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Pitcher GS, Biggs JH, Dayama A, Newton DH, Tran K, Stoner MC, Smeds MR, Schermerhorn ML, Mix D. A national census for the off-label treatment of complex aortic aneurysms. J Vasc Surg 2024; 80:604-611. [PMID: 38904580 DOI: 10.1016/j.jvs.2024.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.
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Affiliation(s)
- Grayson S Pitcher
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Joedd H Biggs
- Division of Vascular Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Anand Dayama
- Sanford Vascular Associates, Sanford Health, Sioux Falls, SD
| | - Daniel H Newton
- Division of Vascular Surgery, Virginia Commonwealth University Health System, Richmond, VA
| | - Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, St Louis University School of Medicine, St Louis, MO
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Boston, MA
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
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Hofmann A, Mlekusch I, Wickenhauser G, Walter C, Falkensammer J, Assadian A, Taher F. Ultrasound Coded-Excitation Imaging for Endoleak Detection After Complex Endovascular Aortic Repair. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:429-437. [PMID: 37972197 DOI: 10.1002/jum.16374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Several imaging modalities have been suggested for surveillance after fenestrated endovascular aortic repair in general and endoleak detection in specific. In the present project a coded excitation-based ultrasound (B-Flow) was investigated for endoleak detection after complex endovascular aortic repair. METHODS Patients post complex endovascular aortic repair (FEVAR or T/FEVAR) undergoing follow-up appointments including ultrasonography of the aorta at a vascular and endovascular surgery outpatient center were included in the study. B-Flow was compared with computed tomography angiography (CTA), Duplex ultrasound (DUS), and contrast-enhanced ultrasound (CEUS) regarding agreement and reliability for endoleak detection and characterization. RESULTS In total, 47 follow-ups were included. They accumulated in a total of 149 imaging investigations. Endoleaks were discovered in 44.7% of B-Flow studies and a majority of these endoleaks were classified as type II. Agreement between B-Flow and other imaging modalities was good (>80.0%) in general. However, with B-Flow 6 and 2 endoleaks would have been missed compared with CEUS and CTA, respectively. Regarding endoleak classification, B-Flow had a strong agreement (94.5%) with CEUS in detected cases. Furthermore, in a limited subset analysis, imaging findings were externally validated using findings from angiography. CONCLUSIONS Ultrasonography allows for endoleak detection and characterization without an invasive procedure or the use of potentially nephrotoxic contrast medium and can reduce radiation exposure. While CEUS mitigates issues of radiation and nephrotoxicity it still requires the intravenous application of contrast enhancers. Ultrasound coded-excitation imaging such as B-Flow could therefore further simplify endoleak surveillance after fenestrated endovascular aortic repair.
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Affiliation(s)
- Amun Hofmann
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Irene Mlekusch
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Georg Wickenhauser
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | | | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Fadi Taher
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
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Dossabhoy SS, Sorondo SM, Fisher AT, Ho VT, Stern JR, Lee JT. Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2023; 97:163-173. [PMID: 37586562 PMCID: PMC10956480 DOI: 10.1016/j.avsg.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. METHODS We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. RESULTS From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0 years, P = 0.04), had increased preoperative creatinine (1.6 vs. 0.9 mg/dL, P < 0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P = 0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228 ml, P = 0.01), longer operative times (186 vs. 162 min, P = 0.04), and longer length of stay (3 vs. 2 days, P < 0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P < 0.01 and 55.4% vs. 70.8%, P = 0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs. 100%, P = 0.015) and 5 years (84.7% vs. 100%, P < 0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P = 0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P = 0.17). On multivariable modeling, age (hazard ratio 1.05, 95% confidence interval 1.01-1.09, P = 0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P < 0.01) were independently associated with mortality. CONCLUSIONS Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Vy T Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Finnesgard EJ, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Schneider DB, Sweet MP, Timaran CH, Simons JP, Schanzer A. Severity of acute kidney injury is associated with decreased survival after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2023; 78:892-901. [PMID: 37330702 DOI: 10.1016/j.jvs.2023.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) occurs frequently in complex aortic surgery and has been implicated in perioperative and long-term survival. This study sought to characterize the relationship between AKI severity and mortality after fenestrated and branched endovascular aortic aneurysm repair (F/B-EVAR). METHODS Consecutive patients enrolled by the US Aortic Research Consortium in 10, prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/B-EVAR, between 2005 and 2023, were included in this study. Perioperative AKI during hospitalization was defined by and staged using the 2012 Kidney Disease Improving Global Outcomes criteria. Determinants of AKI were evaluated with backward stepwise mixed effects multivariable ordinal logistic regression. Survival was analyzed with conditionally adjusted survival curves and backward stepwise mixed effects Cox proportional hazards modelling. RESULTS In the study period, 2413 patients with a median (interquartile range [IQR]) age of 74 years (IQR, 69-79 years) underwent F/B-EVAR. The median follow-up duration was 2.2 years (IQR, 0.7-3.7 years). The median baseline estimated glomerular filtration rate (eGFR) and creatinine were 68 mL/min/1.73 m2 (IQR, 53-84 mL/min/1.73 m2) and 1.1 mg/dL (IQR, 0.9-1.3 mg/dL), respectively. Stratification of AKI identified 316 patients (13%) with stage 1 injury, 42 (2%) with stage 2 injury, and 74 (3%) with stage 3 injury. Renal replacement therapy was initiated during the index hospitalization in 36 patients (1.5% of cohort, 49% of stage 3 injuries). Thirty-day major adverse events were associated with AKI severity (all P ≤ .0001). Multivariable predictors of AKI severity included baseline eGFR (proportional odds ratio, 0.9 per 10 mL/min/1.73 m2 [95% confidence interval (CI), 0.85-0.95 per 10 mL/min/1.73 m2]; P < .0001), baseline serum hematocrit (0.58 per 10% [95% CI, 0.48-0.71 per 10%]; P < .0001), renal artery technical failure during aneurysm repair (3 [95% CI,1.61-5.72]; P = .0006), and total operating time (1.05 per 10 minutes [95% CI, 1.04-1.07 per 10 minutes]; P < .0001). One-year unadjusted survivals for AKI severity strata were 91% (95% CI, 90%-92%) for no injury, 80% (95% CI, 76%-85%) for stage 1 injury, 72% (95% CI, 59-87%) for stage 2 injury, and 46% (95% CI, 35-59%) for stage 3 injury (P<.0001). Multivariable determinants of survival included AKI severity (stage 1, hazard ratio [HR], 1.6 [95% CI, 1.3-2]); stage 2, HR, 2.2 [95% CI, 1.4-3.4]); stage 3 HR, 4 [95% CI, 2.9-5.5]; P < .0001), decreased eGFR (HR, 1.1 [95% CI, 0.9-1.3]; P = .4), patient age (HR, 1.6 per 10 years [95% CI, 1.4-1.8 per 10 years]; P < .0001), baseline chronic obstructive pulmonary disease (HR, 1.5 [95% CI, 1.3-1.8]; P < .0001), baseline congestive heart failure (HR, 1.7 [95% CI, 1.6-2.1]; P < .0001), postoperative paraplegia (HR, 2.1 [95% CI, 1.1-4]; P = .02), and procedural technical success (HR, 0.6 [95% CI, 0.4-0.8]; P = .003). CONCLUSIONS AKI, as defined by the 2012 Kidney Disease Improving Global Outcomes criteria, occurred in 18% of patients after F/B-EVAR. Greater severity of AKI after F/B-EVAR was associated with decreased postoperative survival. The predictors of AKI severity identified in these analyses suggest a role for improved preoperative risk mitigation and staging of interventions in complex aortic repair.
