Fenestrated Stent-Grafts for Salvage of Prior Endovascular Abdominal Aortic Aneurysm Repair

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reinterventions and sac dynamics after fenestrated endovascular aortic repair with physician-modified endografts for index aneurysm repair and following proximal failure of prior endovascular aortic repair

OBJECTIVE

The high frequency of reinterventions after fenestrated endovascular aortic repair (FEVAR) with physician-modified endografts (PMEGs) has been well-studied. However, the impact of prior EVAR on reinterventions and sac behavior following these procedures remains unknown. We analyzed 3-year rates of reinterventions and sac dynamics following PMEG for index aneurysm repair compared with PMEG for prior EVAR with loss of proximal seal.

METHODS

We performed a retrospective analysis of 122 consecutive FEVARs with PMEGs at a tertiary care center submitted to the United States Food and Drug Administration in support of an investigational device exemption trial. We excluded patients with aortic dissection (n = 5), type I to III thoracoabdominal aneurysms (n = 13), non-elective procedures (n = 4), and prior aortic surgery other than EVAR (n = 8), for a final cohort of 92 patients. Patients were divided into those who underwent PMEG for index aneurysm repair (primary FEVAR) and those who underwent PMEG for rescue of prior EVAR with loss of proximal seal (secondary FEVAR). The primary outcomes were freedom from reintervention and sac dynamics (regression as ≥5 mm decrease, expansion as ≥5 mm increase, and stability as <5 mm increase or decrease) at 3 years. Secondary outcomes were perioperative mortality and 3-year survival.

RESULTS

Of the 92 patients included, 56 (61%) underwent primary FEVAR and 36 (39%) underwent secondary FEVAR. Secondary FEVAR patients were older (78 years [interquartile range (IQR), 74.5-83.5 years] vs 73 years [IQR, 69-78.5 years]; P < .001), more frequently male (86% vs 68%; P = .048), and had larger aneurysms (72.5 mm [IQR, 65.5-81 mm] vs 59 mm [IQR, 55-65 mm]; P < .001). Perioperative mortality was 1.8% for primary FEVAR and 2.7% for secondary FEVAR (P = .75). At 3 years, overall survival was 84% for primary FEVAR and 71% for secondary FEVAR (P = .086). Freedom-from reintervention was significantly higher for primary FEVAR than secondary FEVAR, specifically 82% vs 38% at 3 years (P < .001). Primary FEVAR also had more desirable sac dynamics relative to secondary FEVAR at 3 years (primary: 54% stable, 46% regressed, 0% expanded vs secondary: 33% stable, 28% regressed, and 39% expanded; P = .038).

CONCLUSIONS

FEVAR for primary aortic repair and FEVAR for rescue of prior EVAR with loss of proximal seal are two distinct entities. Following primary FEVAR, less than a quarter of patients have undergone reintervention at 3 years, and sac expansion was not seen in our cohort. Comparatively, 3 years after secondary FEVAR, over one-half of patients have undergone reintervention and over one-third have had ongoing sac expansion. Vigilant surveillance and a low threshold for further interventions are crucial following secondary FEVAR.

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair

OBJECTIVE

This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR).

METHODS

Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling.

RESULTS

One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time.

CONCLUSION

Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.

Early Institutional Experience with One-Piece Bifurcated-Fenestrated Stentgraft in the Treatment of Abdominal Aortic Aneurysms

PURPOSE

To review the early experience of the use of a bifurcated-fenestrated endograft (Bif-FEVAR) to treat abdominal aortic aneurysms (AAA) in a high-volume aortic center.

METHODS

A retrospective single-center analysis was conducted between March 2019 and April 2021 including consecutive patients that underwent Bif-FEVAR. Only patients without a proper infrarenal neck and a distance <70 mm between the lowest target artery and the native or prosthetic aortic bifurcation were considered. All Bif-FEVAR custom-made devices were manufactured by Cook Medical (Inc., Bloomington, Indiana). Demographics, anatomical features, technical success, major adverse events, 30-day mortality, and survival according to Kaplan-Meier were analyzed according to Society for Vascular Surgery standards.

RESULTS

Overall, 10 patients (100% male with median age 78) were included. The median preoperative maximal aneurysm diameter was 68 mm [51-84]. Eight patients were treated for a proximal type I endoleak after endovascular aneurysm repair. A total of 36 fenestrations were planned. The median operative time was 144 min [127-168], with a median fluoro time of 40.5 min [34-54] and a median dose area product of 73 Gy cm2 [61-89]. Technical success rate was 100%. No patients experienced a major postoperative adverse event. Median follow-up time was 8 months [6-13].

