity-based algorithm (p < 0.001).

CONCLUSION

A feature-based algorithm for 3D image registration is presented.

Failure of Sandwich Technique for Thoracoabdominal Aneurysm Treated with Custom-Made Fenestrated Endograft

BACKGROUND

Custom-made fenestrated and branched endografts are considered the gold standard devices for thoracoabdominal repair, with lower perioperative mortality and morbidities than open surgical repair. Although they are not feasible in urgent and emergent settings, in which sandwich techniques are often necessary, custom-made devices can still be used as bail-out options to correct late complications such as high-flow endoleaks, as shown in this case report.

METHODS

A complex, symptomatic thoracoabdominal aneurysm, unsuitable for open repair, was treated by sandwich technique on the celiac trunk despite having a short distal neck. After the finding of a high-flow type IB endoleak during postoperative follow-up, reintervention was planned with a custom-made endograft with a distal scallop, to preserve patency of the superior mesenteric artery.

RESULTS

The procedure achieved technical success, with complete exclusion of the aneurysm and patency of all the visceral arteries.

CONCLUSIONS

Bail-out endovascular repair with custom-made endografts after failure of parallel graft repair of thoracoabdominal aneurysms is a valuable treatment option preventing the risks related to an open conversion.

[Thoracoabominal aortic aneurysms-endovascular options]

BACKGROUND

Thoracoabdominal aortic aneurysms (TAAA) are predominantly atherosclerotic related and are usually asymptomatic. Treatment is necessary from a size greater 6.5 cm, while patients with rapidly growing, compression of organ structures, aneurysm-related connecting tissue orders must be treated from a diameter of 6 cm.

METHODS

Elective interventions may be performed with fenestrated and/or branched grafts. Another possibility is the chimney, sandwich or periscop technique for treating TAAA. Depending on the extension of the TAAA, implantation of tube grafts for the thoracic aorta or bifurcation grafts for the abdominal aorta is necessary. Symptomatic TAAA may be treated by implantation of a t-Branch® or using the chimney, sandwich or periscop technique.

CONCLUSIONS

The preinterventional planning and sizing with the help of computed tomography (CT) scans for endovascular repair of TAAA, and the implantation of the grafts during the procedure are challenging; thus, a well-experienced interdisciplinary team of medical and nonmedical specialists is required.

The role of selective stenting for superior mesenteric artery scallops during fenestrated endovascular aneurysm repair

OBJECTIVE

Stenting of small fenestrations of the Zenith fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) is necessary during fenestrated endovascular aneurysm repair (FEVAR) of complex abdominal aortic aneurysms to avoid malalignment. However, stenting of superior mesenteric artery (SMA) scallops of ZFEN devices is optional according to the instructions for use. The objective of this study was to assess the early and midterm outcomes of selective use of stents in SMA scallops of ZFEN during FEVAR procedures.

METHODS

This study is a single-institution retrospective review of prospectively enrolled patients treated at the University of North Carolina at Chapel Hill between July 2010 and August 2014. Only patients with SMA scallops were included for analysis. We compared results between patients grouped as stented or unstented SMA scallops. The scallops were stented when one or more of the following criteria were present: misalignment of scallop determined by balloon testing intraoperatively; configuration consisting of an SMA scallop and a single renal fenestration or stent; and pre-existing stenosis in the vessel adjacent to the graft scallop. The study was approved by the local Institutional Review Board. Primary outcomes addressed were mortality, vessel patency, early and late complications, and reintervention rates. Baseline characteristics of the patients and procedure data were also described.

RESULTS

During the 48-month study period, 61 patients were treated for complex abdominal aortic aneurysms at the University of North Carolina with a mean age of 73 years, and 74.3% of patients were male. Thirty-nine of 61 patients (63.9%) had a device design with an SMA scallop and were included for analysis. Eleven of 39 patients (28%) had the SMA primarily stented and 28 (72%) were unstented. There was only one death (2.5%) during the 30-day postoperative period, with 100% technical success and branch patency. In the unstented group, there were three SMA complications during follow-up, two requiring reintervention; however, there were no associated deaths. Among the stented group, there was one branch-related complication that occurred during the procedure but no stent stenosis or occlusion during the long-term follow-up. During the mean follow-up period of 21.7 months, no SMA stent thrombosis occurred. There was no statistical difference in outcomes between groups.

CONCLUSIONS

Single-wide SMA scallops of ZFEN during FEVAR procedures may be selectively stented using specific criteria and rigorous follow-up, without compromising the safety and efficacy of the SMA.

