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Santos-Venâncio M, Rocha-Neves J, Spath P, Oliveira-Pinto J. Complications and Technical Success on Upper Limb Vascular Access for Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:433-443. [PMID: 39059630 DOI: 10.1016/j.avsg.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Catheterization of target vessels (TV) represented by renal visceral vessels are the crucial aspect during fenestrated and branched endovascular repair. This study aims to assess the efficacy and complications associated with upper limb catheterization during complex aneurysm endovascular surgery repair. METHODS A systematic review was conducted after Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, involving a search across PubMed, Cochrane CENTRAL, and Web of Science. Primary endpoint was represented by 30-day stroke. Secondary endpoints were target vessels' (TVs) technical success, 30-day mortality, and local access-related complications. Meta-analyses were performed using a random-effects model. RESULTS Sixteen observational studies encompassing 4,137 patients were included. The 30-day stroke incidence for upper limb access was 1.4% (95% CI 1.0-1.8%), which was slightly higher than lower limb, despite not statistically significant. Mortality varied between 0 and 6.8%, and local access-related complications occurred in 3.2% (95% CI 1.9-4.4%). Technical success in TV catheterization was 99.2% (95% CI 98.4-100.0%). CONCLUSIONS This systematic review and meta-analysis demonstrate the safety and efficacy of upper limb access for Fenestrated and Branched Endovascular Aortic Repair (f/b-EVAR), with low stroke risk, mortality rates, and minimal local complications. Despite the risk of bias, the findings suggest that upper limb access may be beneficial, especially in bailout situations when femoral access fails, offering valuable insights for clinical decision-making.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; RISE@Health, Porto, Portugal.
| | - Paolo Spath
- Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy; Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Ludwig-Maximilians-Universitat Munchen, Vascular Surgery Marchionisteße Munchen, Bayern, Germany
| | - José Oliveira-Pinto
- RISE@Health, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Koziarz A, Kennedy SA, Awad El-Karim G, Tan KT, Oreopoulos GD, Kalra S, Etz CD, Rajan DK, Mafeld S. Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024; 31:763-771. [PMID: 36625294 PMCID: PMC11408977 DOI: 10.1177/15266028221147451] [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] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. MATERIALS AND METHODS MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data. RESULTS Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013). CONCLUSIONS Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. CLINICAL IMPACT Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.
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Affiliation(s)
- Alex Koziarz
- Department of Radiology, McMaster University, Hamilton, ON, Canada
| | - Sean A Kennedy
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ghassan Awad El-Karim
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Kong T Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - George D Oreopoulos
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Vascular Surgery, University Health Network, Toronto, ON, Canada
| | - Sanjog Kalra
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christian D Etz
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Vigezzi GP, Barbati C, Blandi L, Guddemi A, Melloni A, Salvati S, Bertoglio L, Odone A. Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression. Ann Surg 2024; 279:961-972. [PMID: 38214159 DOI: 10.1097/sla.0000000000006190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair. BACKGROUND Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited. METHODS We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics. RESULTS Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias. CONCLUSIONS Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.
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Affiliation(s)
- Giacomo Pietro Vigezzi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- Collegio Ca' della Paglia, Fondazione Ghislieri, Pavia, Italy
| | - Chiara Barbati
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Lorenzo Blandi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Annalisa Guddemi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Andrea Melloni
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Simone Salvati
- Division of Vascular Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Bertoglio
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- HTA Committee, IRCCS San Raffaele Hospital, Milan, Italy
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Al Adas Z, Uceda D, Mazur A, Zehner K, Agrusa CJ, Wang G, Schneider DB. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg 2024; 79:487-496. [PMID: 37918698 DOI: 10.1016/j.jvs.2023.10.048] [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: 08/29/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.