CONCLUSION

Bif-FEVAR is technically feasible when there is a short distance below the lowest target artery and the aortic bifurcation, with favorable short-term results.

CLINICAL IMPACT

This study assessed the use of an innovative one-piece bifurcated fenestrated stent-graft as a primary procedure or in the treatment of proximal endoleak after standard infrarenal EVAR. We demonstrated these custom-made devices can be used safely with favorable short-term results. One-piece bifurcated fenestrated stent-grafts extend the indications of FEVAR for patients with an unusually short distance between the lowest renal artery and the aorto-iliac bifurcation or the diverter flow of a preexisting bifurcated infrarenal stent-graft.

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

OBJECTIVE

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

DATA SOURCES

Embase, MEDLINE, Cochrane Library.

REVIEW METHOD

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

RESULTS

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

CONCLUSION

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

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Five-factors Modified Frailty Index role as predictors of outcomes after proximal abdominal aortic aneurysms

BACKGROUND

The aim of the study was to evaluate the correlation between frailty, measured by the Five-Factor Modified Frailty Index (mFI-5) and mortality and all major adverse events (MAE) in patients who underwent proximal abdominal aortic aneurysm (p-AAA) open surgery (OS).

METHODS

Data of all elective patients submitted to p-AAA OS from 2010 to 2021 were recorded. Primary endpoints were 30-day mortality and mid-term survival and secondary endpoints included postoperative acute kidney injury (AKI), freedom from aortic reintervention and any MAE. The impact of frailty was assessed by univariate and multivariate analysis; mid-term overall survival were estimated using Kaplan-Meier method (log-rank test).

RESULTS

Two-hundred twenty-one patients (197 male, 24 female; aged 72.2±7.4) were included. Thirty-seven (16.4%) were octogenarians (>80 years). The mFI-5 was assessed in the entire group: mean mFI-5 was 0.29±0.12. One-hundred patients (100/221, 45.25%, 91:9 male-to-female ratio) were defined "frail" considering the mFI-5 cut-off >0.25. At univariate analysis a correlation was found between mFI-5>0.25 and mid-term mortality (Pearson correlation [r] 0.280, P<0.001) and AKI (r=0.146, P=0.030). No correlation with 30-day mortality was found (P not significant). At multivariate analysis mFI-5>0.25 increased the risk for midterm mortality (odds ratio 3.32, P=0.021) and postoperative AKI (OR 2.09, P<0.001). The effect of mFI-5>0.25 on mid-term mortality persisted after adjustment for age (P<0.001). Survival was estimated with Kaplan-Meyer method (mean follow-up of 52.7 months, 95% CI: 48.6-56.8); 68 (30.7%) deaths were recorded: 23 among non-frail patients (19.0%) and 45 among frail patients (45/100, 45%, P<0.001).

CONCLUSIONS

These findings suggest that mFI-5 is a tool capable to identify "frail" patients, who appear to be at increased risk of postoperative AKI and mid-term mortality, but not 30-day mortality. Five-factor modified Frailty Index assessment is simple, fast and can be widely applied in surgical practice to perform appropriate risk stratifications.

Techniques and Limitations of Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) for Type 1A Endoleak After Failed Endovascular Aortic Repairs

PURPOSE

Endovascular aortic aneurysm repair (EVAR) is the dominant treatment modality over open repair for abdominal aortic aneurysms. However, a higher rate of reinterventions remains the Achilles heel of EVAR. Although type 1A endoleak from proximal seal zone failure of EVAR remains one of the leading causes for reintervention, fenestrated branched devices suitable for proximal extension of failed EVAR are not widely available in the United States. Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is an off-the-shelf investigational device that provides supraceliac seal by incorporating 4 visceral and renal arteries via preloaded inner branches.

CASE REPORT

In this article, we describe 2 cases of type 1A endoleak from previous EVAR devices repaired using TAMBE. Both cases were performed under the Food and Drug Administration (FDA) compassionate use exemption. Considerations on the case planning and implantation techniques of TAMBE specific to previous EVAR devices are reviewed.

CONCLUSIONS

Gore TAMBE can be utilized to repair a type 1A endoleak of a previous infrarenal EVAR device. Greater supraceliac coverage necessary for TAMBE relative to the minimal seal zone should be considered when applying this device for a type 1A endoleak.

CLINICAL IMPACT

This report demonstrates the feasibility of applying off-the-shelf TAMBE device to treat one of the most common failure modes of EVAR, type1A endoleak.