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Affiliation(s)
- Eric J Finnesgard
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew J Eagleton
- Divison of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - W Anthony Lee
- Christine E. Lynn Heart & Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Darren B Schneider
- Division of Vascular and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Matthew P Sweet
- Divison of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Carlos H Timaran
- Division of Vascular Surgery, University of Texas Southwestern, Dallas, TX
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
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Gallitto E, Faggioli G, Logiacco A, Mascoli C, Spath P, Palermo S, Pini R, Gargiulo M. Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair. Vascular 2023; 31:833-840. [PMID: 35513794 DOI: 10.1177/17085381221097304] [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: 11/16/2022]
Abstract
PURPOSE Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. MATERIALS AND METHODS All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. RESULTS Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70 mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). CONCLUSION Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70 mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Al-Gburi M, Eiberg JP, Resch TA. Single branch arch stent graft combined with laser fenestration in the treatment of a zone two penetrating thoracic aortic ulcer. J Vasc Surg Cases Innov Tech 2023; 9:101281. [PMID: 37662564 PMCID: PMC10469987 DOI: 10.1016/j.jvscit.2023.101281] [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: 06/10/2023] [Accepted: 07/10/2023] [Indexed: 09/05/2023] Open
Abstract
We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.
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Affiliation(s)
- Mustafa Al-Gburi
- Department of Vascular and Endovascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Jonas P. Eiberg
- Department of Vascular and Endovascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Timothy A. Resch
- Department of Vascular and Endovascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Katsargyris A, Marques de Marino P, Hasemaki N, Nagel S, Botos B, Wilhelm M, Verhoeven ELG. Editor's Choice - Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms. Eur J Vasc Endovasc Surg 2023; 66:160-166. [PMID: 36842460 DOI: 10.1016/j.ejvs.2023.02.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/23/2022] [Accepted: 02/12/2023] [Indexed: 02/28/2023]
Abstract
OBJECTIVE The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre. METHODS Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed. RESULTS A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088). CONCLUSION Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.
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Affiliation(s)
- Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany.
| | - Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Natasha Hasemaki
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Sebastian Nagel
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Manuela Wilhelm
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Eric L G Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
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8
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Yazar O, Pilz da Cunha G, de Haan MW, Mees BM, Schurink GW. Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:268-278. [PMID: 36106397 DOI: 10.23736/s0021-9509.22.12311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The impact of stent-graft complexity on clinical outcome after fenestrated endovascular aortic aneurysm repair (FEVAR) has been conflicting in the literature. The objective of this study was to compare mid-term results of stent-grafts with renal fenestrations alone with more complex stent-grafts including mesenteric fenestrations. METHODS A single center retrospective study was conducted on 154 patients, who underwent FEVAR from 2006 to 2020 at our institution. RESULTS There were 54 (35.1%) patients in the renal FEVAR group and 100 (64.9%) patients in the complex FEVAR group. Median follow-up of the total group was 25 months (IQR 7-45). There were no significant differences in technical success and perioperative mortality. Intraoperative complications (4% vs. 18%, P=0.001), operative time (145 min vs. 191 min, P=0.001), radiation dose (119372 mGy*cm2 vs. 159573 mGy*cm2, P=0.004) and fluoroscopy time (39 min vs. 54 min, P=0.007) were significantly lower in the renal FEVAR group. During follow-up target vessel instability, endoleaks and reinterventions were not significantly different between the two groups. CONCLUSIONS In this single center retrospective study, renal FEVAR was a safe and effective treatment for patients with juxtarenal AAA demonstrating fewer intraoperative complications and similar mid-term outcomes as complex FEVAR. If the anatomy is compatible for renal FEVAR, it might be unnecessary to expose patients to potentially more complications by choosing a complex FEVAR strategy.
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Affiliation(s)
- Ozan Yazar
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Vascular Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Gabriela Pilz da Cunha
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michiel W de Haan
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Barend M Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands -
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9
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Zlatanovic P, Mascia D, Ancetti S, Yeung KK, Graumans MJ, Jongkind V, Viitala H, Venermo M. Short Term and Long Term Clinical Outcomes of Endovascular versus Open Repair for Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using Propensity Score Matching: Results from Juxta- and pararenal aortic Aneurysm Multicentre European Study (JAMES). Eur J Vasc Endovasc Surg 2023; 65:828-836. [PMID: 36858252 DOI: 10.1016/j.ejvs.2023.02.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE The aim of this study was to compare the short and long term clinical outcomes of endovascular (EVAR) vs. open surgical repair (OSR) of juxtarenal (JAAAs) and pararenal abdominal aortic aneurysms (PAAAs) in five high volume European academic centres. METHODS This was a retrospective multicentre cohort study of five high volume European academic centres (> 50 open or 50 endovascular abdominal aortic aneurysm repairs annually) including 834 consecutive patients who were operated on and prospectively followed. Using propensity score matching (PSM) each patient who underwent OSR was matched with one patient who underwent EVAR in a 1:1 ratio (145 patients per group). The primary endpoint was long term all cause mortality, while the secondary endpoint was freedom from aortic related re-intervention. RESULTS After a follow up of 87 months, no difference in overall survival between the two groups was observed (38.6% for EVAR vs. 42.1% for OSR; p = .88). Patients undergoing EVAR underwent aortic related re-interventions more frequently (24.1% vs. 6.9%; p < .001). Acute kidney injury (AKI) occurred more frequently in patients in the OSR group (40.7% vs. 24.8%; p = .006). However, most patients who suffered from AKI recovered without further progression to renal failure. In hospital (3.4% for EVAR vs. 4.1% for OSR; p = 1.0) and 30 day (4.1% for EVAR vs. 5.5% for OSR; p = .80) mortality rates did not differ between groups. CONCLUSION Both open and endovascular treatment can be performed in high volume aortic centres with low short term mortality and morbidity rates, and good long term outcomes. These data provide useful information to help patients choose between the two procedures when both are feasible.
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Affiliation(s)
- Petar Zlatanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia.
| | - Daniele Mascia
- Vascular Surgery Unit at the San Raffaele Hospital, Milan, Italy
| | | | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Maarten Jaap Graumans
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Department of Vascular Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - Herman Viitala
- Vascular Surgery at the Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Vascular Surgery at the Helsinki University Hospital, Helsinki, Finland
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10
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Bordet M, Oliny A, Miasumu T, Tresson P, Lermusiaux P, Della Schiava N, Millon A. EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm. J Vasc Surg 2023; 77:28-36.e3. [PMID: 36070845 DOI: 10.1016/j.jvs.2022.08.035] [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: 06/06/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA). METHODS All patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared. RESULTS The median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23). CONCLUSIONS ESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.
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Affiliation(s)
- Marine Bordet
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France.
| | - Alexandre Oliny
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Tiphaine Miasumu
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Philippe Tresson
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Patrick Lermusiaux
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France
| | - Nellie Della Schiava
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France
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11
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Sénémaud J, Becquemin JP, Chakfé N, Touma J, Desgranges P, Cochennec F. Midterm Results of Physician-Modified Stent Grafts for Thoracoabdominal and Complex Abdominal Aortic Aneurysms Repair. Ann Vasc Surg 2022:S0890-5096(22)00762-2. [PMID: 36460175 DOI: 10.1016/j.avsg.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND To assess midterm results of physician-modified stent grafts (PMSG) for the treatment of emergent complex abdominal and thoracoabdominal aortic aneurysms (TAAA) in high-risk patients. METHODS All consecutive patients with emergent complex abdominal or TAAA undergoing PMSG technique between January 2012 and July 2019 were retrospectively included. Indications for PMSG were symptomatic aneurysms and rapidly growing aneurysms >70 mm. Ruptured aneurysms were excluded. RESULTS Thirty-three patients (mean age: 74 +/- 11 years) were included. The mean aneurysm diameter was 76 +- 20 mm. Patients presented with TAAA (n = 20, 61%), complex abdominal aortic aneurysms (CAAA, n = 9, 27%), type I endoleak after previous endovascular aneurysm repair (n = 3, 9%) and intramural aortic hematoma (n = 1, 3%). Chimney technique was performed in addition to PMSG in seven cases (21%). Intraoperative adverse events were recorded in seven cases (35%) in the TAAA group and one case (11%) in the CAAA group. In-hospital mortality rate was 15% (n = 3) in the TAAA group and 11% (n = 1) in the CAAA group. Moderate to severe complications were recorded in 45% of cases (n = 15). Spinal cord ischemia occurred in two cases (6%, one case without residual deficit and one with minor motor deficit). One (3%) patient required transient hemodialysis. One patient presented with early aortic rupture and required an open conversion. The mean follow-up duration was 31 months (1-79). Overall survival estimates were 81.4% (95% confidence interval [CI]: 63.1.-91.2) at 1 year and 71.6% (95% CI: 52.6-84.1) at 2 years. Freedom from reintervention rates at 1 and 2 years were 61.2% (95% CI: 41.7-75.9) and 57.4% (95% CI: 37.9-72.8). Target vessel primary patency rates at 1 and 2 years were 99.2% (95% CI: 94.2-99.9) and 97.7% (95% CI: 90.7-99.4). CONCLUSIONS PMSG for high-risk patients with complex aneurysms provided acceptable technical success and excellent target vessel patency rates but were associated with a 12% in-hospital mortality rate. Reinterventions were frequent. This technique should be limited to selected high-risk patients for whom the risk of rupture in the short-term is deemed too high to wait for graft manufacturing of custom-made device.
