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Pitcher GS, Biggs JH, Dayama A, Newton DH, Tran K, Stoner MC, Smeds MR, Schermerhorn ML, Mix D. A national census for the off-label treatment of complex aortic aneurysms. J Vasc Surg 2024; 80:604-611. [PMID: 38904580 DOI: 10.1016/j.jvs.2024.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.
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Affiliation(s)
- Grayson S Pitcher
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Joedd H Biggs
- Division of Vascular Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Anand Dayama
- Sanford Vascular Associates, Sanford Health, Sioux Falls, SD
| | - Daniel H Newton
- Division of Vascular Surgery, Virginia Commonwealth University Health System, Richmond, VA
| | - Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, St Louis University School of Medicine, St Louis, MO
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Boston, MA
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
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Hemingway JF, Starnes BW, Kline BR, Singh N. Initial experience with the Terumo aortic Treo device for fenestrated endovascular aneurysm repair. J Vasc Surg 2021; 74:823-831.e1. [PMID: 33592291 DOI: 10.1016/j.jvs.2021.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The Terumo aortic (TA) Treo device (Terumo, Somerset, NJ) is an endograft with unique features that lends itself to fenestrated endovascular aneurysm repair (FEVAR), including a low device profile, a wide amplitude stent design, and an increased interstent distance. We have described our initial experience with the Treo device for FEVAR to treat short neck and juxtarenal abdominal aortic aneurysms. METHODS As part of an ongoing physician-sponsored investigational device exemption clinical trial (ClinicalTrials.gov identifier, NCT01538056), subjects were prospectively enrolled and underwent elective FEVAR using a variety of devices. Demographic and procedural details were collected. The data from subjects treated specifically with the Treo device from November 3, 2016 to May 2, 2019 were collected and analyzed. RESULTS Of a cohort of 161 patients who had undergone elective FEVAR, 46 had been treated with the TA Treo device. Most patients were men (70%), with a mean age of 75 years and high rates of hypertension (74%), hyperlipidemia (83%), coronary artery disease (33%), and chronic obstructive pulmonary disease (33%). The mean aneurysm size was 66 mm, the mean preoperative infrarenal neck length was 5 mm, and the mean final seal zone length was 45 mm. The average hospital and intensive care unit lengths of stay were 2.4 and 1.5 days, respectively. A total of 129 fenestrations were created for 44 superior mesenteric and 85 renal arteries (2.8 fenestrations per patient). Technical success, defined as successful implantation of the device with all target vessels preserved, was 98% (45 of 46), with only one renal artery not successfully preserved. The mean follow-up period was 598 days. During the study period, 18 endoleaks were detected (17 type II and 1 type III), with one patient with a type III endoleak requiring reintervention. Three subjects had died within 30 days, one of intracranial hemorrhage, one of respiratory failure, and one of ischemic colitis. The graft modification times for the TA Treo were significantly shorter (43 minutes) than those for other commercially available devices (Cook Zenith, 55 minutes; Medtronic Endurant, 54 minutes; P < .0001). CONCLUSIONS Our institution has reported exclusive worldwide experience using the TA Treo device for FEVAR. This device provides for a highly efficient and technically successful procedure for most patients. The procedural and fluoroscopy times were low even in the setting of high complexity. The technical success rates and simplification of the FEVAR procedure have made this approach a preferred technique for most patients at our institution.
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Affiliation(s)
- Jake F Hemingway
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Brenda R Kline
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
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Banga P, Oderich GS, Farber M, Reis de Souza L, Tenorio ER, Timaran C, Schneider DB, Baumgardt Barbosa Lima G, Barreira Marcondes G, Timaran D. Impact of Number of Vessels Targeted on Outcomes of Fenestrated-Branched Endovascular Repair for Complex Abdominal Aortic Aneurysms. Ann Vasc Surg 2020; 72:98-105. [PMID: 33227467 DOI: 10.1016/j.avsg.2020.09.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to investigate the impact of number of vessels targeted by fenestrations or branches on early outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) for complex abdominal aortic aneurysms (cAAAs). METHODS The clinical data of 260 patients (209 men; mean, 74 ± 7 years) treated for cAAAs in four academic centers using fenestrated-branched stent grafts with one to five fenestrations or branches were entered into prospectively maintained databases (2010-2015). Data were analyzed in patients treated with ≤2-vessel (group 1, n = 124), 3-vessel (group 2, n = 80), or ≥4 fenestrations or directional branches (group 3, n = 56). For group definition, only vessels incorporated by fenestrations or directional branches were accounted. End points were technical success, procedural variables, 30-day mortality, and major adverse events (MAEs). RESULTS A total of 830 vessels (mean, 3.19 ± 0.8 vessels/patient) were targeted by fenestrations (n = 672), scallops (n = 136), or branches (n = 22). Two-vessel designs were used more often in the early experience (64%), whereas ≥3-vessel design (groups 2 and 3) was preferred in the late experience (68%, P < 0.05). Patients with ≥4-vessel designs had longer operating and fluoroscopy time (+78 min, P < 0.0001 and + 27 min, P < 0.001), higher volume of contrast use (+31 mL, P = 0.03), and longer hospital stay (+3 days, P = 0.007) of those who had ≤2-vessel designs. Technical success, estimated blood loss, mortality, MAEs, and rate of spinal cord injury were similar in all three groups (P > 0.05). CONCLUSIONS F-BEVAR for complex abdominal aortic aneurysms was associated with high technical success and low 30-day mortality and morbidity. Increasing complexity was associated with longer operating and fluoroscopy time, more contrast use, and longer hospital stay but did not affect technical success and MAEs of the procedure.