Comparative outcomes of physician-modified fenestrated/branched endovascular aortic aneurysm repair in the setting of prior failed endovascular aneurysm repair

OBJECTIVE

Endovascular treatment of aortic aneurysms involving renal-mesenteric arteries, especially in the setting of prior failed endovascular aneurysm repair (EVAR) typically requires fenestrated/branched endovascular aneurysm repair (F/BEVAR) with a custom-made device (CMD). CMDs are limited to select centers, and physician-modified endografts are an alternative treatment platform. Currently, there is no data on the outcomes of physician-modified F/BEVAR (PM-F/BEVAR) in the setting of failed prior EVAR. The purpose of this study was to evaluate the use of PM-F/BEVAR in patients with prior failed EVAR.

METHODS

A prospective database of consecutive patients treated at a single center with PM-F/BEVAR between March 2021 and November 2022 was retrospectively reviewed. The cohort was stratified by presence of a failed EVAR (type Ia endoleak or aneurysm development proximal to a prior EVAR) prior to PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. One-year survival and freedom from reintervention were compared using the Kaplan-Meier method.

RESULTS

A total of 103 patients underwent PM-F/BEVAR during the study period; 27 (26%) were in the setting of prior EVAR. Patients with prior failed EVAR had similar age (75.2 ± 7.7 vs 71.5 ± 8.8 years; P = .058), male gender (n = 24 ; 89% vs n = 57 ; 75%; P = .130), and comorbid conditions except higher incidence of moderate-to-severe chronic obstructive pulmonary disease (n = 7 ; 26% vs n = 7 ; 9%; P = .047). Overall, aneurysm diameter was 65.5 ± 13.9 mm with aneurysms categorized as juxta-/pararenal in 43% and thoracoabdominal in 57%, with no differences between the groups. Twelve patients (14%) presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8. Four different aortic devices were modified with a greater proportion of Terumo TREO devices used in the failed EVAR group (P = .03). There was no difference in procedure time, radiation dose, or iodinated contrast use between groups. Overall technical success was 99%. Rates of 30-day mortality (n = 0 ; 0% vs n = 3 ; 4%; P = .565) and major adverse events (n = 6 ; 22% vs n = 16 ; 21%; P = 1.0) were similar between groups. For the overall cohort, rates of type 1 or 3 endoleak, branch vessel stenosis/occlusion, and reintervention were 2%, 1%, and 8%, respectively, with no difference between groups. One-year survival (failed EVAR 94% vs no EVAR 82%; P = .756) was similar between groups.

CONCLUSIONS

PM-F/BEVAR is a safe and effective treatment for patients with aneurysms involving the renal-mesenteric arteries in the setting of prior failed EVAR where additional technical challenges may be present. Additional follow-up is warranted to demonstrate long-term efficacy, but early results are encouraging and similar to those using CMDs.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Complex endoleak treatment after failed endovascular aortic repair

BACKGROUND

Endovascular aneurysm repair (EVAR) has created new possibilities for patients with abdominal aortic aneurysms (AAAs), and in recent years it has become tremendously popular. Use of EVAR in selected groups of patients allows mortality and morbidity to be reduced in comparison to open repair. However, complications such as endoleaks (ELs) can be of great concern and warrant urgent therapy to prevent sac rupture.

CASE PRESENTATION

The case report presents urgent endovascular treatment of a high-risk type IA EL in a polymorbid 68-year-old patient 7 years after primary EVAR. The principle of treatment was parallel implantation of the proximal SG extension with the renal SG into the right renal artery (chimney technique). The subsequent type II collateral EL was treated by direct transabdominal AAA sac puncture and thrombin embolization.

CONCLUSION

EL can be a cause for urgent intervention, but specific anatomic features often require specialized SG types which are not readily available. The chimney technique allows the use of immediately available stent grafts to address endoleak in the setting of impending abdominal aneurysm rupture.

Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms

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.

The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta above 3 cm or 50% greater than the segment above. It is a dangerous condition accounting for a substantial number of deaths per year and increasing at an alarming rate. Various factors come into play in the development of AAAs, which this study has elaborated on, including smoking and old age, demographics, and comorbid conditions. Endovascular aneurysm repair (EVAR) is a newer treatment modality used for AAAs in which an endograft device is placed into the aorta, thereby creating a bypass tract from the aneurysm and generating flow mimicking that of the natural aorta. It is minimally invasive and associated with less postoperative mortality and reduced hospital stay. However, EVAR is also associated with significant postoperative complications, including endoleaks, which were reviewed in depth. Endoleaks are postprocedural leaks into the aneurysm sac that are usually identified immediately after graft placement and indicate treatment failure. They are of five subtypes, categorized according to their mechanism of development. The most common type is type II endoleaks, and the most dangerous is type I endoleaks. Each subtype has multiple management options with varying rates of success. Prompt identification along with appropriate treatment of endoleaks can lead to better postoperative outcomes and improved quality of life for patients.