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Affiliation(s)
- Jean Sénémaud
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Jean-Pierre Becquemin
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France.
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Marques de Marino P, Abu Jiries M, Tesinsky P, Ibraheem A, Katsargyris A, Verhoeven EL. Mid-Term Results of Fenestrated Endovascular Repair after Prior Open Aortic Reconstruction. J Clin Med 2022; 11:jcm11195596. [PMID: 36233467 PMCID: PMC9571734 DOI: 10.3390/jcm11195596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
This study aims to assess the mid-term results of fenestrated endovascular aneurysm repair (FEVAR) for the treatment of proximal aortic pathology after previous open surgical repair (OSR). All patients with a previous history of OSR of an abdominal aortic aneurysm undergoing a FEVAR procedure between October 2010 and November 2021 were included. The endpoints of the study were technical success, mortality, target vessel patency and reinterventions during follow-up. Thirty-five patients (34 male, mean age 72.9 ± 7 years) were included. The median interval from the primary surgery to the FEVAR procedure was 136 months (range 47–261). The indication for treatment was a para-anastomotic aneurysm in 18 (51%) patients and a true aneurysm due to progression of disease in 17 (49%) patients. Technical success was achieved in 33 (94%) patients. There was one (3%) early death due to postoperative bleeding from a renal artery. Estimated survival at 12, 24 and 36 months was 89.1% ± 6%, 84.4% ± 7.3% and 84.4% ± 7.3%, respectively. There was no aneurysm-related mortality. One (3%) target vessel occluded during follow-up and three (9%) patients underwent late reinterventions. In conclusion, FEVAR is a safe and effective alternative for the endovascular treatment of para-anastomotic aneurysms/pseudoaneurysms after OSR showing high technical success, low mortality and morbidity, and good mid-term outcomes.
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13
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Mehta V, Wooster M. Hypogastric artery thrombectomy for spinal cord ischemia following fenestrated endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:413-416. [PMID: 35942496 PMCID: PMC9356088 DOI: 10.1016/j.jvscit.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022] Open
Abstract
Spinal cord ischemia can be a devastating complication after thoracoabdominal aortic surgery. We report a case of a 56-year-old woman who had undergone multiple prior thoracic aneurysm repairs with an increase of a visceral segment aneurysm to 6 cm. The aneurysm was repaired using a physician-modified four-vessel fenestrated graft and iliac branch device. Postoperatively, she developed weakness in her right leg. Computed tomography angiography showed an occluded right hypogastric artery. We proceeded with aspiration thrombectomy with complete resolution of her right leg weakness within hours postoperatively. Our findings have illustrated the important role of hypogastric arteries in the development of spinal cord ischemia.
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Affiliation(s)
- Veena Mehta
- Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, Torrance
- Correspondence: Veena Mehta, MD, Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, 1000 W Carson St, Torrance, CA 90502
| | - Mathew Wooster
- Division of Vascular Surgery, Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston
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14
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Dossabhoy SS, Sorondo SM, Tran K, Stern JR, Dalman RL, Lee JT. Reintervention Does Not Impact Long-term Survival After Fenestrated Endovascular Aneurysm Repair. J Vasc Surg 2022; 76:1180-1188.e8. [PMID: 35709854 DOI: 10.1016/j.jvs.2022.04.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/19/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine if REIs impact long-term survival after FEVAR. METHODS A single-institution retrospective review of all Cook ZFEN repairs was performed. Patients with ≥6 months follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized by early (<30 days) or late (≥30 days), indication (branch, endoleak, limb, access-related, or other), and target branch/device component. Patients were stratified into REI vs No REI and Branch REI vs Non-Branch REI. RESULTS Of 219 consecutive ZFEN from 2012-2021, 158 patients met inclusion criteria. Forty-one (26%) patients underwent a total of 51 REIs (10 early, 41 late) over a mean follow-up of 33.9 months. The most common indication for REI was branch-related 61% (31/51), with the renal arteries most frequently affected 51% (26/51). The only differences found in baseline, aneurysm, or device characteristics were a higher mean SVS comorbidity score (9.6 vs 7.9, P=.04) and larger suprarenal neck angle (23.3 vs 17.1 degrees, P=.04) in No REI, while REI had larger mean proximal seal zone diameter (26.3 vs 25.1 mm, P=.03) and device diameter (31.9 vs 30.0 mm, P=.002) than No REI. Technical success and operative characteristics were similar between groups, except for longer mean fluoroscopy time (74.9 vs 60.8 min, P=.01) and longer median length of stay (2 vs 2 days, P=.006) in REI. While the rate of early major adverse events (<30 days) was higher in REI (24.4% vs 6.0%, P=.001), 30-day mortality was not statistically different (4.9% vs 0.9%, P=.10). On Kaplan-Meier analysis, freedom from REI at 1- and 5-years was 85.7% and 62.6%, respectively, in the overall cohort. There was no difference in estimated 5-year survival between REI and No REI (62.8% vs 63.5%, log-rank P=.87) and Branch REI and Non-Branch REI (71.8% vs 49.9%, log-rank P=.16). In multivariate analysis, REI did not predict mortality; age, the SVS comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (HR 1.07 95% CI 1.02-1.12, P=.007; HR 1.10, 95% CI 1.01-1.18, P=.02; HR 1.05, 95% CI 1.02-1.08, P=.003 respectively). CONCLUSIONS Following ZFEN, 26% of patients required a total of 51 REIs with most occurring ≥30 days and 61% being branch-related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs do not influence 5-year post-procedural survival.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kenneth Tran
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Ronald L Dalman
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Stanford University School of Medicine, Stanford, CA.
