Branched endografts for thoracoabdominal aneurysms

Endovascular Repair of Thoracoabdominal Aortic Aneurysm: A Brief Review

Thoracoabdominal aortic aneurysms (TAAAs) are complex and if untreated have high mortality and morbidity rates. Open surgical repair is the historical treatment approach; however, postoperative complications remain high with spinal cord ischemia notably one of the more serious and common complications. The avoidance of thoracotomy or laparotomy with the advent of endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have decreased the morbidity and mortality with TAAA repair, especially in patients with significant comorbidities such as a history of aortic surgery, underlying cardiac disease, and chronic obstructive pulmonary disease. Endovascular treatment options have grown to include fenestrated EVAR, multibranched EVAR, and physician-modified fenestration stent grafts. These techniques have achieved lower mortality rates than traditional open repair, but complications such as limb ischemia, spinal cord ischemia, and long-term durability must be considered. This review provides an overview of the most common endovascular techniques for TAAAs as well as short- and midterm outcomes.

Operative times and outcomes of complex endovascular repairs of thoracoabdominal aneurysms

BACKGROUND

Owing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs have become increasingly common, but still carry substantial risk. These repairs require large-bore access, with resultant pelvic and lower extremity ischemia. We, therefore, hypothesized that operative timing would be associated with outcomes, because efficient surgery would limit the ischemic time as well as anesthesia time.

METHODS

We studied all thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs (Crawford types 1, 2, 3, and 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was used to compare perioperative outcomes including mortality, thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury, major adverse cardiac events, myocardial infarction, and dialysis.

RESULTS

There were 2925 thoracoabdominal aortic aneurysm surgery with complex endovascular repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female and higher rates of prior stroke and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly used physician-modified endografts or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4- to 13-fold higher odds in the highest quartiles. SCI had the strongest association with procedure times, with seven-fold higher odds (odds ratio, 7.2; 95% confidence interval, 2.9-17.9; P < .001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR, 13.1; 95% confidence interval, 3.9-44.7; P < .001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (hazard ratio, 2.7; 95% confidence interval, 1.4-5.1; P = .002).

CONCLUSIONS

Longer operating times for complex thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs were associated with markedly higher rates of morbidity and mortality, especially SCI. These results emphasize the importance of expeditious repairs by experienced teams.

Performance of a new generation balloon expandable stent-graft (Gore VBX) as bridging stent for B-EVAR

BACKGROUND

The aim of this study was to report the results of a single-centre experience with a new generation balloon expandable stent-graft (Viabahn VBX; W. L. Gore & Associates, Flagstaff, AZ, USA) as bridging stent in branched endovascular aortic repair (B-EVAR).

METHODS

This is a retrospective single institution analysis of a prospectively maintained database. All patients undergone implantation of at least one VBX as bridging stent in B-EVAR over the last 5 years (from July 1, 2018, to November 31, 2023) were included. Primary outcomes were technical success, primary and secondary stent patency rate, branch-related reinterventions, and branch instability. Secondary outcomes were clinical success, mortality, and rate of aortic-related reinterventions.

RESULTS

This study involved 40 patients for a total of 147 VBX stent-grafts implanted in 141 target vessels as bridging stents in B-EVAR (62.5% off-the-shelf and 37.5% custom made devices; 65% with outer branches and 35% with inner branches) for the treatment of 38 (95%) degenerative and 2 (5%) postdissection aneurysms. In 28 cases (70%) a total transfemoral approach was used to deliver the bridging stents. Technical success was 100%. No target vessel was lost intraoperatively. Over a median follow-up of 26.5 months (range 0-74), primary and secondary patency, branch-related reintervention, and branch instability were 98.5% (139/141), 99.3% (140/141), 15% (6/40), and 4.9% (7/141), respectively. Four of the 7 cases of branch instability, all requiring an endovascular correction, were secondary to type Ic endoleak. Clinical success was 97.5% as effect of 1 perioperative death. During the follow-up other 6 patients died, contributing to an overall survival rate of 82.5%. The overall rate of aortic-related reinterventions was 20%.

CONCLUSIONS

Despite further evaluation is mandatory to determine durability of the VBX in the long-term after B-EVAR, in our experience VBX demonstrated a high flexibility and trackability, excellent stent retention, and outstanding patency over time. A generous distal landing of the bridging stent into the target vessel should be always achieved, whereas possible, to reduce the risk of type Ic endoleak, which seems to be the main cause of branch instability.

Comparison of branched, fenestrated, and parallel strategies for endovascular treatment of thoracoabdominal aortic pathologies involving visceral regions

Purpose

To compare the long-term efficacy of the parallel stent graft (PSG), fenestrated stent graft (FSG), and branched stent graft (BSG) techniques to treat thoracoabdominal aortic pathologies.

Materials and methods

In total, 291 patients with thoracic aortic aneurysm (TAA) and dissection (TAD) involving visceral arteries who underwent PSG (n = 85; 15 TAA and 70 TAD), FSG (n = 107; 47 TAD and 60 TAA), or BSG (n = 99; 37 TAD and 62 TAA) were included from multiple centers from January 2015 to December 2022, and a total of 1,108 visceral aortic branches were reconstructed.

Results

The average reconstruction time of each visceral aortic branch for FSG, BSG, and PSG is 27.5 ± 12.1, 23.2 ± 11.9, and 18.8 ± 11.8 min, respectively (P < 0.01). The free-from-endoleak rate at the last follow-up for FSG, BSG, and PSG was 86.9%, 91.9%, and 60.0%, respectively. The last follow-up patency rate for FSG, BSG, and PSG was 85.0%, 91.9%, and 94.1%, respectively. The average reconstruction price of each visceral aortic branch for FSG, BSG, and PSG was 41.40 ± 3.22 thousand RMB, 41.84 ± 3.86 thousand RMB, and 42.35 ± 4.52 thousand RMB, respectively (P = 0.24).

Conclusion

To treat the aortic pathologies involving the visceral segment, BSG had a lower endoleak rate and higher branch patency rate when compared with the FSG and PSG techniques. The expense of BSG was comparable to the other two techniques.

Thoracoabdominal aneurysm repair using the Unitary Manifold Device

OBJECTIVE

To present a single-center prospective study of 126 consecutively treated patients who underwent endovascular repair of a thoracoabdominal aortic aneurysm with the physician-modified, nonanatomic-based Unitary Manifold (UM) device.

METHODS

Data were collected from 126 consecutive all-comer patients treated with the physician-modified, nonanatomic-based UM from 2015 to 2023. Treatment was performed at a single center by a single physician under a Physician Sponsored Investigation Exemption G140207.