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Affiliation(s)
- Peter Banga
- Division of Vascular and Endovascular Surgery, The Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
| | - Mark Farber
- The Division of Vascular Surgery, University of North Carolina Chapel Hill, NC
| | - Leonardo Reis de Souza
- Division of Vascular and Endovascular Surgery, The Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Carlos Timaran
- The Division of Vascular Surgery University of Texas South-Western Medical Center, Dallas, TX
| | - Darren B Schneider
- The Division of Vascular Surgery, Weill Cornell Medical Center, New York, NY
| | - Guilherme Baumgardt Barbosa Lima
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Giulianna Barreira Marcondes
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - David Timaran
- The Division of Vascular Surgery University of Texas South-Western Medical Center, Dallas, TX
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Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 2020; 73:4S-52S. [PMID: 32615285 DOI: 10.1016/j.jvs.2020.06.011] [Citation(s) in RCA: 255] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022]
Abstract
Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
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Vaccarino R, Abdulrasak M, Resch T, Edsfeldt A, Sonesson B, Dias NV. Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR. Ann Vasc Surg 2020; 68:283-291. [PMID: 32339675 DOI: 10.1016/j.avsg.2020.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/23/2020] [Accepted: 04/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events. METHODS All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range. RESULTS About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P = 0.33). Nine patients (2.2%) died within 30 days of the operation, whereas the remaining were followed up for 6.3 (4.7-8.4) years. The iliofemoral calcium score was 8348 (3830-14,179). Estimated overall survival at 5 years was 73 ± 2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5 years: 79 ± 4% vs. 71 ± 3%; P = 0.01) and cardiac event-free survival (5 years: 95 ± 2% vs. 91 ± 2%; P = 0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988-1.045]; P = 0.268) nor cardiac event-free survival (odds ratio, 1.024 [0.986-1.063]; P = 0.222). CONCLUSIONS Low iliofemoral calcium score may be associated with lower incidence of fatal cardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further.
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Affiliation(s)
- Roberta Vaccarino
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Mohammed Abdulrasak
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Timothy Resch
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Andreas Edsfeldt
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Nuno V Dias
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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6
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Končar IB, Jovanović AL, Dučič SM. The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:24-36. [PMID: 32079378 DOI: 10.23736/s0021-9509.19.11187-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Open repair (OR), fenestrated endovascular aneurysm repair (fEVAR) and endovascular exclusion using parallel graft (chEVAR) are complementary procedures used for treatment of juxtarenal abdominal aortic aneurysm (jrAAA). The aim of our study was to assess available literature and analyze dispersion of OR, fEVAR and chEVAR procedures among reported papers related to treatment of jrAAA. EVIDENCE ACQUISITION The PubMed database was systematically searched using predefined strategy and key words related to treatment of jrAAA on September 28th, 2019. Studies were assessed for eligibility using the inclusion and exclusion criteria with at least five patients treated with at least one of the procedures while systematic reviews, meta-analysis, reviews, comments, editorials and letters were excluded as well as studies without clear classification of the location of the aneurysm, studies not specifying the number of patients treated with each of the techniques or not discriminated between aortic pathologies (juxtarenal, paravisceral and thoracoabdominal), hybrid procedures, endoanchors or with branched stent-graft. EVIDENCE SYNTHESIS Overall, 1533 papers were identified while papers that met inclusion criteria were either representing experience of single institution (87 papers) or from multicenter studies (6 papers), national or international registries (18 papers). In the period between January 1977 and December 2017, treatment of 5664 patients with jrAAA was reported in 87 papers as a single institution report. Out of them 2531 (45%) were treated with OR, 2592 (46%) with fEVAR and 541 (9%) with chEVAR. Out of 29 institutions reporting OR, there were 11 (37.9%) with more than 100 treated patients while 21 (41.1%) out of 51 institutions that reported more than 50 jrAAA treated with fEVAR. Only four institutions reported results of all three treatment modalities. CONCLUSIONS Based on the results reported in the literature, regardless of its complexity and costs, fEVAR for jrAAA has been accepted in substantial number of hospitals worldwide, while number of reported procedures is reaching OR.
