Early Experience with Snorkels and Chimneys for Expanding the Indications for Use of Endovascular Aneurysm Repair

Retrograde Superior Mesenteric Artery Stenting in Case of SMA Shuttering

This case describes a patient who underwent endovascular repair for an extent V thoracoabdominal aneurysm with planned coverage of the celiac artery. Following deployment of the stent graft, the superior mesenteric artery was shuttered, and the patient subsequently developed signs and symptoms of bowel ischemia. The patient underwent successful retrograde open superior mesenteric artery stenting with resolution of her symptoms. Although retrograde open mesenteric artery stenting (ROMS) has been primarily shown to be effective in acute mesenteric ischemia, this case demonstrates that ROMS can be used as a salvage option for shuttering during endovascular procedures.

Mid-Term Outcomes of Chimney Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-analysis

BACKGROUND

To provide an overview of the literature on the mid-term outcomes of chimney EVAR (ChEVAR) for the treatment of juxtarenal abdominal aortic aneurysms (JAAA).

METHODS

Different electronic databases were searched for published articles up to January 2020. The eligibility criteria were studies describing mid- or long-term outcomes of chimney EVAR (mean follow-up at least 1 year) for treatment of JAAA, including more than 10 cases, published in English, and with full text available. The outcomes measure were overall survival rate, target vessel patency, and freedom from reintervention at 3 years. Quality of the included studies was analyzed using the MINORS criteria. Pooled effect estimates were analyzed using random-effect models and heterogeneity was tested using I² statistics.

RESULTS

Thirteen articles met the inclusion criteria. The included studies described 1,019 patients. According to the quality assessment, methodological quality was moderate to poor. The pooled overall survival, freedom from reintervention, and target vessel patency at 3 year was 81.4 % (95%CI 73.8-87.9), 85.7% (95%CI 75.6-93.5), and 95.1% (95%CI 89.3-98.7) respectively.

CONCLUSIONS

The results of this review show good to acceptable short and mid-term survival and good mid-term durability, which supports that ChEVAR as a suitable alternative in high-risk JAAA. However, proper patient selection for ChEVAR seems essential to attain good mid-term outcomes, and further large prospective and good quality studies are required to demonstrate its long-term results and enable conclusions on specific determinants for outcome.

Acute Kidney Injury after Complex Endovascular Aneurysm Repair

Background:

Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative morbidity than standard infrarenal endovascular repair.

Objective:

This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.

Methods:

A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal, and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further analyzed by the level of anatomic complexity and method of repair.

Results:

52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017. The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19% (temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency did not demonstrate any associations with the outcome.

Conclusion:

Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively associated factors other than increasing anatomic complexity and operative time. Further study is needed for the identification of predictors related to postoperative acute kidney injury.

Endovascular treatment of proximal para-anastomotic aneurysms after previous surgical repair of infrarenal aortic aneurysms by the chimney technique

OBJECTIVES

To evaluate the use of chimney grafts in the treatment of para-anastomotic aneurysms after previous abdominal aortic aneurysms open repair with short neck.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients who underwent endovascular repair for proximal aortic para-anastomotic aneurysms following previous open repair for infrarenal abdominal aortic aneurysms was performed. All included patients had a short infrarenal aortic neck (<10 mm) excluding standard endovascular aortic repair. Five patients were symptomatic at the admission needed urgent treatment.

RESULTS

Twelve patients with para-anastomotic aneurysms underwent placement of chimney grafts. The median time between the original operations to redo endovascular procedure was 11 years (interquartile range, 9.5 years). The mean infrarenal length was 4.3 mm (1-9 mm). A total of 28 chimneys grafts were deployed for the 12 patients. The technical success rate was 91.7%. At a median radiologic follow-up of 16 months (2.0-29.4, 95% confidence interval), one patient died, while two late endoleaks and two reinterventions at one and three years for type Ia endoleak were performed by proximal extension and triple chimney graft placement.

CONCLUSION

The results of the present study show that ch-endovascular aortic repair is a safe technique for patients who suffered from proximal para-anastomotic aneurysms and having short neck unsuitable for standard endovascular repair. Longer follow up warranted to evaluate the durability of ch-endovascular aortic repair for this specific indication.