Accurate Orientation of the t-Branch Off-the-Shelf Multibranched Endograft After Deployment in Urgent Cases

Purpose: To evaluate the orientation of the standardized off-the-shelf multibranched t-Branch after implantation in urgent thoracoabdominal aortic aneurysm (TAAA) repairs, to characterize the impact of branch malorientation on procedural success, and to identify any predictive factors associated with malorientation. Methods: A retrospective analysis was conducted of 42 consecutive patients (mean age 73.3±7 years; 25 men) with urgent TAAA presentation treated with the t-Branch from January 2014 to June 2017. The primary objective was to quantify the preoperative clock position of the target vessels and determine any rotational deviation between the pre- and postoperative measurements and between the postoperative measurements and the standard branch configuration. Secondary outcomes were to identify factors influencing malorientation (>2 clock face hours) that could affect outcome. Results were compared for early (learning curve; n=18) vs late (n=24) experience and for adherence to (n=23) vs nonobservance of (n=19) the instructions for use (IFU). Results: Technical success was 93% (39/42). No significant difference in rotational deviation was identified between patients treated within the IFU vs outside the IFU. Seven (17%) patients had at least one target vessel maloriented after the procedure, which was not associated with total procedure time, fluoroscopy time, contrast volume, radiation dose, or adherence to the IFU. Female gender was associated with increased rotational deviation in postprocedure measurement for the celiac trunk (p=0.044) and superior mesenteric artery (SMA; p=0.006). Female gender was also associated with increased rotational deviation between the branch origin after deployment and the standard configuration of the t-Branch for every target vessel [celiac trunk (p=0.005), SMA (p=0.001), right renal artery (p=0.037), and left renal artery (p=0.003)]. Conclusion: The implantation of the t-Branch device in urgent cases achieved accurate apposition without rotational deviation between the target vessels and the position of the endograft branches. Gender may have an impact on orientation of the device. The t-Branch appears to have a “forgiving” nature for higher malorientation with no effect on procedure time, target vessel revascularization, or early branch patency.

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

AIM AND BACKGROUND

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

METHODS

A total of 30 patients (24 men and 6 females; mean age 59 ± 8 years) with uncomplicated type B aortic dissection and descending thoracic aortic aneurysm who underwent endovascular aortic repair in National Heart Institute and Cairo University hospitals were followed up. Clinical follow-up data was done at one, three and twelve months thereafter. Clinical follow-up events included death, neurological deficits, symptoms of chronic mal-perfusion syndrome and secondary intervention. Multi-slice computed tomography was performed at three and six months after intervention.

RESULTS

Of the 30 patients, 24 patients had aortic dissection, and 6 patients had an aortic aneurysm. 7 patients underwent hybrid technique and the rest underwent the basic endovascular technique in whom success rate was 100%. Two patients developed type I endoleak, however both improved after short term follow up. The total mortality rate was 10% throughout the follow-up. Both death and endoleak occurred in subacute and chronic cases, while using TEVAR in acute AD and aneurysm showed no side effects. Early thoracic endovascular aortic repair showed better results and less complications.

CONCLUSION

Along with medical treatment, early thoracic endovascular aortic repair in uncomplicated type B aortic dissections and thoracic aortic aneurysms is associated with better outcome.

Open Replacement of the Thoracoabdominal Aorta: Short- and Long-term Outcomes at a Single Institution

Background  Despite much progress in the surgical and endovascular treatment of thoracoabdominal aortic diseases (TAADs), there is no consensus regarding the optimal approach to minimize operative mortality and end-organ dysfunction. We report our experience in the past 16 years treating TAAD by open surgery. Methods  A retrospective review of all TAAD patients who underwent an open repair since January 2000 was performed. The primary endpoints included early morbidity and mortality, and the secondary endpoints were overall death and rate of aortic reintervention. Results  There were 112 patients treated by open surgery for TAAD. Mean age was 66 ± 10 years and 61 (54%) were male. Seventy-seven (69%) patients had aneurysmal degeneration without aortic dissection and the remaining 35 (31%) had a concomitant aortic dissection. There were 12 deaths (10.7%) and they were equally distributed between the aneurysm and dissection groups ( p  = 0.8). The mortality for elective surgery was 3.2% (2/61). The rate of permanent paraplegia and stroke were each 2.6% (3/112). The rate of cerebrovascular accident was significantly higher in the dissection group (8.5% vs. 1.2%, p  = 0.05). The survival at 1, 5, and 10 years was 80.6, 56.1, and 32.7%, respectively. Conclusion  Our data confirm that open replacement of the thoracoabdominal aorta can be performed in expert centers quite safely. Different aortic pathologies (degenerative aneurysm vs. dissection) do not influence the short- and long-term outcomes. Open surgery should still be considered the standard in the management of TAAD.