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Affiliation(s)
- Ziad Al Adas
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Domingo Uceda
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexa Mazur
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kiera Zehner
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill, Cornell Medical Center, New York, NY
| | - Grace Wang
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Darren B Schneider
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Sacha J, Krawczyk K, Gwóźdź W, Lipski P, Milejski W, Feusette P, Cisowski M, Gierlotka M. Percutaneous transaxillary approach through the first segment of the axillary artery for the Impella-supported PCI Versus TAVR. Sci Rep 2024; 14:1016. [PMID: 38200136 PMCID: PMC10781673 DOI: 10.1038/s41598-024-51552-3] [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: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 01/12/2024] Open
Abstract
Percutaneous transaxillary approach (PTAX) through the first segment of the axillary artery is not widely recognized as a safe method. Furthermore, PTAX has never been directly compared between Impella-supported percutaneous coronary interventions (Impella-PCI) and transcatheter aortic valve replacement (TAVR). This study evaluated the feasibility and safety of PTAX through the first axillary segment in Impella-PCI versus TAVR. In cases where standard imaging guidance was insufficient, a technique involving puncturing the axillary artery "on-the-balloon" was employed. The endpoints were bleeding and vascular complications, as defined by BARC and VARC-3 criteria. PTAX was successfully performed in all 46 attempted cases: 23 for Impella-PCI and 23 for TAVR. Strict adherence to BARC and VARC-3 criteria led to the frequent identification of major bleeding (57%) and a moderately frequent diagnosis of vascular complications (17%). These incidences were primarily based on post-procedural hemoglobin reduction (> 3 g/dl) but not overt bleeding. The Impella group exhibited a higher rate of BARC 3b bleeding due to a greater hemoglobin decline resulting from the prolonged implant duration and PCI itself. Left axillary access was linked to smaller blood loss. Bleeding and vascular complications, as per BARC and VARC-3 definitions, did not affect short-term prognosis, with only 3 Impella patients succumbing to heart failure unrelated to the procedures during one-month follow-up period.
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Affiliation(s)
- Jerzy Sacha
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland.
- Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poland.
| | - Krzysztof Krawczyk
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Witold Gwóźdź
- Department of Cardiac Surgery, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Przemysław Lipski
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Wojciech Milejski
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Piotr Feusette
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Marek Cisowski
- Department of Cardiac Surgery, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Marek Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
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Melloni A, Bertoglio L, Van den Eynde W, Agrusa CJ, Parlani G, Howard DPJ, Rio J, Fazzini S, Mansour W, Dias NV, Ronchey S, Branzan D. Outcomes of Percutaneous Access to the First Versus Third Segment of Axillary Artery During Aortic Procedures. J Endovasc Ther 2023:15266028231202456. [PMID: 37750487 DOI: 10.1177/15266028231202456] [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: 09/27/2023]
Abstract
PURPOSE This article aims at investigating the outcomes of percutaneous access via the first versus third axillary artery (AXA) segments with closure devices during aortic procedures. MATERIALS AND METHODS All patients receiving percutaneous AXA access closed with Perclose ProGlide device (Abbott, Santa Clara, California) from 2008 to 2021 were included in a retrospective multicenter registry (NCT: 04589962). Efficacy endpoint was the technically successful percutaneous procedure (no open conversion). Safety endpoints were stroke and access complications according to the Valve Academic Research Consortium-3 reporting standards. The first (AXA1) or third (AXA3) axillary puncture sites were compared. RESULTS A total of 412 percutaneous AXA accesses were included: 172 (42%) in AXA1 and 240 (58%) in AXA3. Left AXA was catheterized in 363 cases (76% of AXA1 vs 97% of AXA3, p<0.001) and 91% of fenestrated/branched endovascular repair (F/BEVAR) procedures were conducted from the left. A ≥12F internal diameter (ID) sheath was used in 49% of procedures. Open conversion rate was 1%, no major vascular complications occurred, and only one major non-vascular complication was recorded. Primary closure failure occurred in 18 AXA1 (11%) and 32 AXA3 accesses (13%), treated by covered (8.3%) or bare-metal (2.7%) stenting. Bailout stent patency was 100% at median follow-up of 12 months, with 6 of 6 stents still patent after >36 months of follow-up. Stroke rate was 4.4%. An introducer sheath >12F was independently associated with both access complications (p<0.001) and stroke (p=0.005), while a right-side access was associated with stroke