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Verlato P, Foresti L, Bloemert-Tuin T, Trimarchi S, Hazenberg CEVB, van Herwaarden JA. Long-term outcomes of chimney endovascular aneurysm repair procedure for complex abdominal aortic pathologies. J Vasc Surg 2024:S0741-5214(24)00935-2. [PMID: 38604322 DOI: 10.1016/j.jvs.2024.03.448] [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: 01/07/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE The aim of this study was to update our earlier experience and to evaluate long-term outcomes of chimney endovascular aortic repair performed for selected cases with complex abdominal aortic aneurysm. METHODS A single-center retrospective cohort study was conducted on 51 consecutive patients who underwent chimney endovascular aortic repair procedure, deemed unfit for open surgical repair and fenestrated endovascular aneurysm repair, from October 2009 to November 2019. Kaplan-Meier analyses were used to assess the estimated overall survival, freedom from aneurysm related mortality, freedom from reintervention, freedom from target vessel instability, and freedom from type Ia endoleaks. RESULTS Fifty-one patients (mean age, 77.1 ± 7.5 years) with a mean preoperative maximum aneurysm diameter of 74.2 ± 20.1 mm were included. Mean follow-up duration was 48.6 months (range, 0-136 months). Estimated overall survival at 5 and 7 years was 36.3% ± 7.1% and 18.3% ± 6.0%, respectively. Freedom from aneurysm-related mortality was 88.6% ± 4.9% at 7 years. Estimated freedom from type Ia endoleaks at 7 years was 91.8% ± 3.9%. A total of 21 late reinterventions were performed in 17 patients (33%). Most of them were performed to treat type II endoleaks with sac growth (47.6%; n = 10) and type Ib endoleak (23.8%; n = 5). Estimated freedom from reintervention at 7 years was 56.3% ± 7.9%. Estimated freedom from target vessel instability at 7 years was 91.5% ± 4.1%. CONCLUSIONS The 7-year results of chimney endovascular aortic repair procedures performed in our center confirm the long-term safety and effectiveness of this technique in a series of high-risk patients with large aneurysms. The present study has, to the best of our knowledge, the longest follow-up for patients treated with chimney endovascular aortic repair, and it provides data to the scarce literature on the long-term outcomes of this procedure, showing acceptable to good long-term results.
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Affiliation(s)
- Paolo Verlato
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Postgraduate School of Vascular Surgery, University of Milan, Milan, Italy
| | - Leonardo Foresti
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Postgraduate School of Vascular Surgery, University of Milan, Milan, Italy.
| | - Trijntje Bloemert-Tuin
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Kim HJ, Jo EA, Park HS, Lee T, Han S. Midterm outcomes of physician-modified endovascular stent grafts for the treatment of complex abdominal aortic aneurysms in Korea: a retrospective study. Ann Surg Treat Res 2024; 106:106-114. [PMID: 38318093 PMCID: PMC10838652 DOI: 10.4174/astr.2024.106.2.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 02/07/2024] Open
Abstract
Purpose Physician-modified endovascular stent grafts (PMEG) are a good treatment option for complex abdominal aortic aneurysms (AAAs), especially in high-risk patients not amenable to open repair, and when commercial fenestrated devices are not available. We report our single-center experience with PMEG for the treatment of complex AAAs. Methods We retrospectively reviewed patients who underwent PMEG repair for AAA from November 2016 to September 2020 at our institution. Demographic data, anatomic characteristics, perioperative and postoperative outcomes, major adverse events, and 30-day mortality were analyzed. Results We identified 12 patients who underwent PMEG for complex AAA. The mean age was 74 years and the mean maximal AAA diameter was 58.1 mm. Indications for treatment included 4 impending or contained ruptures, 2 mycotic aneurysms, and 6 symptomatic cases. The technical success rate was 91.7%. Aneurysm sac regression was observed in 7 patients (58.3%), including 2 cases of complete regression. There was 1 aneurysm-related mortality at 3 months due to mycotic aneurysm. Also, there was 1 postoperative complication case of transient renal failure requiring temporary dialysis. At 1 year, there was 1 branch occlusion from the initial failed cannulation case and 2 type 1A endoleaks, and there was 1 case of open explantation. Conclusion PMEG showed a low technical failure rate and acceptable midterm stent durability and sac stability, comparable to conventional endovascular aneurysm repair. Despite the small number of cases, there was a tendency for a high sac regression rate, although longer follow-up is needed.
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Affiliation(s)
- Hyo Jun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun-Ah Jo
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung Sub Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sukgu Han
- Division of Vascular Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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Tran K, Deslarzes-Dubuis C, DeGlise S, Kaladji A, Yang W, Marsden AL, Lee JT. Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair. JVS Vasc Sci 2023; 5:100183. [PMID: 38314201 PMCID: PMC10832507 DOI: 10.1016/j.jvssci.2023.100183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background Endovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR. Methods Patients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups. Results Patient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (-5.2% vs +2.0%; P < .0001) and peak pressure (-3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs -31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR. Conclusions bEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies. Clinical Relevance This study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford Healthcare, Stanford, CA
| | | | - Sebastien DeGlise
- Division of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Adrien Kaladji
- Department of Vascular Surgery, University of Rennes, Paris, France
| | - Weiguang Yang
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Alison L Marsden
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford Healthcare, Stanford, CA
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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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Taher F, Assadian A, Plimon M, Saemann M, Nguyen J, Anokhina D, Walter C, Kliewer M, Falkensammer J. Acute Kidney Injury and Mortality After Fenestrated Endovascular Aortic Repair. J Surg Res 2023; 289:164-170. [PMID: 37119618 DOI: 10.1016/j.jss.2023.03.033] [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: 09/26/2022] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a common complication following endovascular aortic repair (EVAR). An association of AKI with patient survival after fenestrated EVAR (FEVAR) is currently under investigation. METHODS Patients undergoing FEVAR between April 2013 and June 2020 were included in the study. AKI was defined according to acute kidney injury network criteria. Demographic and perioperative data, complications, and survival are reported for the study cohort. The data were analyzed to identify possible predictors of AKI. RESULTS Two hundred and seventeen patients underwent FEVAR during the study period. Survival at last follow-up (20.4 ± 20.1 mo) was 75.1%. Thirty patients experienced AKI (13.8%). Six of 30 patients with AKI (20%) died within 30 days or in-hospital and 1 (3.3%) progressed to hemodialysis. Within 1 y, renal function had recovered in 23 patients (76.7%). In-hospital mortality was higher in patients with AKI (20% versus 4.3%, P = 0.006). A higher rate of AKI was seen in patients in whom an intraoperative technical complication had been documented (38.5% versus 8.4%, P = 0.001). CONCLUSIONS Patients undergoing FEVAR are at risk of developing AKI, especially if they experience technical intraoperative complications. Most patients see recovery of renal function within the first 30 days to 1 y, but AKI remains associated with significantly increased in-hospital mortality.