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Affiliation(s)
- Igor B Končar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia - .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia -
| | - Aleksa L Jovanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan M Dučič
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia
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Mohamed N, Galyfos G, Anastasiadou C, Sachmpatzidis I, Kikiras K, Papapetrou A, Giannakakis S, Kastrisios G, Papacharalampous G, Geroulakos G, Maltezos C. Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review. Ann Vasc Surg 2020; 63:399-408. [DOI: 10.1016/j.avsg.2019.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 12/20/2022]
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Doonan RJ, Girsowicz E, Dubois L, Gill HL. A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair. J Vasc Surg 2019; 70:2054-2064.e3. [DOI: 10.1016/j.jvs.2019.04.464] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022]
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9
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Comparison of commercially available versus customized branched-fenestrated devices in the treatment of complex aortic aneurysms. J Vasc Surg 2019; 69:645-650. [DOI: 10.1016/j.jvs.2018.05.215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/10/2018] [Indexed: 11/18/2022]
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Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Swerdlow NJ, McCallum JC, Liang P, Li C, O'Donnell TFX, Varkevisser RRB, Schermerhorn ML. Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously. J Vasc Surg 2018; 70:381-390. [PMID: 30583892 DOI: 10.1016/j.jvs.2018.09.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/29/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. METHODS We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. RESULTS Fifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. CONCLUSIONS Whereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.
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Affiliation(s)
- Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - John C McCallum
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Ciani O, Epstein D, Rothery C, Taylor RS, Sculpher M. Decision uncertainty and value of further research: a case-study in fenestrated endovascular aneurysm repair for complex abdominal aortic aneurysms. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:15. [PMID: 29686541 PMCID: PMC5902886 DOI: 10.1186/s12962-018-0098-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 04/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Fenestrated endovascular aneurysm repair (fEVAR) is a new approach for complex abdominal aortic aneurysms, limited to a few specialist centers, with limited evidence base. We developed a cost-effectiveness decision model of fEVAR compared to open surgical repair (OSR) to investigate the likely direction of costs and benefits and inform further research projects on this technology. Methods A systematic review with meta-analysis and a four-state Markov model were used to estimate the cost-effectiveness of fEVAR versus OSR. We used a recent coverage with evidence development framework to characterize the main sources of uncertainty and inform decisions about the type of further research that would be most worthwhile and feasible. Results Seven observational comparative studies were identified, of which four presented odds ratios adjusted for confounders. The odds ratios for operative mortality varied widely between studies. Assuming a central estimate of the odds ratio of 0.54 (95% CI 0.05–6.24), the decision model estimated that the incremental cost per quality adjusted life year (QALY) was £74,580/QALY with a probability of 9 and 16% of being cost-effective at standard cost-effectiveness thresholds of £20,000/QALY and £30,000/QALY, respectively. The Expected Value of Perfect Information over 10 years at a threshold of £20,000/QALY was £11.2 million. Operative mortality contributed to most of the uncertainty in the decision model. Conclusions In the case of “maturing technologies”, decision modelling indicates the likely direction of costs and benefits and guides the development of further research projects. In our analysis of fEVAR versus OSR, decision uncertainty, particularly around operative mortality, might be effectively resolved by a short-term RCT, or possibly a well-conducted comparative observational study. Decision makers may consider that a conditional coverage decision is warranted with assessments required to make this type of recommendation depending on local priorities and circumstances. Electronic supplementary material The online version of this article (10.1186/s12962-018-0098-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Oriana Ciani
- 1Evidence Synthesis and Modeling for Health Improvement, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke's Campus, Exeter, EX1 2LU UK.,2Center for Research on Health and Social Care Management, SDA Bocconi University, via Roentgen 1, 20136 Milan, Italy
| | - David Epstein
- 3Centre for Health Economics, University of York, Heslington, Alcuin 'A' Block, York, YO10 5DD UK.,4Department of Applied Economics, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain
| | - Claire Rothery
- 3Centre for Health Economics, University of York, Heslington, Alcuin 'A' Block, York, YO10 5DD UK
| | - Rod S Taylor
- 1Evidence Synthesis and Modeling for Health Improvement, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke's Campus, Exeter, EX1 2LU UK
| | - Mark Sculpher
- 3Centre for Health Economics, University of York, Heslington, Alcuin 'A' Block, York, YO10 5DD UK
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Shiraev TP, Kwok TMY, Dubenec SR. Medium-term outcomes of fenestrated endovascular repair of juxtarenal abdominal aortic aneurysms. ANZ J Surg 2017; 88:306-310. [PMID: 28922688 DOI: 10.1111/ans.14162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/26/2017] [Accepted: 06/05/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms pose a substantial clinical burden, and a significant proportion are not anatomically suitable for open repair or standard endovascular aneurysm repair (EVAR), instead requiring fenestrated EVAR (fEVAR). We sought to compare clinical outcomes and trends over time in patients undergoing fEVAR in Australia. METHODS We conducted a retrospective analysis of all patients undergoing fEVAR at a tertiary referral centre between 2010 and 2015, including outcomes and complications, both as inpatients and after discharge. RESULTS Thirty-nine patients underwent fEVAR during the study period, with mean age of 75 years and mean aneurysm size of 61 mm. One hundred and thirty-four target vessels were treated and inhospital mortality was 5% (two patients). There were nine inhospital, eight Type II and one Type III endoleaks. Ten patients suffered acute kidney injury, one of whom required dialysis. Mean follow-up was 14.5 months (range: 0-46.7). Target vessel patency was 99.2% at follow-up. There were six Type II endoleaks at follow-up, and two patients died during the follow-up period (of non-aneurysm-related causes). CONCLUSION fEVAR is an effective treatment with low morbidity and mortality, and we have demonstrated excellent survival and target vessel patency at a mean follow-up of 14 months. Endoleak rates were low, despite the high complexity of the aneurysms treated.