Treatment of a type Ia endoleak following EVAR using a custom-made inner branch device

OBJECTIVES

We represent two cases of late proximal type I endoleak following EVAR with aneurysm expansion that were treated with a custom-made graft with inner branches.

METHODS

Two patients of 87 and 82 years old were operated by EVAR 6 and 8 years ago for abdominal aortic aneurysm. Both had proximal type I endoleak with aneurysm sac expansion. Open surgery had a high risk, and a proximal aortic extension with a simple aortic cuff was not possible neither because previous EVAR grafts were already at the level of the renal arteries. A custom-made endograft with inner branches was planned as a fenestrated graft was not technically possible.

RESULTS

We successfully treated both patients using a custom-made graft with four inner branches from Jotec (Cryolife, Kennesaw, GA). Three months' follow-up CT scan did not show any endoleaks. All target vessels were patent with good conformability of the bridging stents.

CONCLUSION

The treatment of proximal type I endoleak using inner branches' endografts is feasible. This novel technology might broaden the indications for complex aortic repair in a group of patients where fenestrated endografts are not possible.

A fenestrated, double-barrel technique for proximal reintervention after open or endovascular abdominal aortic aneurysm repair

Objective

Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique.

Methods

Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πD_LIMB = πD_ZFEN + 2D_ZFEN.

Results

Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively.

Conclusions

This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.

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

PURPOSE

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

TECHNIQUE

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

CONCLUSION

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

CLINICAL IMPACT

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

Rescue of Failed Aortic Repair with Fenestrated Endovascular Device

INTRODUCTION

The incidence of failed endovascular (EVAR) and open repair (OR) is increasing. Redo aortic repair is required in 10% of patients. Extension of the proximal sealing zone above the visceral arteries to adequate, healthier thoracic aorta using a fenestrated graft (FEVAR) can rescue a failing repair. A custom-made device can treat proximal type 1A endoleaks or proximal dilatation post endovascular or open repair, respectively. The aim of this investigation was to present a single-centre experience with FEVAR for patients with a failing aortic repair.

METHODS

A prospectively maintained database of FEVAR patients treated with a Zenithࣨ Fenestrated endovascular (ZFEN) device (Cook Medical LLC, Bloomington, Indiana, USA) was interrogated for individuals who had the device implanted as a rescue therapy after prior endovascular (EVAR) or open repair (OR). Statistical analysis was performed with SPSS v 25 software.

RESULTS

Between January 1, 2011 and March 31, 2019, 17 ZFEN devices were implanted. Ten patients had a type 1A endoleak from a prior EVAR and seven patients had proximal disease progression after prior OR. There were 12 males and 5 females, median age of 75 (interquartile range, IQR 7). 76.4% (n=13) of patients had an American Society of Anaesthesiologists (ASA) grade of 3. Primary technical success was 70.5% (n=12). Of the remainder, four cases (24%) had a type III endoleak at completion angiogram; of which, two patients (12%) required re-intervention within 30 days. One further case (6%) had primary assisted technical success as stenting of a flow limiting dissection flap in an iliac vessel was required. Peri-operative rate of deployment related complications and systemic complications were 5.8% (n=1) and 35% (n=6), respectively. Median length of hospital stay was 11 days (IQR 11). There was no mortality within the study follow up. Overall thirty-day re-intervention rate was 23.5%. Overall survival was 92% at one year.

CONCLUSION

FEVAR is a safe but technically challenging option for rescue of failing aortic repairs. These are a high risk group of patients and this is reflected in the high post-operative morbidity rate. Technical success was high and 30-day mortality was low.

Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair

OBJECTIVE

The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair.

METHODS

Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency.

RESULTS

A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002).

CONCLUSIONS

F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.

Late Type 1A Endoleaks: Associated Factors, Prognosis and Management Strategies

BACKGROUND

Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described.

METHODS

We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival.

RESULTS

Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P = 0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P = 0.02), neck length <20mm (HR 3.0 [1.1-8.6], P = 0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P = 0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years).

CONCLUSION

Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.

Impact of proximal neck anatomy on short-term and mid-term outcomes after treatment of abdominal aortic aneurysms with new-generation low-profile endografts. Results from the multicentric "ITAlian north-east registry of ENDOvascular aortic repair with the BOltOn Treo endograft (ITA-ENDOBOOT)"

INTRODUCTION

The aim of the study was to evaluate the short-term and mid-term technical and clinical outcomes of the Bolton Treo endograft in subjects with abdominal aortic aneurysm (AAA) requiring endovascular aortic repair (EVAR) and assess if presence of hostile proximal neck would represent a risk factor for increased failure rates.