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Affiliation(s)
- Fadi Taher
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria.
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Markus Plimon
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Marcus Saemann
- Department of Nephrology, Klinik Ottakring, Vienna, Austria
| | | | - Daria Anokhina
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Miriam Kliewer
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
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Hostalrich A, Porterie J, Boisroux T, Marcheix B, Ricco JB, Chaufour X. Outcomes of Secondary Endovascular Aortic Repair After Frozen Elephant Trunk. J Endovasc Ther 2023:15266028231169172. [PMID: 37125426 DOI: 10.1177/15266028231169172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR). METHODS This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter. RESULTS From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2-34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity. CONCLUSIONS In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft. CLINICAL IMPACT In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study.
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Affiliation(s)
- Aurélien Hostalrich
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Porterie
- Department of Cardiovascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Thibaut Boisroux
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Bertrand Marcheix
- Department of Cardiovascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Baptiste Ricco
- Department of Clinical Research, University Hospital of Poitiers, Poitiers, France
| | - Xavier Chaufour
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
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Rastogi V, de Bruin JL, Verhagen HJM. Re: Contrast Induced Nephropathy After Elective Infrarenal and Complex Endovascular Repair. Eur J Vasc Endovasc Surg 2023; 65:161-162. [PMID: 36328185 DOI: 10.1016/j.ejvs.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Rastogi V, de Bruin JL, Bouwens E, Hoeks SE, Ten Raa S, van Rijn MJ, Fioole B, Schermerhorn ML, Verhagen HJM. Incidence, Prognostic Significance, and Risk Factors of Acute Kidney Injury Following Elective Infrarenal and Complex Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2022; 64:621-629. [PMID: 36029944 DOI: 10.1016/j.ejvs.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a well known complication following cardiovascular procedures. The objective was to assess the incidence, risk factors, and prognostic significance of AKI after infrarenal endovascular aneurysm repair (EVAR) and complex EVAR (cEVAR; fenestrated or branched EVAR). METHODS Consecutive patients undergoing elective infrarenal EVAR or cEVAR between 2000 and 2018 in two large teaching hospitals in the Netherlands were included. AKI was determined by serum creatinine levels increasing > 1.5 times or by an absolute increase of 26.5 mmol/L from baseline value (KDIGO criteria). The primary outcome was incidence of peri-operative AKI development. Secondary outcomes included mid-term renal function (RIFLE criteria), overall survival, and risk factors for AKI development. To determine survival and risk factors for AKI, multivariable Cox regression and logistic regression analyses were performed, accounting for pre-operative renal function and other confounders. RESULTS In total, 540 patients who underwent infrarenal EVAR with 147 patients who underwent cEVAR also included. The incidence of AKI was 8.7% (n = 47) in infrarenal EVAR patients and 23% (n = 34) in cEVAR patients (fenestrated EVAR 18%; branched EVAR 38%). In contrast to patients without AKI, the renal function of surviving patients with AKI remained significantly reduced at six weeks and did not return to pre-operative values following infrarenal EVAR (three year estimated glomerular filtration rate [eGFR] 59.3 ± 23.1 mL/min/1.73m2vs. pre-operative eGFR 74.0 ± 21.7 mL/min/1.73m2; p = .006) or following cEVAR (three year eGFR 52.0 ± 23.7 mL/min/1.73m2vs. pre-operative eGFR 65.4 ± 18.6 mL/min/1.73m2; p = .082). After risk adjusted analysis, compared with non-AKI, post-operative AKI development was associated with a higher three year mortality rate following both infrarenal and cEVAR (infrarenal EVAR mortality hazard ratio [HR 1.6, 95% confidence interval [CI] 1.01 - 2.7 [p = .046]; cEVAR mortality HR 2.4, 95% CI 1.1 - 5.2 [p = .033]). Following multivariable logistic regression, pre-operative chronic kidney disease (eGFR < 60 mL/min/1.73m2; odds ratio [OR] 2.2, 95% CI 1.03 - 4.8) and neck diameter (OR 1.1, 95% CI 1.01 - 1.2) were significantly associated with AKI following infrarenal EVAR, whereas for cEVAR only contrast volume (OR 1.1, 95% CI 1.0 - 1.2]) was found to be statistically significantly associated with AKI. CONCLUSION AKI is a well described complication following infrarenal EVAR and is common after cEVAR. As AKI seems to be associated with permanent renal deterioration and lower survival, efforts to prevent AKI are essential. Future studies are required to assess what factors are associated with a higher risk of developing AKI following cEVAR.
