Perioperative Outcome of Fenestrated and Branched Stent Grafting after Previous Open or Endovascular Abdominal Aortic Repair

A Retrospective Analysis of Late Open Conversions Following Failed Endovascular Aneurysm Repair

Background

The incidence of late open surgical conversions (OSCs) has recently increased. Vascular surgeons face additional technical challenges in late conversion surgery of failed endovascular aneurysm repair (EVAR) due to the presence of a previously deployed endograft. Based on our institutional experience, this study aimed to delineate methods to improve late open conversion outcomes, proposing solutions for technical challenges.

Methods

All preoperative OSC data on failed EVARs operated in our Cardiovascular Surgery Clinic between January 2017 and January 2024 were evaluated retrospectively. Study endpoints included early (30-day or in-hospital) and late follow-up outcomes. Early outcomes included perioperative mortality and morbidities, intensive care unit (ICU) period, and length of hospital stay (LOS). The main outcome of interest during follow-up was overall survival.

Results

Sixteen patients in our hospital, comprising eight elective and eight emergency procedures, underwent OSCs following EVAR. The difference between the 30-day mortality rates for the elective and urgent late conversions was significant (p < 0.001). Of these patients, 15 were male, with a mean age of 70.8 years (range: 62-80). Preoperative cardiac shock status and low hematocrit level (<20%) were independent mortality factors (p < 0.001). The ICU period was 8.7 ± 5.3 days (2-20 days) on average, and LOS was 17.3 ± 8.4 (6-29 days) days on average. The mean time to open surgical conversion in this cohort was 44.4 ± 16.8 months. The 5-year overall survival rate was 43.75%.

Conclusions

The incidence of open surgical conversion is notably growing. Emergent open surgical conversions exhibit poorer mortality outcomes compared to elective procedures. Further data are essential to evaluate the ramifications of expanding the use of EVAR beyond the instructions for use (IFU) guidelines. The procedures involving patients who challenge the IFU criteria should be conducted at experienced centers and require close monitoring. Open surgical repair (OSR) as the initial treatment opportunity could be an alternative strategy for improving outcomes in this patient cohort.

Branched Endovascular Aortic Repair After a Migrated EVAR Bypassing a Severely Kinked Previous Endograft

PURPOSE

To describe a novel technique to repair a juxtarenal abdominal aortic aneurysm (JAAA) after failed endovascular aortic repair (EVAR) with severely kinked anatomy.

TECHNIQUE

We present a patient who underwent an EVAR with a Medtronic Talent device 15 years ago and a proximal cuff extension 3 years earlier for an abdominal aortic aneurysm. Computed tomography (CT) done for a known gastritis showed a 12 cm JAAA, with a migrated endograft and a type Ia endoleak (EL). Endovascular repair was performed, accessing and navigating the aneurysmal sac outside the previous graft. The type I EL was reached and the suprarenal aorta catheterized. A 4-vessel inner-branched EVAR device was deployed in the distal thoracic aorta and their target vessels bridged through femoral access. A distal bifurcated component was deployed and both iliac limbs were extended to the native distal iliac arteries. Completion angiogram as well as early and 12-month CT showed a fully patent straight course branched EVAR with no ELs.

CONCLUSION

Complex aortic reinterventions in the presence of previous EVAR can be performed by choosing a straighter course along and parallel to the previous endograft. Several technical aspects must be considered to successfully perform this type of reinterventions.

CLINICAL IMPACT

We present a technique of a complex endovascular aortic repair in a failed EVAR with kinked anatomy, navigating through the thrombosed aneurysmal sac, outside the previously placed endograft and thus obtaining a straighter path for a new branched endograft. The novelty lies in a different approach to repair a failed EVAR with a branched graft through an uncommon access on the side of the previous endograft, avoiding repeated displacement or occlusion of the new endograft. We exemplify the feasibility of such a complex procedure and highlight important steps to perform it, whether in the abdominal or even thoracic Aorta.