Accuracy of implementing principles of fusion imaging in the follow up and surveillance of complex aneurysm repair

Fusion imaging is standard for the endovascular treatment of complex aortic aneurysms, but its role in follow up has not been explored. A critical issue is renal function deterioration over time. Renal volume has been used as a marker of renal impairment; however, it is not reproducible and remains a complex and resource-intensive procedure. The aim of this study is to determine the accuracy of a fusion-based software to automatically calculate the renal volume changes during follow up. In this study, computerized tomography (CT) scans of 16 patients who underwent complex aortic endovascular repair were analysed. Preoperative, 1-month and 1-year follow-up CT scans have been analysed using a conventional approach of semi-automatic segmentation, and a second approach with automatic segmentation. For each kidney and at each time point the percentage of change in renal volume was calculated using both techniques. After review, volume assessment was feasible for all CT scans. For the left kidney, the intraclass correlation coefficient (ICC) was 0.794 and 0.877 at 1 month and 1 year, respectively. For the right side, the ICC was 0.817 at 1 month and 0.966 at 1 year. The automated technique reliably detected a decrease in renal volume for the eight patients with occluded renal arteries during follow up. This is the first report of a fusion-based algorithm to detect changes in renal volume during postoperative surveillance using an automated process. Using this technique, the standardized assessment of renal volume could be implemented with greater ease and reproducibility and serve as a warning of potential renal impairment.

A prospective observational trial of fusion imaging in infrarenal aneurysms

OBJECTIVE

Use of three-dimensional fusion has been shown to significantly reduce radiation exposure and contrast material use in complex (fenestrated and branched) endovascular aneurysm repair (EVAR). Cydar software (CYDAR Medical, Cambridge, United Kingdom) is a cloud-based technology that can provide imaging guidance by overlaying preoperative three-dimensional vessel anatomy from computed tomography scans onto live fluoroscopy images both in hybrid operating rooms and on mobile C-arms. The aim of this study was to determine whether radiation dose reduction would occur with the addition of fusion imaging to infrarenal repair in all imaging environments.

METHODS

All patients who consented to involvement in the trial and who were treated with EVAR in our center from March 2016 until April 2017 were included. A teaching session about radiation protection and Cydar fusion software use was provided to all operators before the start of the fusion group enrollment. This group was compared with a retrospective cohort of patients treated in the same center from March 2015 to March 2016, after a dedicated program of radiation awareness and reduction was introduced. Ruptured aneurysms and complex EVAR were excluded. Preoperative and perioperative characteristics were recorded, including parameters of radiation dose, such as air kerma and dose-area product. Results were expressed in median and interquartile range.

RESULTS

Forty-four patients were prospectively enrolled and compared with 21 retrospective control patients. No significant differences were found in comparing sex, body mass index, and age at repair. The median operation time (wire to wire) and fluoroscopy time were 90 (75-105) minutes and 30 (22-34) minutes, respectively, without significant differences between groups (P = .56 and P = .36). Dose-area product was nonsignificantly higher in the control group, 21.7 (8.9-85.9) Gy cm², compared with the fusion group, 12.4 (7.5-23.4) Gy cm² (P = .10). Air kerma product was significantly higher in the control group, 142 (61-541) mGy, compared with 82 (51-115) mGy in the fusion group (P = .03). The number of digital subtraction angiography runs was significantly lower in the fusion group (8 [6-11]) compared with the control group (10 [9-14]); (P = .03). There were no significant differences in the frequency of adverse events, endoleaks, or additional procedures required.

CONCLUSIONS

When it is used in simple procedures such as infrarenal aneurysm repair, image-based fusion technology is feasible both in hybrid operating rooms and on mobile systems and leads to an overall 50% reduction in radiation dose. Fusion technology should become standard of care for centers attempting to maximize radiation dose reduction, even if capital investment of a hybrid operating room is not feasible.