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Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Elke Bouwens
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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10
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Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
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Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
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11
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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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12
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Tran K, Feliciano KB, Yang W, Schwarz EL, Marsden AL, Dalman RL, Lee JT. Patient-specific changes in aortic hemodynamics is associated with thrombotic risk after fenestrated endovascular aneurysm repair with large diameter endografts. JVS Vasc Sci 2022; 3:219-231. [PMID: 35647564 PMCID: PMC9133635 DOI: 10.1016/j.jvssci.2022.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/06/2022] [Indexed: 12/24/2022] Open
Abstract
Background The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. In the present study, we used patient-specific computational fluid dynamic (CFD) simulation to investigate the effect of the endograft diameter on hemodynamics after fEVAR and explore the hypothesis that diameter-dependent alterations in aortic hemodynamics can predict for thrombotic events. Methods A single-institutional retrospective study was performed of patients who had undergone fEVAR for juxtarenal aortic aneurysms. The patients were stratified into large diameter (34-36 mm) and small diameter (24-26 mm) endograft groups. Patient-specific CFD simulations were performed using three-dimensional paravisceral aortic models created from computed tomographic images with allometrically scaled boundary conditions. Aortic time-averaged wall shear stress (TAWSS) and residence time (RT) were computed and correlated with future thrombotic complications (eg, renal stent occlusion, development of significant intraluminal graft thrombus). Results A total of 36 patients (14 with a small endograft and 22 with a large endograft) were included in the present study. The patients treated with large endografts had experienced a higher incidence of thrombotic complications compared with small endografts (45.5% vs 7.1%; P = .016). Large endografts were associated with a lower postoperative aortic TAWSS (1.45 ± 0.76 dynes/cm2 vs 3.16 ± 1.24 dynes/cm2; P < .001) and longer aortic RT (0.78 ± 0.30 second vs 0.34 ± 0.08 second; P < .001). In the large endograft group, a reduction >0.39 dynes/cm2 in aortic TAWSS demonstrated discriminatory power for thrombotic complications (area under the receiver operating characteristic curve, 0.77). An increased aortic RT of ≥0.05 second had similar accuracy for predicting thrombotic complications (area under the receiver operating characteristic curve, 0.78). The odds of thrombotic complications were significantly higher if patients had met the hemodynamic threshold changes in aortic TAWSS (odds ratio, 7.0; 95% confidence interval, 1.1-45.9) and RT (odds ratio, 8.0; 95% confidence interval, 1.13-56.8). Conclusions Patient-specific CFD simulation of fEVAR in juxtarenal aortic aneurysms demonstrated significant endograft diameter-dependent differences in aortic hemodynamics. A postoperative reduction in TAWSS and an increased RT correlated with future thrombotic events after large-diameter endograft implantation. Patient-specific simulation of hemodynamics provides a novel method for thrombotic risk stratification after fEVAR. The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. Using patient-specific computational flow simulation, the present retrospective study of 36 patients with juxtarenal aortic aneurysms treated with fEVAR identified several endograft diameter-dependent changes in aortic hemodynamics associated with thrombotic complications. A postoperative reduction in aortic wall shear stress and increased particle residence time correlated with the development of intraluminal graft thrombus and renal stent occlusion in patients treated with large diameter (>34 mm) endografts. These computationally estimated hemodynamic parameters could provide a novel method for patient-specific risk stratification for adverse events after fEVAR.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Correspondence: Kenneth Tran, MD, Department of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Ste H3600, Stanford, CA 94305-5851
| | - K. Brennan Feliciano
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
| | - Weiguang Yang
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA
| | - Erica L. Schwarz
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
| | - Alison L. Marsden
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA
| | - Ronald L. Dalman
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | - Jason T. Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
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13
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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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14
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Long-term Outcomes after FEVAR for Juxtarenal Aortic Aneurysm. J Vasc Surg 2021; 75:1164-1170. [PMID: 34838610 DOI: 10.1016/j.jvs.2021.11.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Fenestrated endovascular aortic repair (FEVAR) for juxtarenal aortic aneurysm (jAAA) disease is safe and effective with good short- and mid-term outcomes. Durability issues focus mainly on proximal and distal seal as well as target vessel (TV) instability, and long-term data is scarce. In previous publications we have reported short-term outcomes after FEVAR while comparing early- and late-experience patient groups, as well as long-term results for the early cohort. In this series we provide long-term outcome in the late experience cohort treated with FEVAR in Vascular Center Malmö. METHODS Consecutive patients treated in Vascular Center Malmö with FEVAR for jAAA between 2007 and 2011 were included. Data was collected retrospectively from medical- and imaging records. Follow up consisted of a clinical examination 1 month post-operatively, and computed tomography angiography combined with plain abdominal X-ray at 1 and 12 months, and annually thereafter. Primary endpoints were TV instability, reinterventions and survival. Changes in aneurysm diameter and renal function as well as endoleaks were also analyzed. RESULTS 94 patients were treated. Median follow-up time was 89 (range 0-152) months. 280 fenestrations or scallops were employed of which 205 were stented. Technical success was 89.4%. Primary TV patency was 94% ± 1 % at 1year, 90% ± 2% at 3 years and 89% ± 2% at 5 years. 37 (39.4%) patients needed a total of 70 reinterventions and mean time to first reintervention was 21 ± 3.97 months. 5 (5.3%) patients died of aneurysm related causes and overall survival was 95.7% ± 2.1% at 1 year, 87.1% ± 3.5% at 3 years and 71.0 ± 4.7% at 5 years. A stable or decreasing aortic diameter after treatment was seen in 91% of cases. Mean glomerular filtration rate (GFR) fell from 59.2 ± 14.9 ml/min/1.73m2 pre-operatively to 50.0 ± 18.6 ml/min/1.73 m2 at end of follow-up. CONCLUSION Long-term results after treatment of jAAA with FEVAR remain good and the treatment is safe and effective. Although the need for reintervention remains high, long-term renal function and survival support the use of FEVAR as a valid treatment option for jAAA disease.
