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Lindström D, Wanhainen A, Mani K, Asciutto G. Assessment of Bridging Stents in In Situ Laser Fenestrations of Aortic Endografts With Intravascular Ultrasound. EJVES Vasc Forum 2024; 61:141-144. [PMID: 38939115 PMCID: PMC11209001 DOI: 10.1016/j.ejvsvf.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 06/29/2024] Open
Abstract
Objective Treatment of complex aortic aneurysms with the in situ laser fenestration (ISLF) technique involves implantation of a balloon expandable stent graft (bSG) in the created fenestration. Adequate expansion of this bSG is of importance both to achieve seal and to ensure target vessel stability. This experimental study assessed the expansion rate of different bSGs in the ISLF setting using intravascular ultrasound (IVUS). Methods A commercially available aortic endograft was used to test the laser fenestration technique (Zenith Alpha, Cook Medical LLC, Bloomington, IN, USA). The ISLF was stented with the following bSGs: two Gore Viabahn VBX balloon expandable endoprostheses (WL Gore & Associates, Bloomington, IL, USA), three BeGraft Peripheral and three BeGraft Plus (Bentley InnoMed GmbH; Hechingen, Germany), and three Advanta V12 (Atrium, Hudson, NH, USA). The bSGs were expanded in three steps: (1) nominal, (2) rated burst pressure, and (3) dilation with a non-compliant balloon at 15 atmospheres. After each step, an IVUS assessment of the bSG minimum diameter and the area at the fenestration (FA) and in a fully expanded segment distal to the fenestration (SA) was performed. A mean of the three IVUS measurements was used as the value for comparison. An insufficient bSG expansion was defined as a mean of FA/SA of <0.8 (i.e., <80% expansion). Results The VBX was the only bSG that could be expanded to its intended diameter (i.e., at least 80%) at nominal pressure. The BeGraft Peripheral and BeGraft Plus had the lowest degree of expansion after nominal and rated burst pressure. All bSGs that were tested reached a sufficient expansion degree after using a higher pressure balloon. Conclusion In this ex vivo experiment, dilation up to nominal pressure showed satisfactory expansion only for the VBX. The consistency of the results when applied to the different types of stent grafts that were analysed reflects structural stent graft specific issues to consider when choosing the right device in cases of ISLF.
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Affiliation(s)
- David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Peri-operative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Giuseppe Asciutto
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Haulon S, Guo M, Fabre D. The steerable sheath revolution. J Vasc Surg 2024; 79:1024-1025. [PMID: 38642968 DOI: 10.1016/j.jvs.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Stéphan Haulon
- Aortic Centre Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France.
| | - Ming Guo
- Aortic Centre Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France; Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Dominique Fabre
- Aortic Centre Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
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Shehab M, Wanhainen A, Tegler G, Mani K, Kuzniar M. In situ laser fenestration of the Thoraflex Hybrid frozen elephant trunk for emergent revascularization of the left subclavian artery and laser fenestration for spinal cord perfusion. J Vasc Surg Cases Innov Tech 2024; 10:101426. [PMID: 38375347 PMCID: PMC10875571 DOI: 10.1016/j.jvscit.2024.101426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024] Open
Abstract
In situ laser fenestration (ISLF) has emerged as a promising technique for emergent revascularization of the left subclavian artery in the case of thoracic endovascular aortic repair coverage, presenting excellent technical success rates in most studies. We describe a case of ISLF of the Thoraflex Hybrid frozen elephant trunk device to achieve immediate left subclavian artery revascularization. We demonstrate the feasibility and technical success of using ISLF in this setting, providing a less invasive alternative to conventional surgical revascularization when required.
