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Santos-Venâncio M, Rocha-Neves J, Spath P, Oliveira-Pinto J. Complications and Technical Success on Upper Limb Vascular Access for Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:433-443. [PMID: 39059630 DOI: 10.1016/j.avsg.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Catheterization of target vessels (TV) represented by renal visceral vessels are the crucial aspect during fenestrated and branched endovascular repair. This study aims to assess the efficacy and complications associated with upper limb catheterization during complex aneurysm endovascular surgery repair. METHODS A systematic review was conducted after Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, involving a search across PubMed, Cochrane CENTRAL, and Web of Science. Primary endpoint was represented by 30-day stroke. Secondary endpoints were target vessels' (TVs) technical success, 30-day mortality, and local access-related complications. Meta-analyses were performed using a random-effects model. RESULTS Sixteen observational studies encompassing 4,137 patients were included. The 30-day stroke incidence for upper limb access was 1.4% (95% CI 1.0-1.8%), which was slightly higher than lower limb, despite not statistically significant. Mortality varied between 0 and 6.8%, and local access-related complications occurred in 3.2% (95% CI 1.9-4.4%). Technical success in TV catheterization was 99.2% (95% CI 98.4-100.0%). CONCLUSIONS This systematic review and meta-analysis demonstrate the safety and efficacy of upper limb access for Fenestrated and Branched Endovascular Aortic Repair (f/b-EVAR), with low stroke risk, mortality rates, and minimal local complications. Despite the risk of bias, the findings suggest that upper limb access may be beneficial, especially in bailout situations when femoral access fails, offering valuable insights for clinical decision-making.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; RISE@Health, Porto, Portugal.
| | - Paolo Spath
- Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy; Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Ludwig-Maximilians-Universitat Munchen, Vascular Surgery Marchionisteße Munchen, Bayern, Germany
| | - José Oliveira-Pinto
- RISE@Health, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Chen Y, Bashir M, Guo J, Piffaretti G, Jubouri M, D'Oria M. Expert-Based Narrative Review on Contemporary Use of an Off-The-Shelf Multibranched Endograft for Endovascular Treatment of Thoracoabdominal Aortic Aneurysms: Device Design, Anatomical Suitability, Technical Tips, Perioperative Care, Clinical Applications, and Real-World Experience. Ann Vasc Surg 2024; 108:98-111. [PMID: 38942377 DOI: 10.1016/j.avsg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 06/30/2024]
Abstract
Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm patients have anatomic limitations to fenestrated stent-grafts given a large lumen, that is, the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, IN), which has been commercially available in Europe to treat thoracoabdominal aortic aneurysm since June 2012, represents a feasible off-the-shelf alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior endovascular aneurysm repair), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been carried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Jiayin Guo
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Matti Jubouri
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Mario D'Oria
- Department of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
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Oliny A, Vasseur MA, Frisch N, Alimi Y, Omnes V, Ducasse E, Albertini JN, Millon A. Fenestrated Endovascular Aortic Repair of Complex Aneurysm Using the Anaconda Fenestrated Device: 1-Year Results From the French Multicenter Registry. J Endovasc Ther 2024:15266028241284034. [PMID: 39323372 DOI: 10.1177/15266028241284034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
PURPOSE This study aims to assess the safety and efficacy of the fenestrated Anaconda device for the treatment of complex aortic aneurysms over 1 year in daily clinical practice. MATERIALS AND METHODS All patients who received the graft between October 2019 and October 2020 were prospectively enrolled in an observational, multicenter national registry. The primary endpoint was the aneurysm-related 1-year mortality rate. Secondary endpoints included all-cause mortality, technical success, device-related adverse events (AEs) and major complications, secondary reinterventions, endoleaks, target vessel (TV) outcomes, and a center-volume analysis comparing mortality and secondary reintervention rate between expert centers (>15 F/BEVAR per year) and nonexpert centers (≤15 F/BEVAR per year). RESULTS Ninety-seven patients from 28 centers were treated. Aneurysms types included juxta-renal and short neck (84.6%), pararenal (5.2%), paravisceral (3.1%), and type IV thoracoabdominal (2.5%). Configurations with 1, 2, 3, and 4 fenestrations were used in 2, 12, 18, and 65 cases, respectively, totaling 350 TVs. Technical success was 98.0%, with 1 type Ic and 1 type IIIc endoleak. Mean follow-up was 468 days. Ten patients died, with 8 deaths (8.2%) due to non-aortic causes and 2 deaths (2.1%) from unknown causes. The estimated 1-year survival rate was 92.7% (95% CI: 87.8-98.1%). The reintervention rate at 30 days was 11.3% and the estimated reintervention rate at 1 year was 21.6% (95% CI: 12.7-29.6%). No type Ia endoleak occurred during follow-up. Three type III endoleaks occurred and required reintervention. Three TV occlusion occurred, yielding a 1-year TVI-free rate of 92.4% (95% CI: 89.4-99.3). No device-related major complication was recorded, and 3 device-related AEs occurred: 1 limb migration, 1 limb kinking and 1 limb thrombosis. There was no statistically significant difference in mortality and survival without reintervention between expert and nonexpert centers (Log rank p=0.52 and p=0.16, respectively). CONCLUSION The fenestrated Anaconda device demonstrated acceptable early and at 1-year safety and efficacy for treating primarily juxta-renal and short-neck aortic aneurysms, in centers with varying levels of experience. CLINICAL IMPACT The Anaconda Fenestrated, as the second commercially available custom-made device for complex endovascular aortic surgery, might adress some anatomical challenges. Following market authorization, this registry presents the 1-year outcomes of real-world device usage in a large number of centers, including small clinics. The results indicate that the device provided adequate efficacy and safety for treating mostly juxta-renal and short neck aneurysms, with notable improvement in technical success rate compared to older reports.
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Affiliation(s)
- Alexandre Oliny
- Vascular Surgery Department, Hopital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | | | | | - Yves Alimi
- Centre Hospitalier Universitaire Nord, Marseille, France
| | - Virgile Omnes
- Centre Hospitalier Universitaire Timone, Marseille, France
| | - Eric Ducasse
- Centre Hospitalier Universitaire Pellegrin, Bordeaux, France
| | - Jean-Noël Albertini
- Centre Hospitalier Universitaire de Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Antoine Millon
- Vascular Surgery Department, Hopital Louis Pradel, Hospices Civils de Lyon, Bron, France
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Xu C, Xu GX, Chen L, Zhang ZX, Jin YQ. Feasibility of a modified hybrid glubran-supported single-proglide technique for access closure during endovascular aneurysm repair. Front Cardiovasc Med 2024; 11:1426961. [PMID: 39027005 PMCID: PMC11254816 DOI: 10.3389/fcvm.2024.1426961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024] Open
Abstract
Objective This study aimed to evaluate the feasibility of a hybrid Glubran-supported single-Proglide technique for large bore femoral access closure during percutaneous access endovascular aneurysm repair (EVAR). Methods A retrospective cohort study was performed for all percutaneous EVARs at our center from January 2023 to June 2023. All patients received the hybrid Glubran-supported single-Proglide technique involving a mixture of surgical glue and Lipiodol injection after single suture placement for femoral access closure. Technical success was defined as achieving complete hemostasis without a bailout strategy. Vascular complications and bleeding were defined by Valve Academic Research Consortium-3 (VARC-3) criteria. Vascular access changes and 30-day mortality were recorded. Results The technique success rate for the entire study population was 100% (55 femoral access in 37 patients; median age: 72; 78% males). The mean sheath size was 20.4 ± 2.3F. The mean manual compression time was 3.5 ± 1.4 min, the mean hemostasis time was 9.0 ± 2.5 min, and the mean procedural time was 103.9 ± 34.7 min. One patient (1.6%) developed an access site infection and recovered conservatively. No VARC-3 vascular complications and access changes were observed. No 30-day mortality happened. Conclusions The hybrid Glubran-supported single-Proglide technique is feasible for large bore access closure during EVAR and may be a viable alternative; however, larger prospective studies are required to confirm its efficacy.
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Affiliation(s)
| | | | | | | | - Yi-qi Jin
- Department of Vascular Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
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Al Adas Z, Uceda D, Mazur A, Zehner K, Agrusa CJ, Wang G, Schneider DB. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg 2024; 79:487-496. [PMID: 37918698 DOI: 10.1016/j.jvs.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.