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15
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Tran K, Yang W, Marsden A, Lee JT. Patient-specific computational flow modelling for assessing hemodynamic changes following fenestrated endovascular aneurysm repair. JVS Vasc Sci 2021; 2:53-69. [PMID: 34258601 PMCID: PMC8274562 DOI: 10.1016/j.jvssci.2020.11.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to develop an accessible patient-specific computational flow modelling pipeline for evaluating the hemodynamic performance of fenestrated endovascular aneurysm repair (fEVAR), with the hypothesis that computational flow modelling can detect aortic branch hemodynamic changes associated with fEVAR graft implantation. Methods Patients who underwent fEVAR for juxtarenal aortic aneurysms with the Cook ZFEN were retrospectively selected. Using open-source SimVascular software, preoperative and postoperative visceral aortic anatomy was manually segmented from computed tomography angiograms. Three-dimensional geometric models were then discretized into tetrahedral finite element meshes. Patient-specific pulsatile in-flow conditions were derived from known supraceliac aortic flow waveforms and adjusted for patient body surface area, average resting heart rate, and blood pressure. Outlet boundary conditions consisted of three-element Windkessel models approximated from physiologic flow splits. Rigid wall flow simulations were then performed on preoperative and postoperative models with the same inflow and outflow conditions. We used SimVascular's incompressible Navier-Stokes solver to perform blood flow simulations on a cluster using 72 cores. Results Preoperative and postoperative flow simulations were performed for 10 patients undergoing fEVAR with a total of 30 target vessels (20 renal stents, 10 mesenteric scallops). Postoperative models required a higher mean number of mesh elements to reach mesh convergence (3.2 ± 1.8 × 106 vs 2.6 ± 1.1 × 106; P = .005) with a longer mean computational time (10.3 ± 6.3 hours vs 7.8 ± 3.5 hours; P = .04) compared with preoperative models. fEVAR was associated with small but statistically significant increases in mean peak proximal aortic arterial pressure (140.3 ± 11.0 mm Hg vs 136.9 ± 8.7 mm Hg; P = .02) and peak renal artery pressure (131.6 ± 14.8 mm Hg vs 128.9 ± 11.8 mm Hg; P = .04) compared with preoperative simulations. No differences were observed in peak pressure in the celiac, superior mesenteric, or distal aortic arteries (P = .17-.96). When measuring blood flow, the only observed difference was an increase in peak renal flow rate after fEVAR (17.5 ± 3.8 mL/s vs 16.9 ± 3.5 mL/s; P = .04). fEVAR was not associated with changes in the mean pressure or the mean flow rate in the celiac, superior mesenteric, or renal arteries (P = .06-.98). Stenting of the renal arteries did not induce significant changes time-averaged wall shear stress in the proximal renal artery (23.4 ± 8.1 dynes/cm2 vs 23.2 ± 8.4 dynes/cm2; P = .98) or distal renal artery (32.7 ± 13.9 dynes/cm2 vs 29.6 ± 11.8 dynes/cm2; P = .23). In addition, computational visualization of cross-sectional velocity profiles revealed low flow disturbances associated with protrusion of renal graft fabric into the aortic lumen. Conclusions In a pilot study involving a selective cohort of patients who underwent uncomplicated fEVAR, patient-specific flow modelling was a feasible method for assessing the hemodynamic performance of various two-vessel fenestrated device configurations and revealed subtle differences in computationally derived peak branch pressure and blood flow rates. Structural changes in aortic flow geometry after fEVAR do not seem to affect computationally estimated renovisceral branch perfusion or wall shear stress adversely. Additional studies with invasive angiography or phase contrast magnetic resonance imaging are required to clinically validate these findings. (JVS–Vascular Science 2021;2:53-69.) Clinical Relevance Using a computational flow modelling for assessing the hemodynamic performance of fenestrated endovascular aneurysm repair (fEVAR), this real-world, patient-specific study included 10 participants and found that structural changes in aortic flow geometry after fEVAR did not seem to adversely impact estimated renal or visceral branch perfusion metrics (eg, peak and mean arterial pressure and flow rates) or wall shear stress. These findings overall support the ongoing clinical use of commercially available fEVAR devices for repair of juxtarenal aortic aneurysms, and provides a computational framework for future evaluation of fEVAR configurations in a preoperative or postoperative settings.
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Affiliation(s)
- Kenneth Tran
- Division of Vascular Surgery, Stanford University.,Cardiovascular Institute, Stanford University
| | - Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University
| | - Alison Marsden
- Department of Pediatrics (Cardiology), Stanford University.,Department of Bioengineering, Stanford University
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University.,Cardiovascular Institute, Stanford University
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Respiratory-induced changes in renovisceral branch vessel morphology after fenestrated thoracoabdominal aneurysm repair with the BeGraft balloon-expandable covered stent. J Vasc Surg 2021; 74:396-403. [PMID: 33548438 DOI: 10.1016/j.jvs.2020.12.093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We evaluated the respiratory-induced changes in branch vessel geometry after thoracoabdominal fenestrated endovascular aneurysm repair (fEVAR) with the Bentley BeGraft graft (Innomed GmbH, Hechingen, Germany) as the covered bridging stent. METHODS Patients treated with fEVAR for thoracoabdominal aortic aneurysms with a custom-made Zenith fenestrated endograft (Cook Medical Europe Ltd, Limerick, Ireland) and Bentley BeGraft peripheral stents were prospectively recruited. Using SimVascular software (Open-Source Medical Software Corp, San Diego, CA), the pre- and postoperative aortic and branch contours were segmented from computed tomography angiograms performed during inspiratory and expiratory breath-holds. The centerlines were extracted from the lumen contours, from which the branch take-off angles, distal stent angles, and peak branch curvature changes were computed. Paired, two-tailed t tests were performed to compare the pre- and postoperative deformations. RESULTS Renovisceral vessel geometry was evaluated in 12 patients undergoing fEVAR with a total of 46 target vessels (10 celiac arteries, 12 superior mesenteric arteries [SMAs], 24 renal arteries). Implantation of BeGraft bridging stents was associated with a significant reduction in respiration-induced changes in vessel branch angulation (Δ5.3° ± 3.9° vs Δ12.0° ± 8.3° [postoperative vs preoperative]; P = .001) and mean curvature (0.72 ± 0.22 cm-1 vs 0.53 ± 0.18 cm-1) in the renal arteries, without significant changes in the celiac arteries or SMAs. No significant difference was found in end-stent angle motion in the renal arteries (P = .77), celiac arteries (P = .34), or SMAs (P = .55). The maximum local vessel curvature change decreased after fEVAR in the SMAs (Δ0.28 cm-1 vs Δ0.47 cm-1; P = .04) but was unchanged in the celiac (P = .61) and renal (P = .51) arteries. CONCLUSIONS Implantation of the BeGraft as a bridging stent in fEVAR was associated with decreased respiratory-induced deformation in the renal branch take-off angulation and mean renal artery curvature, with reduced maximum curvature bending in the SMA compared with the preoperative anatomy. However, the BeGraft allowed for celiac and renal artery bending similar to that in the native preoperative state. These findings suggest that the use of BeGraft peripheral stents with fEVAR will closely mimic the native arterial branch geometry and vessel conformability caused by relatively aggressive respiratory motion.
