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Fenelli C, Tsilimparis N, Faggioli G, Stana J, Gallitto E, Stavroulakis K, Fernandez Prendes C, Gargiulo M. Early and Mid-Term Outcomes of the Inverted Limb Configuration Below Fenestrated and Branched Endografts: Experience from Two European Centers. J Endovasc Ther 2024; 31:410-420. [PMID: 36189939 DOI: 10.1177/15266028221125158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE To report a European experience on the use of the Inverted Limb (IL) below fenestrated and branched endografts (FB-EVAR) for the treatment of juxta/pararenal (JP-AAAs), thoracoabdominal (TAAAs), and para-anastomotic aortic aneurysms. MATERIALS AND METHODS Between 2016 and 2020, all FB-EVAR with distal IL due to previous open (OSR) or endovascular repair (EVAR) or infrarenal aortic length <76 mm at two European university centers were retrospectively analyzed. Technical success, early and mid-term iliac complications (occlusion; type Ib endoleak [EL]), IL-related complications (type III EL), and reinterventions were assessed as primary endpoints; 30-day mortality, survival and freedom from (FF) overall complications/reinterventions were assessed as secondary outcomes. RESULTS Forty-one high-risk patients (male 30%-73%; mean age 71±10 years; ASA 3-4, 41%-100%) underwent FB-EVAR with distal IL for 8 (19.5%) J/P-AAAs and 33 (80.5%) TAAAs. Sixteen (39%) patients with previous aortic treatment (8 OR, 8 EVAR) were included. Preoperative computed tomographic angiography showed infrarenal aortic length <76 mm in all cases. Custom-made endografts were configured as 31 (75.6%) fenestrated-only, 6 (14.6%) branched-only, and 4 (9.8%) fenestrated+branched for an overall of 158 target visceral vessels (TVVs; 3.8±0.7 TVVs/case). The IL main body was planned with 1-stent, 2-stents, and 3-stents in 6 (14.6%), 23 (56.1%), and 12 (29.3%) cases, respectively. Technical success and 30-day mortality were 97.6% (40/41) and 0%. Thirty-day complications occurred in 2 (4.9%) patients: 1 limb occlusion, requiring reintervention, 1 type III EL, spontaneously resolved. Mean follow-up was 21±16 months. Three After 30-day, 3 (7.3%) iliac complications (2 occlusions; 1 type Ib EL) were successfully managed by endovascular reinterventions; no IL-related complications were observed. The patency of TVVs was 96.8%. No correlation between anatomical characteristics, endograft configuration, and primary outcomes was observed, except for 1-stent IL and type III EL (log rank p=0.01). At 1- and 2-year follow-up survival, FF overall iliac/IL-related complications and FF reinterventions were 90% and 80%, 90% and 84%, and 92% and 87%, respectively. CONCLUSION The IL configuration allows a safe endovascular treatment of challenging aortic lesions in high-risk patients although needing a number of adjunctive procedures. A short main body of IL could be associated with intraoperative and perioperative type III EL. CLINICAL IMPACT Bifurcated endograft with inverted limb configuration increases the feasibility of a total endovascular approach in patients with challenging anatomy. The use of inverted limb overcomes the anatomical limitations of short-body initial grafts and short distance between lowest target artery and the aortic bifurcation, leading the fixation inside the endograft. Although technically demanding, this advanced technology could avoid surgical reinterventions in previous open or endovascular repair that are burdened with higher rates of morbidities and complications.
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Affiliation(s)
- Cecilia Fenelli
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Enrico Gallitto
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | | | | | - Mauro Gargiulo
- Vascular Surgery, DIMES, University of Bologna, Bologna, Italy
- Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
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Prendes CF, Grab M, Stana J, Gouveia E Melo R, Mehmedovic A, Grefen L, Tsilimparis N. In vitro evaluation of the optimal degree of oversizing of thoracic endografts in prosthetic landing areas: a pilot study. J Vasc Surg Cases Innov Tech 2023; 9:101195. [PMID: 37496652 PMCID: PMC10366543 DOI: 10.1016/j.jvscit.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/28/2023] [Indexed: 07/28/2023] Open
Abstract
Objective The optimal degree of proximal thoracic endograft oversizing when aiming for durable sealing in prosthetic grafts is unknown. The aim of the present study was to create an in vitro model for testing different oversized thoracic endografts in a reproducible and standardized manner and, subsequently, determine the optimal oversizing range when planning procedures with a proximal landing in prosthetic zones in the descending thoracic aorta or aortic arch. Methods An in vitro model consisting of a fixed 24-mm polyethylene terephthalate (Dacron; DuPont) graft sutured proximally and distally to two specifically designed 40-mm rings, with four force sensing resistors attached at four equally distant positions and a USB camera attached proximally for photographic and video documentation was used for deployment of Zenith TX2 (Cook Medical Inc) dissection platform endografts with diameters between 24 and 36 mm. After deployment, ballooning with a 32-mm compliant balloon was performed to simulate real-life conditions. The assessment of oversizing included visual inspection, calculation of the valley areas created between the prosthetic wall and the stent graft fabric, distance between the stent graft peaks, the radial force exerted by the proximal sealing stent, and the pull-out force necessary for endograft extraction. Results A total of 70 endografts were deployed with the oversizing ranging from 0% to 50%: 10 × 24 mm, 10 × 26 mm, 10 × 28 mm, 10 × 30 mm, 10 × 32 mm, 10 × 34 mm, and 10 × 36 mm. Two cases of infolding occurred with 50% oversizing. The valley areas increased from 8.79 ± 0.23 mm2 with 16.7% oversizing to 14.26 ± 0.45 mm2 with 50% oversizing (P < .001). A significant difference was found in the pull-out force required for endografts with <10% oversizing vs ≥10% oversizing (P < .001). The difference reached a plateau at ∼4 N with oversizing of >15%. The mean radial force of the proximal sealing stent was greater after remodeling with a compliant balloon (0.55 ± 0.02 N vs 0.60 ± 0.02 N after ballooning; P < .001). However, greater oversizing did not lead to an increase in the radial force exerted by the proximal sealing stent. Conclusions The findings from the present study offer additional insight into the mechanics of oversized stent grafts in surgical grafts. In endografts with the Zenith stent design (TX2), oversizing of <16.7% resulted in reduced resistance to displacement forces, and oversizing of >50% was associated with major infolding in 20% of cases. Long-term in vitro and in vivo testing is required to understand how these mechanical properties affect the clinical outcomes of oversizing.