RESULTS

The UM was indicated for repair of all Crawford extents including juxtarenal, pararenal, and short-neck infrarenal aneurysms (<10 mm) in 126 consecutive patients. Patients were not excluded from the study based on presentation, extent of aneurysm or dissection, or history of a spinal cord event. Patients with a thoracoabdominal aortic aneurysm were categorized by Crawford classification: types I and V (3.3%, n = 4), type II (3.3%, n = 4), type III (1%, n = 1), and type IV (93.3%, n = 117). The type IV classification patients were further categorized with 33 (28.2%) true type IV, 68 (58.1%) pararenal or infrarenal, and 16 (13.7%) with dissection. Technical success was 99.2% (n = 125). The most common major adverse event within both 30 days and 365 days of all patients was respiratory failure (11.9%, n = 15, and 13.5%, n = 17, respectively). One patient (0.8%) experienced persistent paraplegia at 365 days. Reintervention for patients at 365 days was 5.6% (n = 7). Of the 444 branches stented, the primary patency rate was remarkably high as only three patients (2.4%) required reintervention due to loss of limb patency within 365 days. Aneurysm enlargement (≥5 mm) occurred in 1.6% (n = 2) patients, and no patients experienced aneurysm rupture. No patients underwent conversion to open repair. The aneurysm-related mortality at 365 days for all patients was 4.0% (n = 5), whereas all-cause mortality was 16.7% (n = 21). Physician-modified endograft device integrity failure was not observed in any patient.

CONCLUSIONS

The UM device demonstrated remarkable technical surgical success, treatment success, and device patency rates with very reasonable major adverse events and reintervention rates. This study is the most representative example of the general population in comparison with other studies of off-the-shelf devices, with 126 consecutive all-comer patients with diverse pathologies.

Appropriateness of care in complex fenestrated-branched aortic endografting

Fenestrated and branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms is increasingly replacing open repair as the primary modality of treatment. Mid- and long-term results are encouraging and support its use in the correct settings. Nevertheless, appropriateness of indication for treatment, patient selection, and surgeon and hospital performance has not been clearly evaluated and reviewed. The objective of this review article was to identify areas in which appropriateness of care is relevant and can be optimized when considering treatment of patients with fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms.

National trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms

INTRODUCTION

Custom-branched/fenestrated grafts are widely available in other countries, but in the United States, they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEGs). We therefore sought to determine how widespread the use of these grafts is.

METHODS

We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the Vascular Quality Initiative from 2014 to 2022 to examine temporal trends.

RESULTS

A total of 5826 repairs were performed during the study period: 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7 ± 0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256) and nearly twofold for juxtarenal repairs. In three-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFENs (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P < .001). The differences in PMEG use were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEGs and ZFENs. However, surgeons in the highest quartile of volume performed a median of 18 (interquartile range: 10-21) PMEGs/y, but only 1.6 (interquartile range: 0.8-3.4) ZFENs/y. The number of physician-sponsored investigational device exemption trials of PMEGs has expanded from 1 in 2012 to 8 currently enrolling. As those data are not included in the Vascular Quality Initiative, the true number of PMEGs is likely substantially higher.

CONCLUSIONS

PMEGs have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of investigational device exemptions. The field of endovascular aortic surgery and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes, and comparisons to custom-manufactured grafts.

How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective

A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.

Quadruple fenestration aortic stent implantation combined with unilateral IBE and internal iliac artery stent implantation for complex abdominal aortic aneurysm: one case report

An abdominal aortic aneurysm is a frequently encountered clinical condition, which necessitates prompt and effective remediation to avoid rupture. Surgeons must meticulously select an appropriate method of repair and assess the long-term surgical prognosis when dealing with patients with complex abdominal aortic aneurysms. In this case report, a 74-year-old man was hospitalized due to acute abdominal pain. Upon further examination, it was discovered that he was suffering from a complex abdominal aortic aneurysm. The thoracoabdominal aorta CTA showed that the aneurysm involved both renal arteries, the part below the kidney was severely twisted, the neck of the aneurysm was short, and it was accompanied by bilateral common iliac and internal iliac aneurysms, and there were considerable thrombus attached to the vessel wall. In this case, our team used 3D technology to simulate the spatial structure of the aneurysm and comprehensively evaluate the patient's condition. Ultimately, we decided to perform a quadruple fenestration aortic stent implantation and endovascular repair of aortic aneurysm, combined with right IBE and internal iliac artery stent implantation, right internal iliac artery reconstruction, and left internal iliac artery aneurysm embolization on this patient. This is an innovative surgical method. The operation was successful and the patient recovered well after the operation.

Successful Endovascular Treatment of an Anastomotic Pseudoaneurysm in the Ascending Aorta

We present a case of a 72-year-old-male with an ascending aortic anastomotic pseudoaneurysm following Dacron graft repair of an iatrogenic ascending aortic dissection that occurred during an open mitral valve repair, which was successfully treated with endovascular graft placement. In conclusion, this uncommon finding demonstrates a complex pathology and additional clinical examples of the versatility of endovascular stent grafts within the ascending aorta.

Mid-term Outcomes of Physician-Modified Fenestrated or Branched Endovascular Repair for Post-dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

To report the early experience and mid-term outcomes of physician-modified fenestrated or branched endovascular repair (PM-F/BEVAR) for patients with post-dissection thoracoabdominal aortic aneurysm (PD-TAAA).

METHODS

PD-TAAA patients treated with PM-F/BEVAR between December 2014 and September 2020 in our institution were retrospectively analyzed.

RESULTS

Out of the 39 patients, technical success defined as successful deployment of all stent grafts with patent target vessels (TVs) and exclusion of the lesion without type I or III endoleak was achieved in 35 patients (89.7%). A total of 126 TVs were successfully reconstructed. Thirty-day mortality was 0%. Seven major adverse events occurred including one acute kidney injury, four renal infarctions, one retroperitoneal hematoma and one left renal artery occlusion. Seven type II endoleak and three type III endoleak were detected. During a mean 29.4 ± 15.5 months follow-up period, the mortality was zero. Three renal arteries and one external iliac artery occluded in four patients. No other new onset major adverse event occurred. No patient required reintervention. One type II endoleak spontaneously resolved, while the remaining six remained stable. One early type III endoleak diminished, and one new type III endoleak occurred at 2 months. The primary patency of TV was 96.8% (120/124). Shrinkage or stability of aneurysm diameter can be observed in 38 patients (97.4%). The false lumen thrombosis rate was 89.7% (35/39).

CONCLUSIONS

The present study showed encouraging results of PM-F/BEVAR for treatment of PD-TAAAs.

LEVEL OF EVIDENCE

Level 4, Case Series.