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Affiliation(s)
- Ziad Al Adas
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Domingo Uceda
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexa Mazur
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kiera Zehner
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill, Cornell Medical Center, New York, NY
| | - Grace Wang
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Darren B Schneider
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Meertens MM, Tenorio ER, Lemmens CC, Marcondes GB, Lima GBB, Schurink GWH, Mendes BC, Oderich GS, Mees BME. Safety of Percutaneous Femoral Access for Endovascular Aortic Aneurysm Repair Through Previously Surgically Exposed or Repaired Femoral Arteries. J Endovasc Ther 2023; 30:730-738. [PMID: 35514295 PMCID: PMC10503241 DOI: 10.1177/15266028221092980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Percutaneous femoral artery access is being increasingly used in endovascular aortic repair (EVAR). The technique can be challenging in patients with previously surgically exposed or repaired femoral arteries because of excessive scar tissue. However, a successful percutaneous approach may cause less morbidity than a "re-do" open femoral approach. The aim of this study was to assess the impact of prior open surgical femoral exposure on technical success and clinical outcomes of percutaneous approach. METHODS This study retrospectively reviewed the clinical data of patients who underwent percutaneous EVAR between 2010 and 2020 at 2 major aortic centers. Patients were divided into 2 groups (with or without prior open surgical femoral access) for analysis of clinical outcomes. Only punctures with sheaths ≥12Fr were included for analysis. The access and (pre)closure techniques were similar in both institutions. Primary end points were intraoperative technical success, access-related revision, and access complications. A multivariate analysis was performed to identify determinants of conversion to open approach and femoral access complications in intact and re-do groins. RESULTS A total of 632 patients underwent percutaneous (complex) EVAR: 98 had prior open surgical femoral access and 534 patients underwent de novo femoral percutaneous access. A total of 1099 femoral artery punctures were performed: 149 in re-do and 950 in intact groins. The extent of endovascular repair included 159 infrarenal, 82 thoracic, 368 fenestrated/branched, and 23 iliac branch devices. No significant differences were seen in technical success (re-do 93.3% vs intact 95.3%, p=0.311), access-related surgical revision (0.7% vs 0.6%, p=0.950), and access complications (2.7% vs 4.0%, p=0.443). For the whole group, significant predictors for access complications in multivariate analyses were main access site (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.07%-5.35%; p=0.033) and increase of the procedure time per hour (OR 1.65; 95% CI 1.34%-2.04%; p<0.001), while increase in sheath-vessel ratio had a protective effect (OR 0.33; 95% CI 0.127%-0.85%; p=0.021). Surgical conversion was predicted by main access site (OR 2.32; 95% CI 1.28%-4.19%; p=0.007) and calcification of 50% to 75% of the circumference of the access vessel (OR 3.29; 95% CI 1.38%-7.86%; p=0.005). CONCLUSION Within our population prior open surgical femoral artery exposure or repair had no negative impact on the technical success and clinical outcomes of percutaneous (complex) endovascular aortic aneurysm repair.
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Affiliation(s)
- Max M. Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Emanuel R. Tenorio
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Charlotte C. Lemmens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Giulianna B. Marcondes
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Guilherme B. B. Lima
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Geert Willem H. Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Barend M. E. Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
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Mario D, Alessandro G, Giovanni P, Gianbattista P, Rocco G, Mauro G, Nicola M, Roberto C, Sandro L, Luca B. Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry. J Endovasc Ther 2023:15266028231179864. [PMID: 37326371 DOI: 10.1177/15266028231179864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. MATERIALS AND METHODS The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). RESULTS Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. CONCLUSIONS A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. CLINICAL IMPACT Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.
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Affiliation(s)
- D'Oria Mario
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Grandi Alessandro
- Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pratesi Giovanni
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Parlani Gianbattista
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giudice Rocco
- UOC di Chirurgia Vascolare, Dipartimento Cardiovascolare, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Gargiulo Mauro
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Mangialardi Nicola
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Lepidi Sandro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
- Division of Vascular Surgery, Department of Surgical and Clinical Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
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Grandi A, Melloni A, D'Oria M, Lepidi S, Bonardelli S, Kölbel T, Bertoglio L. Emergent endovascular treatment options for thoracoabdominal aortic aneurysm. Semin Vasc Surg 2023; 36:174-188. [PMID: 37330232 DOI: 10.1053/j.semvascsurg.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy.
