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Corden J, Khan K, Wong JH, Hodgin R, Serracino-Inglott F. An In-Vitro Comparison of Steady State Leakage Rates through Introducer Sheaths Used for Fenestrated Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2024; 105:67-76. [PMID: 38582209 DOI: 10.1016/j.avsg.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Fenestrated Endovascular Aneurysm Repair (fEVAR) involves deploying a covered stent into the aorta followed by multiple visceral stents through fenestrations in the main body of graft. The most commonly used large sheaths for cannulation of visceral vessels are the Gore DrySeal Flex, Cook Performer Check-Flo, and Medtronic Sentrant. None of these sheaths were designed for the insertion of multiple sheaths, and so a slow but steady leakage of blood occurs during the procedure. The aim of this paper is to assess in an in vitro setting which large bore sheath has the best valve for use when multiple smaller sheaths are inserted through it. METHODS Three large bore introducer sheaths (LBISs) were used for this study, The Gore DrySeal Flex LBIS, Medtronic Sentrant LBIS and Cook Performer Check-Flo LBIS. A test rig was constructed, made of an 18-liter fluid reservoir mounted vertically and receiving a constant supply of water from a domestic water supply which flowed into the reservoir and out of an overflow. The reservoir was connected to the LBIS by a vertical plastic pipe with an internal diameter of 40 mm and an isolation valve. The LBIS was connected to the isolation valve by inserting the LBIS up a flexible silicone tube connected to the isolation valve. The LBIS was subject to a constant column/pressure of water and fluid leakage from the LBIS was collected in a plastic pot/tray placed underneath the LBIS. The leakage rates through each LBIS were determined for the following smaller diameter sheath combinations inserted through the valve, one 6 French Sheath, two 6 French Sheaths, two 6 French Sheaths and one 7 French Sheath. This was done to closely mimic a fEVAR procedure in vitro. The procedure was to insert different sheath combinations through the nonreturn valves in the LBIS and measure the volume of fluid that leaked through the valves. The leaked fluid was weighed, and the weight was converted to volume using the density of water (1 g/ml). RESULTS The average (mean) leakage rates for each LBIS and each sheath combination showed that leakage rates when only one sheath was inserted were very low. For all 3 LBIS's tested, the leakage rates increased dramatically when multiple sheaths were inserted. The Medtronic LBIS leaked the most, followed by Cook, followed by Gore. For the Cook LBIS, the leakage rates exhibited with 2 × 6 French sheaths were approx. 106 times greater than those for the Gore LBIS and 5 times greater for the 2 × 6 French +1 × 7 French sheath combination. A similar comparison for the Medtronic LBIS versus the Gore LBIS yields factors of 132 and 8. CONCLUSIONS Leakage rates increase significantly when multiple sheaths are inserted and the Gore LBIS demonstrates significantly lower leakage than both the Cook and Medtronic during procedures that require simultaneous, multiple insertions of smaller sheaths. Although the Gore Dryseal has by far the lowest leakage rate when 3 small diameter sheaths are inserted (just under 1 ml/s), depending on the duration of the procedure this could still result in significant blood loss.
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Affiliation(s)
- James Corden
- Department of Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kamran Khan
- Department of Vascular & Endovascular Surgery, Manchester Academic Health Science Centre, University of Manchester, Manchester Royal Infirmary, Manchester, UK.