only (p=0.034). Even after adjustment for covariates, AXA1 versus AXA3 showed an equal success rate (odds ratio [OR]=0.537, 95% confidence interval [CI]=0.011-1.22 for AXA3, p=0.104). The combination of AXA3 and a >10F introducer sheath provided worse outcomes compared with >10F sheaths through AXA1 (OR for success=0.367, 95% CI=0.176-0.767, p=0.008). This was not confirmed for >12F sheaths, associated with similar outcomes (p=0.31 AXA 1 vs AXA 3). CONCLUSION Major local complications with the percutaneous axillary approach and ≤12F sheaths are infrequent and solvable by complementary endovascular interventions. Stroke risk remains an issue. First and third AXA segments are both amenable for access with good results, but larger sheaths (12F) perform better in AXA1. CLINICAL IMPACT Percutaneous access with vascular closure devices at the first or third axillary artery (AXA) segments during aortic procedures is burdened by a negligible risk of open conversion. Local complications with the percutaneous axillary approach are infrequent and solvable by complementary endovascular interventions. First and third AXA segments are both amenable to access with excellent results, but larger sheaths (12F) perform better in the wider first AXA segment. In this setting, bailout stenting does not appear to be associated with mid-term stent occlusion.
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Affiliation(s)
- Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Gianbattista Parlani
- Vascular and Endovascular Surgery Unit, S. Maria Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Dominic P J Howard
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Javier Rio
- Servicio de Angiología y Cirugía Vascular, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Stefano Fazzini
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome Tor Vergata, Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini," Policlinico Umberto I, "Sapienza" University, Rome, Italy
| | - Nuno V Dias
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, and Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum Munich at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
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Mario D, Alessandro G, Giovanni P, Gianbattista P, Rocco G, Mauro G, Nicola M, Roberto C, Sandro L, Luca B. Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry. J Endovasc Ther 2023:15266028231179864. [PMID: 37326371 DOI: 10.1177/15266028231179864] [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: 06/17/2023]
Abstract
OBJECTIVE The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. MATERIALS AND METHODS The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). RESULTS Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. CONCLUSIONS A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. CLINICAL IMPACT Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.
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Affiliation(s)
- D'Oria Mario
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Grandi Alessandro
- Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pratesi Giovanni
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Parlani Gianbattista
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giudice Rocco
- UOC di Chirurgia Vascolare, Dipartimento Cardiovascolare, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Gargiulo Mauro
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Mangialardi Nicola
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Lepidi Sandro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
- Division of Vascular Surgery, Department of Surgical and Clinical Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
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8
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Rohlffs F, Grandi A, Panuccio G, Detter C, von Kodolitsch Y, Kölbel T. Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review. Ann Vasc Surg 2023:S0890-5096(23)00316-3. [PMID: 37328096 DOI: 10.1016/j.avsg.2023.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Alessandro Grandi
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christian Detter
- Cardiothoracic Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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9
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Bertoglio L, Oderich G, Melloni A, Gargiulo M, Kölbel T, Adam DJ, Di Marzo L, Piffaretti G, Agrusa CJ, Van den Eynde W. Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures. Eur J Vasc Endovasc Surg 2023; 65:729-737. [PMID: 36740094 DOI: 10.1016/j.ejvs.2023.01.046] [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: 06/16/2022] [Revised: 09/08/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. METHODS A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. RESULTS Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p < .001). CONCLUSION AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gustavo Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Luca Di Marzo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University, Rome, Italy
| | - Gabriele Piffaretti
- Vascular Surgery and Interventional Radiology, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Centre, New York, NY, USA
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