METHODS

A retrospective review of all consecutive patients who had undergone elective or non-elective EVAR with the Bolton Treo endograft at five institutions located in the North-East of Italy (January 2016-December 2020) was performed. The main exposure variable for this study was presence of hostile (HAN) or friendly (FAN) aortic neck.

RESULTS

A total of 137 consecutive patients were treated with the Bolton Treo endograft at participating institutions; of these 63 (46%) presented HAN while 74 (54%) had FAN. At baseline, no significant differences were observed in the distribution of demographics and comorbidities between study groups. Two type Ia endoleaks (EL) were detected at completion angiography, all in patients with HAN but none in patients with FAN (3% vs 0%, p=.04), but no type III EL were identified in the whole cohort. The median duration of follow-up in the study cohort was 30 months (IQR 22-34 months) and was similar between study groups (p=.87). At three-years, survival estimates were 89% and 91% (p=.82) in patients with HAN and FAN, respectively. At three years, patients with HAN had significantly lower freedom from type IA endoleak as compared with patients with FAN (87% vs 94%, p=.02). No significant differences were found between study groups in the three-year estimates of freedom from reinterventions (80% vs 86%, p=.28). Using cox proportional hazards, presence of type II EL (HR 3.15, 95%CI 1.18-8.5, p=.02) and presence of type IA EL (HR 4.22, 95%CI 1.39-12.85, p=.01) were found as independent predictors for reinterventions in univariate analysis, although they were no longer significant in the multivariate model. Freedom from sac increase >5mm at three years were not significantly different between study groups (92% vs 91%, p=.95).

CONCLUSIONS

Within a contemporary multicentric real-world experience, EVAR with the Bolton Treo endograft shows a satisfactory safety profile in the immediate postoperative phase and acceptable outcomes during mid-term follow-up. Presence of HAN is correlated with development of type Ia EL (either early following stent-graft implantation or late after EVAR) which, in turn, may represent a significant factor leading to reinterventions.

Prospective Multicentre Cohort Study of Fenestrated and Branched Endografts After Failed Endovascular Infrarenal Aortic Aneurysm Repair with Type Ia Endoleak

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.

Systematic review of embolization of type I endoleaks using liquid embolic agents

OBJECTIVE

The long-term success of endovascular aneurysm repair (EVAR) is limited by complications, most importantly endoleaks. In case of (persistent) type I endoleak (T1EL), secondary intervention is indicated to prevent secondary aneurysm rupture. Different treatment options are suggested for T1ELs, such as endo anchors, (fenestrated) cuffs, embolization, or open conversion. Currently, the treatment of T1EL with liquid embolic agents is available; however, results are not yet addressed. This review presents the safety and efficacy of embolization with liquid embolic agents for treatment of T1ELs after EVAR.

METHODS

A systematic literature search was performed for all studies reporting the use of liquid embolic agents as monotherapy for treatment of T1ELs after EVAR. Patient numbers, technical success (successful delivery of liquid embolics in the T1EL) and clinical success (absence of aneurysm related death, endoleak recurrence or additional interventions during follow-up) were examined.

RESULTS

Of 1604 articles, 10 studies met the selection criteria, including 194 patients treated with liquid embolics; 73.2% of the patients were male with a median age of 71 years. The overall technical success was 97.9%. Clinical success was 87.6%. Because the median follow-up was only 13.0 months (range, 1-89 months), data on long-term success are almost absent. Four cases (2.1%) of secondary aneurysm rupture after embolization owing to endoleak recurrence were reported. All ruptures occurred in aneurysms exceeding initial treatment diameter of 70 mm.

CONCLUSIONS

Initial technical success after liquid embolization for T1EL is high, although long-term clinical success rates are lacking. Within this review, the risk of secondary rupture is comparable with untreated T1EL at 2% with a median follow-up of 13 months, regardless of the initial success of embolization. In general, no decrease in secondary aneurysm rupture after embolization of T1EL after EVAR is demonstrated, although the results of late embolization are debated.

Hybrid Approach with Angiography and Limited Open Exposure to Treat Type Ia Endoleaks after Endovascular Aortic Aneurysm Repair

BACKGROUND

Type Ia endoleaks after endovascular aortic repair (EVAR) almost always mandate secondary percutaneous reinterventions. Several patients, however, will require conversion to open surgical repair with complete graft explant, which is associated with significant morbidity and mortality. We herein present 3 cases of hybrid surgical repair for type Ia endoleaks, using a limited open exposure for proximal stent graft edge revision to achieve graft preservation and effective aneurysm sac exclusion.