Midterm Outcomes and Aneurysm Sac Dynamics Following Fenestrated Endovascular Aneurysm Repair after Previous Endovascular Aneurysm Repair

OBJECTIVE

Fenestrated endovascular aneurysm repair (FEVAR) is a feasible option for aortic repair after endovascular aneurysm repair (EVAR), due to improved peri-operative outcomes compared with open conversion. However, little is known regarding the durability of FEVAR as a treatment for failed EVAR. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine midterm outcomes and aneurysm sac dynamics of FEVAR after prior EVAR.

METHODS

Patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two hospitals in The Netherlands were included. Patients were categorised into primary FEVAR and FEVAR after EVAR. Outcomes included five year mortality rate, one year aneurysm sac dynamics (regression, stable, expansion), sac dynamics over time, and five year aortic related procedures. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, chi square tests, and linear mixed effect models.

RESULTS

One hundred and ninety-six patients with FEVAR were identified, of whom 27% (n = 53) had had a prior EVAR. Patients with prior EVAR were significantly older (78 ± 6.7 years vs. 73 ± 5.9 years, p < .001). There were no significant differences in mortality rate. FEVAR after EVAR was associated with a higher risk of aortic related procedures within five years (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.1 - 6.5, p = .037). Sac dynamics were assessed in 154 patients with available imaging. Patients with a prior EVAR showed lower rates of sac regression and higher rates of sac expansion at one year compared with primary FEVAR (sac expansion 48%, n = 21/44, vs. 8%, n = 9/110, p < .001). Sac dynamics over time showed similar results, sac growth for FEVAR after EVAR, and sac shrinkage for primary FEVAR (p < .001).

CONCLUSION

There were high rates of sac expansion and a need for more secondary procedures in FEVAR after EVAR than primary FEVAR patients, although this did not affect midterm survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention, and the underlying process that drives aneurysm sac growth following successful FEVAR after EVAR.

Early and Mid-Term Outcomes of the Inverted Limb Configuration Below Fenestrated and Branched Endografts: Experience from Two European Centers

PURPOSE

To report a European experience on the use of the Inverted Limb (IL) below fenestrated and branched endografts (FB-EVAR) for the treatment of juxta/pararenal (JP-AAAs), thoracoabdominal (TAAAs), and para-anastomotic aortic aneurysms.

MATERIALS AND METHODS

Between 2016 and 2020, all FB-EVAR with distal IL due to previous open (OSR) or endovascular repair (EVAR) or infrarenal aortic length <76 mm at two European university centers were retrospectively analyzed. Technical success, early and mid-term iliac complications (occlusion; type Ib endoleak [EL]), IL-related complications (type III EL), and reinterventions were assessed as primary endpoints; 30-day mortality, survival and freedom from (FF) overall complications/reinterventions were assessed as secondary outcomes.

RESULTS

Forty-one high-risk patients (male 30%-73%; mean age 71±10 years; ASA 3-4, 41%-100%) underwent FB-EVAR with distal IL for 8 (19.5%) J/P-AAAs and 33 (80.5%) TAAAs. Sixteen (39%) patients with previous aortic treatment (8 OR, 8 EVAR) were included. Preoperative computed tomographic angiography showed infrarenal aortic length <76 mm in all cases. Custom-made endografts were configured as 31 (75.6%) fenestrated-only, 6 (14.6%) branched-only, and 4 (9.8%) fenestrated+branched for an overall of 158 target visceral vessels (TVVs; 3.8±0.7 TVVs/case). The IL main body was planned with 1-stent, 2-stents, and 3-stents in 6 (14.6%), 23 (56.1%), and 12 (29.3%) cases, respectively. Technical success and 30-day mortality were 97.6% (40/41) and 0%. Thirty-day complications occurred in 2 (4.9%) patients: 1 limb occlusion, requiring reintervention, 1 type III EL, spontaneously resolved. Mean follow-up was 21±16 months. Three After 30-day, 3 (7.3%) iliac complications (2 occlusions; 1 type Ib EL) were successfully managed by endovascular reinterventions; no IL-related complications were observed. The patency of TVVs was 96.8%. No correlation between anatomical characteristics, endograft configuration, and primary outcomes was observed, except for 1-stent IL and type III EL (log rank p=0.01). At 1- and 2-year follow-up survival, FF overall iliac/IL-related complications and FF reinterventions were 90% and 80%, 90% and 84%, and 92% and 87%, respectively.