Techniques and outcomes of secondary endovascular repair for postdissection TAA/TAAA

Postdissection aortic aneurysms (PDAA) affect 20-40% of patients with aortic dissection. Open repair remains the first line therapy of PDAA, but is still associated with high mortality and morbidity rates. Endovascular repair is increasingly being used as a less invasive treatment option. Thoracic endovascular aneurysm repair (TEVAR) covering only the proximal entry tear has proven to be insufficient in most patients with chronic PDAA and has a limited role only for PDAA with distal sealing zone in the thoracic aorta. In PDAA extending to the thoracoabdominal aorta, a more complex repair is needed to achieve aneurysm exclusion. Fenestrated and branched stent-grafts have been used lately in some expert centres to treat PDAA of the thoracoabdominal aorta with good preliminary results despite the technical difficulties in these patients (narrow true lumen, stiff chronic dissection flap, target vessels that originate from the false lumen [FL]). A subset of patients with aneurysmal degeneration mainly in the descending thoracic aorta, can be treated with TEVAR landing proximal to the celiac artery along with adjuvant techniques such as coils, plugs, glue or "Candy-Plug" and "Knickerbocker" concepts to occlude the FL, preventing retrograde flow and reducing the pressure in the aneurysm. Other options that have been used in limited numbers of patients with PDAA include the PETTICOAT (provisional extension to induce complete attachment) and STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) techniques. This article aims to review the outcomes of different endovascular techniques and strategies available for the repair of PDAA.

Endovascular Treatment of Various Aortic Pathologies: Review of the Latest Data and Technologies

The technologies and innovations applicable to endovascular treatment for complex aortic pathologies have progressed rapidly over the last two decades. Although the initial outcomes of an endovascular aortic repair have been excellent, as long-term data became available, complications including endoleaks, endograft migration, and endograft infection have become apparent and are of concern. Previously, the indication for endovascular therapy was restricted to descending thoracic aortic aneurysms and abdominal aortic aneurysms. However, its indication has expanded along with the improvement of techniques and devices, and currently, it has become possible to treat pararenal aortic aneurysms and Crawford type 4 thoracoabdominal aortic aneurysm (TAAA) using the off-the-shelf devices. Additionally, custom-made devices allow for the treatment of arch or more extensive TAAAs. Endovascular treatment is applied not only to aneurysms but also to acute/chronic dissections. However, long-term outcomes are still unclear. This article provides an overview of available devices and the results of endovascular treatment for various aortic pathologies.

Complications and Reinterventions After Fenestrated and Branched EVAR in Patients with Paravisceral and Thoracoabdominal Aneurysms

The application of endovascular strategies to treat aneurysms involving the abdominal and thoracoabdominal aorta has evolved significantly since the inception of endovascular aneurysm repair. Advances in endograft technology and operator experience have enabled the management of a wider spectrum of challenging aortic anatomy. Fenestrated endovascular and branched endovascular aneurysm repair represent two technical innovations, which have expanded endovascular treatment options to include patients with paravisceral and thoracoabdominal aortic aneurysms. Although similar in many ways to standard aortic endografts, fenestrated and branched endografts have specific short- and long-term complications due to their unique modular endograft design and their sophisticated deployment mechanisms. This article aims to examine the commonly encountered complications with these devices and the endovascular reintervention strategies.

Early outcomes of patients transferred with ruptured suprarenal aneurysm or dissection

Objective Despite centralisation of the provision of vascular care, not all areas in England and Wales are able to offer emergency treatment for patients with acute conditions affecting the aorta proximal to the renal arteries. While cardiothoracic centres have made network arrangements to coordinate care for the repair of type A dissections, a similar plan for vascular care is lacking. This study investigates early outcomes in patients with ruptured suprarenal aortic aneurysm or dissection (rSRAD) transferred to a specialist centre. Methods Retrospective observational study over a five-year period (2009-2014) assessing outcomes of patients with ruptured sRAD diagnosed at their local hospital and then transferred to a tertiary centre capable of offering such treatment. Results Fifty-two patients (median age 73 years, 32 male) with rSRAD were transferred and a further four died during transit. The mean distance of patient transfer was 35 miles (range 4-211 miles). One patient did not undergo intervention due to frailty and two died before reaching the operating theatre. A total of 23 patients underwent endovascular repair, 9 hybrid repair and 17 open surgery. Median follow-up was 12 months (range 1-43 months). Complications included paraplegia (n = 3), stroke (n = 2), type IA endoleak (n = 4); 30-day and in-hospital mortality were 16% and 27%. For patients discharged alive from hospital, one-year survival was 67%. Conclusions Although the number of patients with rSRAD is low and those who are transferred alive are a self-selecting group, this study suggests that transfer of such patients to a specialist vascular centre is associated with acceptable mortality rates following emergency complex aortic repair.