METHODS

Angiography was used to confirm type Ia endoleak in 3 patients (2 males) who had previous EVAR between October 2017 and October 2019. Time to the endoleak after the index EVAR was immediate in 1 patient during repair of a ruptured aneurysm, 2 months in 1 patient and 2 years in 1 patient. The aorta was exposed through a limited transabdominal (n = 1) or retroperitoneal (n = 2) approach and circumferential aortic control was achieved below the renal arteries. A row of interrupted horizontal mattress sutures of 3-0 polypropylene reinforced with Teflon pledgets was placed along the aortic neck circumference. Multi-planar angiography was then repeated to verify the absence of sac filling and successful type Ia endoleak exclusion. Follow-up abdominal duplex was obtained for all 3 patients after discharge to monitor the stent graft and confirm endoleak resolution. Furthermore, there were no instances of acute renal failure.

RESULTS

In the period of review, 77 patients underwent EVAR. In the 3 patients described, we were able to achieve complete aneurysm sac exclusion and stent graft preservation in all cases. Follow-up imaging was available on 2 patients at 4-6 weeks after surgery demonstrating sustained exclusion of the endoleak. Two patients died during follow-up: one from a myocardial infarction 7 weeks after surgery and one from metastatic lung cancer at 8 months after surgery. Follow up duplex imaging at one year on the single survivor demonstrated sac shrinkage and absence of endoleak.

CONCLUSIONS

Type Ia endoleaks represent a significant source of morbidity and mortality after EVAR and typically require repair to avoid aneurysm rupture. Our use of limited proximal revision without explant provides an alternative approach to resolve the endoleaks while reducing the magnitude of physiological stress when compared to an open explant. It represents a feasible option for high-risk patients.

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

BACKGROUND

To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoracoabdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair.

METHODS

Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality.

RESULTS

We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and 8 with a tube graft. Of these, 2 patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, 3 of them with additional type Ia endoleak, 2 with stent-graft migration and 2 with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P = 0.746). Eighteen patients (86%) had branched stent grafting in the post-open versus 11 (52%) in the post-endo group (P < 0.01). In 2 patients in the post-open group, 3 renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, 2 due to cerebral hemorrhage and 2 due to pneumonia, and none in the post-endo fbEVAR group (P = 0.101). There were 5 nonstent-graft-related reinterventions, 2 (10%) in the post-open fbEVAR group and 3 (14%) in the post-endo fbEVAR group (P = 0.844). After 12 months there were 4 events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and 2 type II endoleaks were embolized with coils. There were no reinterventions in the post-open fbEVAR group during 12 months.

CONCLUSIONS

Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair.

Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair

OBJECTIVE

Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR).

METHODS

A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared.

RESULTS

Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65-100) and 70 mm (60-80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%).

CONCLUSION

Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.

Consecutive failing proximal landing zones

We report the case of a 77-year-old man who presented with successive aortic aneurysms during a 12-year period. He was first treated in 2006 for an abdominal aortic aneurysm with a bifurcated endograft, then in 2016 for a tender type IV thoracoabdominal aortic aneurysm with a proximal aortic cuff with in situ laser fenestrations. He presented in 2018 with a 9-cm distal thoracic aorta aneurysm managed by an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, Ind). The perioperative course was uneventful, and 6-month follow-up computed tomography scan has shown freedom from endoleaks and branch patency. This case illustrates that apparently “healthy” aortic necks can degenerate after endovascular aneurysm repair.

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Background

Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR).

Methods

A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates.

Results

During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively.

Conclusion

Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts

BACKGROUND

This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center.

METHODS

All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively.

RESULTS

Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively.

CONCLUSIONS

Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.

Outcomes of endovascular treatment of endoleak type Ia after EVAR: a systematic review of the literature

INTRODUCTION

Endovascular repair of infra-renal aortic aneurysm (EVAR) has become treatment of choice. However, individuals undergoing EVAR have a high re-intervention rate. The aim of this study is to evaluate the current endovascular treatment modalities of endoleak type Ia (ET Ia) treatment after EVAR and their outcome.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was performed. MEDLINE, EMBASE and Cochrane databases were searched with PRISMA methodology for studies reporting on endovascular treatment of ET Ia after EVAR. Studies presenting treatment of intra-operative ET Ia were excluded.

EVIDENCE SYNTHESIS

Two international registries, fourteen non-randomized retrospective and twelve case-report studies were included reporting on 356 patients. Reported endovascular techniques included fenestrated-, branched-, chimney EVAR, endovascular sealing (EVAS), endoanchors, embolization techniques, cuff and/or "giant" Palmaz stents. Technical success rate ranged from 90% to 100%, with intra-operative mortality rate of 0%. During early period, persistence of ET Ia was 3.4% (9/262) and the re-intervention rate was 3.5% (8/227). The 30-day mortality rate was 2% (7/356). Mean follow-up was 22.4 months±18. Presence of ET Ia was 5.9% (21/356), and the reintervention rate was 5.1% (18/349). The mortality rate was 13% (26/203), while the primary patency rate of TVs ranged from 94.3% to 100%.