Our experience with 1000 recent thoracoabdominal aneurysm repairs, including endovascular stenting

OBJECTIVE

Managing patients with thoracoabdominal aneurysms is demanding yet fascinating, and requires a team effort. This invited talk presents lessons learned as our history with open and endovascular procedures evolved for 2578 descending and thoracoabdominal repairs over the past 20 years.

METHODS

Beginning in 1985 with an analysis of 596 traumatic aortic ruptures and the risk of spinal cord ischemia, the evolution of research and procedures for thoracoabdominal aneurysms progressed. The focus of these studies, medication trials, and procedure adjustments was on lowering the risk of spinal cord ischemia.

RESULTS

Between January 2002 and December 2021, 2578 aneurysm repairs were performed. The respective mortality rates were 6.8% and 4.0% for all patients treated. The permanent spinal cord ischemia rates were 1.3% for open descending thoracic aortas and 4.9% for open thoracoabdominal aneurysms. A detailed analysis of open and thoracoabdominal repairs showed better long-term outcomes with open repairs.

CONCLUSIONS

Through multiple randomized trials and innovations with procedures and techniques, the risk of death and spinal cord ischemia have been reduced. Long-term survival has also been improved. The pursuit of reducing the risks of descending and ascending thoracoabdominal repairs is a fascinating endeavor that has resulted in better patient outcomes. Nevertheless, this is a journey, and there will always be more room to achieve even better results.

Outcomes of off-the-shelf multibranched stent grafts with intentional occlusion of directional branches using endovascular plugs during endovascular repair of complex aortic aneurysms

OBJECTIVE

To evaluate the technique and outcomes of intentional occlusion of directional branches (DBs) using endovascular plugs during branched endovascular aortic repair using off-the-shelf Zenith t-Branch thoracoabdominal (TAAA) stent grafts.

METHODS

We reviewed the clinical data and outcomes of all consecutive patients treated by branched endovascular aortic repair using off-the-shelf Zenith t-Branch TAAA stent-graft (Cook Medical, Bloomington, Ind) in seven academic centers from 2013 to 2019. All patients had at least one DB intentionally occluded using extension of the branch with balloon or self-expandable covered stent, followed by placement of endovascular plugs. Intentional occlusion was indicated in patients with variations in the normal four-vessel renal-mesenteric anatomy, pre-existing dialysis, or in those who failed catheterization of a target vessel. End points were 30-day/in-hospital mortality, major adverse events, secondary interventions, target artery (TA) patency, TA instability, and patient survival.

RESULTS

There were 100 patients, 65 male and 35 female, with median age of 71 years (interquartile range [IQR], 66-75 years). Of these, 31 patients (31%) had urgent/emergent operations for symptomatic/contained ruptured aneurysms. The median aneurysm diameter was 72 mm (IQR, 61-85 mm). A total of 290 renal-mesenteric arteries were incorporated with a median of three (IQR, 3-3) vessels/patient. Indications for DB occlusion were less than four suitable renal-mesenteric targets in 84 patients or pre-existing dialysis and inability to catheterize a target vessel in eight patients each. There were 110 DBs occluded by vascular plugs, including 48 celiac axis, one superior mesenteric artery, and 61 renal DBs. Thirty-day/in-hospital mortality was 10%, including 9% for elective and 13% for urgent/emergent procedures. Major adverse events occurred in 44 patients (44%), including acute kidney injury in 19 patients (19%), estimated blood loss >1 L in 12 patients (12%), respiratory failure and new onset dialysis in six patients (6%) each, bowel ischemia in five patients (5%), and myocardial infarction and paraplegia in two patients (2%) each. The median follow-up was 5 months (range, 1-13 months). Eighteen patients (18%) required secondary interventions, none for problems related to the occluded DB. There were no endoleaks related to the occluded DB. At 2 years, primary and secondary patency and freedom from TA instability were 93% ± 3%, 97% ± 2%, and 91% ± 4%, respectively. Freedom from secondary interventions and patient survival were 75% ± 6% and 63% ± 7%, respectively.

CONCLUSIONS

Intentional occlusion of DBs using endovascular plugs allows versatile use of a four-vessel off-the-shelf multi-branched TAAA stent graft in patients with variations in the normal renal and mesenteric anatomy or when technical difficulties prevent successful target vessel stenting. There were no endoleaks or secondary interventions associated with the occluded DB.

Meta-analysis of Comparative Studies Between Self- and Balloon-Expandable Bridging Stent Grafts in Branched Endovascular Aneurysm Repair

PURPOSE

Currently there is no robust evidence which type of bridging stent graft provides better outcomes after branched endovascular aortic repair (BEVAR). Self-expanding (SESG) and balloon-expandable (BESG) stent grafts are both commonly used to connect branches to their respective target vessels (TV). The aim of the current review was to evaluate the impact of the type of bridging stent grafts on TV outcomes during the mid-term follow-up after BEVAR.

MATERIALS AND METHODS

The study protocol was registered to the PROSPERO (CRD42021274766). A search of the English literature was conducted, using PubMed and EMBASE databases via Ovid and Cochrane database via CENTRAL, from inception to June 30, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Only comparative studies on BEVAR reporting TV outcomes related to BESG vs SESG were considered eligible. Individual studies were assessed for risk of bias using the Newcastle Ottawa Scale. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcomes were primary patency, freedom from endoleak, TV instability, and re-intervention between BESG and SESG, used as bridging stents in branches. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis.

RESULTS

Five out of 609 articles published from 2016 to 2020 were included in the analysis. In total, 1406 TV were revascularized, 547 (38.9 %) with BESGs and 859 with SESGs. The overall pooled primary patency (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.29-1.09; p=.256, I²=4.24%) and freedom from branch-related endoleak (OR, 0.65; 95% CI, 0.17-1.48; p<.122, I²=0.18%) did not differ between the stent types during the available follow-up (17 months, range = 12-35 months). In 4 studies (619 TV), SESG required fewer secondary interventions (OR, 1.04; 95% CI, 0.23-1.83; p=.009, I²=0%) and TV instability rate was lower (OR, 0.99; 95% CI, 0.33-1.65; p=.003, I²=0%) compared with BESG during the available follow-up.

CONCLUSION

BESG and SESG seem to perform similarly in terms of primary patency and branch-related endoleak during the mid-term follow-up. Current data from retrospective studies suggest that overall TV instability and re-intervention rates are favorable for SESG as bridging stent grafts in BEVAR.

Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

PURPOSE

The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR).

MATERIALS AND METHODS

All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis.

RESULTS

A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18).

CONCLUSION

The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.