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10
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Bertoglio L, Melloni A, Bugna C, Grignani C, Bucci D, Foglia E, Chiesa R, Odone A. In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms. J Vasc Surg 2023:S0741-5214(23)01034-0. [PMID: 37076108 DOI: 10.1016/j.jvs.2023.03.503] [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: 01/23/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center. METHODS This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness. RESULTS Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved. CONCLUSIONS ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Bugna
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Camilla Grignani
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daria Bucci
- School of Public Health, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Foglia
- School of Industrial Engineering, Carlo Cattaneo - LIUC University and LIUC Business School, Castellanza, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
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Wittig T, Sabanov A, Schmidt A, Scheinert D, Steiner S, Branzan D. Feasibility and Safety of Percutaneous Axillary Artery Access in a Prospective Series of 100 Complex Aortic and Aortoiliac Interventions. J Clin Med 2023; 12:jcm12051959. [PMID: 36902745 PMCID: PMC10003984 DOI: 10.3390/jcm12051959] [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: 01/19/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
We aimed to review the feasibility and safe use of the percutaneous axillary artery (AxA, 100 patients) approach for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA, 90 patients) using fenestrated, branched, and chimney stent grafts and other complex endovascular procedures (10 patients) necessitating AxA access. Percutaneous puncture of the AxA in its third segment was performed using sheaths sized between 6 to 14F. For closing puncture sites greater than 8F, two Perclose ProGlide percutaneous vascular closure devices (PVCDs) (Abbott Vascular, Santa Clara, CA, USA) were deployed in the pre-close technique. The median maximum diameter of the AxA in the third segment was 7.27 mm (range 4.50-10.80). Device success, defined as successful hemostasis by PVCD, was reported in 92 patients (92.0%). As recently reported results in the first 40 patients suggested that adverse events, including vessel stenosis or occlusion, occurred only in cases with a diameter of the AxA < 5 mm, in all subsequent 60 cases AxA access was restricted to a vessel diameter ≥ 5 mm. In this late group, no hemodynamic impairment of the AxA occurred except in six early cases below this diameter threshold, all of which could be repaired by endovascular measures. Overall mortality at 30 days was 8%. In conclusion, percutaneous approach of the AxA in its third segment is feasible and represents a safe alternative access to open access for complex endovascular aorto-iliac procedures. Complications are rare, especially if the maximum diameter of the access vessel (AxA) is ≥5 mm.
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Affiliation(s)
- Tim Wittig
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
| | - Arsen Sabanov
- Department of Vascular Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Sabine Steiner
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-9718770; Fax: +49-341-9718779
| | - Daniela Branzan
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
- Department of Vascular Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
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12
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Marques de Marino P, Hagen M, Katsargyris A, Botos B, Verhoeven EL. Outcomes of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2022; 64:332-338. [PMID: 35963515 DOI: 10.1016/j.ejvs.2022.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study aims to assess the safety of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurologic and local complications as well as reinterventions associated with this technique. METHODS All patients undergoing a F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single-centre study. Endpoints were neurological and access-related complications and reinterventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury and arterial complications. RESULTS 264 patients (192 male, mean age 70 ± 7 years) were included. Upper access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2,2%) patients had early complications related to the arterial access: four with postoperative bleeding and two with acute arm ischaemia. Two patients with postoperative bleeding and both patients with ischaemic complications required reintervention. One of these patients with arm ischaemia died five weeks after the reintervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented transient arm paraesthesia or sensory neurologic deficit postoperatively. The symptoms completely recovered in all cases with no residual deficits. Perioperative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. CONCLUSIONS Upper access with surgical exposure of the axillary artery is a safe method for antegrade catheterization of fenestrations and branches in complex endovascular aneurysm repair.