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15
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Uijtterhaegen G, VAN Langenhove K, Moreels N, VAN Herzeele I, Vermassen F. Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:317-327. [PMID: 35142459 DOI: 10.23736/s0021-9509.22.11964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Gilles Uijtterhaegen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium -
| | - Karen VAN Langenhove
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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16
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Wu H, Zhang L, Li M, Wei S, Zhang C, Bai H. Systematic Review and Meta-Analysis of Published Studies on Endovascular Repair of Abdominal Aortic Aneurysm With the p-Branch. Front Surg 2022; 9:879682. [PMID: 35574550 PMCID: PMC9098825 DOI: 10.3389/fsurg.2022.879682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/23/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Haoliang Wu
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Zhengzhou, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cong Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hualong Bai
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Zhengzhou, China
- *Correspondence: Hualong Bai ;
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17
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Camazine M, Kruse RL, Bath J, Singh P, Vogel TR. 30-Day Readmission and Outcomes after Fenestrated versus Traditional Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2022; 85:314-322. [PMID: 35339596 DOI: 10.1016/j.avsg.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a minimally invasive alternative for repairing complex abdominal aortic aneurysms (AAA). Comparisons of outcomes for FEVAR and traditional endovascular aneurysm repair (EVAR) are limited. We evaluated outcomes following elective endovascular AAA repair with FEVAR or EVAR. METHODS Hospitalizations for elective nonruptured AAA repair from 2014-2016 were selected from the Nationwide Readmissions Database (NRD) using ICD-9 and ICD-10 procedure and diagnosis codes. In-hospital mortality, length of stay (LOS), complications, 30-day readmission, and charges were evaluated. Multivariable logistic regression was used to control for confounding between groups. RESULTS We identified 23,262 EVAR and 2,373 FEVAR with nonruptured elective procedures. In-hospital mortality was 0.14% for both groups (p=.99). Of those at risk for readmission (21,152 EVAR, 1,915 FEVAR), index LOS was greater for FEVAR compared to EVAR, 1.8 days vs. 1.7 days (p=0.028). There was no difference in procedure type based on hospital location (p=0.37), teaching status (p=0.17) or hospital size (p=0.26). During the index hospitalization, pneumonia, renal, and respiratory complications were similar between groups (all p>0.05). FEVAR patients were more likely to experience cardiac complications (p=0.0098) or hemorrhage (p=0.029). Total charges for the index stay were greater for FEVAR compared to EVAR ($125,381 vs. $113,513, p<.0001). All-cause 30-day readmission was similar between groups (7.0% EVAR vs. 8.0% FEVAR, p=0.37), as were time to readmission (11.9 vs. 13.3 days, p=0.16) and readmission charges ($53,967 vs $56,617, p=0.75). Renal failure was the most common readmission stay complication, with similar rates for EVAR and FEVAR patients (p=0.22). Pneumonia was a more common complication during the readmission stay for EVAR patients (p=0.004). Renal disease and chronic pulmonary disease were the most common comorbidities in the readmission stay for both groups. CONCLUSION For patients with nonruptured elective AAA , FEVAR was not associated with increased mortality, length of stay, readmission, or most complications compared to traditional EVAR. Despite increased technical complexity of cannulating and stenting visceral arteries with FEVAR, these data demonstrate that FEVAR carries similar risk of renal, respiratory, and infectious complications compared to traditional EVAR. FEVAR patients were more likely to experience hemorrhagic and cardiac complications during the index hospitalization. EVAR patients were more likely to have pneumonia during readmission. Overall risk for readmission after endovascular aortic repair was associated with female sex, greater age, chronic pulmonary disease, malignancy, and loss of function. Further investigation into causes and prevention of 30-day readmissions are needed for both procedures.
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Affiliation(s)
- Maraya Camazine
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Priyanka Singh
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO.
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Vasudevan TM, Sivakumaran Y. “More or less”: management of type A aortic dissections in the endovascular era. Indian J Thorac Cardiovasc Surg 2022; 38:193-197. [PMID: 35463709 PMCID: PMC8980979 DOI: 10.1007/s12055-021-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/17/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022] Open
Abstract
The management of type A aortic dissection presents a major therapeutic challenge in modern surgical practice. Whilst the traditional dictum, to provide timely surgical intervention with the minimum treatment needed to repair the ascending aorta as well as the primary tear, may be a reasonable strategy in older patients, a tailored approach is desired for younger patients to manage the immediate life-threatening condition, as well as for the management of lifelong complications of the residual dissected aorta. Endovascular technology continues to advance, providing an adjunctive role to open cardiac repair presently to manage downstream aortic pathology, with the aim of striving towards a complete endovascular solution for type A aortic dissections.
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Affiliation(s)
| | - Yogeesan Sivakumaran
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, QLD Australia
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19
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Siada S, Malgor EA, Al-Musawi M, Giannopoulos S, Jacobs DL, Malgor RD. Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2022; 56:376-384. [PMID: 35200054 DOI: 10.1177/15385744211037616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. METHODS All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. RESULTS Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9 years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68 days in the endovascular and 107 ± 79 days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22 months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28 days) and 7 days (ranging, 3-18 days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30 days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. CONCLUSIONS Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.
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Affiliation(s)
- Sammy Siada
- Division of Vascular Surgery, University of California at Fresno, Fresno, CA, USA
| | - Emily A Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Mohammed Al-Musawi
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Donald L Jacobs
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Rafael D Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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20
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Blakeslee-Carter J, Beck AW, Spangler EL. Type 3 Endoleaks in Complex Endovascular Abdominal Aortic Aneurysm Repair within the Vascular Quality Initiative. J Vasc Surg 2021; 75:1172-1180. [PMID: 34740805 DOI: 10.1016/j.jvs.2021.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Type 3 Endoleaks (T3EL) following complex EVAR (c-EVAR) for abdominal aortic aneurysm have been historically difficult to study due to their relative rarity. Previous studies within standard infrarenal EVAR have found an association between T3EL and decreased survival. This study aims to evaluate the occurrence of T3EL in a national multicenter cohort, identify potential procedural characteristics associated with T3EL development, and determine their impact on clinical outcomes in c-EVAR. METHODS A retrospective cohort review was conducted of elective c-EVAR for non-ruptured aneurysms within the Vascular Quality Initiative (VQI) between January 2010 and March 2020. The VQI standards define c-EVAR as suprarenal or pararenal AAA repaired with any thoracoabdominal repairs, fenestrated/branched repairs, parallel stent repairs, custom manufactured devices, and physician modified endografts. End-points assessed were rates of T3EL within c-EVAR, and impact of T3EL on reintervention and survival. Index endoleaks were defined as endoleaks discovered during index hospitalization. Incident endoleaks were defined as new endoleaks, that were not present at index hospitalization, discovered at follow-up. RESULTS 4,070 c-EVAR cases were identified between January 2010 and March 2020, of which, 2,656 (65.2%) had appropriate follow-up data. Half the cohort had a modified or custom graft (n=2,055/4,070, 50.5%). Branches were employed in 3,687 patients (90.5%), while fenestrations and chimney techniques were documented in 13% (n=533) and 15.1% (n=613) respectively . The rate of index T3EL was 4.1% (n=167), and the rate of incident T3EL at follow-up was 0.04% (n=1). Devices categorized as either custom or physician modified were utilized more frequently in patients with index T3EL (78.4%, n=131/167) compared to patients without index T3EL (49.2%, n=1,924/3,903) (p<0.001). Compared to those without T3EL, the presence of index T3EL was not statistically associated with increased aortic reinterventions or increased mortality. CONCLUSIONS T3EL in c-EVAR remain relatively uncommon and are identified predominately at index hospitalization. Development of T3EL was associated with higher device modularity and modification, which suggests that as device technologies continue to advance and become more intricate the occurrence of T3EL may persist and continue to require evaluation. In this study, the presence of T3EL did not appear to have a statistically significant relationship with aortic reinterventions or survival, however these findings are not definitive due to low event rate numbers and high potential for Type 2 errors. Amid the theoretical risk of device fatigue and degeneration, continued evaluations of large cohorts at extended follow-up intervals and diligent reporting remain paramount.
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Affiliation(s)
- Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
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21
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Marques de Marino P, Katsargyris A, Ibraheem A, Gafur N, Botos B, Verhoeven EL. Editor's Choice - Four Fenestration Endovascular Aortic Aneurysm Repair Without Stenting of the Coeliac Artery in Selected Cases. Eur J Vasc Endovasc Surg 2021; 62:652-653. [PMID: 34493451 DOI: 10.1016/j.ejvs.2021.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/10/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Anas Ibraheem
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Nargis Gafur
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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22
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Hostalrich A, Mesnard T, Soler R, Girardet P, Kaladji A, Jean Baptiste E, Malikov S, Reix T, Ricco JB, Chaufour X. Prospective Multicentre Cohort Study of Fenestrated and Branched Endografts After Failed Endovascular Infrarenal Aortic Aneurysm Repair with Type Ia Endoleak. Eur J Vasc Endovasc Surg 2021; 62:540-548. [PMID: 34364770 DOI: 10.1016/j.ejvs.2021.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/25/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Failed endovascular infrarenal aortic aneurysm repair (EVAR) due to development of late type Ia endoleak exposes patients to the risk of rupture and should be treated. The purpose of this study was to evaluate the results of fenestrated/branched EVAR (F/BEVAR) for treatment of failed EVAR with type Ia endoleak. METHODS From January 2010 to December 2019, a prospective multicentre study was conducted (ClinicalTrials.gov identifier: NCT04532450) that included 85 consecutive patients who had undergone F/BEVAR to treat a type Ia endoleak following EVAR. The primary outcome was overall freedom from any re-intervention or death related to the F/BEVAR procedure. RESULTS In 30 cases (35%) EVAR was associated with a short < 10 mm or angulated (> 60°) infrarenal aortic neck, poor placement of the initial stent graft (n = 3, 4%), sizing error (n = 2, 2%), and/or stent graft migration (n = 7, 8%). Type Ia endoleak was observed after a period of 59 ± 25 months following EVAR. The authors performed 82 FEVAR (96%) and three BEVAR (4%) procedures with revascularisation of 305 target arteries. Overall technical success was 94%, with three failures including one persistent Type Ia endoleak and two unsuccessful stent graft implantations. Intra-operative target artery revascularisation was successful in 303 of 305 attempts. The in hospital mortality rate was 5%. Cardiac, renal and pulmonary complications occurred in 6%, 14%, and 7% of patients, respectively. Post-operative spinal cord ischaemia occurred in four patients (4.7%). At three years, the survival rate was 64% with overall freedom from any re-intervention or aneurysm related death of 40%, and freedom from specific F/BEVAR re-intervention of 73%. At three years, the secondary patency rate of the target visceral arteries was 96%. During follow up, 27 patients (33%) required a revision procedure of the fenestrated (n = 11) or index EVAR stent graft (n = 16), including six open conversions. CONCLUSION While manufactured F/BEVAR was effective in treating type Ia endoleak in patients with failed EVAR, it was at the cost of a number of secondary endovascular and open surgical procedures.