CONCLUSION

The IL configuration allows a safe endovascular treatment of challenging aortic lesions in high-risk patients although needing a number of adjunctive procedures. A short main body of IL could be associated with intraoperative and perioperative type III EL.

CLINICAL IMPACT

Bifurcated endograft with inverted limb configuration increases the feasibility of a total endovascular approach in patients with challenging anatomy. The use of inverted limb overcomes the anatomical limitations of short-body initial grafts and short distance between lowest target artery and the aortic bifurcation, leading the fixation inside the endograft. Although technically demanding, this advanced technology could avoid surgical reinterventions in previous open or endovascular repair that are burdened with higher rates of morbidities and complications.

Systematic Review and Meta-Analysis of Elective Open Conversion versus Fenestrated and Branched Endovascular Repair for Previous Non-Infected Failed Endovascular Aneurysm Repair

OBJECTIVE

To evaluate outcomes of patients electively undergoing fenestrated and branched endovascular repair (F/B-EVAR) or open conversion for failed previous non-infected endovascular aneurysm repair (EVAR).

DATA SOURCES

Embase, MEDLINE, Cochrane Library.

REVIEW METHOD

The protocol was prospectively registered on PROSPERO (CRD42023404091). The review followed the PRISMA guidelines; certainty was assessed through the GRADE and quality through MINORS tools. Outcomes data were pooled separately for F/B-EVAR and open conversion. A random effects meta-analysis of proportions was conducted; heterogeneity was assessed with the I2 statistic.

RESULTS

Thirty eight studies were included, for a total of 1 645 patients of whom 1 001 (60.9%) underwent an open conversion and 644 (39.1%) a F/B-EVAR. The quality of evidence was generally limited. GRADE certainty was judged low for 30 day death (in both groups) and F/B-EVAR technical success, and very low for the other outcomes. Pooled 30 day death was 2.3% (I2 33%) in the open conversion group and 2.4% (I2 0%) in the F/B-EVAR conversion group (p = .36). Technical success for F/B-EVAR was 94.1% (I2 23%). The pooled 30 day major systemic complications rate was higher in the open conversion (21.3%; I2 74%) than in the F/B-EVAR (15.7%; I2 78%) group (p = .52). At 18 months follow up, the pooled re-intervention rate was 4.5% (I2 58%) in the open conversion and 26% (I2 0%) in the F/B-EVAR group (p < .001), and overall survival was 92.5% (I2 59%) and 81.6% (I2 68%), respectively (p = .005).

CONCLUSION

In the elective setting, and excluding infections, the early results of both open conversion and F/B-EVAR after failed EVAR appear satisfactory. Although open conversion presented with higher complication rates in the first 30 days after surgery, at follow up it seemed to be associated with fewer re-interventions and better survival compared with F/B-EVAR.

Systematic review of reintervention with fenestrated or branched devices after failed previous endovascular aortic aneurysm repair

BACKGROUND

A proximal seal extension, after previously failed standard endovascular abdominal aortic aneurysm repair (EVAR), has been described using various endovascular techniques. The aim of the present systematic review was to assess the technical success, 30-day mortality, and mortality and reintervention rates during the available follow-up for patients managed with endovascular methods after failed endovascular repair.

METHODS

The present systematic review followed the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and was preregistered at PROSPERO (no. CRD42022350436). A search of the English literature, via Ovid, using the MEDLINE, EMBASE, and CENTRAL databases, until June 15, 2022, was performed. Observational studies (2000-2022) and case series with at least five patients who had undergone fenestrated/branched EVAR (F/BEVAR) after failed EVAR were considered eligible. Technical success and mortality at 30 days and the mortality and reintervention rates during available follow-up had to have been reported. The Newcastle-Ottawa scale was used to assess the risk of bias. The primary outcome was technical success and mortality at 30 days.