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Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Maike Hagen
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
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13
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Porras-Colon J, Knowles M, Timaran CH. Outcomes and strategies for utilization of brachial access and preloaded systems during F/BEVAR. Semin Vasc Surg 2022; 35:287-296. [DOI: 10.1053/j.semvascsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/11/2022]
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14
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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15
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Meertens MM, van Herwaarden JA, de Vries JPPM, Verhagen HJM, van der Laan MJ, Reijnen MMPJ, Schurink GWH, Mees BME. Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1150-1159. [PMID: 35709857 DOI: 10.1016/j.jvs.2022.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/10/2022] [Accepted: 04/26/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR). METHODS In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received upper extremity access during complex EVAR were included. Primary outcome was a composite endpoint of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions and incidence of ischemic cerebrovascular events. RESULTS 417 patients underwent 437 UEA for 303 fenestrated/branched EVARs, and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. 413 approaches were performed surgically and 24 percutaneously. Distal brachial access was used in 89 cases, medial brachial in 149, proximal brachial in 140 and axillary access in 59 cases. No significant differences regarding the composite endpoint of access complications were seen (DBA 11.3% vs. MBA 6.7% vs. PBA 13.6% vs. AA 10.2%; p=.29). Postoperative neuropathy occurred most after proximal brachial access (DBA 1.1% vs. MBA 1.3% vs. PBA 9.3 % vs. AA 5.1%; p=.003). There were no differences in cerebrovascular complications between access sides (right 5.9% vs. left 4.1% vs. bilateral 5%; p=.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs. 6.8%; p=.002). In multivariate analysis the risk for access complications after open approach was decreased by male gender (OR 0.27; CI 95% 0.10 - 0.72; p= .009), while an increase in age per year (OR 1.08; CI 95% 1.004 - 1.179; p=.039) and diabetes mellitus type 2 (OR 3.70; CI 95% 1.20 - 11.41; p= .023) increased the risk. CONCLUSION Between the four access localizations, there were no differences in overall access complications. Female gender, diabetes mellitus type 2 and ageing increased the risk for access complications after surgical approach. Furthermore, a percutaneous upper extremity access resulted in higher complication rates than a surgical approach.
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Affiliation(s)
- M M Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - J A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M J van der Laan
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - M M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, and Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - G W H Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany
| | - B M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany.
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16
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Percutaneous proximal axillary artery versus femoral artery access for endovascular interventions. J Vasc Surg 2022; 76:165-173. [PMID: 35351603 DOI: 10.1016/j.jvs.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/11/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The primary objective of this study is to describe and illustrate the technique of ultrasound-guided percutaneous proximal axillary artery (PAA) access, and secondarily to evaluate the versatility and safety of this approach in peripheral, visceral, and aortic endovascular interventions. METHODS This is a single-center retrospective review of all peripheral, visceral, and aortic endovascular cases using percutaneous PAA access from February 2019 to March 2021 compared with a sample of an equivalent number of consecutive cases completed via percutaneous common femoral artery (CFA) access during the same time period. Access entry success, minor and major access site complications within 30 days, major adverse events within 30 days, demographics, and procedural details were analyzed using standard statistical analyses. RESULTS A total of 115 accesses-59 PAA and 56 CFA-were reviewed during the study period. Group demographics were not significantly different. Access entry success was achieved in 58 (98.3%) and 56 (100%) of PAA and CFA accesses, respectively, with no statistically significant difference. There were no significant differences in minor access-site complications (13.6% vs 5.4%; P = .21) major access site complications (3.4% vs 7.1%; P = .43), or major adverse events (6.8% vs 5.4%). between the PAA and CFA groups. With respect to versatility, PAA cases had a significantly greater mean number of vessels intervened on per procedure compared with CFA access (2.59 ± 1.31 vs 1.95 ± 0.98; P < .01). A wide range of target vessels were intervened on in both groups. PAA cases had significantly more bilateral lower leg interventions (28.8% vs 12.5%; P = .04). PAA access had a significantly longer mean procedure time (103.2 minutes vs 58.63 minutes; P < .001) and fluoroscopy time (18.21 minutes vs 12.87 minutes; P = .02). CONCLUSIONS The PAA is a feasible, versatile, and safe percutaneous access option for endovascular intervention. The in-line trajectory from this site facilitates visceral, renal, aortic, and bilateral lower extremity interventions with ease. Outcomes, complications, and major adverse events are similar to those of conventional CFA access in the short term.