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Affiliation(s)
- Timothy P Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Trevor M Y Kwok
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Steven R Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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15
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Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair. AJR Am J Roentgenol 2017; 208:885-890. [DOI: 10.2214/ajr.16.16562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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de Lachomette MF, Della N, Maucort-Boulch D, Duprey A, Rosset E, Feugier P, Lermusiaux P, Albertini JN, Millon A. Renal Function after Fenestrated or Branched Endovascular Aortic Repair: The Early Impairment Predictive Factors. Ann Vasc Surg 2017; 40:1-9. [DOI: 10.1016/j.avsg.2016.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/29/2016] [Accepted: 06/02/2016] [Indexed: 11/30/2022]
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de Souza LR, Oderich GS, Farber MA, Haulon S, Banga PV, Pereira AH, Gloviczki P, Textor SC, Jia F. Editor's Choice - Comparison of Renal Outcomes in Patients Treated by Zenith ® Fenestrated and Zenith ® Abdominal Aortic Aneurysm Stent grafts in US Prospective Pivotal Trials. Eur J Vasc Endovasc Surg 2017; 53:648-655. [PMID: 28285957 DOI: 10.1016/j.ejvs.2017.02.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE/BACKGROUND Fenestrated endovascular repair (FEVAR) has been used to treat complex abdominal aortic aneurysms (AAAs). The risk of renal function deterioration compared with infrarenal endovascular aortic repair (EVAR) has not been determined. METHODS Patients with preserved renal function (estimated glomerular filtration rate [eGFR] > 45 mL/minute) enrolled in two prospective, non-randomised studies evaluating Zenith fenestrated and AAA stent grafts were matched (1:2) by propensity scores for age, sex, hypertension, diabetes, and pre-operative eGFR. Sixty-seven patients were treated by FEVAR and 134 matched controls treated by EVAR. Mean follow-up was 30 ± 20 months. Outcomes included acute kidney injury (AKI) defined by RIFLE and changes in serum creatinine (sCr), eGFR, and chronic kidney disease (CKD) staging up to 5 years. RESULTS AKI at 1 month was similar between groups, with > 25% decline in eGFR observed in 5% of FEVAR and 9% of EVAR patients (p = .39). There were no significant differences in > 25% decline in eGFR at 2 years (FEVAR 20% vs. EVAR 20%; p > .99) or 5 years (FEVAR 27% vs. EVAR 50%; p = .50). Progression to stage IV-V CKD was similar at 2 years (FEVAR 2% vs. EVAR 3%; p > .99) and 5 years (FEVAR 7% vs. EVAR 8%; p > .99), with similar sCr and eGFR up to 5 years. During follow-up, there were more renal artery stenosis/occlusions (15/67 [22%] vs. 3/134 [2%]; p < .001) and renal related re-interventions (12/67 [18%] vs. 4/134 [3%]; p < .001) in patients treated by FEVAR. Rate of progression to renal failure requiring dialysis was low and identical in both groups (1.5% vs. 1.5%; p > .99). CONCLUSION Aortic repair with FEVAR and EVAR was associated with similar rates of renal function deterioration in patients with preserved pre-operative renal function. Renal related re-interventions were higher following FEVAR, although net changes in renal function were similar in both groups.
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Affiliation(s)
- L R de Souza
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA; Surgery PhD Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - G S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - M A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - S Haulon
- Aortic Center, CHRU Lille, France
| | - P V Banga
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA; Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - A H Pereira
- Surgery PhD Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - P Gloviczki
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - S C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - F Jia
- Cook Research Incorporated, West Lafayette, IN, USA
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Tanious A, Lee JT, Shames M. Snorkel endovascular abdominal aortic aneurysm repair versus fenestrated endovascular aneurysm repair: is it a competition? Semin Vasc Surg 2016; 29:68-73. [PMID: 27823593 DOI: 10.1053/j.semvascsurg.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The endovascular treatment of juxtarenal abdominal aortic aneurysm (AAA) can be performed by either a standard endovascular stent graft with additional snorkle grafts to aorta branches (snorkel endovascular aneurysm repair) or implantation of a fenestrated stent graft (fenestrated endovascular aneurysm repair). While many vascular surgeons consider snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair to be competing techniques or alternate strategies, published procedural outcomes suggest more complementary roles. In this clinical review, the advantages and disadvantages of these two approaches are debated, as much can be learned from both strategies. Because the indications and circumstances for juxtarenal AAA repair vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons have access to, and experience with, both treatment strategies. Based on published outcomes, patient outcomes, stent-graft patency, and re-intervention rates are generally similar and acceptable compared with open AAA repair. We conclude that there is a time and a place for both snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair for the endovascular management of juxtarenal and pararenal AAA anatomy.