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MELANI C, BASTIANON M, MOZZETTA G, DI GREGORIO S, DI BARTOLO M, CAPONE A, PRATESI C, PULLI R, MAURI F, PIFFARETTI G, PALERMO D, ANGILETTA D, PRATESI G. Multicenter real-life study on access-related outcomes after EVAR: percutaneous is the way. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2023. [DOI: 10.23736/s1824-4777.22.01559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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10
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Dias-Neto M, Tenorio ER, Lima GBB, Baghbani-Oskouei A, Saqib N, Mendes BC, Mirza AK, Oderich GS. Outcomes of low- and standard-profile fenestrated and branched stent grafts for treatment of complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg 2022; 76:1160-1169.e1. [PMID: 35810953 DOI: 10.1016/j.jvs.2022.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We compared the outcomes of fenestrated-branched (FB) endovascular abdominal aortic aneurysm repair (EVAR) using low-profile (LP) and standard-profile (SP) stent grafts for the treatment of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). METHODS We reviewed the clinical data of 466 consecutive patients (70% male; mean age, 74 ± 8 years) enrolled in a prospective nonrandomized study to investigate FB-EVAR for the treatment of CAAAs and TAAAs (2013-2021). The endpoints compared between the patients treated with LP (18F-20F) and SP (20F-22F) devices included procedural metrics, access-related complications, major adverse events (MAE), patient survival, freedom from secondary intervention, thromboembolic events, stent graft integrity issues, aneurysm sac enlargement, and the rate of sac shrinkage. RESULTS Of the 466 aneurysms treated by FB-EVAR, 138 were CAAAs and 141 were extent IV and 187 extent I to III TAAAs, with a mean number of 3.9 ± 0.5 vessels stented per patient. LP devices had been used in 239 patients (51%) and SP devices in 227 patients (49%). LP devices had been used more frequently for chronic dissections (12% vs 7%; P = .041) and with preloaded systems (77% vs 65%; P = .005) and bilateral percutaneous femoral access (83% vs 74%; P = .020) and less frequently with upper extremity access (67% vs 88%; P < .001) and iliac conduits (2% vs 6%; P = .020). The patients treated using LP devices had experienced similar technical success (96% vs 97%; P = .527), with a shorter total operating time (225 ± 81 minutes vs 243 ± 78 minutes; P = .018), lower radiation exposure (median, 0.93 Gy; interquartile range [IQR], 0.94; vs median, 1.01 Gy; IQR, 0.91 Gy; P < .001), and less use of contrast (median, 135 mL; IQR, 68 mL; vs median, 144 mL; IQR, 80 mL; P = .008). No differences were found in the rates of iliofemoral access complications between the LP and SP device groups (1.3% vs 3.5%; P = .107). At 30 days, 5 patients had died (1%) and MAEs had occurred in 89 patients (19%), with no differences between the two groups. The mean follow-up was 28 months (95% confidence interval, 25-30 months). At 4 years, the patients treated with LP devices had had similar freedom from all-cause mortality (69% ± 6% vs 68% ± 4%; P = .199), freedom from aortic-related mortality (97% ± 1% vs 98% ± 1%; P = .488), freedom from any secondary intervention (65% ± 6% vs 70% ± 4%; P = .433), freedom from thromboembolic events (98% ± 1% vs 99% ± 1%; P = .364) and aneurysm sac enlargement (93% ± 3% vs 91% ± 3%; P = .293). However, the LP group had had less freedom from any integrity-related issues (92% ± 5% vs 100%; P < .001). The cumulative risk of sac shrinkage was greater for patients treated with LP devices (adjusted hazard ratio, 2.040; 95% confidence interval, 1.516-2.744; P < .001). CONCLUSIONS FB-EVAR was performed with low rates of mortality and MAEs, irrespective of the device profile. However, the procedures performed with LP devices had had less need for iliac conduits and had had better procedural metrics. The use of LP devices resulted in higher rates of sac shrinkage. However, the results on stent graft integrity require future investigation.
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Affiliation(s)
- Marina Dias-Neto
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Guilherme B Barbosa Lima
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Naveed Saqib
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Aleem K Mirza
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.