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17
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"First in Man" Total Percutaneous Aortic Arch Repair With 3-Inner-branch Endografts: A Report of Two Cases. Ann Surg 2021; 274:e652-e657. [PMID: 34784671 DOI: 10.1097/sla.0000000000005167] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
SUMMARY BACKGROUND DATA Aneurysms of the arch are a complex clinical problem and a technical challenge. Currently, over 40% of patients are considered unfit for conventional open surgery, requiring a cardiopulmonary bypass and hypothermic circulatory arrest. In experienced hands and appropriate anatomic conditions, arch-branched graft technology has shown to be a safe and effective alternative to open conventional surgery to patients that historically have had no surgical options. OBJECTIVES This report summarizes the first in man implant of a three-vessel arch branch stent graft using a total percutaneous approach without the need for exposure of the cervical arteries-a surgical step with inherent problems and risks. METHODS This approach was performed in two consecutive patients, a 66-year-old woman with a chronic post type A dissection 60 mm diameter aneurysm of the aortic arch, and a 72-year-old man with a 70 mm saccular degenerative atheromatous aortic arch aneurysm. RESULTS Technical success was obtained in both cases. The patients were extubated in the operating theatre. Neither suffered any pre- or postoperative neurological deficits. Both were discharged home after remarkably uneventful hospital stays. There were no access complications. Postoperative computerized tomography scans and ultra-sound confirmed patent supra-aortic branches and completely excluded aneurysms. CONCLUSIONS Our new truly minimally invasive approach demonstrates that it is possible to manage one of the most challenging treatments of aortic pathologies without any surgical incision. Further, evaluation and experience are required to confirm these promising results.
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Percutaneous transAXillary access for endovascular aortic procedures in the multicenter international PAXA registry. J Vasc Surg 2021; 75:868-876.e3. [PMID: 34600031 DOI: 10.1016/j.jvs.2021.08.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. METHODS A physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. RESULTS Three hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. CONCLUSIONS Percutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.
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Loschi D, Melloni A, Grandi A, Baccellieri D, Monaco F, Melissano G, Chiesa R, Bertoglio L. Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes. Eur J Cardiothorac Surg 2021; 61:120-129. [PMID: 34355733 DOI: 10.1093/ejcts/ezab335] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the outcomes of open and endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology in patients who underwent previous frozen elephant trunk (FET). METHODS Data were retrieved to evaluate mortality, cardiac, pulmonary, cerebrovascular, renal and spinal cord major adverse events, early- and mid-term reintervention and survival rates. The Society for Vascular Surgery endovascular reporting standards were used. RESULTS From 2011 to 2020, 48 patients (36 males, median age 60 years) underwent downstream aortic repair at a median of 18 months (interquartile range: 6-57) after the initial FET. Twenty-eight patients (58.3%) received open and 20 (41.7%) endovascular repair. The overall 30-day mortality was 6.3% and the initial clinical success was 88%, with no inter-group differences (P = 0.22 and 0.66 respectively). Six spinal cord deficits were recorded (13%): 3 (6.3%) were permanent. The major adverse events incidence was lower in the endovascular cohort [4 (20%) vs 14 (50%); P = 0.047], mainly due to a lower rate of grade ≥2 respiratory complications (5% vs 42.9%; P = 0.004). Assisted primary clinical success at 5 years was higher in the endovascular group (95% vs 68%, P = 0.022); freedom from reintervention at competing risk analysis (P = 0.3) and overall survival at Kaplan-Meier curves (log-rank P = 0.29) were similar. CONCLUSIONS Downstream aortic repair after FET is feasible with both open and endovascular repair with acceptable mortality and permanent paraplegia rates. The endovascular approach has potential perioperative and mid-term advantages, but long-term durability has to be further investigated in larger cohorts.
