Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair – A Systematic Review

Use of Branched EVAR in Treatment of Juxtarenal Aortic Aneurysm and Essential Accessory Renal Artery: Another Tool on the Shelf? A Case Report

OBJECTIVE

We present the case of a 58-year-old male patient referred to our department from a smaller facility for further evaluation and treatment strategy regarding the choice between open or endovascular surgery. The patient was diagnosed with a 6 cm asymptomatic juxtarenal aortic aneurysm and a 5 mm diameter accessory renal artery (ARA) supplying the lower half of left kidney. Further diagnostic assessments indicated that the left ARA was perfusing over 40% of the left kidney.

METHODS

Given the patient's significant pre-existing medical conditions and elevated perioperative risk, the decision was made to proceed with minimally invasive endovascular surgery using a custom-made 5-branches stent graft (BEVAR).

RESULTS

In the early postoperative period, the patient reported left flank pain. A subsequent CT scan identified a partial infarction in the left kidney due to the occlusion of an early small branch from the upper left renal artery. However, laboratory results showed no significant change in renal function compared to preoperative values. The patient was discharged 6 days post-surgery, with no additional complications observed during the early postoperative period.

CONCLUSION

This case report demonstrates that BEVAR is acceptable technique with satisfactory early postoperative outcomes for treating juxtarenal aortic aneurysms with an accessory renal artery in patients who are high-risk candidates for open repair and anatomically unsuitable for FEVAR or Ch-EVAR procedures.

Congenital pelvic kidney perfusion during infrarenal aortic aneurysm repair

Purpose: This case report describes a patient with a pelvic kidney associated with an aortoiliac aneurysm amenable to open repair. Methods: We chose the selective cold renal perfusion to preserve renal function. Results: Other techniques such as transient or permanent extra-anatomic bypass, extracorporeal circulation and proximal aortic double clamping are also described in this report. Conclusions: Choosing the renal perfusion technique depended on the anatomical evaluations of the kidney and the renal artery location during the preoperative period.

Adoption and clinical outcomes of fenestrated endovascular aneurysm repair in a regional, multistate community hospital system

OBJECTIVE

Complex endovascular abdominal aortic aneurysm (AAA) repair techniques have evolved over the last decade, yet patterns of physician and hospital system adoption of fenestrated endovascular aneurysm repair (FEVAR) remain poorly defined. We investigated clinical outcomes, use trends, and surgeon and hospital experience for FEVAR in a large community hospital system.

METHODS

We conducted a retrospective cohort study of all FEVAR procedures within our 5-state hospital system between April 2012 and June 2021. AAA repair volumes (open, EVAR, and FEVAR) were captured at the hospital and surgeon levels using Current Procedural Terminology and International Classification of Diseases codes. Clinical and outcomes data were collected for FEVAR patients. To consider if surgeon or hospital experience influenced outcomes, sequential case number was used to divide patients into surgeon experience and hospital experience groups. Inverse probability weighted and generalized linear mixed models, adjusted for demographics and comorbidities, were built to examine risk-adjusted outcomes for surgeon and hospital experience groups.

RESULTS

Of 3850 patients treated with AAA procedures of any kind between 2012 and 2021, 160 (4.2%) underwent FEVAR. FEVAR procedures were performed by 34 different surgeons at 12 hospitals, with intraoperative complications and unplanned adjunctive procedures occurring in 18.8% (n = 30) and 19.4% (n = 31) of patients, respectively. Among FEVAR patients, in-hospital mortality was 1.3% (n = 2) and postoperative morbidity was 16.9% (n = 27). Renal function decline occurred postoperatively in 5.1% of patients. Early (<30 day) postoperative endoleaks occurred in 15.3% of patients (n = 21). Target vessel patency was 95.6% on initial postoperative imaging. Surgeon and hospital experience had a small positive impact on outcomes after the first one to three cases. Significant decreases in operative time, fluoroscopy time, and estimated blood loss were observed with increased surgeon experience, relative to a surgeon's first case (P < .05). There were lower odds of intraoperative complications after a surgeon's first case (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03-0.77, for cases 2-3) or after a hospital's first one to three cases (OR, 0.19; 95% CI, 0.04-0.89, for cases 4-8; OR, 0.12; 95% CI, 0.03-0.55 for cases 9-49).

CONCLUSIONS

Clinical outcomes of FEVAR across our hospital system compare favorably with previously published reports. Although system-wide FEVAR adoption increased 3-fold over the last decade, FEVAR continued to be performed by a minority of hospitals in our system. The results from this cohort demonstrate low rates of adverse events, high rates of technical efficiency, and a small impact of surgeon and hospital experience, thereby supporting this advanced endovascular technology as a safe, efficacious, and generalizable treatment alternative to open repair for patients with complex aortic anatomy.

Outcome Analysis Comparing Asymptomatic Juxtarenal Aortic Aneurysms Treated with Custom-Manufactured Fenestrated-Branched Devices and the "Off-The-Shelf" Zenith p-Branch Device

BACKGROUND

Numerous endovascular options have been used for the repair of juxtarenal aortic aneurysms (JRAAs) over the last 15 years. This study aims to compare the performance between the Zenith p-branch device and custom-manufactured fenestrated-branched devices (CMD) for the treatment of asymptomatic JRAA.