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Association Between Psoas Muscle Sarcopenia and Long-Term Survival Following Elective EVAR. J Surg Res 2022; 280:459-468. [PMID: 36058011 DOI: 10.1016/j.jss.2022.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The aims of this study were as follows: i) to identify the prevalence of sarcopenia in patients undergoing elective endovascular aortic repair (EVAR) for intact abdominal aortic aneurysm; ii) to assess its association with perioperative morbidity and long-term survival; and iii) to estimate its diagnostic accuracy for prediction of 5-year mortality following the intervention. METHODS We performed a retrospective review of all patients who underwent elective EVAR from January 1, 2010 through December 31, 2019. The lean psoas muscle area (LPMA; cm2 × HU) was calculated on computed tomography angiography by multiplying psoas muscle area and psoas muscle density. The main exposure variable for this study was the presence of preoperative sarcopenia (LPMA value < 350), and the study cohort was divided in two groups for all subsequent analyses. The primary endpoint was all-cause mortality. RESULTS The study cohort eventually comprised 338 patients who underwent elective EVAR for intact abdominal aortic aneurysm. In the overall population, 154 patients (45.5%) were classified as sarcopenic. At baseline, patients with sarcopenia were older (mean age: 78 ± 5 versus 75 ± 7 y, P < 0.001) and had lower proportion of males (73.5% versus 93.5%, P < 0.001). At 5 y, the estimated survival rates were 52% versus 74% in sarcopenic and nonsarcopenic patients, respectively (P < 0.001). Using multivariate Cox proportional hazard regression, an independent association was identified between sarcopenia and all-cause mortality in the whole cohort (hazard ratio: 2.63, 95% confidence interval: 1.43-3.36, P = 0.009). CONCLUSIONS Sarcopenia, defined as LPMA <350 as measured on preoperative computed tomography angiography, can be highly prevalent in patients undergoing elective EVAR. Although the intervention remains safe in the short term, presence of sarcopenia was significantly associated to lower long-term survival irrespective of patients' age or gender.
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12
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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Outcomes of Unilateral Versus Bilateral Use of the Iliac Branch Endoprosthesis for Elective Endovascular Treatment of Aorto-iliac Aneurysms. Cardiovasc Intervent Radiol 2022; 45:939-949. [DOI: 10.1007/s00270-022-03166-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/05/2022] [Indexed: 12/19/2022]
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14
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Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:1501-1511. [PMID: 34861361 DOI: 10.1016/j.jvs.2021.11.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed. METHODS The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI. RESULTS A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS). CONCLUSIONS For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.
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Kölbel T, Spanos K, Jama K, Behrendt CA, Panuccio G, Eleshra A, Rohlffs F, Jakimowicz T. Early outcomes of the t-Branch off-the-shelf multi-branched stent graft in 542 patients for elective and urgent aortic pathologies - a retrospective observational study. J Vasc Surg 2021; 74:1817-1824. [PMID: 34171424 DOI: 10.1016/j.jvs.2021.05.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in >500 patients being treated with the t-Branch device. METHODS A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia. RESULTS A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P < .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P < .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P < .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P < .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P < .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P < .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively. CONCLUSIONS Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable.