Fenestrated Endovascular Aortic Repair With Chimney Graft for Thoracoabdominal Aneurysm

Thoracoabdominal aneurysms pose technical challenges for endovascular repair due to involvement of visceral and renal vessels. We report a case series of four patients diagnosed with thoracoabdominal aneurysm who underwent complex endovascular repair with Fenestrated Device and chimney grafts (FEVARCh). FEVARCh is a technically feasible approach for repair of thoracoabdominal aneurysms that involve renal, superior mesenteric, and celiac arteries for patients not appropriate for open surgical repair. Further studies are needed to understand the implications of resultant Type 1a endoleaks and strategies to minimize the displacement of the main body graft with adjunct chimneys.

Impact of gap distance between fenestration and aortic wall on target artery instability following fenestrated-branched endovascular aortic repair

OBJECTIVE

Target artery (TA) instability is the most frequent indication for secondary intervention following fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to evaluate the impact of gap distance between the endograft reinforced fenestration and TA origin at the aortic wall (fenestration gap, FG) on target-related outcomes following FB-EVAR.

METHODS

Clinical data and imaging of 430 patients enrolled in a prospective, non-randomized study to evaluate FB-EVAR using manufactured stent-grafts were reviewed. Three hundred and forty patients (79%) had >1 vessel incorporated by fenestration. FG distance was retrospectively measured on postoperative imaging and classified into three groups: no gap (FG=0 mm), FG distance 1-4 mm, and FG≥5 mm. Primary outcome was freedom from TA instability. Secondary endpoints included TA-related endoleak, TA secondary intervention, and TA patency.

RESULTS

A total of 1558 renal-mesenteric TAs were incorporated by 1104 reinforced fenestrations and 454 directional branches (DBs), with a mean of 3.9±0.5 vessels per patient. Mean FG distance was 2.8±4.5mm with FG distance of 0mm for 646 TAs, 1-4mm for 209 TAs, and ≥5mm for 249 TAs. FG distance ≥5mm was associated with significantly lower (p<.001) freedom from TA instability, type IC/IIIC endoleak, and secondary interventions at 5-years. As compared to DBs, fenestrations with FG ≥5mm had similar primary patency and freedom from TA instability, but significantly lower freedom from type IC/IIIC endoleak (91±2 vs 95±1%, log rank=0.02) and secondary interventions (87±3% vs 93±2%, log rank=0.02) at 5-years. Independent predictors of TA instability included post-dissection TAAAs (HR 2.5; 95% CI 1.2-5.4) and FG distance ≥5mm (HR 1.6; 95% CI 1.2-1.8). TAs incorporated by reinforced fenestrations had higher primary (99±0.8% vs 97±1.0%, p=.039) and secondary patency rates (100% vs 98±1.0%, p=.012) at 5-years compared DBs, with the lowest primary patency observed for renal DBs (80±6% v 92±2% p=.008).

CONCLUSION

FG distance ≥5mm was independently associated with increased risk of TA instability, type IC/IIIC endoleaks, and secondary interventions in patients treated by FB-EVAR using fenestrated designs. Targets incorporated by DBs have lower 5-year primary and secondary patency as compared to those with reinforced fenestrations, with the lowest 5-year patency of 80% for renal branches. As compared to DBs, fenestrations with FG ≥5mm carried higher risk of type IC/IIIC endoleak and secondary interventions. Independent predictors of TA instability included post-dissection TAAAs and greater FG distance, whereas dual antiplatelet therapy and larger TA diameters were protective.

Ulcer-like projections into the dilated false lumen after stent-graft placement for aortic dissection: A case report

RATIONALE

Acute type A aortic dissection and chronic type B aortic dissection (TBAD) occurs simultaneously in rare cases. Although the development of ulcer-like projection (ULP) is associated with an increase in adverse aorta-related events, the false-lumen enlargement caused by the ULP progression is uncommon.

PATIENT CONCERNS

A 72-year-old female with chronic TBAD was admitted to our unit with back and chest pain. Computed tomography revealed acute type A aortic dissection and a hematoma caused by rupturing of the descending aorta due to chronic TBAD. After endovascular intervention, the false lumen thrombosed and shrunk.

DIAGNOSIS

After 9 months, a developing ULP, which projected into a dilating false lumen, was found. An impending ruptured descending aortic aneurysm was confirmed.

INTERVENTIONS

Emergency Total arch replacement and thoracic endovascular aortic repair (TEVAR) was performed.

OUTCOMES

The procedure was successful. One year later, regular follow-up showed that the false lumen had completely shrunk.

LESSONS

ULP can arise and cause progressive dilation of false lumen after TEVAR. Careful and regular computed tomography examinations are required for early diagnosis of false lumen becoming thrombosed after TEVAR. Close follow-up and timely intervention, including TEVAR, should be considered in cases of aortic enlargement due to a newly developed ULP.

Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies

PURPOSE

To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms.

TECHNIQUE

We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography.

CONCLUSION

Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.

Multi-staged endovascular repair of thoracoabdominal aneurysms by fenestrated and branched endografts

AIM

To report outcomes of a multi-staged approach for endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) by fenestrated/branched endografting (F/B-EVAR).

METHODS

Between 2010 and 2020 (June), patients undergoing F/B-EVAR for TAAAs were collected. Data of cases managed by a multi-staged approach, to reduce the incidence of spinal cord ischemia (SCI), were retrospectively analyzed and reported in a cohort study. Thirty-day mortality and SCI were assessed as study's outcomes.

RESULTS

One hundred and thirty-seven patients underwent TAAAs repair by F/B-EVAR. A multi-staged approach was applied in 73(53%) cases, more frequently for Crawford's extent I-III (60/78) compared with IV (13/59) (P: <.0001). A complete TAAAs exclusion was achieved in 2, 3 or 4 steps in 64(88%), 8(11%) and 1(1%) cases, respectively, within the same hospitalization in 68(93%) cases. The mean time between first and last step was 16±8days, with a mean hospital stay of 21±12days. In 3(4%) cases the complete TAAA repair was not achieved due to inter-steps mortality (2) or permanent paraplegia (1). There were no cases of aortic rupture or target visceral vessels occlusions between the different steps. Seven (10%) patients suffered postoperative SCI with 2(4%) cases of permanent paraplegia. In 5/7 cases SCI occurred after the first stage; in 3/5 cases TAAAs exclusion was successfully completed with total SCI recovery. The 30-day mortality was 4% (3/73).

CONCLUSION

A multi-staged endovascular repair with F/B-EVAR can be safely performed for TAAAs repair. The majority of cases can be treated within a single, long hospitalization. The cost/effectiveness of the prolonged in-hospital time should be evaluated.

Early outcomes of t-Branch off-the-shelf multibranched stent-graft in urgent and emergent repair of thoracoabdominal aortic aneurysms

OBJECTIVE

We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent-graft (Cook Medical, Bloomington, Ind).

METHODS

All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests.

RESULTS

The t-Branch stent-graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively.

