Early experience with the snorkel technique for juxtarenal aneurysms

Pulmonary Artery Endograft Implantation Using a Parallel Stent Grafting Technique to Enable the Treatment of a Bronchial Anastomosis Complication After Lung Transplantation

BACKGROUND

Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions.

PURPOSE

To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation.

RESEARCH DESIGN

This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed.

RESULTS

The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108.

DATA ANALYSIS

The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation.

CONCLUSION

This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated.

Comparison of Outcomes Between Right and Left Upper Extremity Access in Endovascular Aortic Repair for Patients with Thoracoabdominal and Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

Traditionally, left-sided upper extremity (LUE) access has been preferred in patients undergoing endovascular aortic repair (EVAR) to manage aortic aneurysms and decrease the risk of cerebrovascular adverse events. Recently, right-sided upper extremity access (RUE) has gained popularity owing to its greater maneuverability and ergonomics. However, synthesized data comparing the safety and efficacy of RUE and LUE accesses are limited. A comprehensive literature search was conducted on various databases from inception to September 2023 to retrieve all studies that compared RUE and LUE access in EVAR. Data on stroke, 30-day mortality, technical success, access-site complications, total time required for fluoroscopy, and contrast agent requirement were extracted, pooled, and analyzed. Forest plots were generated using a random-effects model on review manager by pooling the risk ratios (RRs) and standard mean differences (SMDs). Ten observational studies with a total of 3994 patients were included in our analysis with 1186 patients in the RUE and 2808 patients in the LUE access groups. EVAR using RUE access was associated with a significantly lower amount of contrast agent requirement than the LUE access group [SMD, -0.23; 95% confidence interval (CI), -0.45 to -0.02; P = 0.03]. There was no significant difference between the 2 groups in terms of the risk of stroke (RR, 1.62; 95% CI, 0.81-3.22; P = 0.17), 30-day mortality (RR, 1.42; 95% CI, 0.50-4.06; P = 0.51), rate of technical success (RR, 0.98; 95% CI, 0.95-1.01; P = 0.18), risk of access-site complications (RR, 1.00; 95% CI, 0.72-1.39; P = 0.99), and total time required for fluoroscopy (SMD, 0.07; 95% CI, -0.39 to 0.26; P = 0.69). The use of RUE access in EVAR appears to be comparable to LUE access in terms of the risk of stroke, access-related complications, all-cause mortality, technical success rate, and fluoroscopy duration. The RUE group required a lower volume of contrast agent.

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15 mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39 months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.

Impact of renal chimney intra-aortic stent length on branch and end-stent angle in chimney endovascular aneurysm repair and endovascular aneurysm sealing configurations

OBJECTIVE

Practice patterns and durability of parallel stent graft techniques in complex endovascular aneurysm repair (EVAR) remain poorly defined. We aimed to quantify and compare the impact of renal chimney intra-aortic stent length (IASL) on geometric deformations of renal arteries in complex EVAR.

METHODS

Thirty-eight nonconsecutive patients underwent EVAR utilizing parallel stent graft techniques (chimney EVAR [chEVAR], n = 28; chimney endovascular aneurysm sealing [chEVAS], n = 10) between 2010 and 2016. A total of 59 renal chimney stent grafts were used. Geometric quantification was derived from three-dimensional model-based centerline extraction. Renal chimney intra-aortic stent length (IASL) was defined as the length of chimney stent that extended from the proximal edge of the chimney stent to the ostium of the corresponding renal artery.

RESULTS

Mean IASL for both left and right renal arteries in the cohort was 35.7 mm. Renal arteries containing chimney IASL <30 mm trended toward a greater branch angle (135.4 vs. 127.8°, p = .06). Left renal arteries showed significantly greater branch angle among those with IASL <40 mm (135.5 vs. 121.7°, p = .045). Mean IASL for renal arteries in chEVAR was significantly longer compared to chEVAS (39.2 vs. 26.3 mm, p = .003). No difference was noted in overall branch angle or end-stent angle based on procedure type. ChEVAR with IASL <30 mm had significantly greater end-stent angle (48.2 vs. 33.5°, p = .03). In contrast, chEVAS patients showed no difference in end-stent angle based on IASL thresholds, but did have significantly greater branch angle among those with IASL <30 mm when grouped by both all renal arteries (133.5 vs. 113.5°, p = .004) and right renal arteries (134.3 vs. 111.6°, p = .02).

CONCLUSIONS

Renal chimney stents with longer IASL appear to exhibit less renal artery deformation, suggesting a more gradual and perpendicular transition of the chimney stent across the renal ostium.

A fenestrated, double-barrel technique for proximal reintervention after open or endovascular abdominal aortic aneurysm repair

Objective

Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique.

Methods

Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πD_LIMB = πD_ZFEN + 2D_ZFEN.

Results

Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively.

Conclusions

This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.

A Single Center Review of a Total Transfemoral Approach to Upper Extremity Access in Branched and Fenestrated Physician Modified Endografts

BACKGROUND

Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches.

METHODS

Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes.

RESULTS

Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke.

CONCLUSIONS

This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.

Outcomes of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair

OBJECTIVES

This study aims to assess the safety of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurologic and local complications as well as reinterventions associated with this technique.

METHODS

All patients undergoing a F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single-centre study. Endpoints were neurological and access-related complications and reinterventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury and arterial complications.

RESULTS

264 patients (192 male, mean age 70 ± 7 years) were included. Upper access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2,2%) patients had early complications related to the arterial access: four with postoperative bleeding and two with acute arm ischaemia. Two patients with postoperative bleeding and both patients with ischaemic complications required reintervention. One of these patients with arm ischaemia died five weeks after the reintervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented transient arm paraesthesia or sensory neurologic deficit postoperatively. The symptoms completely recovered in all cases with no residual deficits. Perioperative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion.