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Affiliation(s)
- Adam Tanious
- Division of Vascular and Endovascular Surgery of University of South Florida College of Medicine, Tampa, FL
| | - Jason T Lee
- Divisions of Vascular and Endovascular Surgery of Stanford University, Palo Alto, CA
| | - Murray Shames
- Division of Vascular and Endovascular Surgery of University of South Florida College of Medicine, Tampa, FL.
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Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure. Eur J Vasc Endovasc Surg 2016; 51:664-73. [DOI: 10.1016/j.ejvs.2016.01.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/19/2016] [Indexed: 11/23/2022]
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Georgiadis GS, van Herwaarden JA, Antoniou GA, Giannoukas AD, Lazarides MK, Moll FL. Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm. Vasc Med 2016; 21:223-38. [DOI: 10.1177/1358863x16631841] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - George A Antoniou
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Miltos K Lazarides
- Department of Vascular Surgery, ‘Demokritus’ University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
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Part Two: Against the Motion. Fenestrated EVAR Procedures are not Better than Snorkels, Chimneys, or Periscopes in the Treatment of Most Thoracoabdominal and Juxtarenal Aneurysms. Eur J Vasc Endovasc Surg 2015; 50:557-61. [PMID: 26602953 DOI: 10.1016/j.ejvs.2015.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Hertault A, Haulon S, Lee JT. Debate: Whether branched/fenestrated endovascular aneurysm repair procedures are better than snorkels, chimneys, or periscopes in the treatment of most thoracoabdominal and juxtarenal aneurysms. J Vasc Surg 2015; 62:1357-65. [DOI: 10.1016/j.jvs.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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A Systematic Review of Fenestrated Endovascular Repair for Juxtarenal and Short-Neck Aortic Aneurysm: Evidence So Far. Ann Vasc Surg 2015; 29:1680-8. [DOI: 10.1016/j.avsg.2015.06.074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 05/15/2015] [Accepted: 06/04/2015] [Indexed: 11/21/2022]
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Ou J, Cheng SW, Chan YC. The compatibility of p-branch “off-the-shelf” fenestrated endovascular graft in Asian patients with juxtarenal aortic aneurysm. J Vasc Surg 2015; 61:1417-23. [DOI: 10.1016/j.jvs.2014.12.061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
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Sveinsson M, Sobocinski J, Resch T, Sonesson B, Dias N, Haulon S, Kristmundsson T. Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm. J Vasc Surg 2015; 61:895-901. [DOI: 10.1016/j.jvs.2014.11.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 11/04/2014] [Indexed: 11/26/2022]
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26
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Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms. J Vasc Surg 2015; 61:355-64. [DOI: 10.1016/j.jvs.2014.09.068] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022]
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Rao R, Lane TR, Franklin IJ, Davies AH. Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms. J Vasc Surg 2015; 61:242-55. [DOI: 10.1016/j.jvs.2014.08.068] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022]
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Resch TA. Invited commentary. J Vasc Surg 2014; 60:578. [PMID: 25154962 DOI: 10.1016/j.jvs.2014.03.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/17/2014] [Indexed: 11/17/2022]
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Outcomes after abdominal aortic aneurysm repair requiring a suprarenal cross-clamp. J Vasc Surg 2014; 60:893-9. [PMID: 24856910 DOI: 10.1016/j.jvs.2014.04.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/11/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the early and late outcomes of patients who require a suprarenal aortic cross-clamp during elective open repair of an abdominal aortic aneurysm (AAA). METHODS Patients from 1998 to 2012 who required a suprarenal aortic cross-clamp during elective open AAA repair were reviewed. Data abstracted included demographics and comorbidities; preoperative, perioperative, and late renal function; late interventions related to AAA repair; and late mortality. A decrease in renal function was defined as a >30% decline in estimated glomerular filtration rate (eGFR) compared with the preoperative value. Primary outcomes included renal function, intervention-free survival, and overall survival. RESULTS During the study period, 211 patients underwent open elective or urgent AAA repair; 69 required a suprarenal cross-clamp. The mean age was 71 years, and 80% were men. The mean preoperative creatinine concentration was 1.2 mg/dL, and the mean preoperative eGFR was 66 mL/min/1.73 m2. Location of the aortic cross-clamp was suprarenal (37), supramesenteric (21), and supraceliac (11). Perioperatively, 21 patients (30%) experienced a significant decrease in eGFR; four patients required hemodialysis. Six patients had full recovery of renal function by discharge. Perioperative morbidity and mortality were 35% and 4%, respectively. At a mean follow-up of 3 years, seven patients had an eGFR significantly less than the preoperative value. Late interventions related to the AAA repair were required in eight patients. Indications included wound complication (3), anastomotic aneurysm (2), incisional hernia (1), anastomotic graft stenosis (1), and proximal aortic dilation (1). Overall 5-year intervention-free survival was 62% and overall survival 77%. Intervention-free survival was enhanced by antiplatelet use (P = .04), whereas overall survival was decreased by chronic obstructive pulmonary disease (P = .003) and perioperative pneumonia (P = .001). CONCLUSIONS More than a quarter of patients requiring a suprarenal cross-clamp during open AAA repair experience renal dysfunction. Late graft-related complications are few, with preoperative and perioperative pulmonary function negatively affecting overall patient survival.