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Affiliation(s)
- Aurélien Hostalrich
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Thomas Mesnard
- Department of Vascular Surgery, University Hospital, Lille, INSERM U1008, University of Lille, Lille, France
| | - Raphael Soler
- Department of Vascular Surgery, University Hospital La Timone, Marseille, France
| | - Paul Girardet
- Department of Vascular Surgery, University Hospital E. Herriot, Lyon, France
| | - Adrien Kaladji
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Rennes, France
| | | | - Serguei Malikov
- Department of Vascular Surgery, University Hospital, Vandoeuvre les Nancy, France
| | - Thierry Reix
- Department of Vascular Surgery, University Hospital, Amiens, France
| | | | - Xavier Chaufour
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
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Gallitto E, Faggioli G, Pini R, Logiacco A, Mascoli C, Fenelli C, Abualhin M, Gargiulo M. Reinterventions after fenestrated and branched endografting for degenerative aortic aneurysms. J Vasc Surg 2021; 74:1808-1816.e4. [PMID: 34087395 DOI: 10.1016/j.jvs.2021.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Fenestrated/branched endovascular abdominal aortic aneurysm repair (F/B-EVAR) is widely accepted technique to treat juxta/pararenal abdominal aortic aneurysms (J/P-AAAs) and thoracoabdominal aortic aneurysms (TAAAs) for patients at high-surgical risk. However, the follow-up results should be carefully evaluated, especially in terms of the reintervention rate. The aim of the present study was, therefore, to evaluate the early and mid-term reinterventions after FB-EVAR for J/P-AAAs and TAAAs and their effects on follow-up survival. METHODS From 2006 to 2019, all consecutive patients who had undergone F/B-EVAR for J/P-AAAs or TAAAs were prospectively enrolled. Cases requiring reinterventions were retrospectively analyzed. Patients with aortic dissection were excluded from the present analysis. Reinterventions were classified as follows: access related, aortoiliac related, or target visceral vessel (TVV) related. Freedom from reintervention and survival were assessed using the Kaplan-Meier method, and univariate and multivariate analyses were used to determine the risk factors. RESULTS Overall, 221 F/B-EVAR procedures were performed for 111 J/P-AAAs (50.3%) and 110 TAAAs (49.7%) in an elective (182; 82%) or urgent (39; 18%) setting. The median follow-up was 27 months (interquartile range, 13 months). Overall, 41 patients had undergone 52 reinterventions (single, 30 [14%]; multiple, 11 [5%]; access related, 17 [33%]; aortoiliac related, 6 [12%]; TVV related, 29 [55%]). Of the 52 reinterventions, 32 (62%) and 20 (38%) had occurred within and after 30 days, respectively. Eight reinterventions (15%) had been were performed in an urgent setting. Endovascular and open reinterventions were performed in 32 (62%) and 20 (38%) cases, respectively. Open reinterventions were frequently access related (access, 16; no access, 4; P ≤ .001). Technical success was 95% (39 patients); failures consisted of one splenic artery rupture and one renal artery loss. Patients undergoing reintervention had more frequently undergone a primary urgent F/B-EVAR (urgent, 12 of 39 [31%]; elective, 29 of 182 [16%]; P < .001) and had had TAAAs (TAAAs, 34 of 41 [83%]; J/P-AAAs, 7 of 41 [17%]; P < .001). The patients with TAAAs had had a greater incidence of TVV-related reintervention (TAAAs, 26 of 28 [93%]; J/P-AAAs, 2 of 28 [7%]; P < .001) and multiple reinterventions (TAAAs, 9 of 11 [82%]; J/P-AAAs, 2 of 11 [18%]; P = .03) compared with those with J/P-AAAs. Survival at 3 years was 75%. Freedom from reintervention was 81% at 3 years. Patients who had undergone reinterventions had lower 3-year survival (reintervention, 61%; no reintervention, 77%; P = .02). Preoperative chronic renal failure (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .02), TAAAs (HR, 2.3; 95% CI, 1.1-4.8; P = .03), and urgent primary F/B-EVAR procedures (HR, 2.5; 95% CI, 1.2-4.9; P = .01) were independent predictors of late mortality. CONCLUSIONS Reinterventions after F/B-EVAR are not uncommon and were related to TVVs in only one half of cases. Most of them can be performed in an elective setting using endovascular techniques. The technical success rate was excellent. Reinterventions were more frequent after TAAAs and urgent F/B-EVAR procedures and had a significant effect on overall survival in these situations.
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Affiliation(s)
- Enrico Gallitto
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy.
| | - Gianluca Faggioli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonino Logiacco
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Chiara Mascoli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Cecillia Fenelli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Mohammahad Abualhin
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
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Hemingway JF, Starnes BW, Kline BR, Singh N. Initial experience with the Terumo aortic Treo device for fenestrated endovascular aneurysm repair. J Vasc Surg 2021; 74:823-831.e1. [PMID: 33592291 DOI: 10.1016/j.jvs.2021.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The Terumo aortic (TA) Treo device (Terumo, Somerset, NJ) is an endograft with unique features that lends itself to fenestrated endovascular aneurysm repair (FEVAR), including a low device profile, a wide amplitude stent design, and an increased interstent distance. We have described our initial experience with the Treo device for FEVAR to treat short neck and juxtarenal abdominal aortic aneurysms. METHODS As part of an ongoing physician-sponsored investigational device exemption clinical trial (ClinicalTrials.gov identifier, NCT01538056), subjects were prospectively enrolled and underwent elective FEVAR using a variety of devices. Demographic and procedural details were collected. The data from subjects treated specifically with the Treo device from November 3, 2016 to May 2, 2019 were collected and analyzed. RESULTS Of a cohort of 161 patients who had undergone elective FEVAR, 46 had been treated with the TA Treo device. Most patients were men (70%), with a mean age of 75 years and high rates of hypertension (74%), hyperlipidemia (83%), coronary artery disease (33%), and chronic obstructive pulmonary disease (33%). The mean aneurysm size was 66 mm, the mean preoperative infrarenal neck length was 5 mm, and the mean final seal zone length was 45 mm. The average hospital and intensive care unit lengths of stay were 2.4 and 1.5 days, respectively. A total of 129 fenestrations were created for 44 superior mesenteric and 85 renal arteries (2.8 fenestrations per patient). Technical success, defined as successful implantation of the device with all target vessels preserved, was 98% (45 of 46), with only one renal artery not successfully preserved. The mean follow-up period was 598 days. During the study period, 18 endoleaks were detected (17 type II and 1 type III), with one patient with a type III endoleak requiring reintervention. Three subjects had died within 30 days, one of intracranial hemorrhage, one of respiratory failure, and one of ischemic colitis. The graft modification times for the TA Treo were significantly shorter (43 minutes) than those for other commercially available devices (Cook Zenith, 55 minutes; Medtronic Endurant, 54 minutes; P < .0001). CONCLUSIONS Our institution has reported exclusive worldwide experience using the TA Treo device for FEVAR. This device provides for a highly efficient and technically successful procedure for most patients. The procedural and fluoroscopy times were low even in the setting of high complexity. The technical success rates and simplification of the FEVAR procedure have made this approach a preferred technique for most patients at our institution.
