The accuracy of computed tomography central luminal line measurements in quantifying stent graft migration

Physician-Modified Endovascular Graft for Left Subclavian Artery Fenestration during Thoracic Endovascular Aortic Repair

BACKGROUND

This study aimed to evaluate the safety and efficacy of physician-modified endovascular graft for preservation of left subclavian artery during thoracic endovascular aortic repair.

METHODS

From June 2019 to October 2022, 66 patients with a variety of thoracic aortic pathologies were treated with thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration to achieve adequate proximal landing zone. The details of surgical techniques were described. The perioperative morbidity, mortality, and the outcomes of mid-term follow-up were analyzed.

RESULTS

Of the 66 patients (men: women, 53:13; age, 55.18 [55.18 ± 10.62] years), 53 (80.30%) presented with type B aortic dissection, 10 (15.15%) with thoracic penetrating aortic ulcer, 2 (3.03%) with thoracic aortic aneurysm, and 1 (1.52%) with left subclavian artery aneurysm. All of them underwent thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration on the sterile back table. The technique success rate was 96.97% (n = 64). Total operation time was 92 min (interquartile range, 86-118), graft modification time was 19 min (interquartile range, 17-21), fluoroscopy time was 49 min (interquartile range, 41-62), and contrast agent dosage was 165 mL (interquartile range, 155-185). 30-day perioperative morbidities were 3 (4.55%) strokes, 1 (1.52%) retrograde type A aortic dissection, 1 (1.52%) aortic intimal intussusception, 1 (1.52%) left arm ischemia, and 3 (4.55%) type Ia endoleaks. Postoperative 30-day mortality and reintervention rates were 1.52% and 4.55%, respectively. Among the 63 patients included in the follow-up of 17 months (interquartile range, 7.75-18.25), the primary patency of left subclavian artery fenestration stents was 100%. Late complications were 1 (1.59%) distal stent graft-induced new entry and 1 (1.59%) death due to retrograde type A aortic dissection during the follow-up. The stent graft-induced new entry patient was observed with stable false lumen.

CONCLUSIONS

Thoracic endovascular aortic repair with physician-modified endovascular graft for left subclavian artery revascularization is a safe, feasible, and efficacious technique associated with high success rate. Further study is needed for long-term outcome investigation.

Aneurysm Growth After Endovascular Sealing of Abdominal Aortic Aneurysms (EVAS) with the Nellix Endoprosthesis

OBJECTIVE

The aim of this study was to measure the incidence of post endovascular aneurysm sealing (EVAS) abdominal aortic aneurysm (AAA) growth, and its association with stent migration, in a cohort of patients with differing compliance to old and new Instructions For Use (IFU).

METHODS

A retrospective single centre study was conducted to review the computed tomography (CT) and clinical data of elective, infrarenal EVAS cases, performed as a primary intervention, between December 2013 and March 2018. All included patients had a baseline post-operative CT scan at one month and at least one year follow up. The primary outcome measure was the incidence of AAA growth and its association with stent migration. AAA growth was defined as a ≥5% increase in aortic volume between the lowermost renal artery and the aortic bifurcation post EVAS at any time during follow up, in comparison to the baseline CT scan. Migration was defined according to the ESVS guidelines, as > 10 mm downward movement of either Nellix stent frame in the proximal zone.

RESULTS

Seventy-six patients were eligible for inclusion in the study (mean age 76 ± 7.4 years; 58 men). AAA growth was identified in 50 of 76 patients (66%); adherence to IFU did not affect its incidence (mean growth within IFU-2016 compliant cohort vs. non-compliant: 16% vs. 13%, p = .33). Over time, the incidence of AAA growth increased, from 32% at one year to 100% at four years. AAA growth by volume was progressive (p < .001), as its extent increased over time. Migration was detected in 16 patients and there was a statistically significant association with AAA growth (13 patients displayed migration and AAA growth, p = .036).

CONCLUSION

Patients treated with EVAS are prone to AAA growth, irrespective of whether their aortic anatomy is IFU compliant. AAA growth by volume is associated with stent migration. Clinicians should continue close surveillance post EVAS, regardless of whether patients are treated within IFU.

Stent Frame Movement Following Endovascular Aneurysm Sealing in the Abdominal Aorta

Purpose: To investigate the incidence and extent of stent frame movement after endovascular aneurysm sealing (EVAS) in the abdominal aorta and its relationships to aneurysm growth and the instructions for use (IFU) of the Nellix endograft. Methods: A retrospective single-center study was conducted to review the clinical data and computed tomography (CT) images of 75 patients (mean age 76±7.6 years; 57 men) who underwent infrarenal EVAS and had a minimum 1-year follow-up. The first postoperative CT scan at 1 month and the subsequent scans were used to measure the distances between the proximal end of the stent frames and a reference visceral vessel using a previously validated technique. Device migration was based on the Society of Vascular Surgery definition of >10-mm downward movement of either Nellix stent frame in the proximal landing zone; a more conservative proximal displacement measure (downward movement ⩾4 mm) was also recorded. Patients were categorized according to adherence to the old (2013) or new (2016) Nellix IFU. Aneurysm diameter was measured for each scan; a change ⩾5 mm was deemed indicative of aneurysm growth. Results: Over a median follow-up of 24 months (range 12–48), proximal displacement ⩾4 mm occurred in 42 (56%) patients and migration >10 mm in 16 (21%), with similar incidences in the right and left stent frames. Proximal displacement was significantly more frequent among patients whose anatomy did not conform to any IFU (p=0.025). Presence of aneurysm growth ⩾5 mm was observed in 14 (19%) patients and was significantly associated with proximal displacement ⩾4 mm (p=0.03). Conclusion: Infrarenal EVAS may be complicated by proximal displacement and migration, particularly when performed outside the IFU. The definition of migration used for endovascular aneurysm repair may be inappropriate for EVAS; a new consensus on definition and measurement technique is necessary.