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17
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Proximal Aortic Coverage and Clinical Results of the Endovascular Repair of Juxta-/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom-made Fenestrated Endografts. Ann Vasc Surg 2021; 73:397-406. [PMID: 33412242 DOI: 10.1016/j.avsg.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Juxta-renal (JAAA)/para-renal (PAAA) and type IV-thoracoabdominal (TAAA) aneurysms can be repaired by custom-made fenestrated endografts (CM-FEVAR). Differently from open repair, a relatively long segment of healthy proximal aorta needs to be covered to achieve a durable sealing, and this may be considered a disadvantage of the endovascular approach. We aimed to quantify the additional proximal aortic coverage in JAAAs, PAAAs, and type-IV TAAAs treated with CM-FEVAR and to evaluate its impact on early/follow-up clinical outcomes. METHODS Between 2006 and 2018, preoperative, intraoperative, and postoperative data of JAAAs, PAAAs, and type-IV TAAAs submitted to CM-FEVAR were collected. The length of proximal healthy aortic coverage was evaluated on the preoperative endograft planning as the distance between the top of the CM-FEVAR endograft and the hypothetical level of aortic cross-clamping in case of open repair (type-IV TAAA-above the celiac trunk; PAAA-above the superior mesenteric artery; JAAA-above the lowest renal artery). Spinal cord ischemia (SCI), bowel ischemia (BI), renal function worsening (RFW) (estimated glomerular filtration rate reduction > 25% of the baseline level - RFW), and mortality were assessed at 30-day. Survival, target visceral vessel (TVV) patency, and freedom from reinterventions (FFRs) were assessed during follow-up by Kaplan-Meier analysis R2. RESULTS One hundred forty-seven cases were submitted to CM-FEVAR, for 72 (49%) JAAAs, 46 (31%) PAAAs, and 29 (20%) type IV-TAAAs, with 1(4-3%), 2 (28-19%), 3 (48-33%), and 4 (67-45%) fenestrations. JAAAs required a fenestration + bridging stent graft for the superior mesenteric artery and celiac trunk, in 46(64%) and 24(33%) cases, respectively. Nineteen (41%) PAAAs required a fenestration + bridging stent graft for the celiac trunk. The mean proximal additional aortic coverage was 48 ± 2 mm with no differences among JAAAs (52 ± 1 mm), PAAAs (42 ± 2 mm), and type IV-TAAAs (50 ± 2 mm) (P.09). Technical success, defined as correct endograft deployment, with TVV patency, absence of type I-III endoleaks, iliac leg stenosis/occlusions, open surgical conversion, and 24-hour mortality, was achieved in 98% of cases. Failures occurred for 1 type-III endoleak (type-IV TAAA) and 2 renal artery losses (PAAA and type IV-TAAA). The only case of SCI (0.7%) occurred in a type-IV TAAA where the proximal healthy aortic coverage was 80 mm. One BI was caused by acute thrombosis of the bridging stent graft for the superior mesenteric artery at 24 hours in 1 type IV-TAAA (0.7%). Thirty-five patients (24%) suffered postoperative RFW and required hemodialysis in 1 (0.7%) JAAA with severe preoperative chronic renal failure. There was no difference of proximal additional aortic coverage between patients with (49 ± 29 mm) and without (48 ± 23 mm) RFW (P.2). The 30-day mortality was 1.4%. The mean follow-up was 37 ± 2 months with no cases of aneurysm-related late mortality. Survival was 94%, 89%, and 75% at 1, 2, and 5 years, respectively. TVV patency was 97%, 97%, and 93% at 1, 2, and 5 years, respectively. FFR was 98%, 95%, and 87% at 1, 2, and 5 years, respectively. CONCLUSIONS Custom-made FEVAR requires a mean proximal additional aortic coverage of 48 ± 2 mm above the level of hypothetical aortic cross-clamping in case of open repair. This aspect should be considered for CM-FEVAR indication in JAAAs, PAAAs, and type-IV TAAAs; nevertheless, it does not appear to be associated with negative early and follow-up clinical sequelae.