CONCLUSIONS

Upper access with surgical exposure of the axillary artery is a safe method for antegrade catheterization of fenestrations and branches in complex endovascular aneurysm repair.

Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair

OBJECTIVE

Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access.

METHODS

During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications.

RESULTS

UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74).

CONCLUSIONS

Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

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.

Chimney endovascular aneurysm repair (ChEVAR) for hostile neck complex aneurysm

OBJECTIVE

Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR.

METHODS

Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery.

RESULTS

Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18 months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5 mm; p = 0.059), iliac diameter (7.3 vs 7.1 mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0 mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37 mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67 mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7 mm³; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71).

CONCLUSION

Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

Endovascular Aortic Aneurysm Repair: A Narrative Review

Endovascular aortic aneurysm repair (EVAR) has evolved as minimally invasive method of treating infrarenal abdominal aortic aneurysms (AAA) with perioperatively mortality of less than 1% compared with 5% with open AAA repair as suggested by many randomized control trials. Computed tomography angiography is the imaging of choice for appropriate selection of a patient with EVAR. For patients with unsuitable anatomy, advanced EVARs techniques, such as fenestrated, branch, and chimney EVARs, are also increasingly being offered to patients with equal success. Patients with ruptured AAA are treated with this minimally invasive procedure. Percutaneous EVAR emerged with less of wound-related complications. Endoleaks are the most common complications peculiar to this procedure, and most are preventable by preoperative planning. They are detected on completion angiogram or on the surveillance imaging. This review discusses indications of EVAR, its selection criteria, procedural steps, and common complications associated with this procedure and advanced EVARs.

Exclusion of complex aortic aneurysm with chimney endovascular aortic repair is applicable in a minority of patients treated with fenestrated endografts

OBJECTIVES

The Medtronic Endurant II stent graft has recently received Conformité Européenne (CE) approval for the use in chimney endovascular aortic repair (ChEVAR) for the treatment for juxtarenal aortic aneurysms. The aim of this study was to assess the percentage of patients treated by fenestrated endovascular repair who would have been alternatively suitable for the treatment by the CE approved Medtronic ChEVAR.

METHODS

Preoperative computed tomography scans of 100 patients who underwent fenestrated endovascular aortic repair (FEVAR) between April 2013 and February 2017 were retrospectively assessed for the applicability of the ChEVAR technique according to the Medtronic instructions for use. Eligibility criteria included an aortic neck diameter of 19-30 mm, a minimum infrarenal neck length of 2 mm, a total proximal sealing zone of at least 15 mm, thrombus in the aortic neck in ˂25% of the circumference, and maximum aortic angulations of 60° in the infrarenal, 45° in the suprarenal segment and ˂45° above the superior mesenteric artery.

RESULTS

According to CE-approved inclusion criteria, 19 individuals (19%) would have been eligible for ChEVAR. In 81 patients, at least 1 measure was found outside instructions for use: (i) excluding factor was detected in 26 patients, (ii) incongruous measures in 28 patients and in 27 patients, 3-5 measures were outside the instructions for use. The most frequently identified excluding factor was an insufficient infrarenal neck at ˂2 mm length (n = 63; 63%).

CONCLUSIONS

Patients with juxta- or pararenal aneurysm treated by FEVAR are in 19% of the cases alternatively suitable for the treatment by ChEVAR within CE-approved instructions for use. While ChEVAR is suitable in many emergency cases, FEVAR offers a broader applicability in an elective setting.

The PROTAGORAS 2.0 Study to Identify Sizing and Planning Predictors for Optimal Outcomes in Abdominal Chimney Endovascular Procedures

OBJECTIVE

The aim was to identify predictors of adequate pre-operative sizing and planning for chimney endovascular aortic repair (ChEVAR) in order to reduce the incidence of persistent type Ia endoleaks (IaELs) without influencing chimney graft (CG) patency.

METHODS

Consecutive patients who underwent ChEVAR between January 2009 and December 2017 at a single centre were evaluated retrospectively. Included were patients treated with one device combination (Medtronic Endurant mated with Getinge Advanta V12/iCast) and placement of single or double CG. The freedom from IaEL related re-interventions and primary CG patency was estimated by measuring aortic stent graft oversizing (OS), total neck length (TNL), and a composite parameter (L-OS: TNL [mm] + OS [%]).

RESULTS

Seventy-three patients who underwent placement of 101 CGs (45 single, 28 double) met the inclusion criteria. The median radiological follow up was 25.5 (interquartile range [IQR] 12-48) months. Freedom from IaEL related re-intervention was achieved in 94.6% with a median OS of 38.5% (IQR 30%-44%, p = .004), TNL 19 mm (16-25 mm, p = .62), and L-OS 59 (51-65, p = .018). Primary CG patency was achieved in 95% of the cases with a median OS of 36% (29%-42%, p = .008), TNL 19 mm (15.5-26 mm, p = .91), and L-OS 57 (50-64, p = .005). By using the receiver operating characteristic curve, an optimal cut off to prevent IaEL related re-interventions was identified by an OS of 30% (p < .001; L-OS 55, p = .006) and to avoid CG stenosis/occlusions by OS 42% (p < .001; L-OS 65, p < .001). In multivariable analysis, aortic endograft OS was the only independent parameter preventive for IaEL related re-intervention (odds ratio, 0.78; 95% confidence interval, 0.61-0.99).

CONCLUSION

With the Endurant-Advanta V12/iCast combination, an aortic stent graft OS of at least 30% (range 30%-42%) should be used to avoid type Ia endoleaks and likewise to ensure CG patency.