Successful use of retrograde branched extension limb assembling technique in endovascular repair of pararenal abdominal aortic aneurysm

Surgeon-modified retrograde branched extension limb assembling technique and bridged endografts were successfully used to exclude an asymptomatic pararenal abdominal aortic aneurysm and to reconstruct the superior mesenteric artery and bilateral renal arteries in a case with high-grade celiac artery stenosis, nondilated aorta above the superior mesenteric artery, and large lumen below the renal arteries. In patient-specific models for hemodynamics analysis, enhanced flow diversion to visceral arteries up to 6-month follow-up confirmed treatment feasibility; however, endograft configurations could be improved to avoid sharp corners at bifurcations, thereby ensuring smooth flow transport and possibly reducing risk for endograft narrowing or the development of thrombosis.

Preliminary Outcomes of the LifeStream Balloon-Expandable Covered Stent in Fenestrated and Branched Thoracoabdominal Endovascular Repairs

PURPOSE

To evaluate the 1-year outcomes of thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent-grafts and a novel balloon-expandable covered stent.

METHODS

Between March 2015 and January 2017, 18 patients (median age 74.7 years; 14 men) received 43 LifeStream balloon-expandable covered stents in conjunction with Zenith fenestrated/branched stent-grafts to bridge 11 celiac trunks, 8 superior mesenteric arteries, and 24 renal arteries (total 32 fenestrations and 11 branches).

RESULTS

Stent delivery and deployment was successful in all cases. At 30 days, 5 patients presented with perifenestration endoleaks (type IIIc) secondary to inadequate sealing of the LifeStream covered stent in 7 (22%) of 32 fenestrations. No type IIIc endoleaks were reported in the branched cases. Four patients had a secondary endovascular reintervention with proximal relining by means of a bare balloon-expandable stent at the perifenestration transition area, with complete resolution of the endoleak at 1-year follow-up. One patient refused reintervention. The last 4 fenestrated stent-grafts of this series had prophylactic perifenestration bare stent relining with no evidence of type IIIc endoleaks at imaging. At a median follow-up of 14.1 months (interquartile range 11, 22), the 12-month LifeStream patency rate was 100%.

CONCLUSION

This single-center preliminary experience with the LifeStream balloon-expandable covered stent in fenestrated/branched stent-grafts for TAAA repairs demonstrated good patency; however, an unexpectedly high rate of type IIIc endoleaks was observed. These endoleaks were resolved with reintervention or during the index procedure by proximal relining with a bare balloon-expandable stent, achieving adequate perifenestration sealing.

Early Outcomes of the t-Branch Off-the-Shelf Multibranched Stent-Graft in Urgent Thoracoabdominal Aortic Aneurysm Repair

Purpose: To assess the short-term outcomes of the multibranched off-the-shelf t-Branch stent-graft for urgent thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the impact on outcomes of the learning curve and adherence to the instruction for use (IFU). Methods: Between 2014 and 2017, 42 patients (mean age 73.3±7 years; 26 men) underwent urgent TAAA treatment using the t-Branch stent-graft [18 in the early (2014–2015) period and 24 in the late (2016–2017) period]. Nearly half the patients were symptomatic (n=18) and 12 had contained rupture. Aneurysm diameter >80 mm was present in 12 (mean diameter 77.7±13.2 mm). Nineteen patients did not meet the IFU for the t-Branch due to target vessel anatomy. The primary endpoints were spinal cord ischemia (SCI), renal function impairment, and 30-day mortality. Target vessel patency and endoleak incidence were assessed at 30 days. Multivariate analyses examined associations between perioperative variables and outcomes; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The technical success rate was 93% (39/42). Successful catheterization was achieved in 150/155 target vessels (97%). The postoperative SCI rate was 21% (5 paraplegia/4 transient paraparesis) and was correlated with age (OR 1.26, 95% CI 1.01 to 1.56, p=0.04). The renal function impairment rate was 23% (10/42; 2 temporary, 2 permanent dialysis) and was correlated with early experience (OR 7.74, 95% CI 1.3 to 43.9, p=0.019). The 30-day mortality was 14% (no intraoperative deaths); no factor was associated with mortality. During the first month, the incidences of type I, II, and III endoleaks were 0%, 43%, and 0%, respectively; branch patency was 99% (150/151). Procedure time decreased in the later experience (479±333 vs 407±25 minutes, p=0.09), though it was increased in cases outside the IFU (497±135 vs 389±118 minutes, p=0.009), along with fluoroscopy time (121±48 vs 92±33 minutes, p=0.036). Conclusion: Endovascular repair of urgent TAAA using the t-Branch is a feasible treatment option with acceptable 30-day mortality and morbidity in terms of SCI and renal function impairment. Adherence to the IFU prolonged procedure time but had no effect on outcomes. Increased experience of such cases over time may improve outcomes.