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Cajas-Monson L, D'Oria M, Tenorio E, Mendes BC, Oderich GS, DeMartino RR. Effect of renal function on patient survival after endovascular thoracoabdominal and pararenal aortic aneurysm repair. J Vasc Surg 2020; 74:13-19. [PMID: 33340697 DOI: 10.1016/j.jvs.2020.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Renal dysfunction can be a prohibitive risk for open repair of complex thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). However, the effect of renal dysfunction from fenestrated and branched endovascular aneurysm repair (FB-EVAR) on outcomes is poorly defined. Our objective was to review the association of renal function on patient survival after FB-EVAR. METHODS The present study reviewed the clinical data of consecutive patients enrolled in a prospective nonrandomized study to investigate FB-EVAR for PRAAs and TAAAs at a single institution with 1 year of follow-up (2013-2017). The patients were categorized by preoperative chronic kidney disease (CKD) classification, and the early- and long-term mortality was assessed. RESULTS During the study period, 231 patients had undergone FB-EVAR for 80 PRAAs, 89 type I-III TAAAs, and 62 type IV TAAAs. The mean age was 74.6 ± 6.7 years, and 71% were men. Of the 231 patients, 126 had had CKD stage 1-2, 96 CKD stage 3, and 9 CKD stage 4-5 (all with baseline creatinine >2.0 mg/dL). Patients with CKD stage 4-5 had demographic data similar to those with normal renal function but had had slightly larger aneurysms (6.5 vs 7 cm; P = .15). The 30-day mortality was 0.5% (n = 1) for those with CKD 1-3 vs 0% for those with CKD 4-5 (P = .73). The 1- and 3-year survival analysis showed no major hazards (95% vs 88% and 84% vs 75%, respectively; log-rank P = .98) between the CKD 1-3 and CKD 4-5 groups. The median follow-up period was 2.6 years (interquartile range, 1.5-3.7 years). Two patients with CKD 4-5 had died during the follow-up period. CONCLUSIONS Although a small sample size for evaluation, selected patients with CKD 4-5 might have similar short- and long-term mortality compared with those with normal to moderate renal dysfunction after FB-EVAR. Although a major contraindication for open repair, renal dysfunction might not be as prohibitive for endovascular repair in well-selected patients.
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Affiliation(s)
- Luis Cajas-Monson
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
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Gallitto E, Faggioli G, Vacirca A, Pini R, Mascoli C, Fenelli C, Logiacco A, Abualhin M, Gargiulo M. The benefit of combined carbon dioxide automated angiography and fusion imaging in preserving perioperative renal function in fenestrated endografting. J Vasc Surg 2020; 72:1906-1916. [DOI: 10.1016/j.jvs.2020.02.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/29/2020] [Indexed: 11/25/2022]
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Hostalrich A, Porterie J, Segal J, Lebas B, Matray L, Abaziou T, Ricco JB, Chaufour X. Renal Artery Outcomes After Open Repair of Suprarenal or Type IV Thoraco-abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2020; 60:678-686. [PMID: 32888782 DOI: 10.1016/j.ejvs.2020.07.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 06/23/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the mid and long term patency of elective renal artery reconstructions during open surgical repair of suprarenal aortic aneurysms (SRAA) and type 4 thoraco-abdominal aortic aneurysms (T4AAA). METHODS This retrospective, single centre study included all consecutive patients who underwent surgery for SRAA or T4AAA between January 2009 and December 2019 at Toulouse University Hospital. All patients underwent strict pre-operative planning with computed tomography angiography (CTA) and 3D reconstruction of the aortic aneurysm, visceral and renal artery anatomy to choose the most appropriate surgical technique for each case. Primary patency, primary assisted patency, and rates of re-intervention were calculated using the Kaplan-Meier method. RESULTS In total, 103 patients, having undergone 159 renal artery revascularisation procedures, were enrolled in the study. Fifty-five patients presented with a type T4AAA and 48 patients with a SRAA. In hospital mortality was 2.9%. In association with aortic surgery, 100 direct re-implantation (62.8%), 48 retrograde bypasses (30.1%), and 11 anterograde bypasses (6.9%) of the renal arteries were performed. Median follow up was 45.9 ± 36 months. Renal artery primary patency rates were 99.4%, 96.4%, and 93.1% at one, three, and five years, respectively. Assisted primary patency rates were 99.4%, 97.7%, and 97.7% at one, three, and five years, respectively, with five cases of renal stenosis > 70% successfully treated by renal stenting. No significant difference in patency was found regarding the type of renal revascularisation. CONCLUSION This retrospective study suggests that the mid term patency of elective open renal artery reconstruction during SRAA and type T4AAA surgery preceded by pre-operative planning with 3D-CTA reconstruction, yields excellent outcomes whatever the technique used.
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Affiliation(s)
- Aurélien Hostalrich
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Jean Porterie
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Jean Segal
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Benoit Lebas
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Lauranne Matray
- Department of Vascular Surgery, Amiens University Hospital, Amiens, France
| | - Thimothée Abaziou
- Anaesthesia and Intensive Care Unit, Rangueil University Hospital, Toulouse, France
| | - Jean-Baptiste Ricco
- Department of Clinical Research, Poitiers University Hospital, Poitiers, France
| | - Xavier Chaufour
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France.
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Tenorio ER, Kärkkäinen JM, Marcondes GB, Lima GBB, Mendes BC, DeMartino RR, Macedo TA, Oderich GS. Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair. J Vasc Surg 2020; 73:805-818.e2. [PMID: 32707378 DOI: 10.1016/j.jvs.2020.06.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/23/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms. METHODS We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts. RESULTS There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD. CONCLUSIONS Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.
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Affiliation(s)
- Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Giulianna B Marcondes
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex
| | - Guilherme B B Lima
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Thanila A Macedo
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex.