Lateral Axillary Exposure for Antegrade Access during Endovascular Repair of Complex Abdominal Aortic and Thoracoabdominal Aneurysms

BACKGROUND

During endovascular treatment of pararenal aortic aneurysms (PAA) and thoracoabdominal aortic aneurysms (TAAA), our antegrade vascular access of choice is a lateral axillary exposure (LAE). We directly access the axillary artery with multiple sheaths followed by primary closure of the axillary artery at case completion. The aim of this study is to describe our technique and to report our results with this approach.

METHODS

This study is a single-institution, retrospective review of 53 patients who were treated with parallel grafts for endovascular repair of PAA and TAAA from 2006 to 2018. The aortic repairs requiring LAE included: 9 cases of endo-leaks from prior endovascular repair, 20 TAAAs, and 24 PAAs. The axillary artery was exposed with a vertical axillary skin incision followed by retraction of the lateral border of the pectoralis major to expose the axillary artery distal to the pectoralis minor. A 5-French (F) through 12F sheaths were used to directly access the axillary artery for delivery of endovascular devices.

RESULTS

Two hundred and sixty reno-visceral stents were delivered through 125 axillary sheaths in an antegrade fashion to 114 arteries without intraoperative complications or technical failures. Two postoperative complications included an access-site hematoma managed conservatively (1.9%) and a left brachial vein thrombosis treated with anticoagulation (1.9%). There were no cases of cerebrovascular or peripheral neurologic events, upper extremity ischemia, or reoperation related to LAE.

CONCLUSIONS

LAE is a valid approach for upper extremity access during the endovascular repair of complex aortic aneurysms requiring simultaneous delivery of multiple reno-visceral devices. It does not require the use of a prosthetic conduit. There were no neurologic events or upper extremity ischemia in our series.

Long-term chimney/snorkel endovascular aortic aneurysm repair experience for complex abdominal aortic pathologies within the PERICLES registry

OBJECTIVE

The early and short-term efficacy of the snorkel/chimney technique for endovascular aortic aneurysm repair (ch-EVAR) have been previously reported. However, long-term ch-EVAR performance, vessel patency, and patient survival remain unknown. Our study evaluated the late outcomes to identify possible predictors of failure within the PERICLES (performance of the chimney technique for the treatment of complex aortic pathologies) registry.

METHODS

Clinical and radiographic data from patients who had undergone ch-EVAR from 2008 to 2014 in the PERICLES registry were updated with an extension of the follow-up. Regression models were used to evaluate the relevant anatomic and operative characteristics as factors influencing the late results. We focused on patients with ≥30 months of follow-up (mean, 46.6 months; range, 30-120 months).

RESULTS

A total of 517 patients from the initial PERICLES registry were included in the present analysis, from which the mean follow-up was updated from 17.1 months to 28.2 months (range, 1-120 months). All-cause mortality at the latest follow-up was 25.5% (n = 132), with an estimated patient survival of 87.6%, 74.4%, and 66.1% at 1, 3, and 5 years, respectively. A subgroup of 244 patients with 387 chimney grafts placed (335 renal arteries, 42 superior mesenteric arteries, 10 celiac arteries) and follow-up for ≥30 months was used to analyze specific anatomic and device predictors of adverse events. In the subgroup, the technical success was 88.9%, and the primary patency was 94%, 92.8%, 92%, and 90.5% at 2.5, 3, 4, and 5 years, respectively. The mean aneurysm sac regression was 7.8 ± 11.4 mm (P < .0001). Chimney graft occlusion had occurred in 24 target vessels (6.2%). Late open conversion was required in 5 patients for endograft infection in 2, persistent type Ia endoleak in 2, and endotension in 1 patient. The absence of an infrarenal neck (odds ratio, 2.86; 95% confidence interval, 1.32-6.19; P = .007) was significantly associated with long-term device-related complications. A sealing zone diameter >30 mm was significantly associated with persistent or late type Ia endoleak (odds ratio, 4.86; 95% confidence interval, 1.42-16.59; P = .012).

CONCLUSIONS

The present analysis of the PERICLES registry has provided the missing long-term experience for the ch-EVAR technique, showing favorable results with more than one half of the patients surviving for >5 years and a chimney graft branch vessel patency of 92%. The absence of an infrarenal neck and treatment with a sealing zone diameter >30 mm were the main anatomic long-term limits of the technique, requiring adequate preoperative planning and determination of the appropriate indication.

Right-sided Upper Extremity Access for Patients Undergoing Parallel Graft Placement during Endovascular Aortic Repair is Not Associated with Increased Neurologic Events When Compared with Left Upper Extremity Access

BACKGROUND

The safety and efficacy of right axillary cannulation during complex aortic aneurysm repair for the deployment of chimney grafts is controversial; however, there are few studies that compare right and left upper extremity access. We favor the right axillary approach because of the relative ease of access to the visceral branches and the ability of surgeons and nursing staff to work on the same side of the patient, while avoiding the left sided image intensifier. We aim to demonstrate that right-sided access is equivalent or safer than left-sided access in terms of technical success and complication rates, with a focus on neurologic outcomes.

METHODS

This is a single-institution retrospective study with a review of patients who underwent aortic intervention from January 2012 through December 2018. A total of 398 aortic interventions were performed, and 97 of these required brachial, axillary, or subclavian arterial access for attempted ChEVAR or thoracic endovascular aortic repair with parallel chimney grafts. Primary end points that were analyzed were site or sites of upper extremity access, technical success, 30-day mortality, cerebrovascular events, and subclavian/axillary artery injury. The number of parallel grafts, age, mean hospital length of stay, prior aortic intervention, emergent or elective status were also analyzed.