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Canning C, Martin Z, Colgan MP, Abdulrahim O, McCafferty M, Fitzpatrick J, Haider SN, Madhavan P, O'Neill S. Fenestrated endovascular repair of complex aortic aneurysms. Ir J Med Sci 2014; 184:249-55. [PMID: 24599499 DOI: 10.1007/s11845-014-1095-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 02/18/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Fenestrated endovascular aneurysm repair (FEVAR) provides an endovascular solution for patients with large abdominal aortic aneurysms and challenging neck anatomy in addition to repair of endoleaks and pseudoaneurysms. This article reports the midterm outcomes of FEVAR from a single-tertiary referral centre in Ireland. METHODS From 2006 to 2012, nine consecutive asymptomatic patients with neck anatomy unfavourable for standard EVAR underwent endovascular repair with a customised fenestrated Zenith stent graft. An additional three patients had fenestrated grafts for repair of pseudoaneurysms (n = 2) following open AAA repair and a type I endoleak (n = 1). All patients were prospectively enrolled in a computerised database. Outcomes including mortality, morbidity, renal function, target vessel patency, endoleak and reintervention were analysed. FINDINGS The mean age and aneurysm size in the primary repair group were 74 years (65-84 years) and 6 cm (5-8.3 cm), respectively, and in the secondary repair group, the mean age was 66 years (61-75 years). No procedures required open conversion, and no visceral arteries were lost. On completion angiography, two patients in group 1 had a type I endoleak and one had a type III endoleak. There were no endoleaks in the secondary repair group. Follow-up ranged from 30 days to 6 years. There was one death within 30 days (8 %) and two deaths at 3 years from non-aneurysm-related causes. Six patients required secondary interventions. Three patients had a transient post-operative creatinine rise of >30 %. CONCLUSION Our study supports FEVAR as a feasible and effective therapy in the management of patients with complex aortic aneurysms.
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Affiliation(s)
- C Canning
- St James's Hospital, Dublin, Ireland,
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Kristmundsson T, Sonesson B, Dias N, Törnqvist P, Malina M, Resch T. Outcomes of fenestrated endovascular repair of juxtarenal aortic aneurysm. J Vasc Surg 2014; 59:115-20. [PMID: 24011738 DOI: 10.1016/j.jvs.2013.07.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/01/2013] [Accepted: 07/05/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | - Björn Sonesson
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Nuno Dias
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Per Törnqvist
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Martin Malina
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Timothy Resch
- Vascular Center, Skåne University Hospital, Malmö, Sweden
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Nessvi S, Gottsäter A, Acosta S. Comparable mid-term survival in patients undergoing elective fenestrated endovascular aneurysm repair and endovascular aneurysm repair for abdominal aortic aneurysm. SAGE Open Med 2014; 2:2050312113519986. [PMID: 26770700 PMCID: PMC4607194 DOI: 10.1177/2050312113519986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 12/04/2013] [Indexed: 11/16/2022] Open
Abstract
Objective: To evaluate mid-term survival in patients undergoing elective fenestrated
endovascular aneurysm repair and standard endovascular aneurysm repair for
abdominal aortic aneurysm. Methods: Consecutive patients treated from 2007 to 2011 with elective fenestrated
endovascular aneurysm repair (n = 81) and endovascular aneurysm repair (n =
201) were evaluated concerning age, cardiovascular medication,
comorbidities, and mid-term mortality. Results: Patients in the elective fenestrated endovascular aneurysm repair group were
younger than the endovascular aneurysm repair group (p = 0.006). In
comparison with the endovascular aneurysm repair group, a lower proportion
of patients in the elective fenestrated endovascular aneurysm repair group
had diabetes (p = 0.013) and anemia (p = 0.003), and a higher proportion had
arterial hypertension (p = 0.009). When entering age, endovascular aneurysm
repair or fenestrated endovascular aneurysm repair operation, diabetes,
anemia, and hypertension in a Cox regression model, only age (hazard ratio:
1.07; 95% confidence interval: 1.03–1.11; p < 0.001) was a
risk factor for mid-term mortality. Conclusion: Careful patient selection and medical optimization resulted in comparable
mid-term survival in patients undergoing elective fenestrated endovascular
aneurysm repair and endovascular aneurysm repair.