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Affiliation(s)
- Jake F Hemingway
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Brenda R Kline
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
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Flanagan CP, Crawford AS, Arous EJ, Aiello FA, Schanzer A, Simons JP. Preoperative functional status predicts 2-year mortality in patients undergoing fenestrated/branched endovascular aneurysm repair. J Vasc Surg 2021; 74:383-395. [PMID: 33548435 DOI: 10.1016/j.jvs.2020.12.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is a minimally invasive alternative for patients at high risk of open repair of complex aortic aneurysms. Nearly all investigative study protocols evaluating F/BEVAR have required a predicted life expectancy of >2 years for study inclusion. However, accurate risk models for predicting 2-year survival in this patient population are lacking. We sought to identify the preoperative predictors of 2-year survival for patients undergoing F/BEVAR. METHODS The prospectively collected data for all consecutive F/BEVAR procedures, performed in an institutional review board-approved registry and/or a physician-sponsored investigational device exemption (IDE) trial (IDE no. G130210), were reviewed (November 2010 to February 2019). We assessed 44 preoperative patient characteristics, including comorbidities, preoperative functional status, aneurysm morphologies, and repair techniques. Preoperative functional status was defined as totally dependent (any impairment in activities of daily living or residing in a skilled nursing facility), partially dependent (any impairment in instrumental activities of daily living), or independent (no impairment in activities of daily living or instrumental activities of daily living). Using the results of univariate analysis (P < .2), a Cox proportional hazards model was constructed to identify the independent predictors of 2-year all-cause mortality. RESULTS For the 256 consecutive patients who had undergone F/BEVAR (6 common iliac [2.3%], 94 juxtarenal [41%], 35 pararenal [14%], 119 thoracoabdominal [47%], and 2 arch [0.8%] aneurysms), the 2-year mortality was 18%. On Cox modeling, the only independent preoperative predictor contributing to 2-year mortality was functional status (totally dependent: hazard ratio [HR], 5.4; 95% confidence interval [CI], 1.8-16; P = .0024; partially dependent: HR, 4.5; 95% CI, 2.4-8.7; P < .0000019). A history of an implanted anti-arrhythmic device was protective (HR, 0.4; 95% CI, 0.2-0.99; P = .0495). Factors such as age, congestive heart failure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, aneurysm extent, and previous aortic surgery, were not significant. The 2-year mortality for the independent (n = 176; 69%), partially dependent (n = 69; 27%), and totally dependent (n = 10; 3.9%) groups was 11%, 33%, and 40%, respectively. CONCLUSIONS For patients undergoing F/BEVAR, decreased preoperative functional status was the strongest predictor of 2-year mortality, with totally dependent patients experiencing poor survival. The traditional risk factors were not independently significant, perhaps reflecting the high prevalence of severe chronic illness in these high-risk patients participating in an IDE trial. For the independent patients, the 2-year F/BEVAR survival rate was 89%, equivalent to patient survival after infrarenal EVAR. Therefore, for independent patients, it would be reasonable to expand the indication for F/BEVAR to low-risk patients.
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Affiliation(s)
- Colleen P Flanagan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, Calif
| | - Allison S Crawford
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Edward J Arous
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Francesco A Aiello
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass.
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Sveinsson M, Sonesson B, Dias N, Björses K, Kristmundsson T, Resch T. Five Year Results of Off the Shelf Fenestrated Endografts for Elective and Emergency Repair of Juxtarenal Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2021; 61:550-558. [PMID: 33455820 DOI: 10.1016/j.ejvs.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 11/22/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is a well established treatment for complex abdominal aortic aneurysms (AAAs). FEVAR with custom made devices (CMDs) has limitations in both the emergency and elective settings due to time consuming manufacture. "Off the shelf" (OTS) fenestrated stent grafts are a potential solution. The primary goal was to evaluate the five year outcome of the COOK Zenith p-Branch OTS device at a single centre. METHODS Patients with juxtarenal AAA meeting the inclusion criteria for the COOK Zenith p-Branch device were enrolled in a prospective, non-randomised, non-comparative trial from July 2012 to September 2015. Demographic, anatomical, procedure related, and five year follow up data were collected, analysed, and adjudicated by a core laboratory. The primary aims were to assess intervention free survival and overall survival at five years. RESULTS Twenty-three patients were treated and 21 completed follow up. Mean time to p-Branch implantation after patient presentation was 28 hours (range 0-122 hours) in emergency cases and 67 days (range 20-112 days) in elective cases. Median procedure time was 283 minutes (range 161-475 minutes) and technical success was 91%. Mean follow up was 45 months (standard deviation ± 24.4 months). The most common adverse events were renal injuries. Primary target vessel patency was 96.4% and 94.0% after one and five years respectively. Mean time to first re-intervention was 469 days (range 0-1 567 days). Survival during the follow up period was 76%, with no aneurysm related deaths. CONCLUSION FEVAR with the COOK Zenith p-Branch device is safe and effective for juxtarenal AAA in a selected patient population, in both elective and emergency settings. Long term outcomes are acceptable although inferior to CMDs. Mid and long term outcomes emphasise the p-Branch as a possible endovascular treatment for juxtarenal aortic pathology where CMD is not an option. Further innovation to address target vessel complications is needed, as these seem more prevalent than after repair with CMDs.
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Affiliation(s)
- Magnus Sveinsson
- Helsingborg Regional Hospital, Helsingborg, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Nuno Dias
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | | | | | - Timothy Resch
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Rigshospitalet University Hospital, Copenhagen, Denmark.
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Physician-Modified Branched Double-Trunk Stent-Graft (PBDS) for Thoracoabdominal Aortic Aneurysm. Heart Lung Circ 2020; 30:896-901. [PMID: 33223492 DOI: 10.1016/j.hlc.2020.10.022] [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: 08/10/2020] [Revised: 09/28/2020] [Accepted: 10/16/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the preliminary experience of using physician-modified, branched, double-trunk stent-grafts (PBDS) for treating thoracoabdominal aortic aneurysms (TAAA). MATERIALS AND METHODS Ten (10) patients with TAAA were included in the study from June 2017 to March 2020. The technical success, perioperative complications, re-intervention, and patency of branch arteries were assessed. RESULTS The technical success rate was 100%. There were four type III endoleaks (40%) recorded in the perioperative period. The median follow-up was 13.4 months (range, 3-36 months). During follow-up, two renal stent-graft occlusions (2 of 37 visceral arteries reconstructed, 5.4%), one cerebral infarction (1 of 10, 10%) and one paraplegia (1 of 10, 10%) occurred. No aortic-related death was recorded. CONCLUSION PBDS is useful in sealing TAAA and preventing visceral branches, providing an option for patients unsuited for open surgical repair. A larger sample size of patients is required to confirm the safety and effectiveness of this technique.