CONCLUSIONS

A multitude of techniques for endovascular repair for ET Ia exists. No strong evidence supports one specific technique. The early and mid-term outcomes are encouraging in terms of ET Ia resolution, mortality and morbidity rates.

Abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.

Failure of Sandwich Technique for Thoracoabdominal Aneurysm Treated with Custom-Made Fenestrated Endograft

BACKGROUND

Custom-made fenestrated and branched endografts are considered the gold standard devices for thoracoabdominal repair, with lower perioperative mortality and morbidities than open surgical repair. Although they are not feasible in urgent and emergent settings, in which sandwich techniques are often necessary, custom-made devices can still be used as bail-out options to correct late complications such as high-flow endoleaks, as shown in this case report.

METHODS

A complex, symptomatic thoracoabdominal aneurysm, unsuitable for open repair, was treated by sandwich technique on the celiac trunk despite having a short distal neck. After the finding of a high-flow type IB endoleak during postoperative follow-up, reintervention was planned with a custom-made endograft with a distal scallop, to preserve patency of the superior mesenteric artery.

RESULTS

The procedure achieved technical success, with complete exclusion of the aneurysm and patency of all the visceral arteries.

CONCLUSIONS

Bail-out endovascular repair with custom-made endografts after failure of parallel graft repair of thoracoabdominal aneurysms is a valuable treatment option preventing the risks related to an open conversion.

Early results with the custom-made Fenestrated Anaconda aortic cuff in the treatment of complex abdominal aortic aneurysm

OBJECTIVE

The objective of this study was to investigate the feasibility of a specific custom-made fenestrated aortic cuff in the treatment of complex abdominal aortic aneurysms (AAAs).

METHODS

Between 2013 and 2016, a total of 57 custom-made Fenestrated Anaconda (Vascutek, Inchinnan, Scotland, UK) aortic cuffs were placed in 38 centers worldwide. All centers were invited to participate in this retrospective analysis. Postoperative and follow-up data included the presence of adverse events, necessity for reintervention, and renal function.

RESULTS

Fifteen clinics participated, leading to 29 cases. Median age at operation was 74 years (interquartile range [IQR], 71-78 years); five patients were female. Two patients were treated for a para-anastomotic AAA after open AAA repair, 19 patients were treated because of a complicated course after primary endovascular AAA repair, and 8 cases were primary procedures for AAA. A total of 76 fenestrations (mean, 2.6 per case) were used. Four patients needed seven adjunctive procedures. Two patients underwent conversion, one because of a dissection of the superior mesenteric artery and one because of perforation of a renal artery. Median operation time was 225 minutes (IQR, 150-260 minutes); median blood loss, 200 mL (IQR, 100-500 mL); and median contrast volume, 150 mL (IQR, 92-260 mL). Primary technical success was achieved in 86% and secondary technical success in 93%. The 30-day morbidity was 7 of 29 with a mortality rate of 4 of 29. Estimated glomerular filtration rate remained unchanged before and after surgery (76 to 77 mL/min/m²). Between preoperative and median follow-up of 11 months, estimated glomerular filtration rate was reduced statistically significantly (76 to 63 mL/min/m²). During follow-up, 9 cases had an increase in aneurysm sac diameter (5 cases >5 mm); 14 cases had a stable or decreased aneurysm sac diameter; and in 2 cases, no aneurysm size was reported. No type I endoleak was reported, and two cases with a type III endoleak were treated by endovascular means during follow-up. Survival, reintervention-free survival, and target vessel patency at 1 year were 81% ± 8%, 75% ± 9%, and 99% ± 1%, respectively. After 2 years, these numbers were 81% ± 8%, 67% ± 11%, and 88% ± 6%, respectively. During follow-up, the two patients with a type III endoleak needed endograft-related reinterventions.

CONCLUSIONS

Treatment with this specific custom-made fenestrated aortic cuff is feasible after complicated previous (endovascular) aortic repair or in complex AAAs. The complexity of certain AAA cases is underlined in this study, and the Fenestrated Anaconda aortic cuff is a valid option in selected cases in which few treatment options are left.

Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results

Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). Overall, 70 visceral vessels were targeted for revascularization. Results: Technical success was achieved in 35 (89.7%) cases; 3 persistent type Ia endoleaks and 1 chimney graft occlusion were detected within the first 30 days. Thirty-day mortality was 2.6%. Two other deaths (not aneurysm related) occurred during a mean follow-up of 21.9 months (0.23–71.3). Primary patency of the chimney grafts was 94.3% at 36 months. In a subgroup analysis comparing Endurant to other stent-grafts, no significant differences were observed regarding persistent endoleak [1/20 (5%) vs 2/19 (11%), p=0.6] or reintervention [1/20 (5%) vs 0/19 (0%)]. Conclusion: The present series demonstrates that chEVAR in the treatment of post-EVAR type Ia endoleaks has satisfactory results independent of the abdominal and chimney graft combinations. Midterm results show that chEVAR is an effective method for treating type Ia endoleaks.

Fenestrated and Branched Stent Grafting in Complex Aneurysmatic Aortic Disease: A Single-Center Early Experience

BACKGROUND

The aim of this study is to present our early experience and highlight the technical difficulties associated with the use of fenestrated and branched stent grafts to treat patients with juxtarenal abdominal aortic aneurysm (AAA), pararenal AAA, and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A prospectively held database maintained at our department was queried for patients who have undergone branched and fenestrated stent grafting for AAA or TAAA treatment. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality, morbidity, and reintervention rate were evaluated.

RESULTS

A total of 8 patients underwent repair with a fenestrated or branched stent graft. All patients had aneurysmal degeneration of the juxtarenal aorta, pararenal aorta, and thoracoabdominal aorta not suitable to standard endovascular techniques. Two patients had a prior aortic repair, a failed migrated stent graft, and an old surgical tube graft after an open repair. One patient had a type III TAAA and 1 patient had a postdissection TAAA type I. For all patients, target vessel success rate was 96.4% (27/28) and mean hospital stay was 6.0 days (range 3-21). Thirty-day and 1-year mortality were 0%. Mean follow-up was 23 months (range 7-45). Two endoleaks occurred, 1 type III and 1 type II, which were treated endovascularly. No death or major complication occurred during follow-up.

CONCLUSIONS

Fenestrated and branched endovascular stent grafts can be used to repair juxtarenal AAA, pararenal AAA, and TAAA in patients with significant comorbidities. However, several technical challenges have to be overcome due to the unique complex aortic pathology of each patient.

Treatment of complex aortic aneurysms with fenestrated endografts and chimney stent repair: Systematic review and meta-analysis

Objective

We reviewed data pertaining to fenestrated endograft technique and chimney stent repair of complex aortic aneurysm for comparative analysis of the outcomes.

Methods

A comprehensive search of relevant databases was conducted to identify articles in English, related to the treatment of complex aortic aneurysm with fenestrated endovascular aneurysm repair and chimney stent repair, published until January 2015.

Results

A total of 42 relevant studies and 2264 patients with aortic aneurysm undergoing fenestrated endovascular aneurysm repair and chimney stent repair were included in our review. A total of 4413 vessels were involved in these processes. The cumulative 30-day mortality was 2.4% and 3.2% ( p = 0.459). The follow-up aneurysm-related mortality was 1.4% and 3.2% ( p = 0.018), and target organ dysfunction was 5.0% and 4.0% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively ( p = 0.27). A total of 156 vessels showed restenosis or occlusion after primary intervention (3.6% and 3.4% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively, p = 0.792). The cumulative type I endoleak was 2.0% (38/1884) after fenestrated endovascular aneurysm repair compared with 3.4% (13/380) after chimney stent repair ( p = 0.092), and the type II endoleak was 5.4% (102/1884) and 5.3% (20/380), respectively ( p = 0.905). Approximately, 1.1% and 1.6% increase in aneurysm was observed following fenestrated endovascular aneurysm repair and chimney stent repair, respectively ( p = 0.437). The re-intervention frequency was 205 and 19 cases after fenestrated endovascular aneurysm repair and chimney stent repair, respectively (11.7%, 5.6%, p = 0.001).

Conclusions

Fenestrated endovascular aneurysm repair and chimney stent repair are safe and effective in treating patients with complex aortic aneurysm. A higher aneurysm-related mortality was observed in chimney stent repair while fenestrated endovascular aneurysm repair was associated with a higher re-intervention rate.

Spontaneous Sealing of a Type Ia Endoleak after Ovation Stent Graft Implantation in a Patient with On-Label Aortic Neck Anatomy

We report a case of an early type Ia endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm by Ovation Stent Graft implantation and spontaneously resolved without further reintervention. The patient presents a conical aortic neck, but EVAR was performed within the instruction for use proposed by manufactory. At completion angiography, a low-flow type Ia endoleak was present and left untreated. Computed tomographic angiography performed on the third postoperative day showed infolding of the 2 sealing rings. The patient was dismissed without further treatment. At 3-month follow-up, the leak appeared spontaneously sealed with partial expansion of the 2 rings.