METHODS

A single-center retrospective analysis of prospectively collected data was performed. Patients with a diagnosis of JRAA submitted to endovascular repair between July 2012 and November 2021 were included in the study, being divided into 2 groups: CMD and Zenith p-branch. The following variables were analyzed: preoperative information: demographics, comorbidities, and maximum aneurysm diameter; procedural data: contrast volume, fluoroscopy time, radiation dose, estimated blood loss, and technical success; and postoperative data: 30-day mortality, duration of intensive care unit and hospital stay, major adverse events, secondary interventions, target vessel instability, and long-term survival.

RESULTS

From a total of 373 physician-sponsored investigational device exemption (Cook Medical devices) cases performed at our institution, 102 patients presented the diagnosis of JRAA. Of these, 14 patients were treated with the p-branch device (13.7%) and 88 (86.3%) with a CMD. Both groups presented similar demographic composition and maximum aneurysm diameter. All devices were successfully deployed, with no type I or III endoleaks observed at procedure completion. The contrast volume (P = 0.023) and radiation dose (P = 0.001) were significantly higher in the p-branch group. No significant difference was observed between the groups for the remaining intraoperative data. No paraplegia or ischemic colitis has been observed during the first 30 days after the surgical procedures. There was no 30-day mortality in either group. One major cardiac adverse event was registered in the CMD group. Early outcomes were similar in both groups. No significant difference was found between the groups with respect to the presence of type I or III endoleaks during the follow-up. From a total of 313 target vessels stented in the CMD group (mean of 3.55 per patient) and 56 in the p-branch group (mean of 4 per patient), 4.79% and 5.35% presented instability, respectively, with no difference observed between the groups (P = 0.743). Secondary interventions were required in 36.4% of the CMD cases and 50% of the p-branch group, but this was not statistically different (P = 0.382). In the p-branch cohort, 2 of 7 reinterventions (28.5%) were target vessel-related and in the CMD group, 10 of 32 secondary interventions (31.2%) were target vessel-related.

CONCLUSIONS

Comparable perioperative outcomes were obtained when appropriately selected patients were treated with either the off-the-shelf p-branch or CMD for JRAA. The long-term target vessel instability does not appear impacted by the presence of pivot fenestrations in comparison to other target vessel configurations. Given these outcomes, delay in CMD production time should be considered when treating patients with large juxtarenal aneurysms.

Comparison of Fenestrated Stentgrafts and Open Repair for Juxtarenal Aortic Aneurysms Using a Propensity Score Matching

BACKGROUND

The purpose of this study was to compare postoperative morbi-mortality and medium-term follow-up of fenestrated stent grafting and open repair (OR) for patients with juxtarenal aortic aneurysms (JRAAs).

METHODS

All consecutive patients who underwent custom-made fenestrated endovascular aortic repair (FEVAR) or OR for complex abdominal aortic aneurysm between 2005 and 2017 in 2 tertiary centers were scrutinized. Patients with JRAA constituted the study group. Suprarenal and thoracoabdominal aortic aneurysms were excluded. The groups were made comparable through the use of a propensity score matching.

RESULTS

277 patients with JRAAs were included, 102 (36.8%) in the FEVAR group and 175 (63.2%) in the OR group, respectively. After propensity score matching, 54 FEVAR patients (52.9%) and 103 OR patients (58.9%) were included for analysis. In-hospital mortality rates were 1.9% (n = 1) in the FEVAR group versus 6.9% (n = 7) in the OR group (P = 0.483). Postoperative complications were less common in the FEVAR group (14.8% vs. 30.7%; P = 0.033). Mean follow-up was 42.1 months in the FEVAR group and 40 months in the OR group. Overall mortality rates at 12 and 36 months were 11.5% and 24.5% in the FEVAR group versus 9.1 % (P = 0.691) and 11.6% (P = 0.067) in the OR group. Late reinterventions were more frequent in the FEVAR group (11.3% vs. 2.9%; P = 0.047). However, freedom from reintervention rates were not significantly different at 12 months (FEVAR: 86% vs. OR: 90%; P = 0.560) and 36 months (FEVAR: 86% vs. OR: 88.4%, P = 0.690). In the FEVAR group, persistent endoleak during follow-up was identified in 11.3% of cases.

CONCLUSIONS

In the present study, there was no statistical difference in terms of mortality in-hospital at 12 or 36 months between FEVAR and OR groups for JRAA. FEVAR for JRAA was associated with a significant reduction of overall postoperative major complications compared with OR. There were significantly more late reinterventions in the FEVAR group.

Females experience elevated early morbidity and mortality but similar mid-term survival compared to males after branched/fenestrated endovascular aortic aneurysm repair

OBJECTIVE

The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal (JRAA) aortic aneurysms.

METHODS

Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range [IQR], 1.6-5.3 years).

RESULTS

No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 [IQR, 425-625] vs 420 [IQR, 350-510] minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 [IQR, 150-270] vs 175 [IQR, 130-225] mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 [IQR, 1-5] vs 1 [IQR, 1-3] days; P = .002) and hospital stay (8 [IQR, 5-13] vs 5 [IQR, 3-9] days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but mid-term (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in mid-term follow-up reintervention, endoleak, and rupture rates were observed.