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Plotkin A, Ding L, Han SM, Oderich GS, Starnes BW, Lee JT, Malas MB, Weaver FA, Magee GA. Association of upper extremity and neck access with stroke in endovascular aortic repair. J Vasc Surg 2020; 72:1602-1609. [DOI: 10.1016/j.jvs.2020.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/06/2020] [Indexed: 11/28/2022]
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Steerable Sheath for Cannulation and Bridging Stenting of Challenging Target Visceral Vessels in Fenestrated and Branched Endografting. Ann Vasc Surg 2020; 67:26-34. [DOI: 10.1016/j.avsg.2019.11.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
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Dossabhoy SS, Simons JP, Crawford AS, Aiello FA, Judelson DR, Arous EJ, Messina LM, Schanzer A. Impact of acute kidney injury on long-term outcomes after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2020; 72:55-65.e1. [DOI: 10.1016/j.jvs.2019.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
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Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-Renal Aortic Aneurysms. Ann Vasc Surg 2020; 66:132-141. [DOI: 10.1016/j.avsg.2019.10.077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 11/21/2022]
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Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 2020; 73:4S-52S. [PMID: 32615285 DOI: 10.1016/j.jvs.2020.06.011] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022]
Abstract
Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
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Verhoeven ELG, Marques de Marino P, Katsargyris A. Increasing Role of Fenestrated and Branched Endoluminal Techniques in the Thoracoabdominal Segment Including Supra- and Pararenal AAA. Cardiovasc Intervent Radiol 2020; 43:1779-1787. [PMID: 32556605 DOI: 10.1007/s00270-020-02525-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/09/2020] [Indexed: 01/06/2023]
Abstract
Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.
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Affiliation(s)
- Eric L G Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany
| | - Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany.
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A reliable method for renal volume measurement and its application in fenestrated endovascular aneurysm repair. J Vasc Surg 2020; 71:1515-1520. [DOI: 10.1016/j.jvs.2019.07.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/29/2019] [Indexed: 11/22/2022]
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Mohamed N, Galyfos G, Anastasiadou C, Sachmpatzidis I, Kikiras K, Papapetrou A, Giannakakis S, Kastrisios G, Papacharalampous G, Geroulakos G, Maltezos C. Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review. Ann Vasc Surg 2020; 63:399-408. [DOI: 10.1016/j.avsg.2019.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 12/20/2022]
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Khaĭrutdinov AI, Iakubov RA, Sharafutdinov MR. [Treatment of a patient with Crawford type III thoracoabdominal aortic aneurysm]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:163-169. [PMID: 32597898 DOI: 10.33529/angio2020221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Presented herein is a clinical case report regarding hybrid techniques successfully used in a patient suffering from a Crawford type III thoracoabdominal aortic aneurysm and DeBakey type IIIB aortic dissection. The first stage consisted in endoprosthetic reconstruction of the descending portion of the thoracic aorta, with the second stage including visceral debranching with endoprosthetic reconstruction of the thoracoabdominal portion of the aorta. As the final stage, the patient was subjected to debranching of brachiocephalic arteries, followed by endoprosthetic repair of the aortic arch. The chosen approach made it possible to avoid the use of extracorporeal circulation, aortic occlusion, and, consequently, prolonged postoperative recovery.
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Affiliation(s)
- A I Khaĭrutdinov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
| | - R A Iakubov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
| | - M R Sharafutdinov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
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Gargiulo M, Gallitto E, Pini R, Giordano J, Mascoli C, Sonetto A, Logiacco A, Ancetti S, Faggioli G. Fenestrated endografting is the preferred option for juxta-renal aortic aneurysm reconstruction. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:2-9. [PMID: 31833736 DOI: 10.23736/s0021-9509.19.11185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Mauro Gargiulo
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Rodolfo Pini
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Giordano
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Chiara Mascoli
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessia Sonetto
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonino Logiacco
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Ancetti
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Current status of endovascular treatment for thoracoabdominal aortic aneurysms. Surg Today 2019; 50:1343-1352. [PMID: 31776776 DOI: 10.1007/s00595-019-01917-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAAAs) is maximally invasive and associated with high rates of operative mortality and perioperative complications including spinal cord ischemia (SCI), despite improvements in surgical techniques and perioperative care. Elderly patients, patients with a history of aortic surgery, and patients with severe comorbidities are often considered ineligible for this surgery and endovascular treatment may be their only treatment option. Total endovascular aneurysm repair (t-EVAR) without debranching surgery does not require thoracotomy and laparotomy and could improve the outcomes of these patients. t-EVAR includes fenestrated EVAR (f-EVAR), multi-branched EVAR (b-EVAR), and physician-modified fenestration endograft (PMFG). Although these techniques have achieved lower mortality rates than OSR, there are concerns about perioperative complications including limb ischemia, SCI, and long-term outcomes such as endograft migration and endoleaks (ELs). This article provides an overview of available endovascular devices for TAAAs and reviews the short and mid-term results of t-EVAR, as well as alternative options.
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Yoon WJ. Fenestrated Endovascular Aneurysm Repair versus Snorkel Endovascular Aneurysm Repair: Competing yet Complementary Strategies. Vasc Specialist Int 2019; 35:121-128. [PMID: 31620398 PMCID: PMC6774433 DOI: 10.5758/vsi.2019.35.3.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 11/20/2022] Open
Abstract
Juxtarenal/pararenal aortic aneurysms and type IV thoracoabdominal aneurysms pose particular technical challenges for endovascular repair as they involve the visceral segment in addition to insufficient infrarenal neck for the use of standard endovascular aneurysm repair (EVAR) devices. To overcome these challenges, complex EVAR techniques have been developed to extend the proximal landing zone cephalad with maintaining perfusion to vital aortic branches, thereby broadening the applicability of endografting from the infrarenal to the suprarenal aorta. Complex EVAR can be divided into two broad categories: fenestrated endovascular aneurysm repair (FEVAR) and snorkel EVAR. FEVAR is a valid procedure with the standardized procedure, although it remains as a relatively complex procedure with a learning curve. Given time constraints for the custom fenestrated graft, snorkel EVAR may be an alternative for complex repairs in symptomatic or ruptured patients for whom custom-made endografts may not be immediately available. This article discusses these two most commonly used complex EVAR strategies.
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Affiliation(s)
- William J Yoon
- Division of Vascular Surgery, Department of Surgery, University of California-Davis Medical Center, Sacramento, CA, USA
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Endovascular Treatment of Complex Aneurysms with the Use of Covera Stent Grafts. J Vasc Interv Radiol 2019; 30:1942-1948.e1. [PMID: 31530494 DOI: 10.1016/j.jvir.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To characterize the short-term results of a newly available self-expanding covered stent (Covera; CR Bard Peripheral Vascular Inc., Murray Hill, New Jersey) for the reconstruction of target vessels in complex aneurysms. MATERIALS AND METHODS From August 2017 to November 2018, this self-expanding covered stent was used in 17 patients (mean 72.6 ± 7.6 years of age) during endovascular aneurysm repair (EVAR) with hypogastric preservation (11.8%), branched EVAR (29.4%), fenestrated (F)-EVAR (17.6%), chimney + F-EVAR (11.8%), or chimney EVAR (29.4%). In more than 48 stented arteries (2.8 ± 1.1/patient), 25 were preserved using this self-expanding covered stent. RESULTS All target vessels were successfully preserved. There was no 30-day mortality and 1 in-hospital death. Intraoperative aneurysm exclusion was successful in 14 patients (82.4%) with a perioperative technical success rate of 82.4%. The actuarial survival rate was 93.8% at 6 months and 85.9% at 12 months. Aneurysm sac regression of >5 mm was observed in 4 cases (23.5%), and the sac remained stable in the remaining patients (13 cases [76.5%]). At 12 months, the primary clinical success rate was 76.5%, and assisted primary clinical success rate was 82.4%. No type 3 endoleak was related to a disruption of the reconstruction with the self-expanding covered stent. CONCLUSIONS This new self-expanding covered stent provides good short-term patency in chimneys, branches, or fenestrations. Larger series with long-term follow-up are required to determine if the stent can sustain the mechanical stress to which it will be submitted in these repairs.
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Motta F, Crowner JR, Kalbaugh CA, Knowles M, Pascarella L, McGinigle KL, Farber MA. Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair. J Vasc Surg 2019; 70:691-701. [DOI: 10.1016/j.jvs.2018.11.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/13/2018] [Indexed: 11/17/2022]
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Lomazzi C, Grassi V, Domanin M, De Vincentiis C, Piffaretti G, Trimarchi S. Art of operative techniques: treatment options in arch penetrating aortic ulcer. Ann Cardiothorac Surg 2019; 8:500-508. [PMID: 31463216 DOI: 10.21037/acs.2019.07.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.