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Affiliation(s)
- Carlota F. Prendes
- Department of Vascular Surgery, University Hospital of Munich, Munich, Germany
| | - Maximilian Grab
- Department of Cardiac Surgery, University Hospital of Munich, Munich, Germany
- Department of Medical Materials and Implants, Technical University of Munich, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, University Hospital of Munich, Munich, Germany
| | - Ryan Gouveia E Melo
- Vascular Surgery Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Aldin Mehmedovic
- Department of Vascular Surgery, University Hospital of Munich, Munich, Germany
| | - Linda Grefen
- Department of Cardiac Surgery, University Hospital of Munich, Munich, Germany
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Tenorio ER, Oderich GS, Schanzer A, Beck AW, Gargiulo M, Farber MA, Modarai B, Jakimowicz T, Bertoglio L, Chiesa R, Gallitto E, Marcondes GB, Parodi FE, Motta F, Gkoutzios P, Jama K. Endovascular repair of intercostal and visceral aortic patch aneurysms following open thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 165:1261-1271.e5. [PMID: 34030882 DOI: 10.1016/j.jtcvs.2021.04.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE Reoperative open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs) is associated with high morbidity and mortality. The aim of this study was to analyze outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) for the treatment of intercostal or visceral aortic patch aneurysms after OSR of TAAAs. METHODS We reviewed the clinical data and outcomes of consecutive patients treated at 8 academic centers by F-BEVAR for visceral and intercostal aortic patch aneurysms after OSR of TAAAs (2011-2019). All patients had involvement of at least one target vessel requiring incorporation by a fenestration or directional branch. End points were technical success, 30-day and/in-hospital mortality, major adverse events, patient survival, target vessel patency/instability, and freedom from reintervention. RESULTS There were 29 patients with a median age of 70 (interquartile range, 63-74) years. Seven patients (24%) had connective tissue disorders. Technical success was 100%. There were no 30-day/in-hospital mortalities. Major adverse events occurred in 5 patients (17%), including estimated blood loss >1 L in 3 patients (10%), acute kidney injury and respiratory failure in 2 patients (7%) each, and transient paraparesis in 1 patient (3%). Median follow-up was 14 (interquartile range, 7-37) months. At 2 years, primary and secondary patency, freedom from target artery instability, freedom from reintervention, and patient survival were 95%, 100%, 83%, 61%, and 96%, respectively. CONCLUSIONS F-BEVAR could be considered as an alternative to reoperative OSR in patients with visceral or intercostal aortic patch aneurysms. This series showed no mortality and a low rate of major adverse events, but a significant need for reintervention.
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Gallitto E, Sobocinski J, Mascoli C, Pini R, Fenelli C, Faggioli G, Haulon S, Gargiulo M. Fenestrated and Branched Thoraco-abdominal Endografting after Previous Open Abdominal Aortic Repair. Eur J Vasc Endovasc Surg 2020; 60:843-852. [DOI: 10.1016/j.ejvs.2020.07.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/03/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
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Nguyen TT, Simons JP, Schanzer A. Use of fenestrated-branched endovascular aneurysm repair to treat Carrel patch aneurysmal degeneration after open thoracoabdominal aortic aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:117-121. [PMID: 31193425 PMCID: PMC6529688 DOI: 10.1016/j.jvscit.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/11/2018] [Indexed: 10/28/2022]
Abstract
Two patients with a history of open type II thoracoabdominal aortic aneurysm repair presented with saccular aneurysmal degeneration of the Carrel patch. The degenerated segments measured 6.2 cm and 7.4 cm, respectively, and involved the celiac artery, superior mesenteric artery, and right renal artery. Both patients successfully underwent a custom fenestrated-branched endovascular aneurysm repair with downgoing branches to the celiac artery, superior mesenteric artery, and right renal artery and a stented fenestration to the left renal artery. Completion angiography demonstrated no endoleak and patent visceral-renal segments. Both patients were discharged home on postoperative day 2.