CONCLUSIONS

Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar mid-term outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.

Endovascular Abdominal Aortic Aneurysm Repair: Overview of Current Guidance, Strategies, and New Technologies, Perspectives from the United Kingdom

Endovascular aortic aneurysm repair has changed the management of patients affected by this condition, offering a minimally invasive solution with satisfactory outcomes. Constant evolution of this technology has expanded the use of endovascular devices to more complex cases. The purpose of this review article is to describe the current strategies, guidance, and technologies in this field, with a particular focus on practices in the United Kingdom.

Mid-term Outcomes of Physician-Modified Fenestrated or Branched Endovascular Repair for Post-dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

To report the early experience and mid-term outcomes of physician-modified fenestrated or branched endovascular repair (PM-F/BEVAR) for patients with post-dissection thoracoabdominal aortic aneurysm (PD-TAAA).

METHODS

PD-TAAA patients treated with PM-F/BEVAR between December 2014 and September 2020 in our institution were retrospectively analyzed.

RESULTS

Out of the 39 patients, technical success defined as successful deployment of all stent grafts with patent target vessels (TVs) and exclusion of the lesion without type I or III endoleak was achieved in 35 patients (89.7%). A total of 126 TVs were successfully reconstructed. Thirty-day mortality was 0%. Seven major adverse events occurred including one acute kidney injury, four renal infarctions, one retroperitoneal hematoma and one left renal artery occlusion. Seven type II endoleak and three type III endoleak were detected. During a mean 29.4 ± 15.5 months follow-up period, the mortality was zero. Three renal arteries and one external iliac artery occluded in four patients. No other new onset major adverse event occurred. No patient required reintervention. One type II endoleak spontaneously resolved, while the remaining six remained stable. One early type III endoleak diminished, and one new type III endoleak occurred at 2 months. The primary patency of TV was 96.8% (120/124). Shrinkage or stability of aneurysm diameter can be observed in 38 patients (97.4%). The false lumen thrombosis rate was 89.7% (35/39).

CONCLUSIONS

The present study showed encouraging results of PM-F/BEVAR for treatment of PD-TAAAs.

LEVEL OF EVIDENCE

Level 4, Case Series.

Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility.

METHODS

This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR.

RESULTS

One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak.

CONCLUSIONS

This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.

Editor's Choice - Comparison of Open, Standard, and Complex Endovascular Aortic Repair Treatments for Juxtarenal/Short Neck Aneurysms: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Abdominal aortic aneurysms (AAAs) with adverse morphology of the aneurysm neck are "complex". Techniques employed to repair complex aneurysms include open surgical repair (OSR) and a number of on label endovascular techniques such as fenestrated endovascular aneurysm repair (FEVAR) and endovascular aneurysm repair (EVAR) with adjuncts (including chimneys and endo-anchors), as well as off label use of standard EVAR. The aim was to conduct a network meta-analysis (NMA) of published comparative outcomes.

DATA SOURCES

An electronic search was performed in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL). These databases were interrogated using the PubMed interface and the Healthcare Databases Advanced Search (HDAS) interface developed by the National Institute of Health and Care Excellence.

REVIEW METHODS

Online databases were interrogated up to April 2020. Studies were included if they compared outcomes between at least two methods of repair for complex aneurysms (those with at least one adverse neck feature: absent/short neck, conicality, angulation, calcification, large diameter, and thrombus). The primary outcome measure was peri-operative death. Pre-registration was done in PROSPERO (CRD42020177482).

RESULTS

The search identified 24 observational studies and 7854 patients who underwent OSR, FEVAR, off label EVAR, or chimney EVAR. No comparative studies included EVAR with endo-anchors. NMA was performed on 23 studies that reported outcomes of aneurysms with short/absent infrarenal neck. Compared with OSR, off label EVAR (relative risk [RR] 0.10, 95% confidence interval [CI] 0.01 - 0.41) and FEVAR (RR 0.62, 95% CI 0.32-0.94) were associated with lower peri-operative mortality. This difference was not seen at the midterm follow up (30 months). Compared with OSR, FEVAR was associated with a lower peri-operative myocardial infarction (MI) rate (RR 0.37, 95% CI 0.16 - 0.62) but a higher midterm re-intervention rate (hazard ratio 1.65, 95% CI 1.04 - 2.66). All studies had a "moderate" or "high" risk of bias. Confidence in the network findings (GRADE) was generally "low".

CONCLUSION

This NMA demonstrated a peri-operative survival benefit for off label EVAR and FEVAR compared with OSR, potentially due to reduced risk of MI. FEVAR carries a greater midterm re-intervention risk than OSR, with potential implications for cost effectiveness. There is paucity of comparative data for cases with adverse neck features other than short length.