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Affiliation(s)
- Chiara Lomazzi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Viviana Grassi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Carlo De Vincentiis
- Cardiac Surgery Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Hurd JR, Tatum B, Grillo J, Arthurs Z, Singh N, Fong H, Sarikaya M, Allen-Kline B, Starnes BW. Long-term durability of a physician-modified endovascular graft. J Vasc Surg 2019; 71:628-634. [PMID: 31401117 DOI: 10.1016/j.jvs.2019.04.471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
We present a unique assessment confirming the long-term durability of a physician-modified endograft deployed as part of an Investigational Device Exemption clinical trial (NCT# 01538056). After receiving an intact postmortem aorta 7 years after the index procedure, we performed microcomputed tomography, necropsy, and metallurgical analysis on the specimen. Microcomputed tomography showed a single strut fracture not noted during previous surveillance. Necropsy revealed no graft fabric compromise, and examination of all three visceral fenestrations showed excellent alignment with no evidence of degradation. Analysis of the strut fracture implicated an initially small, fatigue-induced crack that likely succumbed during postmortem handling.
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Affiliation(s)
- Jason R Hurd
- Division of Vascular Surgery, University of Washington, Seattle, Wash
| | - Billi Tatum
- Division of Vascular Surgery, University of Washington, Seattle, Wash
| | - Jenna Grillo
- Autopsy and Pathology Lab, University of Washington, Seattle, Wash
| | | | - Niten Singh
- Division of Vascular Surgery, University of Washington, Seattle, Wash
| | - Hanson Fong
- Genetically Engineered Materials Science and Engineering Center, University of Washington, Seattle, Wash
| | - Mehmet Sarikaya
- Genetically Engineered Materials Science and Engineering Center, University of Washington, Seattle, Wash
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Zacharias N, Wang GJ, Sedrakyan A, Columbo JA, Boyle JR, Goodney PP. Using the Idea, Development, Exploration, Assessment, Long-Term Study Framework for Devices (IDEAL-D) to Better Understand the Evolution of Evidence Surrounding Fenestrated Abdominal Aortic Endovascular Grafts. Ann Vasc Surg 2019; 59:293-299. [PMID: 31009709 PMCID: PMC10767621 DOI: 10.1016/j.avsg.2019.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/06/2019] [Accepted: 02/10/2019] [Indexed: 12/20/2022]
Abstract
The use of fenestrated endovascular devices for repair of complex aortic aneurysms has increased to nearly 5,000 implantations annually among Medicare patients in the United States in recent years. Given that nearly all aspects of treatment for minimally invasive aortic intervention rely on medical devices to better care for patients with vascular disease, clearly understanding how new and innovative technology evolves over the life cycle of a medical device is an essential skill set for cardiovascular physicians. Despite the need for this understanding, there is no standard framework upon which cardiovascular physicians, regulators, and patients can rely on to better understand the evolution of evidence from product inception through adoption and long-term effectiveness evaluation. As the aforementioned devices are increasingly and broadly used, the need for a formal framework for regulation and device approval has emerged. The goal of this review is to describe the Idea, Development, Exploration, Assessment, Long-term Study Framework for Devices (IDEAL-D). This framework is a model developed recently by an international panel of experts dedicated to better understanding the data steps necessary to bring a device from idea to routine practice and further to marketing, approval, and monitoring. In this review, we use the example of fenestrated endovascular aortic devices to illustrate the IDEAL-D framework, how it can help cardiovascular physicians improve their understanding of new technology, and the evidence which surrounds it from inception to long-term use.
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Affiliation(s)
- Nikolaos Zacharias
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Grace J Wang
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Art Sedrakyan
- Department of Surgery, Weill Cornell Medical College, New York, NY
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Cambridge, UK
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
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Durability of open surgical repair of type I-III thoracoabdominal aortic aneurysm. J Vasc Surg 2019; 70:413-423. [DOI: 10.1016/j.jvs.2018.10.110] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022]
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Outcomes of the Chimney Technique for Endovascular Repair of Aortic Dissection Involving the Arch Branches. Ann Vasc Surg 2019; 58:238-247.e3. [DOI: 10.1016/j.avsg.2018.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/30/2018] [Accepted: 10/16/2018] [Indexed: 11/19/2022]
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Van Calster K, Bianchini A, Elias F, Hertault A, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Risk factors for early and late mortality after fenestrated and branched endovascular repair of complex aneurysms. J Vasc Surg 2019; 69:1342-1355. [DOI: 10.1016/j.jvs.2018.08.159] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/17/2018] [Indexed: 11/27/2022]
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Walker J, Kaushik S, Hoffman M, Gasper W, Hiramoto J, Reilly L, Chuter T. Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms. J Vasc Surg 2019; 69:341-347. [PMID: 30683193 DOI: 10.1016/j.jvs.2018.04.074] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/09/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. METHODS There were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. RESULTS Mean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. CONCLUSIONS Total endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.
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Affiliation(s)
- Joy Walker
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Smita Kaushik
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Megan Hoffman
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Warren Gasper
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Jade Hiramoto
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Linda Reilly
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Timothy Chuter
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
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Torsello GF, Herten M, Müller M, Frank A, Torsello GB, Austermann M. In Vitro Evaluation of the Gore Viabahn Balloon-Expandable Stent-Graft for Fenestrated Endovascular Aortic Repair. J Endovasc Ther 2019; 26:361-368. [DOI: 10.1177/1526602819842569] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate the safety and integrity of a new stent-graft as a potential bridging device in fenestrated stent-grafts using an in vitro fenestrated model. Materials and Methods: Polyester test sheets with ten 6-mm- or 8-mm-diameter fenestrations were used to simulate a fenestrated main body endoprosthesis. In total, 50 Viabahn balloon-expandable (VBX) stent-grafts of varying lengths (29 and 39 mm) and diameters (6, 7, and 8 mm) were implanted in the fitting fenestrations. After release, the 6- and 7-mm-diameter stent-grafts were flared with a 10×20-mm angioplasty balloon; a 12×20-mm balloon was used in the 8-mm-diameter devices. Safety of the devices was defined as absence of fractures detected on radiography or computed tomography (CT), as well as material failure detected by microscopy and water permeability testing. The forces (in Newtons, N) needed for perpendicular dislocation (pullout force) and axial dislocation (shear stress force) were also evaluated. Results: Forty VBX stent-grafts were subjected to digital radiographic imaging and multiplanar CT. None showed any stent fracture. Subsequent microscopy indicated no damage to the fabric or separation of the graft after flaring. Ten VBX stent-grafts underwent water permeability testing after flaring; no water passed through the graft wall during a 10-minute period under an intraluminal pressure at 120 mm Hg. Testing of 25 VBX stent-grafts revealed initial pullout forces between 11.3 and 31 N. Shear stress tests showed that the average force needed to dislocate the stent-grafts by 50% of their diameter ranged between 5.75 and 6.91 N (mean 6.1±0.5 N) for the 6-mm stents and between 3.31 and 5.4 N (mean 4.4±0.8) for the 8-mm stents. Conclusion: This preliminary study demonstrated the applicability of the VBX as a bridging stent-graft in a simulated fenestration model. A comparison with other stent-grafts and clinical assessment are required.
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Affiliation(s)
- Giovanni Federico Torsello
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Charité Campus Virchow-Klinikum, Charité University Medicine Berlin, Germany
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
| | - Monika Herten
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Department of Orthopedic and Trauma Surgery, Essen University Hospital, Essen, Germany
| | - Markus Müller
- Biomechanics Laboratory, Department for Hand, Trauma and Reconstructive Surgery, University Hospital Münster, Germany
| | - André- Frank
- Biomechanics Laboratory, Department for Hand, Trauma and Reconstructive Surgery, University Hospital Münster, Germany
| | | | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
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50
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Tenorio ER, Oderich GS, Sandri GA, Ozbek P, Kärkkäinen JM, Macedo TA, Vrtiska T, Cha S. Impact of onlay fusion and cone beam computed tomography on radiation exposure and technical assessment of fenestrated-branched endovascular aortic repair. J Vasc Surg 2019; 69:1045-1058.e3. [DOI: 10.1016/j.jvs.2018.07.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/09/2018] [Indexed: 11/29/2022]
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