RESULTS

Ninety-seven endovascular aortic operations required upper extremity access, with 67 using access from the right upper extremity, 26 using access from the left upper extremity, and 4 using bilateral upper extremity access. A total of 68.0% of patients had undergone prior aortic surgery. Technical success was achieved in 85 cases (87.6%). Five total patients suffered cerebrovascular accidents, with 2 occurring in left-sided access (7.7%), 2 in right-sided access (3.0%), and 1 in bilateral access (25%).

CONCLUSIONS

Right upper extremity access for patients undergoing parallel graft placement during endovascular aortic aneurysm repair is a safe and feasible approach that is not associated with an increased risk of stroke or neurological events as compared with left upper extremity access.

Comparison of transfemoral versus upper extremity access to antegrade branches in branched endovascular aortic repair

OBJECTIVE

We studied the outcomes of transfemoral access (TFA) vs upper extremity access (UEA) for branched endovascular aortic repair (BEVAR).

METHODS

From January 2016 to October 2019, 152 consecutive patients underwent BEVAR under general anesthesia at a single institution. In 2018, an alternative approach to the antegrade branches using TFA compared with conventional UEA was introduced. The cohort was divided into TFA and UEA groups according to the access approach. The end points were technical success, adverse events (including perioperative stroke/transient ischemic attack), access complications, operation time, and radiation exposure.

RESULTS

The TFA group included 60 patients (63% male; median age, 71 years; interquartile range [IQR], 65-76 years). The UEA group included 92 patients (67% male; median age, 73 years; IQR, 66-78 years). The number of target vessels (TVs) was similar in both groups (median, 4.0 TVs per procedure; range, 1-7 TVs for both). Technical success was greater in the TFA group (60 of 60 patients; 209 of 209 TVs) than in the UEA group (87 of 92 patients; 334 of 346 TVs; P < .01). The fluoroscopy time (median, 69 minutes; IQR, 48-87 minutes; vs 88 minutes; IQR, 65-104 minutes; P = .39) and contrast agent volume (median, 141 mL; IQR, 123-165 mL; vs median, 130 mL; IQR, 101-157 mL; P = .34) were similar in both groups. The radiation exposure (221 Gy × cm²; IQR, 138-406 Gy × cm²; vs median, 255 Gy × cm²; IQR, 148-425 Gy × cm²; P = .05) was lower and the operation time (median, 300 minutes; IQR, 240-356 minutes; vs median, 364 minutes; IQR, 290-475 minutes; P = .01) was shorter in the TFA group. Brachial access complications (0 of 60 vs 3 of 92 patients) and perioperative strokes/transient ischemic attacks (0 of 60 vs 8 of 92 patients) only occurred in the UEA group (P = .018).

CONCLUSIONS

The use of TFA to catheterize antegrade branches was associated with a lower rate of complications in the present study and has become our preferred approach for BEVAR.

Evolving Concepts, Management, and Treatment of Type 1 Endoleaks after Endovascular Aneurysm Repair

Over the past 20 years, there has been tremendous progress in endovascular aneurysm repair techniques and devices. The application of new third- and fourth-generation devices (from 2003 onward) has led to changes in the incidence and management of endoleaks. This comprehensive review aims to outline the most recent concepts with respect to pathophysiology/risk factors and management of Type 1 endoleaks.

Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries

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.

Chimney grafts in renal arteries: a clinical model for coronary perfusion in future transcatheter aortic root repair techniques

OBJECTIVES

Given the similarities between coronary ostia and renal arteries, chimney grafts (CG) for kidney perfusion during abdominal endovascular aneurysm repair (EVAR) can be considered for coronary perfusion in future transcatheter aortic root repair (TARR) techniques. We analysed the results of renal CG and compared anatomic and technical details with root and coronary anthropometric data.

METHODS

Current status of kidney perfusion with CG was reviewed from literature. Anatomic details, technical data, CG performance and clinical outcome were collected and analysed. Anatomic details of aortic landing zone and renal arteries were compared with human anthropometric data of aortic root, ascending aorta and coronary ostia.

RESULTS

Seventeen articles reported 430 patients (mean age:74.5 ± 2.9 years) treated with renal CG. Mean length and diameter of proximal landing zone were 2.0 ± 2.0 mm and 26.4 ± 4.3 mm, respectively (anthropometric correspondence: ascending aorta diameter of 29.3 mm). Aortic endograft mean diameter was 26.4 ± 7.3 mm with reported oversize of 19.5 ± 6.0%. In total, 590 renal arteries were treated (left:325; right:265; bilateral:139 cases). Mean left and right renal artery diameters were 5.7 ± 0.6 mm and 5.8 ± 0.7 mm, respectively (anthropometric correspondence: coronary ostia diameters of 4.8 mm (left) and 3.7 mm (right)) with reported CG oversize of 19.75 ± 6% (left) and 18.1 ± 5.1% (right). Mean follow-up time was 16.5 ± 8.5 months, CG occlusion rate was 3.2% and endoleak I or II was reported in 83 patients (19.3%), requiring 7 procedures.

CONCLUSIONS

CG provides satisfactory results in patients with suitable renal artery diameter. Based on aortic root and coronary anthropometric data, CG can be considered in future TARR technologies for coronary perfusion but further tests for flow evaluations are mandatory.

Cerebrovascular Complications After Upper Extremity Access for Complex Aortic Interventions: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to review the risk of developing cerebrovascular complications from upper extremity access during endovascular treatment of complex aortic aneurysms.

METHODS

A systematic review and meta-analysis were conducted according to the PRISMA guideline. An electronic search of the public domains Medline (PubMed), Embase (Ovid), Web of Science and Cochrane Library was performed to identify studies related to the treatment of aortic aneurysms involving upper extremity access. Meta-analysis was used to compare the rate of cerebrovascular event after left, right and bilateral upper extremity access. Results are presented as relative risk (RR) and 95% confidence intervals (CIs).