Systematic Review and Meta-Analysis of Published Studies on Endovascular Repair of Abdominal Aortic Aneurysm With the p-Branch

Background

Endovascular treatment of juxtarenal or pararenal abdominal aortic aneurysms is more popular than open surgery, mainly because it reduces perioperative mortality and morbidity. The custom-made fenestrated devices need to be tailored to each patient, so these devices require extra manufacturing and shipping time. The increased wait time may increase the risk of aneurysm rupture in some patients. In some situations, “Off-the-shelf” (OTS) fenestrated grafts can be used. The Cook Zenith p-Branch device (William Cook Australia, Brisbane, Australia) is a relatively common OTS. This study aimed to systematically evaluate all published experiences with p-Branch.

Methods

We searched PubMed, Embase, and Cochrane to find works of literature that reported on the outcomes of patients treated with the p-Branch stent-grafts. Then we conducted an assessment of quality and meta-analysis of the results. The primary endpoints were the application rate of p-Branch stent-graft (type A, B), technical success rate, and early re-intervention rate. We estimated pooled proportions and 95% CIs.

Results

Initial search of the literature included 111 articles, of which 7 studies were included in the end. A total of 260 patients were enrolled in these studies, and 218 patients were eventually treated with p-Branch. The pooled application rate of type A devices was 48% (95% CI, 29–67%), and pooled application rate of type B devices was 30% (95% CI, 16–44%). The pooled technical success rate was 87% (95% CI, 75–98%). The early re-intervention rate was 10% (95% CI, 3–17%). Midterm renal infarct rate (after 30 days) was 3% (95% CI, 0–6%). Midterm re-intervention rate (after 30 days) was 30% (95% CI, 3–57%). Midterm renal failure rate (after 30 days) was 6% (95% CI, 2–10%).

Conclusions

This pooled analysis indicated an acceptable technical success rate after p-Branch stent-graft implantation, with early and midterm re-intervention rate and renal failure rate that cannot be ignored. The p-Branch repair of juxtarenal abdominal aortic aneurysms may be an appropriate and safe option, especially in emergency situations.

A risk-adjusted and anatomically stratified cohort comparison study of open surgery, endovascular techniques and medical management for juxtarenal aortic aneurysms-the UK COMPlex AneurySm Study (UK-COMPASS): a study protocol

INTRODUCTION

In one-third of all abdominal aortic aneurysms (AAAs), the aneurysm neck is short (juxtarenal) or shows other adverse anatomical features rendering operations more complex, hazardous and expensive. Surgical options include open surgical repair and endovascular aneurysm repair (EVAR) techniques including fenestrated EVAR, EVAR with adjuncts (chimneys/endoanchors) and off-label standard EVAR. The aim of the UK COMPlex AneurySm Study (UK-COMPASS) is to answer the research question identified by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme: 'What is the clinical and cost-effectiveness of strategies for the management of juxtarenal AAA, including fenestrated endovascular repair?'

METHODS AND ANALYSIS

UK-COMPASS is a cohort study comparing clinical and cost-effectiveness of different strategies used to manage complex AAAs with stratification of physiological fitness and anatomical complexity, with statistical correction for baseline risk and indication biases. There are two data streams. First, a stream of routinely collected data from Hospital Episode Statistics and National Vascular Registry (NVR). Preoperative CT scans of all patients who underwent elective AAA repair in England between 1 November 2017 and 31 October 2019 are subjected to Corelab analysis to accurately identify and include every complex aneurysm treated. Second, a site-reported data stream regarding quality of life and treatment costs from prospectively recruited patients across England. Site recruitment also includes patients with complex aneurysms larger than 55 mm diameter in whom an operation is deferred (medical management). The primary outcome measure is perioperative all-cause mortality. Follow-up will be to a median of 5 years.

ETHICS AND DISSEMINATION

The study has received full regulatory approvals from a Research Ethics Committee, the Confidentiality Advisory Group and the Health Research Authority. Data sharing agreements are in place with National Health Service Digital and the NVR. Dissemination will be via NIHR HTA reporting, peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN85731188.

Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency

OBJECTIVE

Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI.

METHODS

All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups.

RESULTS

There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001).

CONCLUSION

For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.

Renal Stent Complications and Impact on Renal Function after Standard Fenestrated Endovascular Aneurysm Repair

BACKGROUND

To report renal outcomes including long-term patency, secondary interventions, and related renal function after fenestrated endovascular aortic repair (fEVAR).

METHODS

Single-center retrospective review of patients undergoing fEVAR between 2012 and 2018 using the Cook ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent-related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease formula.

RESULTS

During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4%, and the mean follow-up was 23.3 months. Seventeen renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations, and 1 type III endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1 day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5 days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48 months, respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23 (0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs. 55.58 mL/min/1.73 m², P = 0.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by chronic kidney disease staging compared with baseline (P = 0.51).

CONCLUSIONS

fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent-graft complications.

Experience with physician-modified Ankura™ endografts for endovascular repair of thoracoabdominal aortic aneurysms

BACKGROUND

The aim of this study was to evaluate the early results of fenestrated/branched endovascular aortic repair (F/B-EVAR) of thoracoabdominal aortic aneurysms (TAAAs) using physician-modified Ankura^™ endografts (PMEGs).

METHODS

Sixteen consecutive patients who underwent F/B-EVAR using PMEGs between July 2017 and December 2018 were retrospectively reviewed. The perioperative mortality and morbidity of the PMEG technique were assessed, and the early results of follow-up were evaluated.