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Affiliation(s)
- Maysam Shehab
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Gustaf Tegler
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Marek Kuzniar
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Nana P, Le Houérou T, Rockley M, Guihaire J, Gaudin A, Costanzo A, Fabre D, Haulon S. Early and Midterm Outcomes of Endovascular Aortic Arch Repair Using In Situ Laser Fenestration. J Endovasc Ther 2024:15266028241234497. [PMID: 38409773 DOI: 10.1177/15266028241234497] [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: 02/28/2024]
Abstract
INTRODUCTION The aim of this study is to present single-center outcomes in patients treated with in situ laser fenestration thoracic endovascular aortic repair (LFTEVAR) for various aortic arch pathologies and assess the impact of increasing experience. METHODS The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A retrospective analysis of prospectively collected single aortic center data was conducted, including baseline information and peri- and post-operative outcomes of consecutive patients managed with LFTEVAR for aortic arch pathologies. Patients were enrolled from April 1, 2017 to January 31, 2023. The cohort was dichotomized to compare early (2017-2019) and late experience (2020-2023). Primary outcomes were peri-operative mortality and cerebrovascular morbidity. RESULTS Thirty patients were included (63.3% males, mean age 69.8±9.6 years); 21.4% presented with aortic ruptures. Aortic aneurysm involving the aortic arch was the most frequent pathology (53.3%). Forty target vessels (TVs) were revascularized, including 19 left subclavian arteries (47.5%) and 17 left common carotid arteries (42.5%). Double fenestrations were performed in 10 patients. The proximal landing zone was Ishimaru zone 0 in 5 patients (16.7%) and zone 1 in 13 patients (43.3%). Technical success was 93%. No spinal cord ischemia was recorded, and 3 patients (10%) suffered a post-operative stroke, of which 1 was major (3.3%). The median follow-up was 12 months (range=1-48 months). Thirty-day and follow-up mortality rates were 13.5% and 15.3%, respectively. Target vessel instability was 10%, of which 3.8% required reintervention. There was no statistically significant difference in outcomes between the early and late experience groups. CONCLUSIONS Laser fenestration thoracic endovascular aortic repair of the aortic arch performed in experienced aortic centers is associated with low early mortality and stroke rates. It is a safe and effective therapeutic option in patients considered unfit for open repair. CLINICAL IMPACT Custom-made devices for arch pathologies requiring urgent repair are not an option because of manufacturing delays. Off-the-shelf devices with single branch arch prostheses, and outside IFU techniques such as parallel-grafts and surgeon-modified endografts have been proposed in this setting. Another off-the-shelf alternative is in situ laser fenestration thoracic endovascular repair (LFTEVAR), which addresses many limitations of the other off-the-shelf options. Our study reports the outcomes of 30 patients treated with LFTEVAR, showing that it is a viable therapeutic option in patients considered unfit for open repair acknowledging that sufficient experience with complex endovascular aortic repair is mandatory to achieve acceptable outcomes in these high-risk patients with challenging aortic anatomies.
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Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Mark Rockley
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Julien Guihaire
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Alessandro Costanzo
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Jónsson GG, Shehab M, Wanhainen A, Mani K, Kuzniar M, Lindström D. Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm. J Endovasc Ther 2023:15266028231215976. [PMID: 38049945 DOI: 10.1177/15266028231215976] [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: 12/06/2023]
Abstract
INTRODUCTION Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. METHODS Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. RESULTS (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. CONCLUSIONS Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. CLINICAL IMPACT Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Maysam Shehab
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Marek Kuzniar
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - David Lindström
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
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Pierce FN, Raza A, McKinley H, Rathore A. Back-table fenestrated endograft limb inversion for type Ia endoleak repair. J Vasc Surg Cases Innov Tech 2023; 9:101358. [PMID: 38106341 PMCID: PMC10725063 DOI: 10.1016/j.jvscit.2023.101358] [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: 07/26/2023] [Accepted: 10/10/2023] [Indexed: 12/19/2023] Open
Abstract
We present a case of a type Ia endoleak from an aortic endograft in close proximity to the renal arteries that was successfully treated with a back-table physician-modified endograft with inversion of the contralateral limb. This modification allowed for deployment of a fenestrated cuff and bifurcated distal main body over the flow divider of the previous endograft, thus avoiding the need for either an open aneurysm repair, physician-made fenestrations, or aorto-uni-iliac repair with femoral-femoral bypass. This case demonstrates that back-table physician-modified endograft contralateral limb inversion is an easy, reproducible, and effective technique.