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Affiliation(s)
- Tammy T Nguyen
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
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Alternative Debranching in Patients with Thoracoabdominal Aortic Aneurysm after Open and Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2019; 57:272.e1-272.e4. [PMID: 30684616 DOI: 10.1016/j.avsg.2018.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
Management of recurrent thoracoabdominal aneurysmal disease of the aorta is challenging. We report three patients with previous endovascular or open aortic repair requiring redo repair by treatment by stent-graft implantation of the thoracoabdominal aorta and visceral debranching using an antegrade inflow from the ascending aorta. All three interventions were successful, with two patients alive 5 and 2 years, respectively, after this operation, while the third patient died 2 days after the procedure due to cardiac failure. No paraplegia was observed. As complications from complex open and endovascular procedures are increasing, vascular surgeons should get familiar with alternative management options.
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Gallitto E, Faggioli G, Mascoli C, Pini R, Ancetti S, Vacirca A, Stella A, Gargiulo M. Impact of previous open aortic repair on the outcome of thoracoabdominal fenestrated and branched endografts. J Vasc Surg 2018; 68:1667-1675. [DOI: 10.1016/j.jvs.2018.02.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 02/13/2018] [Indexed: 11/24/2022]
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Bertoglio L, Mascia D, Cambiaghi T, Kahlberg A, Tshomba Y, Gomez JC, Melissano G, Chiesa R. Management of visceral aortic patch aneurysms after thoracoabdominal repair with open, hybrid, or endovascular approach. J Vasc Surg 2018; 67:1360-1371. [DOI: 10.1016/j.jvs.2017.09.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/13/2017] [Indexed: 10/17/2022]
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Bertoglio L, Mascia D, Cambiaghi T, Kahlberg A, Melissano G, Chiesa R. Fenestrated and Branched Endovascular Treatment of Recurrent Visceral Aortic Patch Aneurysm after Open Thoracoabdominal Repair. J Vasc Interv Radiol 2018; 29:72-77.e2. [DOI: 10.1016/j.jvir.2017.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022] Open
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Gallitto E, Gargiulo M, Freyrie A, Bianchini Massoni C, Mascoli C, Pini R, Faggioli GL, Ancetti S, Stella A. Fenestrated and Branched Endograft after Previous Aortic Repair. Ann Vasc Surg 2016; 32:119-27. [DOI: 10.1016/j.avsg.2015.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/10/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
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Endovascular Repair of an Asymptomatic Aortic Pseudoaneurysm after Penetrating Injury. Ann Vasc Surg 2014; 28:1933.e15-8. [DOI: 10.1016/j.avsg.2014.06.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/30/2014] [Accepted: 06/19/2014] [Indexed: 11/21/2022]
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Bianchini Massoni C, Geisbüsch P, Gallitto E, Hakimi M, Gargiulo M, Böckler D. Follow-up outcomes of hybrid procedures for thoracoabdominal aortic pathologies with special focus on graft patency and late mortality. J Vasc Surg 2014; 59:1265-73. [DOI: 10.1016/j.jvs.2013.11.064] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 11/18/2013] [Accepted: 11/19/2013] [Indexed: 12/01/2022]
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Gargiulo M, Gallitto E, Freyrie A, Stella A. Endovascular treatment of penetrating ulcers of the paraceliac aorta using fenestrated endografts. Ann Vasc Surg 2013; 28:738.e7-10. [PMID: 24342443 DOI: 10.1016/j.avsg.2013.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/27/2013] [Accepted: 05/01/2013] [Indexed: 11/16/2022]
Abstract
Penetrating atherosclerotic ulcers (PAUs) are usually focal aortic lesions found in patients with significant comorbidities. They are ideal targets for an endovascular approach if localized in the descending thoracic or infrarenal aorta, but when an origin in the visceral vessels is involved, a standard endovascular approach might not be feasible or effective. We report 2 cases of endovascular treatment of PAUs involving the paraceliac abdominal aorta, using a custom-made tube fenestrated endograft with 4 fenestrations for the abdominal visceral vessels (i.e., celiac-trunk, superior mesenteric artery, and renal arteries). There were no intra- or perioperative complications. At 1 year of follow-up, patients were asymptomatic and computed tomography angiography revealed total lesion exclusion and patency of the visceral vessels. The use of a fenestrated endograft is a safe and effective option to treat paraceliac PAUs.
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Affiliation(s)
- Mauro Gargiulo
- Department of Vascular Surgery, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum, Bologna University, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum, Bologna University, Bologna, Italy.
| | - Antonio Freyrie
- Department of Vascular Surgery, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum, Bologna University, Bologna, Italy
| | - Andrea Stella
- Department of Vascular Surgery, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum, Bologna University, Bologna, Italy
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