RESULTS

The median age of the patients was 75.3 years old (range: 48-83 years), and 12 (75.0%) patients were male. The median TAAA diameter was 7.1±1.5 cm (range: 5.1-11 cm). The initial technical success rate of vessel revascularization was 98.2% (55 of 56). Target vessel patency was 98.1% (52/53), and freedom from reintervention was 98.1% (52/53) at follow-up. The 30-day mortality rates 6.3%. There was no death during follow-up.

CONCLUSIONS

PMEGs represent an important innovation, with favorable initial results, in the treatment of patients with complex TAAAs who may be unfit for open repair. In addition, they remain a promising option for high-risk patients in need of urgent repair who cannot wait for a custom-made device.

Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting

OBJECTIVE

Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years.

METHODS

Patients aged ≥70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups.

RESULTS

A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040).

CONCLUSIONS

In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

BACKGROUND

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

RESULTS

Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

CONCLUSIONS

The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

Fenestrated repair improves perioperative outcomes but lacks a hospital volume association for complex abdominal aortic aneurysms

BACKGROUND

Complex abdominal aortic aneurysms (AAAs) have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of complex AAAs has been well established, but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigated the outcomes of OSR and FEVAR for the treatment of complex AAAs and examined the hospital volume-outcome relationship for these procedures.

METHODS

A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2018 who underwent elective repair of a juxtarenal/pararenal AAA with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, and new dialysis. Secondary end points included postoperative pneumonia, renal dysfunction (creatine concentration increase of >2 mg/dL from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low- and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting in comparing outcomes between treatment groups.

RESULTS

A total of 589 patients underwent FEVAR (n = 186) or OSR (n = 403) for a complex AAA. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs 2.9%; P < .001) and need for dialysis (11.3% vs 1.8; P < .001). Postoperative pneumonia (6.8% vs 0.3%; P < .001) and need for transfusion (39.4% vs 10.4%; P < .001) were also significantly higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days, respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1 year, with the majority being type II. With a median follow-up period of 331 days (229-378 days), 1% of FEVAR patients required a secondary procedure, and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low- and high-volume aortic centers based on their annual FEVAR volume of complex AAAs. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction.

CONCLUSIONS

FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity, although long-term durability warrants further research.

Geometric and hemodynamic analysis of fenestrated and multibranched aortic endografts

OBJECTIVE

The objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair.

METHODS

Patients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations.

RESULTS

Twenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10^-3 N ± 18.7 × 10^-3 N vs 12.31 × 10^-3 N ± 6.8 × 10^-3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively.

CONCLUSIONS

Longer stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.

Fenestrated endografting is the preferred option for juxta-renal aortic aneurysm reconstruction

BACKGROUND

The aim of this study was to report early/mid-term-up outcomes of fenestrated endografting (FEVAR) for juxta-renal aneurysms (j-AAAs).

METHODS

Between 2008 and 2019, all consecutive j-AAAs treated by FEVAR were prospectively collected and retrospectively analyzed. Early endpoints were technical success, renal function worsening and 30-day mortality. Follow-up endpoints were survival, freedom from re-interventions (FFRs) and target visceral vessels (TVVs) patency.

RESULTS

Among 240 cases of FB-EVAR, 98(41%) were j-AAAs. Endografts with 1,2,3,4 and 5 fenestrations were planned in 3(3%), 25(26%), 35(36%), 33(34%) and 2(1%) cases, respectively. Overall, 360 TVVs were treated by fenestrations and scallops. Technical success was achieved in 97(99%) cases. The only failure was 1 type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening was reported in 22(22%) and 12(12%) cases at 24-hour and 30-day, respectively. One patient required hemodialysis and died within 30-day (1%). This was the only case of 30-day mortality. The mean follow-up was 36±32months. Aneurysm sac shrinkage or stability was observed in 55(56%) and 41(42%) cases, respectively. Two (2%) patients with persistent type II endoleak had sac enlargement and required re-interventions. Freedom from reinterventions at 5-year was 86%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24-month in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. TVVs-patency was 96% at 5-year. Renal function worsening was reported in 10(10%) patients during follow-up. Survival at 5-year was 73%, with no j-AAA related mortality. Chronic obstructive pulmonary disease (COPD) (P=0.007; OR:4.8; 95% CI: 1.5-15.3) and postoperative renal function worsening (P=0.028; OR:1,1; 95% CI: 1.1-1.2) were independent predictor for mortality at the multivariate analysis.

CONCLUSIONS

FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with these results, it could be proposed as the first line treatment in high risk patients if anatomically fit. Long term survival is reduced in the presence of preoperative COPD and postoperative renal function worsening.

Short-term and Midterm Results of Fenestrated Anaconda Endograft in Patients with Previous Endovascular Aneurysm Repair

PURPOSE

To review short-term and midterm results of the fenestrated Anaconda stent graft in management of patients with pre-existing endovascular aortic stent graft and persistent type 1a endoleak.