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Affiliation(s)
- Fletcher N. Pierce
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Ahmed Raza
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Hilary McKinley
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Animesh Rathore
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA
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Berczeli M, Sonesson B, Karelis A, Oderich GS, Dias NV. Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair. J Endovasc Ther 2023:15266028231208656. [PMID: 37902446 DOI: 10.1177/15266028231208656] [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: 10/31/2023]
Abstract
PURPOSE To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). TECHNIQUE A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. CONCLUSIONS Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. CLINICAL IMPACT Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).
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Affiliation(s)
- Marton Berczeli
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Angelos Karelis
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Division of Vascular and Endovascular Surgery, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Dias-Neto M, Vacirca A, Huang Y, Baghbani-Oskouei A, Jakimowicz T, Mendes BC, Kolbel T, Sobocinski J, Bertoglio L, Mees B, Gargiulo M, Dias N, Schanzer A, Gasper W, Beck AW, Farber MA, Mani K, Timaran C, Schneider DB, Pedro LM, Tsilimparis N, Haulon S, Sweet MP, Ferreira E, Eagleton M, Yeung KK, Khashram M, Jama K, Panuccio G, Rohlffs F, Mesnard T, Chiesa R, Kahlberg A, Schurink GW, Lemmens C, Gallitto E, Faggioli G, Karelis A, Parodi E, Gomes V, Wanhainen A, Habib M, Colon JP, Pavarino F, Baig MS, Gouveia E Melo RECD, Crawford S, Zettervall SL, Garcia R, Ribeiro T, Alves G, Gonçalves FB, Kappe KO, Mariko van Knippenberg SE, Tran BL, Gormley S, Oderich GS. Outcomes of Elective and Non-elective Fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms. Ann Surg 2023; 278:568-577. [PMID: 37395613 DOI: 10.1097/sla.0000000000005986] [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: 07/04/2023]
Abstract
OBJECTIVE To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). BACKGROUND FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. METHODS Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. RESULTS A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001). CONCLUSIONS Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.
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Affiliation(s)
- Marina Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | | | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Tilo Kolbel
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Jonathan Sobocinski
- Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM U1008, CHU Lille, France
| | - Luca Bertoglio
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
- Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Nuno Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | | | - Warren Gasper
- University of California San Francisco, San Francisco, CA
| | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Kevin Mani
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Carlos Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Luis Mendes Pedro
- Department of Vascular Surgery, Centro Hospitalar Universitário Lisboa Norte; Faculdade de Medicina da Universidade de Lisboa; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Lisbon, Portugal
| | | | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Emília Ferreira
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | | | - Fiona Rohlffs
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Thomas Mesnard
- Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM U1008, CHU Lille, France
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Geert Willem Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Charlotte Lemmens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Angelos Karelis
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Vivian Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Anders Wanhainen
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Mohammed Habib
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jesus Porras Colon
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Felipe Pavarino
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Mirza S Baig
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Ryan Eduardo Costeloe De Gouveia E Melo
- Department of Vascular Surgery, Centro Hospitalar Universitário Lisboa Norte; Faculdade de Medicina da Universidade de Lisboa; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Lisbon, Portugal
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich
| | - Sean Crawford
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Rita Garcia
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Tiago Ribeiro