| | | | | | - Ferdinand Serracino-Inglott
- Department of Vascular & Endovascular Surgery, Manchester Academic Health Science Centre, University of Manchester, Manchester Royal Infirmary, Manchester, UK
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Georgiadis GS, van Herwaarden JA, Antoniou GA, Giannoukas AD, Lazarides MK, Moll FL. Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm. Vasc Med 2016; 21:223-38. [DOI: 10.1177/1358863x16631841] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - George A Antoniou
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Miltos K Lazarides
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
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Georgiadis GS, van Herwaarden JA, Antoniou GA, Hazenberg CEVB, Giannoukas AD, Lazarides MK, Moll FL. Systematic Review of Off-the-Shelf or Physician-Modified Fenestrated and Branched Endografts. J Endovasc Ther 2015; 23:98-109. [DOI: 10.1177/1526602815611887] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To determine the safety and efficacy of off-the-shelf fenestrated/branched grafts (OSFGs) and physician-modified stent-grafts (PMSGs) for the treatment of complex abdominal aortic aneurysms. Methods: A systematic search of the MEDLINE database via PubMed from January 2001 through March 2015 retrieved 23 relevant articles evaluating the clinical outcomes following the management of patients with pararenal or thoracoabdominal aortic aneurysms. The 15 articles on PMSGs and 8 on OSFGs contained data on 308 patients (mean age 72.93±2.89 years; 213 men). The safety endpoint was major adverse events; the efficacy outcome measure was clinical treatment success (aneurysm exclusion without type I/III endoleak, permanent paralysis, long-term dialysis, or unresolved major complications). Extracted outcome data were pooled and compared between groups; data are given as the pooled proportions and 95% confidence interval (CI). Clinical data are presented as the weighted mean. Results: Of the 308 patients analyzed, almost one third were operated on an emergency basis. The mean aneurysm diameters were 75.9±17.3 mm (range 56–115) for the PMSGs and 68.1±13.7 mm (range 60–100) for the OSFGs. A total of 936 renal and visceral vessels were targeted. Major adverse events (safety) occurred in 24 (12.8%) PMSG patients (95% CI 8.6% to 18.7%) and in 9 (7.4%) OSFG patients (95% CI 3.7% to 14%). Clinical treatment success (efficacy) was observed in 171/187 (91.4%) PMSG patients (95% CI 86.2% to 94.9%) and in 115/121 (95%) OSFG patients (95% CI 89.1% to 98.0%). Corresponding cumulative 30-day target vessel and branch stent perfusion rates were 97.2% (95% CI 95.1% to 98.4%) and 97.6% (95% CI 95.5% to 98.8%) for the PMSG group and 99.6% (95% CI 98.3% to 99.9%) and 98.4% (95% CI 96.5% to 99.4%) for the OSFG group. Six (3.2%) deaths occurred in the PMSG group only; 2 (1.1%) were aneurysm related. Overall branch patency was recorded in 443/458 (96.7%) and in 468/478 (97.9%) of target vessels in the PMSG and OSFG groups, respectively. Conclusion: Off-the-shelf and physician-modified technology seems effective and safe, in both the elective and acute settings, for the treatment of complex aortic aneurysms. Future research within a randomized trial should investigate the true limitations of these devices.
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Affiliation(s)
- George S. Georgiadis
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
- Department of Vascular Surgery, “Democritus” University of Thrace, University General Hospital of Alexandroupolis, Greece
| | | | - George A. Antoniou
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | | | | | - Miltos K. Lazarides
- Department of Vascular Surgery, “Democritus” University of Thrace, University General Hospital of Alexandroupolis, Greece
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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Endovascular Hypogastric Artery Preservation During Endovascular Aneurysm Repair: A Review of Current Techniques and Devices. Ann Vasc Surg 2015; 29:367-76. [DOI: 10.1016/j.avsg.2014.10.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 10/21/2014] [Accepted: 10/25/2014] [Indexed: 11/23/2022]
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Results and Factors Affecting Early Outcome of Fenestrated and/or Branched Stent Grafts for Aortic Aneurysms. Ann Surg 2015; 261:197-206. [DOI: 10.1097/sla.0000000000000612] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dijkstra ML, Tielliu IF, Meerwaldt R, Pierie M, van Brussel J, Schurink GWH, Lardenoye JW, Zeebregts CJ. Dutch experience with the fenestrated Anaconda endograft for short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair. J Vasc Surg 2014; 60:301-7. [DOI: 10.1016/j.jvs.2014.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/03/2014] [Accepted: 02/07/2014] [Indexed: 11/26/2022]