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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: 221] [Impact Index Per Article: 55.3] [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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Rouer M, Monnot A, Bubenheim M, Fuda M, Godier S, Lebras M, Thomas P, Benadiba L, Elleboode B, Plissonnier D. Early Postoperative Renal Dysfunction Predicts Long-Term Renal Function Degradation after Type IV Thoracoabdominal Aortic Aneurysm Surgical Repair. Ann Vasc Surg 2020; 68:316-325. [PMID: 32439519 DOI: 10.1016/j.avsg.2020.04.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/10/2019] [Accepted: 04/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Type IV thoracoabdominal aortic aneurysm surgical repair is often complicated by postoperative acute kidney injury. The aim was to evaluate early renal injury influence on long-term renal function. METHODS All type IV thoracoabdominal surgical repair performed between January 2000 and January 2014 in our tertiary hospital were included in this retrospective observational study. All procedures were performed through a retroperitoneal approach with at least suprarenal aortic cross-clamping. Cold Ringer Lactate was used to perfuse the kidneys. Serum creatinine (Scr.) and glomerular filtration rate (GFR) were recorded preoperatively, daily until discharge and at least annually during follow-up. Postoperative renal dysfunction was classified using the RIFLE score. Predictors of long-term renal decline were identified by logistic regression and a Cox model. RESULTS Of total, 80 patients were included. Aortic clamping level was suprarenal (10%), supramesenteric (37%) or supracoeliac (53%). Ischemic durations were 29 ± 9 min for the gastrointestinal tract and the right kidney, 54 ± 28 min for the left kidney. Three patients died postoperatively. At discharge, 31 (38.8%) patients did not have a postoperative renal impairment (RIFLE-), compared with 49 (61.2%) who had a renal dysfunction (RIFLE+). GFR was 89 ± 29 ml/min vs 68 ± 37 ml/min, respectively (P < 0.01). In the RIFLE + group, Scr. was increased by x1.5 (Risk) for 22 patients, x2 (Injury) for 19 patients, and ×3 (Failure) for 8 patients. Mean follow-up was 59 months. Eighteen patients died, and 2 patients started permanent dialysis at 46 and 118 months during follow-up. The only predictive factor of long-term GFR degradation was a postoperative GFR below 45 ml/min (OR: 16.5; 95%; P < 0.001). CONCLUSIONS Postoperative renal dysfunction was a frequent complication, associated with long-term renal function degradation.
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Affiliation(s)
- Martin Rouer
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
| | - Antoine Monnot
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Michael Bubenheim
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Michelangelo Fuda
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Sylvie Godier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Marie Lebras
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Pascale Thomas
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Laurent Benadiba
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | | | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
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Witheford M, Chong DS, Martin-Gonzalez T, Van Calster K, Davis M, Prent A, Haulon S, Mastracci TM. Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively. J Vasc Surg 2020; 71:748-757. [DOI: 10.1016/j.jvs.2019.05.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/19/2019] [Indexed: 12/18/2022]
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Pather K, Tenorio ER, Kärkkäinen JM, Mendes BC, DeMartino RR, Macedo TA, Gloviczki P, Oderich GS. Outcomes of fenestrated-branched endovascular aortic repair in patients with a solitary functional kidney. J Vasc Surg 2020; 72:457-469.e2. [PMID: 31987670 DOI: 10.1016/j.jvs.2019.10.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/08/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal abdominal aortic aneurysms or thoracoabdominal aortic aneurysms (TAAAs) in patients with a solitary functional kidney (SFK). METHODS We analyzed the outcomes of 287 consecutive patients (206 male; mean age, 74 ± 8 years old) enrolled in a prospective nonrandomized study to investigate use of F-BEVAR for treatment of patients with pararenal abdominal aortic aneurysms or TAAAs between 2013 and 2018. Outcomes were analyzed in patients with solitary kidney (functional or congenital) and compared with control patients who had two functioning kidneys. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease criteria, and renal function deterioration (RFD) was defined by a decline in estimated glomerular filtration the estimated glomerular filtration rate of more than 30% from baseline. End points included 30-day mortality and major adverse events, AKI, freedom from RFD, and patient survival. RESULTS There where 30 patients (10%) with a SFK and 257 patients with two functioning kidneys. Patients with a SFK were younger and had significantly (P < .05) higher baseline creatinine (+0.3 mg/dL), lower estimated glomerular filtration rate (-16 mL/minute/1.73 m2) and more often had stage III to V chronic kidney disease (73% vs 43%). There were no differences in cardiovascular risk factors and aneurysm extent. Technical success was achieved in 98.9% of patients with SFK and in 99.8% of controls (P = .10). At 30 days, there was no significant differences in mortality (0% vs 1%) and major adverse events (40% vs 24%; P = .08), including rates of AKI (20% vs 12%) and new-onset dialysis (3% vs 1%) between patients with a SFK and the control group, respectively. Mean follow-up was 18 ± 15 months. At 2 years, there was no difference (P = .36) in patient survival (92 ± 5% vs 84 ± 3%) and freedom from RFD (100 ± 0% vs 84 ± 3%) for patients with SFK and controls, respectively. Presence of a SFK was not a predictor for AKI or RFD. By multivariable analysis, estimated blood loss of more than 1 L (odds ratio [OR], 2.9; P = .04) and total fluoroscopy time (OR, 1.8; P = .05) were predictors for AKI, and postoperative AKI (OR, 4.9; P < .001), renal branch occlusion/stenosis (OR, 3.1; P = .001), and Crawford extent II TAAA (OR, 2.4; P = .007) were predictors for RFD. CONCLUSIONS Despite the worse baseline renal function, F-BEVAR is safe and effective with nearly identical outcomes in patients with a SFK as compared with patients with two functioning kidneys. Development of postoperative AKI is the most important predictor for RFD.