RESULTS

Thirteen studies including 1276 patients with complex endovascular treatment of aortic aneurysms using upper extremity access were included in the systematic review. Left upper extremity access (UEA) was used in 1028 procedures, right access in 148 and bilateral access in 100 procedures. The rate of cerebrovascular complications for patients treated through left UEA was 1.7%, through right UEA 4% and through bilateral UEA 5%. In the meta-analysis, we included seven studies involving 645 patients treated with a left upper extremity access, 87 patients through a right and 100 patients through a bilateral upper extremity access. Patients, who underwent right-sided (RR 5.01, 95% CI 1.51-16.58, P = 0.008) or bilateral UEA (RR 4.57, 95% CI 1.23-17.04, P = 0.02), had a significantly increased risk of cerebrovascular events compared to those who had a left-sided approach.

CONCLUSION

Left upper extremity access is associated with a significantly lower rate of cerebrovascular complications as compared to right or bilateral upper extremity access.

Sex differences in perioperative outcomes after complex abdominal aortic aneurysm repair

OBJECTIVE

Female sex is associated with worse outcomes after infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. Therefore, we compared outcomes between female and male patients after open and endovascular treatment of complex AAA.

METHODS

We identified all patients who underwent complex aneurysm repair between 2011 and 2017 in the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Complex repairs were defined as those for juxtarenal, pararenal, or suprarenal aneurysms. We compared rates of perioperative adverse events between female and male patients stratified by open AAA repair and endovascular aneurysm repair (EVAR). We calculated propensity scores and used inverse probability-weighted logistic regression to identify independent associations between female sex and our outcomes.

RESULTS

We identified 2270 complex aneurysm repairs, of which 1260 were EVARs (21.4% female) and 1010 were open repairs (30.7% female). After EVAR, female patients had higher rates of perioperative mortality (6.3% vs 2.4%; P = .001) and major complications (15.9% vs 7.6%; P < .001) compared with male patients. In contrast, after open repair, perioperative mortality was not significantly different (7.4% vs 5.6%; P = .3), and the rate of major complications was similar (29.4% vs 27.4%; P = .53) between female and male patients. Furthermore, even though perioperative mortality was significantly lower after EVAR compared with open repair for male patients (2.4% vs 5.6%; P = .001), this difference was not significant for women (6.3% vs 7.4%; P = .60). On multivariable analysis, female sex remained independently associated with higher perioperative mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9; P = .007) and major complications (OR, 2.0; 95% CI, 1.3-3.2; P = .002) in patients treated with EVAR but showed no significant association with mortality (OR, 0.9; 95% CI, 0.5-1.6; P = .69) or major complications (OR, 1.1; 95% CI, 0.8-1.5; P = .74) after open repair. However, the association of female sex with higher perioperative mortality in patients undergoing complex EVAR was attenuated when diameter was replaced with aortic size index in the multivariable analysis (OR, 1.9; 95% CI, 0.9-3.9; P = .091).

CONCLUSIONS

Female sex is associated with higher perioperative mortality and more major complications than for male patients after complex EVAR but not after complex open repair. Continuous efforts are warranted to improve the sex discrepancies in patients undergoing endovascular repair of complex AAA.

Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution

OBJECTIVE

Despite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs.

METHODS

This retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests.

RESULTS

Seventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months).

CONCLUSIONS

Parallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.

Retrograde Branched Endovascular Repair as a Feasible Option to Treat Complex Aortic Aneurysm Using the Retrograde Branched Extension Limb Assembling Technique

PURPOSE

To present the primary experiences in treating suprarenal aneurysms, juxtarenal aneurysms, thoracoabdominal aortic aneurysms, and aneurysms after dissection with hostile anatomical features using the retrograde branched extension limb assembling (REBEL) technique.

MATERIALS AND METHODS

The study included 23 consecutive patients undergoing total endovascular repair with the REBEL technique from August 2014 to January 2019. Twelve patients had abdominal aortic aneurysms (4 juxtarenal, 8 suprarenal), 6 had thoracoabdominal aortic aneurysms (type IV), and 5 had postdissection aneurysms. The patients were unsuitable for treatment with current off-the-shelf devices or required emergent repair. The evaluated outcomes were technical success, operative mortality, complication morbidity, late survival, endoleakage, and reintervention during follow-up.

RESULTS

Technical success rate was 100%. In total, 60 visceral vessels were targeted (38 renal arteries, 1 accessory renal artery, 14 superior arteries, and 7 celiac arteries). The mean follow-up period was 20.1 ± 15.1 months (range 2-56), and no aneurysm-related mortality occurred during follow-up. No occlusion of target vessels occurred. Two type II endoleaks and 1 stent migration occurred in 3 (13.0%) patients, and reinterventions were successfully performed. One patient (4.3%) died of myocardial infarction at 38 months.

CONCLUSIONS

The REBEL technique is a feasible option with acceptable results for complex aortic aneurysms. Long-term follow-up of a large sample size is needed to determine the efficacy and durability of this novel technique.

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Background

Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR).

Methods

A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates.

Results

During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively.