CONCLUSIONS

The technical success of TAAA repair using t-Branch stent-graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation.

Impact of Cone Beam Computed Tomography in Advanced Endovascular Aortic Aneurysm Repair Using Last Generation 3D C-arm

BACKGROUND

To report the early outcomes of cone beam computed tomography (CBCT) using last generation 3D C-arm in patients undergone advanced endovascular aortic aneurysm repair (AdEVAR) and to identify risk factors that may predict any un-planned procedures.

METHODS

Patients undergone AdEVAR between December 2017 and December 2018 were enrolled. Final CBCT was performed in all patients after digital subtraction angiography. Primary end points were the incidence of any positive findings and the following unplanned procedures intended as any endovascular manoeuvre performed to fix such technical defect. The secondary endpoints were comparison of outcomes between patients with positive findings undergone unplanned procedure (Group A) versus patients without findings (Group B).

RESULTS

132 patients underwent endovascular treatment for aortic aneurysm. Of these, 22 (33%) fenestrated-branched endovascular aneurysm repairs (F-BEVAR), 21 (29%) EVAR with iliac branch devices, 19 (26%) abdominal and 10 (14%) thoracic EVAR were included in the study. Unplanned procedures after CBCT were necessary in 22 patients (31%). Patients in both groups were similar excepted for BMI >25 kg/m² (55% vs. 26%), hostile iliac anatomy (64% vs. 32%) and previous aortic treatment (73% vs. 32%) (P < 0.05). The odds ratios for unplanned procedure in case of previous aortic treatment was 6.76 (95% CI, 1.97-23.16; P = 0.002).

CONCLUSION

The use of CBCT, especially in challenging scenarios, can reveal technical defects and may potentially limit the need for late reintervention. Patients undergone previous aortic surgery should be carefully evaluated and routine CBCT should be performed.

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

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.

The Early Outcomes of BeGraft Peripheral Plus in Branched Endovascular Repair of Thoracoabdominal Aneurysms

OBJECTIVE

No bridging stent-graft (BSG) has been specifically designed for branched endovascular aortic repair (BEVAR) and therefore different "off-label" stent-grafts have been used. Recently, a third generation of balloon-expandable stent-graft has become available. Here we evaluate the outcomes of the BeGraft Peripheral Plus (B+) used as a BSG for internal/externalor inner branches during BEVAR.

MATERIALS AND METHODS

Consecutive patients undergoing BEVAR using B+ as a BSG since its release in 2017 were included into the study. The primary endpoints were technical success and target vessel patency during follow-up. Secondary endpoints included the need for adjunct extension and relining of the BSG, branch instability rate, including occlusion, reinterventions for restonosis, kink, fracture, or endoleak (types 1 and 3).

RESULTS

A total of 163 visceral branches in 46 patients were included with a median follow-up 15 months (4-36 months). Primary technical success was achieved in all visceral branches (69 inner branches and 94 internal/external branches) with the exception of 1 BSG that required serial dilatation until full expansion was achieved with overall branch patency was 98% at 2 years. An additional stent-graft was necessary in 35 branches (21%) following deployment of a B+ BSG to cover a longer bridging distance and optimize the distal and proximal sealing. Relining of B+ BSG was not routinely carried out during the index procedure and a self-expanding uncovered nitinol stent was necessary in only 3% of branches to smooth the distal transition zone between the BSG and target vessel. There were 4 events (2.4%) of branch related instability, including 2 occlusions and 2 late reinterventions for a partial in-stent-graft thrombosis.

CONCLUSION

Our study findings show satisfactory early outcomes of B+ as a BSG in BEVAR with low occlusion and reintervention rates. Extensions of BSG might be required to achieve adequate seal in the target vessels but routine relining BSG in branches was not required.

Selective Versus Routine Spinal Drain Use for Fenestrated/Branched Endovascular Aortic Repair (F-BEVAR)

BACKGROUND

Spinal drains are used to ameliorate spinal cord ischemia (SCI), but their use may result in inherent morbidity and mortality. Although prophylactic spinal drain has proven of benefit in open repairs, that is not the case for endovascular repairs. The aim of this study was to assess the outcomes of spinal cord protection with and without the routine use of spinal drains during fenestrated-branched endovascular repair (F-BEVAR).

METHODS

A retrospective single center study was performed using a prospectively maintained dataset of all patients undergoing F-BEVAR over a 4-year period. The primary endpoint of the study was the frequency of SCI. Prophylactic spinal drain was placed pre-operatively in 33 patients (23%) with a median time for removal of 3 days (IQR, 2-3 days). Routine intraoperative neuromonitoring was used. Spinal cord protection relied primarily on maintaining a perioperative systolic blood pressure between 140 and 160 mm Hg or a mean arterial pressure >90 mm Hg, avoiding hypotension, preservation of as many collateral beds as possible, staged repairs and early lower extremity reperfusion based on neuromonitoring.

RESULTS

A total of 145 patients, 104 men (71%) and 41 women (28%) with a median age of 70 years (interquartile range [IQR], 53-62) underwent F-BEVAR. Branched custom-made devices (CMDs) (11%), fenestrated CMDs (70%) and off-the-shelf T-Branch device (17%) were used with a median number of branches/fenestrations of 4 (IQR, 3-4). SVS classification of implantation zones were determined as follows: 9 (6%) zone 2, 21 (20%) zone 3, 26 (18%) zone 4 and 89 (61%) zone 5. SCI was present in 8 patients (5.5%) and classified according to the SVS SCI grading system as follows: 1 grade 1, 5 grade 2 and 2 grade 3a. When evaluating implantation zone independently of coverage length and patency of collateral beds, a high implantation zone (1-4) was not associated with SCI (P = 0.9). Similarly, prophylactic spinal drain did not demonstrate association with the occurrence of SCI (3[9%] vs. 5[4%], with and without spinal drain, respectively) (P = 0.3). For patients with high implantation zones, staged repair was performed in 38 patients (26%) at a median time of 2 months (IQR, 2-6 months). Among these patients, the frequency of SCI was 13%. Staged repair was associated with an 80% reduction in the frequency of SCI (OR, 0.19 [95% CI, 0.04-0.084]) (P = 0.02).

CONCLUSION

F-BEVAR can be performed with a minimal risk of SCI without the need for routine prophylactic spinal drains. High implantation zones did not predict SCI after F-BEVAR; however, staged repair significantly decreased the risk of SCI after F-BEVAR.