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Affiliation(s)
- Keouna Pather
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jussi M Kärkkäinen
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bernardo C Mendes
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Randall R DeMartino
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Thanila A Macedo
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Peter Gloviczki
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
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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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Motta F, Kalbaugh CA, Luckett DJ, Fine J, Antonescu I, Ohana E, Crowner JR, Farber MA. Renal volumes and estimated glomerular filtration rate changes after fenestrated-branched endovascular aortic repair. J Vasc Surg 2019; 70:1040-1047. [DOI: 10.1016/j.jvs.2018.12.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 12/16/2018] [Indexed: 11/29/2022]
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Fenestrated endovascular aneurysm repair-induced acute kidney injury does not result in chronic renal dysfunction. J Vasc Surg 2019; 69:1679-1684. [DOI: 10.1016/j.jvs.2018.09.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/30/2018] [Indexed: 01/10/2023]
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Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States. J Vasc Surg 2019; 69:1036-1044.e1. [DOI: 10.1016/j.jvs.2018.06.211] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/04/2018] [Indexed: 11/22/2022]
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Kärkkäinen JM, Sandri GDA, Tenorio ER, Macedo TA, Hofer J, Gloviczki P, Cha S, Oderich GS. Prospective assessment of health-related quality of life after endovascular repair of pararenal and thoracoabdominal aortic aneurysms using fenestrated-branched endografts. J Vasc Surg 2018; 69:1356-1366.e6. [PMID: 30714570 DOI: 10.1016/j.jvs.2018.07.060] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/21/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to investigate changes in health-related quality of life (QOL) in patients treated for pararenal aortic aneurysms (PAAs) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated-branched endovascular aneurysm repair (F-BEVAR). METHODS A total of 159 consecutive patients (70% male; mean age, 75 ± 7 years) were enrolled in a prospective, nonrandomized single-center study using manufactured F-BEVAR (2013-2016). All patients were observed for at least 12 months (mean follow-up time, 27 ± 12 months). Patients' health-related QOL was assessed using the 36-Item Short Form Health Survey questionnaire at baseline (N = 159), 6 to 8 weeks (n = 136), 6 months (n = 129), and 12 months (n = 123). Physical component scores (PCSs) and mental component scores (MCSs) were compared with historical results of patients enrolled in the endovascular aneurysm repair (EVAR) 1 trial who were treated by standard EVAR for simple infrarenal abdominal aortic aneurysms. RESULTS There were 57 patients with PAAs and 102 patients with TAAAs (50 extent IV and 52 extent I-III TAAAs). There were no 30-day deaths, in-hospital deaths, conversions to open surgery, or aorta-related deaths. Survival was 96% at 1 year and 87% at 2 years. Major adverse events occurred in 18% of patients, and 1-year reintervention rate was 14%. There were no statistically significant differences between the groups in 30-day outcomes. Patients treated for TAAAs had lower baseline scores compared with those treated for PAAs (P < .05). PCS declined significantly 6 to 8 weeks after F-BEVAR in both groups and returned to baseline values at 12 months in the PAA group but not in the TAAA group. Patients with TAAAs had significantly lower PCSs at 12 months compared with those with PAAs (P < .001). There was no decline in mean MCS. Major adverse events were associated with decline in PCS assessed at 6 to 8 weeks (P = .021) but not in the subsequent evaluations. Reinterventions had no effect on PCS or MCS. Overall, patients treated by F-BEVAR had similar changes in QOL measures as those who underwent standard EVAR in the EVAR 1 trial, except for lower PCS in TAAA patients at 12 months. CONCLUSIONS Patients treated for TAAAs had lower scores at baseline in their physical aspect of health-related QOL. F-BEVAR was associated with significant decline in PCSs in both groups, which improved after 2 months and returned to baseline values at 12 months in patients with PAAs but not in those with TAAAs. Patients treated for PAAs had similar changes in QOL compared with those treated for infrarenal aortic aneurysms with standard EVAR.
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Affiliation(s)
- Jussi M Kärkkäinen
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Giuliano de A Sandri
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Thanila A Macedo
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Janet Hofer
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Peter Gloviczki
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Stephen Cha
- Department of Health Science Research, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Mayo Clinic Aortic Center, Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
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Analysis of the Learning Curve and Patient Outcomes of Endovascular Repair of Thoracoabdominal Aortic Aneurysms Using Fenestrated and Branched Stent Grafts. Ann Surg 2018; 268:640-649. [DOI: 10.1097/sla.0000000000002960] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Locham S, Faateh M, Dakour-Aridi H, Nejim B, Malas M. Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels. Ann Vasc Surg 2018; 51:192-199. [DOI: 10.1016/j.avsg.2018.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/08/2018] [Accepted: 02/11/2018] [Indexed: 01/24/2023]
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Practice Patterns of Fenestrated Aortic Aneurysm Repair: Nationwide Comparison of Z-Fen Adoption at Academic and Community Centers Since Commercial Availability. Vasc Endovascular Surg 2018; 52:434-439. [DOI: 10.1177/1538574418776440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context: Over the past decade, a number of endovascular approaches have evolved to treat aortic aneurysms with anatomy that is not amenable to traditional endovascular repair, although the optimal practice and referral patterns remain in question. The Zenith fenestrated (Z-Fen) endograft (Cook Medical) represents the first commercially available fenestrated graft product in the United States. Objective: We aim to quantify practice patterns in Z-Fen use during the first 5 years of commercial availability, and we identify predictors of high and low uptake. Design, Setting, and Patients: This is a retrospective review of complete order records for Z-Fen endografts since June 2012. We performed univariate and multivariate regressions of predictors that surgeons and centers would be in the top and bottom quartiles of annual Z-Fen use. Results: Since June 15, 2012, 744 surgeons have been trained to use Z-Fen, and 4133 cases have been performed at 409 trained centers. The average annual number of cases per trained surgeon was 4.46 [95% confidence interval (CI), 3.58-5.70]; however, many surgeons performed few or no cases following training, and there was a skew toward users with low average annual volumes (25th percentile 1.23, 50th percentile 2.35, 75th percentile 4.93, and 99th percentile 33.29). Predictors of high annual use in the years following training included academic center (aOR 5.87, P = .001) and training within the first 2 years of availability (aOR 46.23, P < .001). Conclusion: While there is literature supporting the safety and efficacy of Z-Fen, adoption has been relatively slow in an era when the vast majority of vascular surgeons have advanced endovascular skills. Given the training and resources required to use fenestrated or branched aortic endovascular devices, referral patterns should be determined and training should be focused on centers with high expected volumes.
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