Conclusion

Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

Fenestrated Endovascular Aneurysm Repair versus Snorkel Endovascular Aneurysm Repair: Competing yet Complementary Strategies

Juxtarenal/pararenal aortic aneurysms and type IV thoracoabdominal aneurysms pose particular technical challenges for endovascular repair as they involve the visceral segment in addition to insufficient infrarenal neck for the use of standard endovascular aneurysm repair (EVAR) devices. To overcome these challenges, complex EVAR techniques have been developed to extend the proximal landing zone cephalad with maintaining perfusion to vital aortic branches, thereby broadening the applicability of endografting from the infrarenal to the suprarenal aorta. Complex EVAR can be divided into two broad categories: fenestrated endovascular aneurysm repair (FEVAR) and snorkel EVAR. FEVAR is a valid procedure with the standardized procedure, although it remains as a relatively complex procedure with a learning curve. Given time constraints for the custom fenestrated graft, snorkel EVAR may be an alternative for complex repairs in symptomatic or ruptured patients for whom custom-made endografts may not be immediately available. This article discusses these two most commonly used complex EVAR strategies.

CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms

Purpose: To evaluate chimney stent-graft position and morphological changes of the aneurysm sac as visualized by postoperative computed tomography angiography (CTA) over a minimum 24-month follow-up period. Materials and Methods: Twenty-one patients (mean age 75.7±8.6 years; 20 men) with juxtarenal aortic aneurysms who underwent successful chimney endovascular aneurysm repair (ch-EVAR) with the Endurant stent-graft and had 2 postoperative CTAs separated by at least 24 months were included in the study. CTA-based measurements of aortic stent-graft migration, target vessel angle, and chimney angle were compared between the serial scans. Results: During a mean follow-up of 34.9 months (range 24-69.2), the mean migration of the aortic stent-grafts was under 5 mm (2.76±2.4 mm). The average migration distance per year was 1.15 mm. The aneurysm diameter reduced a mean 3.25 mm (p=0.048). The right renal artery angle moved significantly upward 6.72° (p=0.025), while the right renal chimney stent-graft moved significantly downward 7.83° (p=0.042). The left renal artery angle also moved upward 1.87° (p=0.388) and the corresponding chimney moved downward 5.68° (p=0.133). During the study period, no type I/III endoleak or chimney occlusion was observed. Conclusion: Midterm morphometric assessment of ch-EVAR using CTA showed significant aneurysm sac shrinkage and a stable 3-year position of the abdominal devices, with the mean downward migration of the aortic stent-graft being <5 mm in the majority of cases. The chimney grafts seem to be prone to take an oblique rather than parallel configuration during follow-up. However, there was no relevant clinical consequence related to this phenomenon.

Optimization schemes for endovascular repair with parallel technique based on hemodynamic analyses

Endovascular repair with parallel stent-grafts (SG) is a challenging technique that reconstructs the luminal flow pathways by implanting parallel-placed SGs into the vessel. After treatment, occlusion and shifting of the parallel SGs are sometimes reported, which could be fatal and difficult to be re-operated. These issues are highly related to the local hemodynamic conditions in the stented region. In this study, a patient case treated by the octopus endograft technique (a head-SG with three limb-SGs) and experienced limb-SG occlusion is studied. 3-D models are established based on computed tomography (CT) angiography datasets pretreatment and posttreatment as well as during follow-ups. Hemodynamic quantities such as pressure drop, wall shear stress-related parameters, and flow division in limb-SGs and visceral arteries are quantitatively investigated. Optimizations on the length of the head-SG and diameter of the limb-SGs are analyzed based on various scenarios. The results indicate that when reconstructing the flow pathways via octopus stenting, it is important to ensure the flow distribution as physiologically required with this new morphology. Position (or length) of the head-SG and diameter of the limb-SGs play an important role in controlling flow division, and high time average wall shear stress (TAWSS) around the head-SG acts as a main factor for graft immigration. This study, by proposing optimization suggestions with hemodynamic analyses for a specific case, implicates that pretreatment SG scenarios may assist in wise selection and placement of the device and thus may improve long-term effectiveness of this kind of challenging endovascular repair techniques.

EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11-18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.

Outcomes after endovascular repair of abdominal aortic aneurysm involving the renovisceral arteries: A multi-center follow-up study

Objectives

To evaluate outcomes after endovascular treatment of abdominal aortic aneurysms (AAA) involving the renovisceral arteries and to compare outcomes after fenestrated/branched endovascular aortic repair (f/b-EVAR), chimney/periscope EVAR (ch-EVAR), and bailout ch-EVAR.

Methods

A retrospective multicenter study including all patients with AAA involving the renovisceral segment, treated with f/b-EVAR, ch-EVAR, or bailout ch-EVAR, between 1 January 2005 and 30 June 2015, in three Swedish vascular centers. Patient charts were reviewed for data. Renovisceral stent graft patency was assessed on follow-up CT. Mortality was cross-checked against the Swedish Population Registry. Bailout ch-EVAR was defined as a perioperative decision of renovisceral endografting, as the artery was accidentally covered, or as the aneurysm neck sealing zone was considered inadequate.

Results

Of the 99 identified patients (76 men; mean age 74 years (range 58–89 years)), 68 underwent f/b-EVAR, 18 ch-EVAR, and 13 bailout ch-EVAR. Follow-up lasted for a median of 3.2 years (Q1, Q3 (2.1, 4.7 years)). Elective surgery comprised 87.9% ( n = 87) of the cases. Six patients died within 30 days, and the 30-day mortality after elective surgery was 4.6% (95% CI, 1.3%–11.4%) overall, 1.6% after f/b-EVAR (95% CI, 0.0%–11.4%), 15.4% after ch-EVAR (95% CI, 1.9%–45.4%), and 10.0% (95% CI, 0.3%–44.5%) after bailout ch-EVAR. During follow-up, there were 16 secondary interventions, of which 75% ( n = 12) were performed within six months after the primary intervention. Compared with f/b-EVAR, ch-EVAR was associated with a higher degree of type 1 endoleaks (1.5% vs. 22.2%, P = 0.001) and re-interventions during follow-up (13.2% vs. 33.3%, P = 0.046). The overall assisted target vessel patency was 96.1% (95% CI, 91.7%–98.6%) at one year and 95.2% (95% CI, 89.2%–98.4%) at two years.