Insights on Bridging Stent Grafts in Fenestrated and Branched Aortic Endografting

Major branches of the aortic arch and visceral aorta pose a particular challenge for endovascular repair of aneurysms involving these regions. To preserve perfusion through these essential branches, fenestrated and branched endografts have been used. Current fenestrated and branched aortic endografts have evolved into modular devices in which the aortic main body provides appropriate access to the target branch vessel either through reinforced fenestrations or directional cuffs as the hinge point for bridging stent grafts (BSGs). BSGs are used to connect the aortic main body and target branch vessel, and must provide both unhindered flow and a seal. Appropriate selection of BSG for target vessels in branched and fenestrated endovascular aortic repair is critical for technical success and durability. At present, there are no dedicated devices for use as BSGs, and a variety of stent grafts are currently used off-label. In this report, we review the available published series on the performance of presently available BSGs in relation to their design and selection.

Pre and postoperative predictors of clinical outcome of fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms in an Italian multicenter registry

OBJECTIVE

Complex aortic aneurysms (juxtarenal j-AAA, pararenal p-AAAs, thoracoabdominal TAAAs) are treated with increasing frequency through fenestrated and branched endovascular repair (F/B-EVAR), however the outcome of these procedures is usually reported separately by single experiences and wider overviews are not frequent. The aim of this study was therefore to report an Italian experience analyzing the results obtained in 4 academic centers in order to evaluate predictors of outcome.

METHODS

Between 2008 and 2019, all consecutive patients undergoing F/B-EVAR in 4 Italian university centers were prospectively recorded and retrospectively analyzed. Preoperative comorbidities and postoperative complications were classified according with the SVS-reporting standard. Postoperative complications and 30-day / in-hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions (FFRs) and target visceral vessels (TVVs) patency were assessed as follow-up outcomes by Kaplan-Meier analysis. Risk factors for 30-day / in-hospital mortality and spinal cord ischemia (SCI) were determined by multivariate analysis. Risk factors for follow-up mortality and reinterventions were evaluated by Cox-regression model.

RESULTS

Five hundred and ninety-six patients underwent F/B-EVAR for 124(21%) j-AAAs, 121(20%) p-AAAs and 351(59%) TAAAs. Elective and urgent procedures were performed in 520(87%) and 76(13%) cases, respectively. Postoperative cardiac, pulmonary and renal complications were reported in 41(7%), 50(8%) and 80(13%) patients, respectively. Seven (1%) bowel ischemia and 23(4%) cerebrovascular complications occurred. Forty-seven (8%) patients suffered SCI with 17(3%) cases of permanent paraplegia. Crawford's extent I-II-III TAAAs (OR:13.41; 95%CI:1.77-101.65; P=.012) and postoperative renal complications (OR:3.84; 95%CI:1.70-8.69; P=.001) independently predicted SCI. Thirty-two (5%) patients died in the perioperative period. Preoperative chronic renal failure (OR:7.81; 95%CI:7.81-26.31; P=.001), postoperative bowel ischemia (OR:26.97; 95%CI:3.37-215.5; P=.002), cardiac (OR:5.77; 95%CI:1.41-23.64; P=<.001),cerebrovascular (OR:28.63; 95%CI:5.20-157.5; P:<.001) complications and SCI (OR:5.99; 95%CI:1.12-32.5; P=.036) were independently correlated with 30-day/hospital mortality. The mean follow-up was 25+7months. Freedom from TVVs occlusion and FFR were 96% and 92% at 1 year and 93% and 85% at 3 years, respectively. TAAAs (HR:3.16; 95%CI:1.68-5.92; P=<.001), post dissection TAAAs (HR:2.20; 95%CI:1.30-4.90; P=.05) and postoperative bowel ischemia (HR:11.98; 95%CI:1.53-93.31; P=.018) were independent predictors of reinterventions. Survival was 88% and 78% at 1 and 3 years, respectively. Preoperative chronic renal failure (HR:2.39; 95%CI:1.59-3.59; P=<.001), urgent repair (HR:1.80; 95%CI:1.03-3.20; P=.039), TAAAs (HR:2.01; 95%CI:1.13-3.56; P=.017),postoperative bowel ischemia (HR:5.55; 95%CI:2.11-14.59; P=.001), cardiac (HR:3.89; 95%CI:2.25-6.71; P=<.001) and pulmonary (HR:1.97; 95%CI:1.56-3.35; P=.013) complications were independent predictors of mortality during follow up.

CONCLUSION

F/B-EVAR is associated with satisfactory mid-term outcomes in a nationwide experience. A variety of risk factors should be considered in FB-EVAR indication and post-operative patients management in order to reduce the risk of postoperative complications and improve mid-term outcome.

Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair

OBJECTIVE

Complex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR).

METHODS

All patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined.

RESULTS

A total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm² (range, 8260-55,070 dGycm²). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non-aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months).

CONCLUSIONS

The use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.

T Branch Repair of Ruptured a Type IV Thoracoabdominal Aortic Aneurysm Complicated by Renal Branch Occlusion

A 60-year male patient presented with a thoracoabdominal aortic aneurysm rupture, which was treated emergently with a modified off-the-shelf t-Branch stent-graft (COOK Medical Inc). The sole renal branch occluded 1 month after TEVAR due to branch compression, and the patient became anuric and temporarily dialysis-dependent. Despite the prolonged renal ischemia time, the occluded renal branch was successfully opened with thrombolysis and reinforced with a bare-metal stent. The patient recovered his renal function and came off dialysis.

Neurologic complications of diseases of the aorta

Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.

Physician-Modified Branched Double-Trunk Stent-Graft (PBDS) for Thoracoabdominal Aortic Aneurysm

PURPOSE

To describe the preliminary experience of using physician-modified, branched, double-trunk stent-grafts (PBDS) for treating thoracoabdominal aortic aneurysms (TAAA).

MATERIALS AND METHODS

Ten (10) patients with TAAA were included in the study from June 2017 to March 2020. The technical success, perioperative complications, re-intervention, and patency of branch arteries were assessed.

RESULTS

The technical success rate was 100%. There were four type III endoleaks (40%) recorded in the perioperative period. The median follow-up was 13.4 months (range, 3-36 months). During follow-up, two renal stent-graft occlusions (2 of 37 visceral arteries reconstructed, 5.4%), one cerebral infarction (1 of 10, 10%) and one paraplegia (1 of 10, 10%) occurred. No aortic-related death was recorded.

CONCLUSION

PBDS is useful in sealing TAAA and preventing visceral branches, providing an option for patients unsuited for open surgical repair. A larger sample size of patients is required to confirm the safety and effectiveness of this technique.

Total Percutaneous Femoral Approach for Branched Custom-Made Device Endovascular Repair of Thoracoabdominal Aneurysm

Thoracoabdominal aortic aneurysm (TAAA) is a challenging vascular condition to manage. Traditionally, open surgical repair has been the standard of treatment. Endovascular repair for TAAA has gained much popularity because it is a minimally invasive approach that results in better mortality and morbidity profiles. We report a case of TAAA successfully treated with a custom-made multi-branch device through a total femoral approach with the use of a steerable sheath for branch cannulation and deployment of bridging stents to targeted visceral vessels. This approach avoided complications related to upper extremity access, such as stroke, and allowed shorter operative time with better workstation ergonomics.

Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape

Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.

Performance of Viabahn balloon-expandable stent compared with self-expandable covered stents for branched endovascular aortic repair

OBJECTIVE

The objective of this study was to compare the performance between the Viabahn balloon-expandable stent (VBX; Viabahn [W. L. Gore & Associates, Flagstaff, Ariz]) and a covered self-expandable stent (SES; Fluency [Bard Peripheral Vascular, Tempe, Ariz]) used as bridging stents for directional branches during fenestrated or branched endovascular aneurysm repair of complex aortic aneurysms.

METHODS

Patients with thoracoabdominal aortic aneurysms (type I-IV) or pararenal aortic aneurysms either at high risk for open repair or unsuitable for endovascular repair with commercially available devices were prospectively enrolled in a physician-sponsored investigational device exemption trial. Descriptive statistics of the cohort included demographics, risk factors, and anatomic and device characteristics. Individual branches were grouped as either VBX or SES and had data analyzed for primary patency, branch-related type I or type III endoleaks, branch instability, branch-related secondary intervention, and branch-related aortic rupture or death. Categorical variables were expressed as total and percentage, and continuous variables were expressed as median (interquartile range). Kaplan-Meier curves were used to estimate long-term results. Groups were compared with the log-rank test. P value <.05 was considered statistically significant.

RESULTS

During the period from July 2012 through June 2019, there were 263 patients treated for complex aortic aneurysm (thoracoabdominal aortic aneurysm) with fenestrated or branched endografts. The devices used were either custom-manufactured devices or off-the-shelf p-Branch or t-Branch (Cook Medical, Bloomington, Ind) devices. The median age was 71 years (interquartile range, 66-79 years); 70% were male, and 81% were white. The most common cardiac risk factors were smoking (92%), hypertension (91%), hyperlipidemia (78%), and chronic obstructive pulmonary disease (52%). The total number of vessels incorporated into the repair was 977, with branches representing 18.4% (179 branches). Among these 179 branches, the celiac artery, superior mesenteric artery, right renal artery, and left renal artery received 54 (30%), 56 (31%), 38 (21%), and 31 (18%) branches, respectively. VBX and SES groups represented 96 (54%) and 81 (46%) of the branches implanted. The celiac artery, superior mesenteric artery, right renal artery, and left renal artery received VBX as a bridging stent in 40%, 46.7%, 33.8%, and 32.2% respectively. The overall cohort survival rate was 78.5% at 24 months. There was no branch-related rupture or mortality. Primary patency at 24 months (VBX, 98.1%; SES, 98.6%; log-rank, P = .95), freedom from endoleak (VBX, 95.6%; SES, 98.6%; log-rank, P = .66), freedom from secondary intervention (VBX, 94.7%; SES, 98.1%; log-rank, P = .33), and freedom from branch instability (VBX, 95.6%; SES, 97.2%; log-rank, P = .77) were similar between groups.

CONCLUSIONS

This initial experience with VBX stents demonstrated excellent primary patency and similarly low rates of branch-related complications and endoleaks, with no branch-related aortic rupture or death. Our results demonstrate that in a high-volume, experienced aortic center, the VBX stent is a safe and effective bridging stent option during branched endovascular aortic repair. Multicenter studies with a larger cohort and longer follow-up are necessary to validate these findings.

Dual fluoroscopy with live-image digital zooming significantly reduces patient and operating staff radiation during fenestrated-branched endovascular aortic aneurysm repair

OBJECTIVE

Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) is a complex procedure that generates high radiation doses. Magnification aids in vessel cannulation but increases radiation. The aim of the study was to compare radiation doses to patients and operating room staff from two fluoroscopy techniques, standard magnification vs dual fluoroscopy with live-image digital zooming during F/B-EVAR.

METHODS

An observational, prospective, single-center study of F/B-EVAR procedures using Philips Allura XperFD20 equipment (Philips Healthcare, Amsterdam, The Netherlands) was performed during a 42-month period. Intravascular ultrasound, three-dimensional fusion, and extreme collimation were used in all procedures. Intraoperative live-image processing was performed with two imaging systems: standard magnification in 123 patients (81%) and dual fluoroscopy with live-image digital zooming in 28 patients (18%). In the latter, the live "processed" zoomed images are displayed on examination displays and live images are displayed on reference displays. The reference air kerma was collected for each case and represents patient dose. Operating staff personal dosimetry was collected using the DoseAware system (Philips Healthcare). Patient and staff radiation doses were compared using nonparametric tests.

RESULTS

Mean age was 71.6 ± 11.4 years. The median body mass index was 27 kg/m² (interquartile range [IQR], 24.4-30.6 kg/m²) and was the same for both groups. Procedures performed with dual fluoroscopy with digital zooming demonstrated significantly lower median patient (1382 mGy [IQR, 999-2045 mGy] vs 2458 mGy [IQR, 1706-3767 mGy]; P < .01) and primary operator radiation doses (101 μSv [IQR, 34-235 μSv] vs 266 μSv [IQR, 104-583 μSv]; P < .01) compared with standard magnification. Similar significantly reduced radiation doses were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with dual fluoroscopy. According to device design, procedures performed with four-fenestration/branch devices generated higher operator radiation doses (262 μSv [IQR, 116.5-572 μSv] vs 171 μSv [IQR, 44-325 μSv]; P < .01) compared with procedures with three or fewer fenestration/branches. Among the most complex design (four-vessel), operator radiation dose was significantly lower with digital zooming compared with standard magnification (128.5 μSv [IQR, 70.5-296 μSv] vs 309 μSv [IQR, 150-611 μSv]; P = .01).

CONCLUSIONS

Current radiation doses to patients and operating personnel are within acceptable limits; however, dual fluoroscopy with live-image digital zooming results in dramatically lower radiation doses compared with the standard image processing with dose-dependent magnification. Operator radiation doses were reduced in half during procedures performed with more complex device designs when digital zooming was used.

Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair

OBJECTIVE

The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair.

METHODS

A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded.

RESULTS

There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively.

CONCLUSIONS

The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.

Sizing and planning fenestrated and branched stent-grafts in patients with chronic post-dissection thoracoabdominal aortic aneurysms

Fenestrated-branched endovascular repair (FB-EVAR) has been widely applied to treat chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) with favorable outcomes. A recent multicenter experience indicates that outcomes of FB-EVAR for chronic post-dissection are comparable to degenerative TAAAs. Anatomical and technical pitfalls are different than degenerative aneurysms because of true lumen compression, separate target vessel origin from true or false lumen and possible extension of dissection flaps into the renal and mesenteric vessels. This article focuses on planning and sizing FB-EVAR in patients with chronic post-dissection TAAAs.