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Gonçalo Alves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Frederico Bastos Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Kaj Olav Kappe
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | | | - Bich Lan Tran
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Sinead Gormley
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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Jayet J, Canonge J, Heim F, Coggia M, Chakfé N, Coscas R. Mechanical Comparison between Fenestrated Endograft and Physician-Made Fenestrations. J Clin Med 2023; 12:4911. [PMID: 37568314 PMCID: PMC10420147 DOI: 10.3390/jcm12154911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION A fenestrated endograft (FE) is the first-line endovascular option for juxta and pararenal abdominal aortic aneurysms. A physician-modified stent-graft (PMSG) and laser in situ fenestration (LISF) have emerged to circumvent manufacturing delays, anatomic standards, and the procedure's cost raised by FE. The objective was to compare different fenestrations from a mechanical point of view. METHODS In total, five Zenith Cook fenestrations (Cook Medical, Bloomington, IN, USA) and five Anaconda fenestrations (Terumo Company, Inchinnan, Scotland, UK) were included in this study. Laser ISF and PMSG were created on a Cook TX2 polyethylene terephthalate (PET) cover material (Cook Medical, Bloomington, IN, USA). In total, five LISFs and fifty-five PMSG were created. All fenestrations included reached an 8 mm diameter. Radial extension tests were then performed to identify differences in the mechanical behavior between the fenestration designs. The branch pull-out force was measured to test the stability of assembling with a calibrated 8 mm branch. Fatigue tests were performed on the devices to assess the long-term outcomes of the endograft with an oversized 9 mm branch. RESULTS The results revealed that at over 2 mm of oversizing, the highest average radial strength was 33.4 ± 6.9 N for the Zenith Cook fenestration. The radial strength was higher with the custom-made fenestrations, including both Zenith Cook and Anaconda fenestrations (9.5 ± 4.7 N and 4.49 ± 0.28 N). The comparison between LISF and double loop PMSG highlighted a higher strength value compared with LISF (3.96 N ± 1.86 vs. 2.7 N ± 0.82; p= 0.018). The diameter of the fenestrations varied between 8 and 9 mm. As the pin caliber inserted in the fenestration was 9 mm, one could consider that all fenestrations underwent an "elastic recoil" after cycling. The largest elastic recoil was observed in the non-reinforced/OC fenestrations (40%). A 10% elastic recoil was observed with LISF. CONCLUSION In terms of mechanical behavior, the custom-made fenestration produced the highest results in terms of radial and branch pull-out strength. Both PMSG and LISF could be improved with the standardization of the fenestration creation protocol.
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Affiliation(s)
- Jérémie Jayet
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Laboratoire de Physique et Mécanique Textiles (LPMT), ENSISA, 68093 Mulhouse, France
- UMR 1018, Inserm-Paris11—CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94800 Villejuif, France
| | - Jennifer Canonge
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Department of Vascular Surgery, Henri Mondor University Hospital, 94010 Créteil, France
| | - Frédéric Heim
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Laboratoire de Physique et Mécanique Textiles (LPMT), ENSISA, 68093 Mulhouse, France
| | - Marc Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
| | - Nabil Chakfé
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- Department of Vascular Surgery and Kidney Transplantation, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67084 Strasbourg, France
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92100 Boulogne-Billancourt, France (M.C.); (R.C.)
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), 67085 Strasbourg, France; (F.H.); (N.C.)
- UMR 1018, Inserm-Paris11—CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94800 Villejuif, France
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Grandi A, Melloni A, D'Oria M, Lepidi S, Bonardelli S, Kölbel T, Bertoglio L. Emergent endovascular treatment options for thoracoabdominal aortic aneurysm. Semin Vasc Surg 2023; 36:174-188. [PMID: 37330232 DOI: 10.1053/j.semvascsurg.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy.
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12
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Adam DJ, Claridge MWC. Back Table Or In Situ? Select Your Window. Eur J Vasc Endovasc Surg 2023; 65:728. [PMID: 36682402 DOI: 10.1016/j.ejvs.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Donald J Adam
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Martin W C Claridge
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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