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Affiliation(s)
- Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany; Departments of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
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Giannopoulos S, Malgor RD, Sobreira ML, Siada SS, Rodrigues D, Al-Musawi M, Malgor EA, Jacobs DL. Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis. J Endovasc Ther 2021; 28:499-509. [PMID: 33899572 DOI: 10.1177/15266028211007468] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies. MATERIALS AND METHODS A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality. RESULTS Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004). CONCLUSION Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Rafael D Malgor
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Marcone L Sobreira
- Division of Vascular Surgery, Sao Paulo State University, Botucatu School of Medicine, Botucatu, Brazil
| | - Sammy S Siada
- Division of Vascular Surgery, University of California San Francisco, Fresno, CA, USA
| | - Diego Rodrigues
- Division of Vascular Surgery, Federal University of Maranhao, Sao Luiz, Brazil
| | - Mohammed Al-Musawi
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Emily A Malgor
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Donald L Jacobs
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
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Puta B, Fazzini S, Torsello G, Pipitone MD, Austermann M, Beropoulis E, Torsello GF. Preliminary Clinical and Radiologic Outcome of Matched Patients with Thoracoabdominal Aortic Aneurysms Treated by Low-Profile vs Standard Profile Branched Aortic Endografts. Ann Vasc Surg 2021; 75:397-405. [PMID: 33556526 DOI: 10.1016/j.avsg.2021.01.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Durability of low-profile branched aortic stent-grafts (LPSG) in the treatment of patients with thoracoabdominal aortic aneurysms (TAAA) remains unclear. Objective of this study is to compare the outcomes of LPSG with standard profile branched aortic stent-grafts (SPSG). METHODS Between January 2016 and January 2020, 225 consecutive patients with TAAA were treated by branched endovascular aortic repair (BEVAR). Twenty-four patients who were treated with a LPSG were compared to 24 patients who received SPSG as a control group. Control patients were selected according to aneurysm size (maximum aneurysm diameter) and extension (Crawford classification) as well as availability of adequate preoperative and postoperative CT-angiograms at 24 months. The primary endpoint was ongoing clinical success defined as successful implantation and freedom from aneurysm- or procedure-related death, secondary intervention, type I or III endoleak, infection, thrombosis, aneurysm expansion or rupture and conversion. Secondary endpoints were radiological changes of the branched endograft (migration, shortening, scoliosis, lordosis, and fracture). RESULTS After a median follow-up of 22.6 (LPSG) and 26.2 months (SPSG), no significant difference was found in terms of technical success (100% in both groups), late mortality (4.2% vs 0%), aneurysm diameter increase (4.2% in both groups) and reinterventions (25% vs 37.5%). Infection, thrombosis, aneurysm expansion or rupture and conversion were not observed. Radiological analysis of aortic graft remodeling showed no fracture and no significant migration, shortening, scoliosis and lordosis of the LPSG (6.1 mm, 7.5 mm, 12.8° and 6.1°) compared to SPSG (3.9 mm, 5.1 mm, 7.9° and 5.6°) after 2 years. CONCLUSION The clinical and radiological findings of the present study showed no increased mortality and complications for the matched patients who underwent treatment with low-profile vs standard-profile BEVAR. This study provides preliminary evidence of safety and efficacy of low-profile branched endografts in patients with demanding iliac access vessels.
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Affiliation(s)
- Besjona Puta
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Stefano Fazzini
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany.
| | - Giovanni Torsello
- Institute for Vascular Research, St. Franziskus Hospital, Münster, Germany
| | | | - Martin Austermann
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | | | - Giovanni Federico Torsello
- Department of Radiology, Charité Campus Virchow-Klinikum, Charité University Medicine Berlin, Münster, Germany
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Effect of obesity on radiation exposure, quality of life scores, and outcomes of fenestrated-branched endovascular aortic repair of pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 73:1156-1166.e2. [PMID: 32853700 DOI: 10.1016/j.jvs.2020.07.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The aim of the present study was to assess the effect of obesity on procedural metrics, radiation exposure, quality of life (QOL), and clinical outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms. METHODS We reviewed the clinical data from 334 patients (236 men; mean age, 75 ± 8 years) enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2019. The patients were classified using the body mass index (BMI) as obese (BMI ≥30 kg/m2) or nonobese (BMI <30 kg/m2). QOL questionnaires (short-form 36-item questionnaire) and imaging studies were obtained preoperatively and at 2 months and 6 months postoperatively, and annually thereafter. The procedures were performed using two different fixed imaging systems. The end points included procedural metrics (ie, total operative time, fluoroscopic time, contrast volume), radiation exposure, technical success, 30-day mortality, and major adverse events, QOL changes, freedom from target vessel instability, freedom from reintervention, and patient survival. RESULTS The aneurysm extent was a pararenal aortic aneurysm in 117 patients (35%) and a thoracoabdominal aortic aneurysm in 217 patients (65%). Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for a greater incidence of hyperlipidemia and diabetes among the obese patients (P < .05). No significant differences were found in the procedural metrics or intraprocedural complications between the groups, except that the obese patients had greater radiation exposure than the nonobese patients (mean, 2.5 vs 1.6 Gy; P < .001), with the highest radiation exposure in those obese patients who had undergone the procedure using system 1 (fusion alone) instead of system 2 (fusion and digital zoom; mean, 4.1 vs 1.5 Gy; P < .001). Three patients had died within 30 days (0.8%), with no difference in mortality or major adverse events between the groups. The mental QOL scores had improved in the obese group at 2 and 12 months compared with the nonobese patients, with persistently higher scores up to 3 years. At 3 years, the obese and nonobese patients had a similar incidence of freedom from target vessel instability (74% ± 6% vs 80% ± 3%; P = .99, log-rank test), freedom from reintervention (66% ± 6% vs 73% ± 4%; P = .77, log-rank test), and patient survival (83% ± 5% vs 75% ± 4%; P = .16, log-rank test). CONCLUSIONS FB-EVAR was performed with high technical success and low mortality and morbidity, with no significant differences between the obese and nonobese patients. The procedural metrics and outcomes were similar, with the exception of greater radiation exposure among obese patients, especially for the procedures performed using system 1 with fusion alone compared with system 2 (fusion and digital zoom). Obese patients had higher QOL mental scores at 2 and 12 months, with a similar reintervention rate, target vessel outcomes, and survival compared with nonobese patients.
