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Ferrer C, Gallitto E, Borghese O, Lodato M, Cappiello A, Cao P, Gargiulo M, Giudice R. Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients. J Vasc Surg 2024:S0741-5214(24)01661-6. [PMID: 39084495 DOI: 10.1016/j.jvs.2024.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally, reported without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients. METHODS All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points. RESULTS A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 year5s) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01]. CONCLUSIONS F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.
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Affiliation(s)
- Ciro Ferrer
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy.
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Ottavia Borghese
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Marcello Lodato
- Vascular Surgery, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Antonio Cappiello
- Vascular Surgery, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Rocco Giudice
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
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Vigezzi GP, Barbati C, Blandi L, Guddemi A, Melloni A, Salvati S, Bertoglio L, Odone A. Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression. Ann Surg 2024; 279:961-972. [PMID: 38214159 DOI: 10.1097/sla.0000000000006190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair. BACKGROUND Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited. METHODS We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics. RESULTS Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias. CONCLUSIONS Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.
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Affiliation(s)
- Giacomo Pietro Vigezzi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- Collegio Ca' della Paglia, Fondazione Ghislieri, Pavia, Italy
| | - Chiara Barbati
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Lorenzo Blandi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Annalisa Guddemi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Andrea Melloni
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Simone Salvati
- Division of Vascular Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Bertoglio
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- HTA Committee, IRCCS San Raffaele Hospital, Milan, Italy
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Fenelli C, Tsilimparis N, Faggioli G, Stana J, Gallitto E, Stavroulakis K, Fernandez Prendes C, Gargiulo M. Early and Mid-Term Outcomes of the Inverted Limb Configuration Below Fenestrated and Branched Endografts: Experience from Two European Centers. J Endovasc Ther 2024; 31:410-420. [PMID: 36189939 DOI: 10.1177/15266028221125158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Cecilia Fenelli
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Enrico Gallitto
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | | | | | - Mauro Gargiulo
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
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Kim M, Han JH, Kim DH, Yoon M, Jung HJ. Simultaneous Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm Combined with Saccular Thoracic Aortic Aneurysm. Vasc Specialist Int 2023; 39:29. [PMID: 37748931 PMCID: PMC10519935 DOI: 10.5758/vsi.230075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023] Open
Abstract
With the recent increase in imaging tests, coexisting abdominal aortic aneurysms (AAAs) and thoracic aortic aneurysms (TAAs) are being discovered accidentally. We report two cases of simultaneous endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) for AAA and TAA. Both 74-year-old and 79-year-old male with infrarenal AAA and saccular TAA were treated simultaneously with EVAR and TEVAR. Saccular TAAs were identified in the upper thoracic aorta during the evaluation of AAA. During endograft placement, carotid-subclavian bypass and cerebrospinal fluid (CSF) drainage were performed. Both patients were successfully discharged without spinal cord ischemia. Simultaneous EVAR and TEVAR can be considered for patients with AAA and saccular TAA in the upper thoracic aorta. Moreover, CSF drainage may be necessary to protect the spinal cord.
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Affiliation(s)
- Minju Kim
- Department of Surgery, Biomedical Research Institue, Pusan National University School of Medicine, Busan, Korea
| | - Jeong Hee Han
- Department of Surgery, Biomedical Research Institue, Pusan National University School of Medicine, Busan, Korea
| | - Dae Hwan Kim
- Department of Surgery, Biomedical Research Institue, Pusan National University School of Medicine, Busan, Korea
| | - Myunghee Yoon
- Department of Surgery, Biomedical Research Institue, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jae Jung
- Department of Surgery, Biomedical Research Institue, Pusan National University School of Medicine, Busan, Korea
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