MATERIALS AND METHODS

This single-center retrospective study assessed all consecutive patients with type 1a endoleak and pre-existing endovascular aneurysm repair (EVAR) treated with fenestrated Anaconda stent grafts. Ten patients (9 males; mean age 78 y) with mean follow-up of 22.4 months ± 13 were included. Average aneurysm size was 80.1 mm (range, 62-101 mm). Mean time for conversion to fenestrated EVAR following original EVAR was 53.7 months (range, 22-101 months; median 54 months). Technical and clinical success; anatomic features, including aortic tortuosity, side vessel angulation, and stenosis; complications; and reinterventions were recorded.

RESULTS

The technical success rate was 90%. There was no open conversion and no 30-day mortality, leading to a clinical success rate of 100%. Five of 10 patients demonstrated an aortic tortuosity index of grade 2 or 3. Additional hostile anatomy that made side vessel catheterization challenging was observed in 15 vessels (45%) with a stenosis of ≥ 50% (related to atherosclerotic disease or struts of indwelling prosthesis) and 21 vessels (66%) with ≤ 70° angulation. Two reinterventions, renal artery stent angioplasty and renal artery covered stent extension, were observed at 2 and 13 months.

CONCLUSIONS

Use of the fenestrated Anaconda endograft in patients with type 1a endoleaks following previous EVAR is safe, feasible, and offers some technical features that facilitate overcoming certain anatomic difficulties.

Correlations Between Branch Vessel Catheterization and Procedural Complexity in Fenestrated and Branched Endovascular Aneurysm Repair

Introduction:

The use of fenestrated and branched endovascular technologies in complex aortic aneurysm repair (F/BEVAR) is increasing, with a trend toward using longer sealing zones and incorporating more target vessels. Successful aneurysm exclusion and prevention of long-term treatment failure need to be balanced against the increased complexity of more extensive procedures. The aim of this study was to analyze relationships between the number of catheterized vessels and multiple operative variables as a means for evaluating procedural complexity.

Methods:

Operative data from consecutive F/BEVAR procedures performed at a single center from 2012 to 2015 were analyzed. An equal number of EVAR procedures, randomly selected, from this period were also analyzed. Only intact aneurysms were included. Complex aneurysms were grouped based on the required number of target vessel catheterization. Ten procedural variables, categorized as perioperative, postoperative, and radiologic-related, were compared. Pearson correlation analysis and regression analysis were performed. The correlation coefficients, r, were classified using Cohen boundaries, r ≥ 0.5 indicating a strong relationship.

Results:

There were 63 EVAR, 40 FEVAR, and 22 BEVAR procedures. There was no significant difference in patient comorbidities between conventional EVAR and complex procedure groups. The complex procedures included 23 two-vessel, 20 three-vessel, and 19 four-vessel catheterizations. Strong linear relationships between the number of branch vessel catheterizations and the following variables were identified: accumulated skin dose ( r = .504), contrast volume ( r = .652), fluoroscopy duration ( r = .598), number of angiography series ( r = .650), anesthesiology duration ( r = .742), procedure duration ( r = .554), and total length of stay ( r = .533).

Conclusion:

The complexity of FEVAR and BEVAR procedures reveals strong correlations between multiple peri- and postoperative variables. These exposures and risks should be borne in mind when considering treatment of complex abdominal aortic aneurysms as well as long-term clinical outcomes.

Technical aspects and 30-day outcomes of the prospective early feasibility study of the GORE EXCLUDER Thoracoabdominal Branched Endoprosthesis (TAMBE) to treat pararenal and extent IV thoracoabdominal aortic aneurysms

OBJECTIVE

This study reports the technical aspects and 30-day outcomes of the prospective, multicenter early feasibility study designed to evaluate the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz).

METHODS

Thirteen patients with pararenal or extent IV thoracoabdominal aortic aneurysms were prospectively enrolled at five U.S sites and one non-U.S. site from 2014 to 2016. The TAMBE included four portals with either retrograde or antegrade renal portal configuration and used GORE VIABAHN Balloon-Expandable Endoprosthesis (W. L. Gore & Associates) for stenting of the renal and mesenteric arteries. The primary end point was procedural safety at 30 days, defined by absence of major adverse events, including any-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, severe acute kidney injury (>50% decline in estimated glomerular filtration rate), dialysis, and procedural blood loss >1000 mL.

RESULTS

There were 11 male and two female patients with a mean age of 69 ± 8 years. Mean aneurysm diameter was 61 ± 13 mm. A total of 52 renal and mesenteric arteries were incorporated (4 vessels/patient). Technical success was achieved in 12 patients (92%). One patient had inadvertent occlusion of a right renal artery due to dissection. There was no mortality, aneurysm rupture, conversion to open repair, dialysis, or spinal cord injury. Mean length of hospital stay was 5 ± 3 days. At 30 days, four patients (31%) had major adverse events, all due to procedural blood loss >1000 mL. One patient had a type I endoleak at the distal renal branch, which was successfully treated by placement of an additional renal stent before dismissal. Computed tomography angiography at 30 days showed patent target vessels and no type I or type III endoleak.

CONCLUSIONS

This study confirms the early feasibility of the TAMBE for treatment of pararenal and extent IV thoracoabdominal aortic aneurysms. The high technical success, no mortality, and low morbidity rate support continuation of clinical investigation in a larger population of patients.