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Affiliation(s)
- Diletta Loschi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Grandi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Baccellieri
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Kölbel T, Spanos K, Jama K, Behrendt CA, Panuccio G, Eleshra A, Rohlffs F, Jakimowicz T. Early outcomes of the t-Branch off-the-shelf multi-branched stent graft in 542 patients for elective and urgent aortic pathologies - a retrospective observational study. J Vasc Surg 2021; 74:1817-1824. [PMID: 34171424 DOI: 10.1016/j.jvs.2021.05.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in >500 patients being treated with the t-Branch device. METHODS A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia. RESULTS A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P < .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P < .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P < .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P < .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P < .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P < .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively. CONCLUSIONS Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable.
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Affiliation(s)
- Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany; Departments of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
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Bertoglio L, Grandi A, Carta N, Cambiaghi T, Bilman V, Melissano G, Chiesa R. Comparison of anatomic feasibility of three different multibranched off-the-shelf stent-grafts designed for thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 74:1472-1482.e4. [PMID: 34023432 DOI: 10.1016/j.jvs.2021.04.066] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We compared the theoretical anatomic feasibility of endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with three off-the-shelf multibranched stent-grafts: t-Branch (Zenith t-Branch; Cook Medical, Bloomington, Ind), Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz), and E-nside (E-nside multibranch stent graft system; Jotec GmbH, Hechingen, Germany). METHODS Computed tomography scans of patients with degenerative TAAAs treated from 2007 to 2019 were reviewed, and the anatomic feasibility of the multibranched stent-grafts was assessed according to the manufacturer's instructions for use. The anatomic factors determining the overall feasibility were divided into access feasibility, aortic feasibility, and visceral vessel feasibility. RESULTS Degenerative TAAAs in 268 patients were analyzed. The overall feasibility did not differ significantly (TAMBE, 33%; t-Branch, 39%; E-nside, 43%; P = .271). Access, aortic, and visceral vessel feasibility alone excluded 18% to 22%, 35% to 49% and 21% to 26% of the patients respectively. The only significant difference between the devices was in aortic feasibility (P = .005), which was more frequently limited by the proximal aortic neck diameter in the TAMBE cohort and the inner visceral aortic diameter in the t-Branch cohort. The overall treatment feasibility using any of the three devices would have been 58%. CONCLUSIONS The new investigational off-the-shelf multibranched stent-grafts did not significantly improve the theoretical applicability in an extensive cohort of patients with TAAAs. Improvements are warranted to increase their overall feasibility.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Alessandro Grandi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Bilman V, Cambiaghi T, Grandi A, Carta N, Melissano G, Chiesa R, Bertoglio L. Anatomical feasibility of a new off-the-shelf inner branch stent graft (E-nside) for endovascular treatment of thoraco-abdominal aneurysms. Eur J Cardiothorac Surg 2020; 58:1296-1303. [DOI: 10.1093/ejcts/ezaa276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 11/15/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the proportion of thoraco-abdominal aortic aneurysms (TAAAs) that could theoretically be treated with the JOTEC® E-nside® Thoracoabdominal Branch Endoprosthesis off-the-shelf multibranched endograft.
METHODS
Preoperative computed tomography scans of patients with atherosclerotic TAAA treated between 2007 and 2019 were reviewed, and the anatomical feasibility of the E-nside graft was verified by a retrospective study (clinicaltrials.gov: NCT03959670) based on the investigational manufacturer instructions for use. The anatomical factors determining overall feasibility were divided into vascular access (AC) feasibility, aortic (AO) feasibility and visceral vessels (VV) feasibility.