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Affiliation(s)
- Sofia Nessvi
- Vascular Center Malmö-Lund, Skåne
University Hospital, Malmö, Sweden
| | - Anders Gottsäter
- Vascular Center Malmö-Lund, Skåne
University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Vascular Center Malmö-Lund, Skåne
University Hospital, Malmö, Sweden
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Fenestrated Endovascular Repair for Pararenal Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2013; 27:1190-200. [DOI: 10.1016/j.avsg.2013.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
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Unno N, Yamamoto N, Higashiura W, Suzuki M, Mano Y, Sano M, Saito T, Sugisawa R, Konno H. Early experience with fenestrated stent grafts for treatment of juxtarenal aortic aneurysm. Ann Vasc Dis 2013; 6:642-50. [PMID: 24130622 DOI: 10.3400/avd.cr.13-00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 08/02/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fenestrated endovascular abdominal aneurysm repair (FEVAR) using branched arteries devices for visceral arteries is increasingly being used for the repair of juxtarenal aortic aneurysms (JAAs) in Europe, United States, Australia, New Zealand, and Asia. This study aimed to evaluate the technical feasibility and short-term results of FEVAR in treating JAAs in Japanese patients. METHODS AND RESULTS FEVAR with Cook fenestrated stent-graft (Cook Medical Inc., Bloomington, Indiana, USA) was performed for 5 patients at high risk for open repair of JAA. Seventeen visceral vessels were successfully accommodated with 12 fenestrations, and five visceral arteries with four scallops with a loss of renal artery. In one case, a type III endoleak occurred at a renal artery fenestration, and this had disappeared in the 1-month postoperative computed tomography (CT). The mean follow-up duration was 8 months. Iliac leg occlusion occurred in 1 case, which was treated with thrombectomy and additional leg device deployment. All patients had survived at the end of the follow-up period and continued their outpatient visits. CONCLUSIONS Implantation of a Cook fenestrated stent-graft incorporating the visceral arteries is technically feasible in high-risk Japanese patients with JAA and may be a viable alternative to current methods.
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Affiliation(s)
- Naoki Unno
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Kitagawa A, Greenberg RK, Eagleton MJ, Mastracci TM. Zenith p-branch standard fenestrated endovascular graft for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2013; 58:291-300. [DOI: 10.1016/j.jvs.2012.12.087] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 12/27/2012] [Accepted: 12/27/2012] [Indexed: 10/26/2022]
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Starnes BW, Tatum B. Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts. J Vasc Surg 2013; 58:311-7. [DOI: 10.1016/j.jvs.2013.01.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/07/2013] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
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37
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Saratzis AN, Goodyear S, Sur H, Saedon M, Imray C, Mahmood A. Acute Kidney Injury After Endovascular Repair of Abdominal Aortic Aneurysm. J Endovasc Ther 2013; 20:315-30. [DOI: 10.1583/12-4104mr2.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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38
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Endovascular Repair of Complex Aortic Pathology. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0019-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV. Durability of branches in branched and fenestrated endografts. J Vasc Surg 2013; 57:926-33; discussion 933. [PMID: 23433817 DOI: 10.1016/j.jvs.2012.09.071] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 09/24/2012] [Accepted: 09/25/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Tara M Mastracci
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Katsargyris A, Oikonomou K, Klonaris C, Töpel I, Verhoeven EL. Comparison of Outcomes With Open, Fenestrated, and Chimney Graft Repair of Juxtarenal Aneurysms: Are We Ready for a Paradigm Shift? J Endovasc Ther 2013; 20:159-69. [PMID: 23581756 DOI: 10.1583/1545-1550-20.2.159] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mendonça CT, de Carvalho CA, Weingartner J, de Melo Costa DS, Shiomi AY. The use of a self-expandable aortic stent to incarcerate microcoils and to create a favourable infrarenal neck in an unusual case of endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2013; 45:465-7. [PMID: 23473782 DOI: 10.1016/j.ejvs.2013.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION We report a case of an emergency high-risk patient with a pararenal aortic aneurysm. REPORT Our patient had a pararenal aneurysm with two components: a wide-neck saccular aneurysm below the left renal artery and a fusiform aneurysm. A self-expandable aortic stent was deployed covering both renal arteries, the saccular aneurysm was embolised with microcoils and a bifurcated aortic endograft was anchored inside the aortic stent. The aortic stent imprisoned the microcoils and avoided proximal type I endoleak. The tomography done 15 months after the procedure showed no endoleaks. DISCUSSION A self-expandable aortic stent can provide an alternative for emergency high-risk patients with pararenal aortic aneurysms.
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Affiliation(s)
- C T Mendonça
- Division of Vascular and Endovascular Surgery, Red Cross University Hospital, Positivo University, Curitiba, Brazil.