Fenestrated aortic endograft branching with Gore VBX poses failure risk from delayed-onset branch kinking

The Gore VBX stent graft (Gore Medical, Flagstaff, Ariz) provides a new option for branching of fenestrated aortic endografts. However, its modular stent structure has raised concerns about potential kinking at the interspace between stent rings if lateralizing force exists between the fenestration and target vessel orifice. We present a case of near-occlusion of a VBX celiac branch due to narrowing of this interspace identified at postoperative month 3. Although the Gore VBX offers several potential advantages as a branch endoprosthesis, its design poses the risk of unpredictable, delayed-onset kinking and raises concern for its use as a fenestrated endograft branch.

Decision uncertainty and value of further research: a case-study in fenestrated endovascular aneurysm repair for complex abdominal aortic aneurysms

Background

Fenestrated endovascular aneurysm repair (fEVAR) is a new approach for complex abdominal aortic aneurysms, limited to a few specialist centers, with limited evidence base. We developed a cost-effectiveness decision model of fEVAR compared to open surgical repair (OSR) to investigate the likely direction of costs and benefits and inform further research projects on this technology.

Methods

A systematic review with meta-analysis and a four-state Markov model were used to estimate the cost-effectiveness of fEVAR versus OSR. We used a recent coverage with evidence development framework to characterize the main sources of uncertainty and inform decisions about the type of further research that would be most worthwhile and feasible.

Results

Seven observational comparative studies were identified, of which four presented odds ratios adjusted for confounders. The odds ratios for operative mortality varied widely between studies. Assuming a central estimate of the odds ratio of 0.54 (95% CI 0.05–6.24), the decision model estimated that the incremental cost per quality adjusted life year (QALY) was £74,580/QALY with a probability of 9 and 16% of being cost-effective at standard cost-effectiveness thresholds of £20,000/QALY and £30,000/QALY, respectively. The Expected Value of Perfect Information over 10 years at a threshold of £20,000/QALY was £11.2 million. Operative mortality contributed to most of the uncertainty in the decision model.

Conclusions

In the case of “maturing technologies”, decision modelling indicates the likely direction of costs and benefits and guides the development of further research projects. In our analysis of fEVAR versus OSR, decision uncertainty, particularly around operative mortality, might be effectively resolved by a short-term RCT, or possibly a well-conducted comparative observational study. Decision makers may consider that a conditional coverage decision is warranted with assessments required to make this type of recommendation depending on local priorities and circumstances.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0098-7) contains supplementary material, which is available to authorized users.

Treatment for thoracoabdominal aortic aneurysm by fenestrated endovascular aortic repair with physician-modified stent graft

Despite being widely used for several years, the endovascular aortic repair (EVAR) of a thoracoabdominal aneurysm (TAAA) remains challenging, particularly the revascularization of the abdominal aortic visceral branches. A 66-year-old male was admitted to hospital with abdominal bloating and pain. Computed tomographic angiography (CTA) confirmed a Crawford type III TAAA from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery. Fenestrated-EVAR was performed successfully and 1 week later CTA showed a type III endoleak, which had resolved 3 months later, without stent migration or visceral artery occlusion. In this present case, the surgeons preferred to perform the procedure in three surgical stages, postponing the deployment of a covered stent in the CA fenestration to provide additional time for the development of collateral circulation to the spinal cord as a possible means of preventing postoperative paraplegia.

Complications and Reinterventions After Fenestrated and Branched EVAR in Patients with Paravisceral and Thoracoabdominal Aneurysms

The application of endovascular strategies to treat aneurysms involving the abdominal and thoracoabdominal aorta has evolved significantly since the inception of endovascular aneurysm repair. Advances in endograft technology and operator experience have enabled the management of a wider spectrum of challenging aortic anatomy. Fenestrated endovascular and branched endovascular aneurysm repair represent two technical innovations, which have expanded endovascular treatment options to include patients with paravisceral and thoracoabdominal aortic aneurysms. Although similar in many ways to standard aortic endografts, fenestrated and branched endografts have specific short- and long-term complications due to their unique modular endograft design and their sophisticated deployment mechanisms. This article aims to examine the commonly encountered complications with these devices and the endovascular reintervention strategies.

Endovascular repair of complex Juxtarenal aortic aneurysm using a combined fenestrated endograft and chimney technique

Chimney EVAR (CHEVAR) and Fenestrated EVAR (FEVAR) are two options for management of very complex abdominal aortic aneurysm (AAA). While some anatomical factors may favor one strategy over the other, there are some cases where the anatomical challenges may require using a hybrid approach. We are reporting the case of an 84-year-old male with a 6.8×5.7cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. This case shows that a combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy.

Evaluation of CT Angiography Image Quality Acquired with Single-Energy Metal Artifact Reduction (SEMAR) Algorithm in Patients After Complex Endovascular Aortic Repair

Purpose

To evaluate the value of single-energy metal artifact reduction (SEMAR) algorithm on image quality in patients after complex endovascular aortic repair (EVAR) with fenestrated and branched devices.