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Outcomes after abdominal aortic aneurysm repair requiring a suprarenal cross-clamp. J Vasc Surg 2014; 60:893-9. [PMID: 24856910 DOI: 10.1016/j.jvs.2014.04.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/11/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the early and late outcomes of patients who require a suprarenal aortic cross-clamp during elective open repair of an abdominal aortic aneurysm (AAA). METHODS Patients from 1998 to 2012 who required a suprarenal aortic cross-clamp during elective open AAA repair were reviewed. Data abstracted included demographics and comorbidities; preoperative, perioperative, and late renal function; late interventions related to AAA repair; and late mortality. A decrease in renal function was defined as a >30% decline in estimated glomerular filtration rate (eGFR) compared with the preoperative value. Primary outcomes included renal function, intervention-free survival, and overall survival. RESULTS During the study period, 211 patients underwent open elective or urgent AAA repair; 69 required a suprarenal cross-clamp. The mean age was 71 years, and 80% were men. The mean preoperative creatinine concentration was 1.2 mg/dL, and the mean preoperative eGFR was 66 mL/min/1.73 m2. Location of the aortic cross-clamp was suprarenal (37), supramesenteric (21), and supraceliac (11). Perioperatively, 21 patients (30%) experienced a significant decrease in eGFR; four patients required hemodialysis. Six patients had full recovery of renal function by discharge. Perioperative morbidity and mortality were 35% and 4%, respectively. At a mean follow-up of 3 years, seven patients had an eGFR significantly less than the preoperative value. Late interventions related to the AAA repair were required in eight patients. Indications included wound complication (3), anastomotic aneurysm (2), incisional hernia (1), anastomotic graft stenosis (1), and proximal aortic dilation (1). Overall 5-year intervention-free survival was 62% and overall survival 77%. Intervention-free survival was enhanced by antiplatelet use (P = .04), whereas overall survival was decreased by chronic obstructive pulmonary disease (P = .003) and perioperative pneumonia (P = .001). CONCLUSIONS More than a quarter of patients requiring a suprarenal cross-clamp during open AAA repair experience renal dysfunction. Late graft-related complications are few, with preoperative and perioperative pulmonary function negatively affecting overall patient survival.
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Smith MT, Gupta R, Jazaeri O, Rochon PJ, Ray CE. Preservation of Internal Iliac Arterial Flow during Endovascular Aortic Aneurysm Repair Using the "Sandwich" Technique. Semin Intervent Radiol 2014; 30:82-6. [PMID: 24436521 DOI: 10.1055/s-0033-1333657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Mitchell T Smith
- Department of Radiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, Colorado
| | - Rajan Gupta
- Department of Radiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, Colorado
| | - Omid Jazaeri
- Department of Radiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, Colorado
| | - Paul J Rochon
- Department of Radiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, Colorado
| | - Charles E Ray
- Department of Radiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, Colorado
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Quiñones-Baldrich WJ, Holden A, Mertens R, Thompson MM, Sawchuk AP, Becquemin JP, Eagleton M, Clair DG. Prospective, multicenter experience with the Ventana Fenestrated System for juxtarenal and pararenal aortic aneurysm endovascular repair. J Vasc Surg 2013; 58:1-9. [DOI: 10.1016/j.jvs.2012.12.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 12/13/2012] [Accepted: 12/14/2012] [Indexed: 10/26/2022]
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Haulon S, Barillà D, Tyrrell M, Tsilimparis N, Ricotta JJ. Debate: Whether fenestrated endografts should be limited to a small number of specialized centers. J Vasc Surg 2013; 57:875-82. [DOI: 10.1016/j.jvs.2013.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tsilimparis N, Ricotta JJ. Part two: Against the motion. Fenestrated endografts should not be restricted to a small number of specialized centers. Eur J Vasc Endovasc Surg 2013; 45:204-7. [PMID: 23333097 DOI: 10.1016/j.ejvs.2013.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- N Tsilimparis
- Department of Vascular Surgery and Endovascular Therapy, Heart and Vascular Institute, Northside Hospital, 980 Johnson Ferry Road NE, Suite 1040, Atlanta, GA 30342, USA
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Affiliation(s)
- Karthikeshwar Kasirajan
- Director of Clinical Research and Endovascular Therapy East Bay Cardiovascular & Thoracic Associates Concord, California, USA
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Chuter TAM, Greenberg RK. Re: “Branched Grafts for Thoracoabdominal Aneurysms: Off-Label Use of FDA-Approved Devices” by Dr. Karthik Kasirajan. J Endovasc Ther 2011; 18:820-2; author reply 822-4. [DOI: 10.1583/11-3697.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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