Conclusions

Results after EVAR involving endografting of renovisceral arteries from three centers in Sweden with medium volumes are consistent with results previously reported from centers with larger volumes.

Comparison of supra-arch in situ fenestration and chimney techniques for aortic dissection involving the left subclavian artery

Introduction

Endovascular intervention involving the aortic arch, particularly in thoracic aortic dissection, remains challenging and controversial at current time when there is no commercially suitable grafts on most of the international markets. This study compared two endovascular treatments that maintain left subclavian artery perfusion using two modified techniques for type-B aortic dissection patients.

Methods

Consecutive cases utilizing chimney or in situ fenestration techniques to preserve left subclavian artery in type B AD from 2006 to 2015 in our single institution were retrospectively reviewed. Statistical analyses were performed with Student t-test, Wilcoxon rank sum, and Fisher exact tests when appropriate. Significant statistical differences were determined with p < 0.05.

Results

A total of 85 cases, including 67 (79.8%) with chimney and 18 (21.2%) with in situ fenestration techniques were identified in this retrospective study. In chimney group, there were 18 (26.9%) acute, 29 (43.3%) sub-acute, and 20 (29.9%) chronic aortic dissections. We implanted 24 Zenith and 43 Talent aortic endografts along with 55 balloon-expandable bare stents and 12 self-expanding covered stents in chimney group. Whereas in in situ fenestration group, there were four (22.2%) acute, six (33.3%) subacute, and eight (44.5%) chronic aortic dissections, all of which received Zenith endografts with 11 balloon-expandable covered and seven self-expanding covered stents, respectively. Demographic variables were similarly distributed with 100% intraoperative technical overall success in both groups. Comparing to in situ fenestration group, chimney group has shorter procedural and fluoroscopy time, less blood loss, and contrast volume used. All patients were followed-up to 52 months (median 38, range 24–52). Overall group mortality is 3.6% (3/84). All deaths were from chimney group. There was no procedure-related stroke observed within the study series. Primary patency was maintained while aortic remodeling with complete false lumen was achieved in all patients except that there were three (4.55%) Type-I endoleak cases in early post-operative period and one (1.5%) stent compression at 3-months follow-up in chimney group. There were no stent-related complications observed in in situ fenestration group.

Conclusion

Although there were previous studies describing the similar techniques, this study appears to be the first study to compare in situ fenestration and chimney techniques for aortic dissection involving the left subclavian artery according to the MEDLINE search. Although we are unable to establish the superiority between two approaches due to small sample size and relative short period of follow-up, in situ fenestration may represent a more favorable option, especially among aortic dissections with short proximal landing zones in the study.

Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair

OBJECTIVE

Visceral artery chimneys have been employed as an adjunct to endovascular aneurysm repair (EVAR) to treat short-neck infrarenal and juxtarenal aortic aneurysms for more than two decades. With the widespread introduction of fenestrated endovascular aneurysm repair by the Food and Drug Administration-approved Zenith Fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) to the United States in 2012, clinicians gained the ability to apply the chimney technique to these custom devices for difficult anatomy. The purpose of this report was to demonstrate feasibility and to provide evidence on the performance of chimneys for the treatment of complex juxtarenal aneurysms that could not be adequately treated with ZFEN alone.

METHODS

A retrospective analysis was performed of a prospectively maintained institutional ZFEN database capturing 110 fenestrated endovascular aneurysm repairs from October 2012 to January 2018 to identify patients undergoing a concomitant visceral artery chimney. All patients with <12 months of follow-up were excluded from further analysis. Demographic, anatomic, intraoperative, perioperative, and follow-up characteristics were tabulated and analyzed.

RESULTS

Six patients met criteria and were included in this investigation. They were universally male with a mean age of 76.2 years at the time of ZFEN/chimney. Chimneys were placed in a total of six visceral arteries (n = 1 per patient) consisting of three renal arteries, two celiac arteries, and one accessory renal artery. Mean estimated blood loss and operative time were 283 mL and 298 minutes, respectively. Technical success was achieved in all cases. Two small type IA "gutter" endoleaks were detected early; both spontaneously resolved on follow-up. We observed no instances of chimney migration, stenosis, or thrombosis perioperatively or on follow-up. Two reinterventions were performed in these six patients; these consisted of a repeated renal stent for ostial stenosis at a main body fenestration and a common femoral artery endarterectomy and patch angioplasty for an access-related common femoral artery occlusion.

CONCLUSIONS

Use of ZFEN in conjunction with a singular chimney is safe, feasible, and durable in patients with difficult anatomy who do not meet instructions for use as demonstrated in this limited series.

Epidemiology and contemporary management of abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) is most commonly defined as a maximal diameter of the abdominal aorta in excess of 3 cm in either anterior-posterior or transverse planes or, alternatively, as a focal dilation ≥ 1.5 times the diameter of the normal adjacent arterial segment. Risk factors for the development of AAA include age > 60, tobacco use, male gender, Caucasian race, and family history of AAA. Aneurysm growth and rupture risk appear to be associated with persistent tobacco use, female gender, and chronic pulmonary disease. The majority of AAAs are asymptomatic and detected incidentally on various imaging studies, including abdominal ultrasound, and computed tomographic angiography. Symptoms associated with AAA may include abdominal or back pain, thromboembolization, atheroembolization, aortic rupture, or development of an arteriovenous or aortoenteric fistula. The Screening Abdominal Aortic Aneurysms Efficiently (SAAAVE) Act provides coverage for a one-time screening abdominal ultrasound at age 65 for men who have smoked at least 100 cigarettes and women who have family history of AAA disease. Medical management is recommended for asymptomatic patients with AAAs < 5 cm in diameter and focuses on modifiable risk factors, including smoking cessation and blood pressure control. Primary indications for intervention in patients with AAA include development of symptoms, rupture, rapid aneurysm growth (> 5 mm/6 months), or presence of a fusiform aneurysm with maximum diameter of 5.5 cm or greater. Intervention for AAA includes conventional open surgical repair and endovascular aortic stent graft repair.