Methods

Routine follow-up computed tomography angiography (CTA) examinations were performed between February 2016 and May 2017 in 18 patients who underwent a complex EVAR procedure at our institution. Objective analysis was performed by measuring the standard deviation (SD) of attenuation (Hounsfield Units), and the contrast-to-noise ratio (CNR) in regions of interests in the stented visceral arteries. Subjective analysis of the degree of artifacts and stent visualization was performed independently by two interventional radiologists, blinded to the image reconstruction.

Results

The SD of attenuation was significantly lower in all target visceral arteries (p < .001), the celiac artery (p = .002), the superior mesenteric artery (SMA; p = .043), and renal arteries (p < .001) in the CT images with SEMAR reconstruction. The CNR significantly increased in all SEMAR-reconstructed target visceral arteries (overall: p < .001, celiac artery: p = .009; SMA: p = .003; renal arteries: p < .001). The reviewers rated a significantly lower artifact degree in all target vessels (overall: p < .001, celiac artery: p = .001; SMA: p = .008; renal arteries: p < .001) and a significantly improved visualization of the stent patency in all target vessels (overall: p < .001, celiac artery: p = .031; SMA: p = .047; renal arteries: p < .001) in the SEMAR images. Overall preference of both reviewers was in favor of the SEMAR reconstruction in 15/18 cases (83%).

Conclusion

Reconstruction with SEMAR algorithm significantly improves CTA image quality in patients after complex EVAR.

Level of Evidence

Level 4, Case series.

Medium-term outcomes of fenestrated endovascular repair of juxtarenal abdominal aortic aneurysms

BACKGROUND

Abdominal aortic aneurysms pose a substantial clinical burden, and a significant proportion are not anatomically suitable for open repair or standard endovascular aneurysm repair (EVAR), instead requiring fenestrated EVAR (fEVAR). We sought to compare clinical outcomes and trends over time in patients undergoing fEVAR in Australia.

METHODS

We conducted a retrospective analysis of all patients undergoing fEVAR at a tertiary referral centre between 2010 and 2015, including outcomes and complications, both as inpatients and after discharge.

RESULTS

Thirty-nine patients underwent fEVAR during the study period, with mean age of 75 years and mean aneurysm size of 61 mm. One hundred and thirty-four target vessels were treated and inhospital mortality was 5% (two patients). There were nine inhospital, eight Type II and one Type III endoleaks. Ten patients suffered acute kidney injury, one of whom required dialysis. Mean follow-up was 14.5 months (range: 0-46.7). Target vessel patency was 99.2% at follow-up. There were six Type II endoleaks at follow-up, and two patients died during the follow-up period (of non-aneurysm-related causes).

CONCLUSION

fEVAR is an effective treatment with low morbidity and mortality, and we have demonstrated excellent survival and target vessel patency at a mean follow-up of 14 months. Endoleak rates were low, despite the high complexity of the aneurysms treated.

Editor's Choice - Comparison of Renal Outcomes in Patients Treated by Zenith® Fenestrated and Zenith® Abdominal Aortic Aneurysm Stent grafts in US Prospective Pivotal Trials

OBJECTIVE/BACKGROUND

Fenestrated endovascular repair (FEVAR) has been used to treat complex abdominal aortic aneurysms (AAAs). The risk of renal function deterioration compared with infrarenal endovascular aortic repair (EVAR) has not been determined.

METHODS

Patients with preserved renal function (estimated glomerular filtration rate [eGFR] > 45 mL/minute) enrolled in two prospective, non-randomised studies evaluating Zenith fenestrated and AAA stent grafts were matched (1:2) by propensity scores for age, sex, hypertension, diabetes, and pre-operative eGFR. Sixty-seven patients were treated by FEVAR and 134 matched controls treated by EVAR. Mean follow-up was 30 ± 20 months. Outcomes included acute kidney injury (AKI) defined by RIFLE and changes in serum creatinine (sCr), eGFR, and chronic kidney disease (CKD) staging up to 5 years.

RESULTS

AKI at 1 month was similar between groups, with > 25% decline in eGFR observed in 5% of FEVAR and 9% of EVAR patients (p = .39). There were no significant differences in > 25% decline in eGFR at 2 years (FEVAR 20% vs. EVAR 20%; p > .99) or 5 years (FEVAR 27% vs. EVAR 50%; p = .50). Progression to stage IV-V CKD was similar at 2 years (FEVAR 2% vs. EVAR 3%; p > .99) and 5 years (FEVAR 7% vs. EVAR 8%; p > .99), with similar sCr and eGFR up to 5 years. During follow-up, there were more renal artery stenosis/occlusions (15/67 [22%] vs. 3/134 [2%]; p < .001) and renal related re-interventions (12/67 [18%] vs. 4/134 [3%]; p < .001) in patients treated by FEVAR. Rate of progression to renal failure requiring dialysis was low and identical in both groups (1.5% vs. 1.5%; p > .99).

CONCLUSION

Aortic repair with FEVAR and EVAR was associated with similar rates of renal function deterioration in patients with preserved pre-operative renal function. Renal related re-interventions were higher following FEVAR, although net changes in renal function were similar in both groups.