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Canavati R, How TV, Brennan JA, Vallabhaneni SR, Fisher RK, McWilliams RG. Fractured superior mesenteric artery stents after fenestrated endovascular aneurysm repair. J Vasc Surg 2013; 57:511-4. [DOI: 10.1016/j.jvs.2012.08.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/06/2012] [Accepted: 08/08/2012] [Indexed: 11/27/2022]
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Unno N, Yamamoto N, Higashiura W, Suzuki M, Mano Y, Sano M, Saito T, Sugisawa R, Konno H. Early Experience with Fenestrated Stent Grafts for Treatment of Juxtarenal Aortic Aneurysm. Ann Vasc Dis 2013. [DOI: 10.3400/avd.oa.13-00047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Constantinou J, Giannopoulos A, Cross J, Morgan-Rowe L, Agu O, Ivancev K. Temporary axillobifemoral bypass during fenestrated aortic aneurysm repair. J Vasc Surg 2012; 56:1544-8. [DOI: 10.1016/j.jvs.2012.05.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 05/08/2012] [Accepted: 05/09/2012] [Indexed: 11/25/2022]
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Farber MA, Vallabhaneni R. Moving Into the Paravisceral Aorta Using Fenestrated and Branched Endografts. Semin Vasc Surg 2012. [DOI: 10.1053/j.semvascsurg.2012.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Starnes BW. Physician-modified endovascular grafts for the treatment of elective, symptomatic, or ruptured juxtarenal aortic aneurysms. J Vasc Surg 2012; 56:601-7. [DOI: 10.1016/j.jvs.2012.02.011] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 01/31/2012] [Accepted: 02/06/2012] [Indexed: 11/28/2022]
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Riga CV, Bicknell CD, Hamady M, Cheshire N. Tortuous iliac systems--a significant burden to conventional cannulation in the visceral segment: is there a role for robotic catheter technology? J Vasc Interv Radiol 2012; 23:1369-75. [PMID: 22920731 DOI: 10.1016/j.jvir.2012.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 07/01/2012] [Accepted: 07/02/2012] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To attempt to quantify the effect of varying degrees of iliac tortuosity on maneuverability and "torquability" of endovascular catheters in the visceral segment, comparing conventional and robotic cannulation techniques. MATERIALS AND METHODS In a fenestrated endograft within a pulsatile phantom, 10 experienced operators cannulated the renal arteries via three different access vessels of varying iliac tortuosity with the use of conventional and robotic techniques. All procedures were performed in the angiography suite and recorded for blinded video assessment for quantitative (time, catheter-tip movements) and qualitative metrics (operator performance scores). RESULTS In total, 120 cannulations were observed. With increasing iliac tortuosity, median time and number of catheter movements required for renal cannulation with conventional techniques increased in stepwise fashion for mild, moderate, and severe iliac tortuosity (times, 7.6 min [interquartile range (IQR), 4.6-9.3 min] vs 6.9 min [4.2-11.4 min] vs 17.7 min [13.3-22.6 min], respectively; movements, 184 [IQR, 110-351] vs 251 [207-395] vs 569 [409-616], respectively). Median renal cannulation times were significantly reduced with the use of the robotic system irrespective of mild, moderate, or severe tortuosity (times, 1.4 min [IQR, 1.1-1.9 min] vs 3 min [2.3-3.3 min] vs 2.8 min [1.5-3.9 min], respectively; movements, 19 [IQR, 14-27] vs 46 [43-58] vs 45 [40-66], respectively; P < .005). Overall operator performance scores improved significantly with the use of the robotic system irrespective of iliac tortuosity severity. CONCLUSIONS In cases of moderate to severe iliac tortuosity, conventional catheter manipulation and control becomes an issue. The improvement in positional control and predictability seen with advanced catheter designs may be amplified in cases of severe iliac tortuosity.
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Affiliation(s)
- Celia V Riga
- Regional Vascular Unit, Imperial College Healthcare, St Mary's Hospital, London, United Kingdom.
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Linsen MA, Jongkind V, Nio D, Hoksbergen AW, Wisselink W. Pararenal aortic aneurysm repair using fenestrated endografts. J Vasc Surg 2012; 56:238-46. [PMID: 22264696 DOI: 10.1016/j.jvs.2011.10.092] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 10/03/2011] [Accepted: 10/16/2011] [Indexed: 10/14/2022]
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Development of Off-the-shelf Stent Grafts for Juxtarenal Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2012; 43:655-60. [DOI: 10.1016/j.ejvs.2012.01.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 01/24/2012] [Indexed: 11/15/2022]
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Scarcello E, Serra R, Morrone F, Tarsitano S, Triggiani G, de Franciscis S. Aortic banding and endovascular aneurysm repair in a case of juxtarenal aortic aneurysm with unsuitable infrarenal neck. J Vasc Surg 2012; 56:208-11. [PMID: 22494691 DOI: 10.1016/j.jvs.2012.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 01/09/2012] [Accepted: 01/09/2012] [Indexed: 11/29/2022]
Abstract
The proximal aortic neck is one of the limiting factors for endovascular aneurysm repair (EVAR) and represents a crucial factor for success or failure of the procedure. In contrast to open surgery, where a clamp can be placed suprarenally but the repair performed infrarenally, EVAR requires a good infrarenal neck for durable fixation and seal. In a high-risk surgical 79-year-old patient with juxtarenal aortic aneurysm with unsuitable infrarenal neck, a hybrid procedure was chosen: juxtarenal aortic banding and EVAR. The banding allowed a successful EVAR by reshaping the juxtarenal aneurysmal aortic segment, hence converting a previously untreatable anatomy into a treatable one.
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Affiliation(s)
- Edoardo Scarcello
- Unit of Vascular and Endovascular Surgery, Annunziata Hospital, Cosenza, Italy
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