Endovascular Treatment for Thoracoabdominal Aortic Aneurysm and Complex Abdominal Aortic Aneurysm Using Fenestrated and Branched Grafts

Fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is a less invasive treatment for thoracoabdominal aortic aneurysm (TAAA) and complex abdominal aortic aneurysm. Fenestrated and branched (cuff) grafts facilitate safe and durable repair, and bail-out maneuvers for target vessel cannulation and stenting have been established; however, the available bridging stent grafts have differences. The present article discusses the optimal selection of fenestrated or branched grafts, the cannulation of target vessels that have difficult anatomies, and the advantages and disadvantages of various bridging stents. We review the causes and risk factors of spinal cord injury (SCI), the protocol for prevention of SCI, and the outcomes of target vessel stent grafting, including patency and endoleak.

Although conventional open surgery is the gold standard for the repair of thoracoabdominal aortic aneurysm (TAAA), it is highly invasive. To reduce invasiveness, hybrid surgery that combines open surgery and endovascular therapy has been developed [1, 2], and fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is frequently performed at centers in the USA, Europe, and Japan [3-5]. Additionally, a hostile neck may be an independent factor for sac enlargement after EVAR for abdominal aortic aneurysm (AAA) [6], but a previous study reported that 41% of AAA cases presented with neck lengths outside the range prescribed by the traditional instruction for use [7]. Stark et al. showed that extending the graft above the highest renal artery would create an augmented neck length in 90% of patients with AAA [7]. F/B-EVAR is based on this principle. However, there are some technical tips for, and limitations of, fenestrated and/or branched graft. F/B-EVAR for TAAA and complex AAA will be reviewed in the present article.

Outcomes of endovascular repair of chronic postdissection compared with degenerative thoracoabdominal aortic aneurysms using fenestrated-branched stent grafts

OBJECTIVE

The objective of this study was to analyze outcomes of fenestrated-branched endovascular aneurysm repair (F/BEVAR) for treatment of postdissection and degenerative thoracoabdominal aortic aneurysms (TAAAs).

METHODS

We reviewed the clinical data of 240 patients with extent I to extent III TAAAs enrolled in seven prospective physician-sponsored investigational device exemption studies from 2014 to 2017. All patients had manufactured off-the-shelf or patient-specific fenestrated-branched stent grafts used to target 888 renal-mesenteric arteries with a mean of 3.7 vessels per patient. End points included mortality, major adverse events (any-cause mortality, stroke, paralysis, dialysis, myocardial infarction, respiratory failure, bowel ischemia, and estimated blood loss >1 L), technical success, target artery patency, target artery instability, occlusion or stenosis, endoleak, rupture or death, reintervention, and renal function deterioration.

RESULTS

There were 50 patients (21%) treated for postdissection TAAAs and 190 (79%) who had degenerative TAAAs. Postdissection TAAA patients were significantly younger (67 ± 9 years vs 74 ± 8 years; P < .001), were more often male (76% vs 52%; P = .002), and had more prior aortic repairs (84% vs 67%; P = .02) and larger renal (6.4 ± 1.2 mm vs 5.8 ± 0.9 mm; P < .001) and mesenteric (8.9 ± 1.7 mm vs 7.8 ± 1.4 mm; P < .001) target artery diameters. There was no difference in aneurysm diameter (66 ± 13 mm vs 67 ± 11 mm; P = .50), extent I or extent II TAAA classification (64% vs 56%; P = .33), and length of supraceliac coverage (22 ± 9.5 cm vs 20 ± 10 cm; P = .38) between postdissection and degenerative patients, respectively. Preloaded guidewire systems (66% vs 43%; P = .003) and fenestrations as opposed to directional branches (58% vs 24%; P < .001) were used more frequently to treat postdissection patients. Technical success was 100% for postdissection TAAAs and 99% for degenerative TAAAs (P = .14). At 30 days, there was no difference in mortality (2% postdissection, 3% degenerative), major adverse events (24% postdissection, 26% degenerative; P = .73), spinal cord injury (6% postdissection, 12% degenerative; P = .25), paraplegia (2% postdissection, 7% degenerative; P = .19), and dialysis (0% postdissection, 5% degenerative; P = .24). Mean follow-up was 14 ± 12 months. Endoleaks were significantly more frequent in patients with postdissection TAAAs (76%) compared with degenerative TAAAs (43%; P < .001). At 2 years, there was no difference in patient survival (84% ± 7% vs 72% ± 4%; P = .13), freedom from aorta-related death (98% ± 2% vs 94% ± 2%; P = .45), primary (95% ± 2% vs 97% ± 1%; P = .93) and secondary target artery patency (99% ± 1% vs 98% ± 1%; P = .48), target artery instability (89% ± 3% vs 91% ± 1%; P = .17), and freedom from reintervention (58% ± 10% vs 67% ± 5%; P = .23) for postdissection and degenerative TAAAs, respectively.

CONCLUSIONS

Despite minor differences in demographics, anatomic factors, and stent graft design, F/BEVAR was safe and effective with nearly identical outcomes in patients with postdissection and degenerative TAAAs. Larger clinical experience and longer follow-up are needed to better evaluate differences in mortality, spinal cord injury, target artery instability, and reintervention.

Endovascular Repair Using a 7-Branch Stent-Graft for a Thoracoabdominal Aortic Aneurysm With Variant Renovisceral Artery Anatomy

Purpose: To present a case of endovascular repair using a custom-made 7-branch stent-graft for a thoracoabdominal aortic aneurysm (TAAA) in a patient with variations in the renovisceral artery anatomy. Case Report: A 70-year-old asymptomatic man presented with a 60-mm-diameter type IV TAAA. Due to severe coronary artery disease, an endovascular approach was elected. In the preoperative computed tomography angiography (CTA) scans, variations in the renovisceral artery anatomy included the common hepatic and splenic arteries deriving separately from the aorta and bilateral double renal arteries (RAs). A custom-made 7-branch stent-graft was manufactured to preserve all renovisceral arteries. The 7 branches were catheterized and connected with a steerable sheath from a femoral access. All branches were bridged to the target vessel (TV) with a self-expanding covered stent; 4 TVs also had balloon-expandable covered stents implanted. Final angiography and predischarge CTA showed patency of all 7 target vessels and corresponding visceral organs, with no endoleak. The patient was discharged on postoperative day 8 without complications. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 7 target vessels. Conclusion: Successful treatment of a TAAA in a patient with multiple variant renovisceral arteries was feasible with a custom-made 7-branch stent-graft, achieving a good early outcome.