RESULTS

The initial search yielded 2558 reports. Ten studies were considered eligible, two of which were prospective. A total of 423 patients had undergone F/BEVAR after failed EVAR. The indication for reintervention was the presence of a type Ia endoleak in 44.9%. Technical success was reported in seven studies, and 319 of 336 interventions were considered successful (94.9%), according to each study's criteria. Of the 423 patients, 10 had died within 30 days (2.4%). Seven patients had presented with spinal cord ischemia (2.4%). Twenty-three acute kidney injury events were reported (6.8%). The mean follow-up was 18 months (range, 1-77 months). During follow-up, 47 deaths were reported (14.8%). Finally, 50 reinterventions of 303 procedures (16.5%) had been performed.

CONCLUSIONS

According to the available literature, F/BEVAR after failed EVAR can be performed with high technical success and low mortality during the perioperative period. The midterm mortality and reintervention rates were acceptable. However, further data are needed to provide firm conclusions regarding the safety and durability of F/BEVAR after failed EVAR.

Outcomes of Directional Branches of the T-Branch Off-the-Shelf Multi-Branched Stent-Graft

Background: A controversy on bridging covered stent (BCS) choice, between self-expanding (SECS) and balloon-expandable (BECS) stents, still exists in branched endovascular repair. This study aimed to determine the primary target vessel (TV) patency in patients treated with the t-Branch device and identify factors impairing the outcomes. Methods: A retrospective study was undertaken, including patients treated with the t-Branch (Cook Medical, Bloomington, IN, USA) between 2014 and 2019 (early 2014–2016; late 2017–2019). The endpoint was the primary patency (CT: celiac trunk, SMA, superior mesenteric artery, RRA: right renal artery, LRA: left renal artery) during the follow-up. Any branch instability event was assessed. The factors affecting the patency were determined using multivariable regression models and Kaplan–Meier analyses. Results: In total, 2018 TVs were analyzed; 1542 SECSs and 476 BECSs. The CT patency was 99.8% (SE 0.2%) at the 1st month, with no other event. The SMA patency was 97.8% (SE 1) at the 12th month. The RRA patency was 96.7% (SE 2) at the 24th month. The LRA patency was 99% (SE 0.4) at the 6th month. Relining was the only factor independently associated with the SMA patency (OR 8.27; 95% CI 1.4–4.9; p = 0.02). The freedom from instability was 62% (SE 4.3%) and 45% (SE 5.4%) at the 24th month and 36th month. No significant difference was identified between the BECSs and SECSs in the early or late experience. Conclusion: BCS for the t-Branch branches performed with a good primary patency during the short-term follow-up. The type of BCS did not influence the patency. Relining might be protective for SMA patency.

Complex Aortic Interventions Can Be Safely Introduced to the Clinical Practice by Physicians Skilled in Basic Endovascular Techniques

Our purpose was to evaluate the risk associated with the learning curve of starting a complex aortic programme in an Eastern European country. A retrospective study was conducted involving the initial 20 patients (16 males, mean age: 65 ± 11 years) undergoing fenestrated/branched endovascular aortic repair in a single centre. Demographic, anatomical, procedural, and postoperative variables were collected. Our elective patient cohort consisted of 9 pararenal aneurysms (45%) and 11 thoracoabdominal aortic aneurysms (55%), with the latter including 4 chronic dissection cases (20%). A total of 71 branch vessels were incorporated (3.5 ± 0.9 per patient). The per vessel technical success rate was 100%. In-hospital mortality was 5% (1/20). At an average follow-up of 14 ± 22 months, the primary clinical success rate was 45% (9/20) and the secondary clinical success was achieved in 75% of cases (15/20). All-cause mortality at 14 months was 20% (4/20; aortic related: 1/20, 5%). Four bridging stent occlusions were found (5.6%). Mortality and reintervention rates were comparable to the initial results of high-volume centres, while the complexity of our cases and the per vessel technical success rate was comparable to the values reported as late experience. The morbidity of the learning curve could be decreased if operators are skilled in basic endovascular procedures.

Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms

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.