RESULTS
Two hundred sixty-eight patients with thoraco-abdominal aneurysms were analysed: the overall treatment feasibility was 43%. AC feasibility was 78%, AO feasibility 60% and VV feasibility 79%. An iliac diameter <8.5 mm excluded 21% of the patients. Aortic feasibility was limited by infrarenal aortic diameter (16%) and size of aortic lumen at the level of visceral vessels (14%). Visceral vessels feasibility was mainly limited by inadequate number (8%) or diameter (12%) of target vessels. Height and orientation of target vessels were adequate in 97% of the cases. Overall feasibility was negatively influenced by female gender (Odds ratio: 3.89; 95% confidence interval 2.03–7.44; P < 0.001): the limiting factors in this subgroup being iliac diameter, infrarenal aortic diameter and visceral vessels diameter.
CONCLUSIONS
The E-nside off-the-shelf stent graft can be theoretically employed in almost half of the cases from an all-comers cohort of patients with TAAA. Improvement of device profile and creation of a dedicated infrarenal component are warranted to increase overall feasibility. Female gender significantly affects the overall feasibility.
Clinicaltrials.gov
NCT03959670.
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Affiliation(s)
- Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro – PUC-Rio, Rio de Janeiro, RJ, Brazil
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alessandro Grandi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Grandi A, Carta N, Cambiaghi T, Bilman V, Melissano G, Chiesa R, Bertoglio L. Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft. J Endovasc Ther 2020; 28:283-294. [DOI: 10.1177/1526602820964916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To evaluate the potential anatomical feasibility of using the off-the-shelf multibranched Zenith t-Branch for the treatment of thoracoabdominal aortic aneurysms (TAAAs) in female patients. Materials and Methods: A total of 268 patients (median age 68 years; 69 women) with degenerative TAAA treated at a single institution by means of open or endovascular repair between 2007 and 2019 were retrospectively analyzed to determine the feasibility of using the Zenith t-Branch based on the manufacturer’s instructions for use. The factors determining overall anatomical feasibility were divided into vascular access, aortic anatomy, and visceral vessels. The results were stratified by sex and compared. A logistic regression model was constructed to determine any association between feasibility and clinical factors or potential confounding variables; results are expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: The overall anatomical feasibility was 39% (22% women vs 45% men, p=0.001). The feasibility was negatively influenced by female sex (p<0.001) in multivariable analysis (OR 2.9, 95% CI 1.5 to 5.4, p=0.001). Vascular access feasibility was 82% (61% women vs 89% men, p<0.001). Aorta feasibility was 65% (52% women vs 69% men, p<0.001), and visceral vessel feasibility was 74% (78% women vs 73% men, p=0.260). An access diameter ≤8.5 mm excluded 17% of the patients (39% women vs 9% men, p<0.001). The aortic feasibility was limited by the infrarenal aortic diameter in 16% of patients (45% women vs 6% men, p<0.001) and the aortic lumen at the visceral vessels in 17% patients (19% women vs 17% men, p=0.741). The visceral vessel feasibility was mainly limited by inadequate numbers or diameters of target vessels. Location and orientation of the target vessels were adequate in 96% of patients. Conclusion: A little more than a third of an all-comers cohort of patients with degenerative TAAA could have been treated with on-label use of the Zenith t-Branch. However, only 22% of women could have been treated because of sex-related anatomical limitations. New generations of multibranched devices should address these differences.
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Affiliation(s)
- Alessandro Grandi
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX, USA
| | - Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro, Brazil
| | - Germano Melissano
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Bertoglio L, Loschi D, Grandi A, Melloni A, Bilman V, Melissano G, Chiesa R. Early Limb Reperfusion Using Routinely Preloaded Fenestrated Stent-graft Designs for Complex Endovascular Aortic Procedures. Cardiovasc Intervent Radiol 2020; 43:1868-1880. [DOI: 10.1007/s00270-020-02596-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/04/2020] [Indexed: 12/17/2022]
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Melloni A, Grandi A, Melissano G, Chiesa R, Bertoglio L. Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1084-1090. [DOI: 10.1007/s00270-020-02508-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/25/2020] [Indexed: 12/17/2022]
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