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Melloni A, Grandi A, Melissano G, Chiesa R, Bertoglio L. Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1084-1090. [DOI: 10.1007/s00270-020-02508-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/25/2020] [Indexed: 12/17/2022]
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D’Oria M, Tenorio ER, Oderich GS, Mendes BC, Kalra M, Shuja F, Colglazier JJ, DeMartino RR. Outcomes of the Gore Excluder Iliac Branch Endoprosthesis Using Division Branches of the Internal Iliac Artery as Distal Landing Zones. J Endovasc Ther 2020; 27:316-327. [DOI: 10.1177/1526602820905583] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate the outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) using division branches of the internal iliac artery (IIA) as distal landing zones. Materials and Methods: Between January 1, 2014, and December 31, 2018, 74 patients (mean age 74±7 years; 72 men) treated for aortoiliac or common iliac artery aneurysms had an IBE deployed with distal landing of the side branch within the main trunk (n=60) of the internal iliac artery (IIA) vs within a division branch (n=25). Thirteen (17%) patients received bilateral IBE implantations for a total of 85 vessels evaluated. Early endpoints were technical success, 30-day mortality, 30-day major adverse events (MAEs), and 30-day major access complications. Late endpoints were survival, primary and secondary IIA patency, freedom from IIA branch instability, freedom from new-onset buttock claudication, and aneurysm sac diameter changes. Time-dependent outcomes were reported as Kaplan-Meier curves with differences assessed using the log-rank test. Estimates are presented with the 95% confidence interval (CI). Results: The overall technical success rate was 97%, with 1 technical failure per group (p=0.43). Two patients, one from each group, died within 30 days (p=0.43). No significant differences were seen in the rates of 30-day MAEs (7% vs 17%, p=0.35) or major access complications (9% vs 11%, p>0.99) for patients receiving distal landing in the main trunk vs a division branch, respectively. The mean follow-up for the entire cohort was 19±12 months. The overall 1-year survival rate was 94% (95% CI 74% to 99%). The primary and secondary patency rates at 1 year were 98% (95% CI 88% to 99%) vs 95% (95% CI 72% to 99%, p=0.72) and 98% (95% CI 88% to 99%) vs 100% (p=0.41) for the main trunk vs division branch groups, respectively. Freedom from IIA branch instability estimates were also similar at 1-year follow-up [93% (95% CI 82% to 97%) vs 90% (95% CI 66% to 97%), p=0.29], as were the freedom from new-onset buttock claudication estimates [98% (95% CI 86% to 99%) and 94% (95% CI 67% to 99%), respectively; p=0.62]. Mean sac diameter change was 5.4±5.3 mm, not significantly different between the groups (p=0.85). Conclusion: Use of the posterior or anterior division of the IIA as a distal landing zone for the Gore Excluder IBE was safe and efficacious in the midterm. This technique may permit extending indications for endovascular repair of aortoiliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Long-term assessment is needed to affirm the efficacy of this technique.
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Affiliation(s)
- Mario D’Oria
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Emanuel R. Tenorio
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Jill J. Colglazier
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Randall R. DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
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