Laser Fenestration of Aortic Stent-Grafts Followed by Noncompliant vs Cutting Balloon Dilation: A Scanning Electron Microscopy Study

Purpose: To examine the effects of in situ laser fenestration and subsequent balloon dilation (noncompliant vs cutting) on the graft fabric of 4 aortic stent-graft models. Method: In an in vitro setup, the Zenith TX2, Talent, Endurant, and Anaconda aortic stent-grafts (all made of polyester graft material) were subjected to laser fenestration with a 2.3-mm-diameter probe at low and high energy in a physiologic saline solution followed by balloon dilation of the hole. For the first series of tests, 6-mm-diameter noncompliant balloons were used and replaced for the second series by 6-mm-diameter cutting balloons. Each procedure was performed 5 times (5 fenestrations per balloon type). The fenestrations were examined visually and with light and scanning electron microscopy. Results: Each fenestration demonstrated various degrees of fraying and/or tearing regardless of the device. The monofilament twill weave of the Talent endograft tore in the warp direction up to 7.09±0.46 mm at high energy compared with 2.41±0.26 mm for the Endurant multifilament device. The fenestrations of the 3 endografts with multifilament weave (Zenith, Anaconda, and Endurant) showed more fraying; fenestration areas in the multifilament Endurant were >10 mm2 at low and high energy. The fenestrations were free of melted fibers, but minor blackening of the filaments was observed in all devices. Overall, the cutting balloons resulted in worse tearing and damage. Of note, the edges of the dilated laser-formed fenestrations of the Talent and the Endurant grafts demonstrated evidence of additional shredded yarns. Conclusion: In situ fenestration does not cause any melting of the polyester; however, the observed structural damage to the fabric construction must be carefully considered. Cutting balloons caused various levels of tearing compared to the noncompliant balloons and cannot be recommended for use in this application. Rather, noncompliant balloons should be employed, but only with endografts constructed from multifilament yarns. The use of in situ fenestration must be restricted to urgent and emergent cases until long-term durability can be determined.

Polar orientation of renal grafts within the proximal seal zone affects risk of early type IA endoleaks after chimney endovascular aneurysm repair

OBJECTIVE

The objective of this study was to describe the polar orientation of renal chimney grafts within the proximal seal zone and to determine whether graft orientation is associated with early type IA endoleak or renal graft compression after chimney endovascular aneurysm repair (ch-EVAR).

METHODS

Patients who underwent ch-EVAR with at least one renal chimney graft from 2009 to 2015 were included in this analysis. Centerline three-dimensional reconstructions were used to analyze postoperative computed tomography scans. The 12-o'clock polar position was set at the takeoff of the superior mesenteric artery. Relative polar positions of chimney grafts were recorded at the level of the renal artery ostium, at the mid-seal zone, and at the proximal edge of the graft fabric. Early type IA endoleaks were defined as evidence of a perigraft flow channel within the proximal seal zone.

RESULTS

There were 62 consecutive patients who underwent ch-EVAR (35 double renal, 27 single renal) for juxtarenal abdominal aortic aneurysms with a mean follow-up of 31.2 months; 18 (29%) early type IA "gutter" endoleaks were identified. During follow-up, the majority of these (n = 13; 72%) resolved without intervention, whereas two patients required reintervention (3.3%). Estimated renal graft patency was 88.9% at 60 months. Left renal chimney grafts were most commonly at the 3-o'clock position (51.1%) at the ostium, traversing posteriorly to the 5- to 7-o'clock positions (55.5%) at the fabric edge. Right renal chimney grafts started most commonly at the 9-o'clock position (n = 17; 33.3%) and tended to traverse both anteriorly (11 to 1 o'clock; 39.2%) and posteriorly (5 to 7 o'clock; 29.4%) at the fabric edge. In the polar plane, the majority of renal chimney grafts (n = 83; 85.6%) traversed <90 degrees before reaching the proximal fabric edge. Grafts that traversed >90 degrees were independently associated with early type IA endoleaks (odds ratio, 11.5; 95% confidence interval, 2.1-64.8) even after controlling for other device and anatomic variables. Polar orientation of the chimney grafts was not associated with graft kinking or compression (P = .38) or occlusion (P = .10). Takeoff angle of the renal arteries was the most significant predictor of chimney graft orientation. Caudally directed arteries (takeoff angle >30 degrees) were less likely to have implanted chimney grafts that traversed >90 degrees in polar angle (odds ratio, 0.09; 95% confidence interval, 0.01-0.55).

CONCLUSIONS

Renal chimney grafts vary considerably in both starting position and their polar trajectory within the proximal seal zone. Grafts that traverse >90 degrees in polar angle within the seal zone may be at increased risk of early type IA endoleaks and require more frequent imaging surveillance. Caudally directed renal arteries result in a more favorable polar geometry (eg, cranial-caudal orientation) with respect to endoleak risk and thus are more ideal candidates for parallel graft strategies.

Configuration affects parallel stent grafting results

OBJECTIVE

A number of adjunctive "off-the-shelf" procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures.

METHODS

This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise.

RESULTS

There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four-stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all-antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication.

CONCLUSIONS

Parallel stent grafting offers an off-the-shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty-day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%.