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Domingues BS, Dalio MB, Miquelin DG, Neto FR, Reis LF, Miquelin AR, Godoy JMP, Joviliano EE. Early results of fenestrated and branched endovascular repair of complex aortic aneurysms with a custom-made national device available in the Brazilian public health system. Ann Vasc Surg 2024:S0890-5096(24)00582-X. [PMID: 39341558 DOI: 10.1016/j.avsg.2024.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/23/2024] [Accepted: 07/31/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Multicenter studies conducted in developed countries demonstrated that custom-made devices are safe, effective, and durable for treating complex abdominal aneurysms. However, the situation in developing countries, such as Brazil, is different. Funding and time to have the endoprosthesis delivered are the major concerns. In order to overcome these conditions, high-volume Brazilian university hospitals started gaining experience with a custom-made device produced in the country. OBJECTIVE The present study aimed to describe the practice of two tertiary centers and report the early results of fenestrated and branched endovascular repair of complex aortic aneurysms with a custom-made national device available in the Brazilian public health system. METHODS Retrospective analysis of all consecutive patients that underwent F/BEVAR of complex aortic aneurysms using custom-made manufactured endoprosthesis in two tertiary centers from January 2020 to July 2022. RESULTS Thirteen cases were included (10 male, mean age 69 ± 9 years). 70 % were complex abdominal aneurysms, and 30% were type II, III and IV thoracoabdominal aneurysms (mean aneurysm diameter 69.2 ± 8.12 mm). F/BEVAR included 33 visceral arteries. The Apolo® device was used in all cases. Technical success was achieved in 12 out of 13 patients (92.3%). Thirty-day major adverse events included one death (7.7%), five acute renal failure (38.4%), two spinal cord ischemia (15.4%). The one-year survival rate was 92.3%. CONCLUSION Fenestrated and branched endovascular repair of complex aortic aneurysms with the custom-made Apolo® device has proven safe and effective in high-volume tertiary centers in the Brazilian public health system. Considering the complexity of the cases, the early patency of vessels and low initial mortality support this device continuation and expansion to treat complex aortic aneurysms in a developing country.
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Affiliation(s)
- Bianca Santos Domingues
- University of São Paulo, Ribeirão Preto Medical School, Department of Surgery and Anatomy, Division of Vascular and Endovascular Surgery
| | - Marcelo Bellini Dalio
- University of São Paulo, Ribeirão Preto Medical School, Department of Surgery and Anatomy, Division of Vascular and Endovascular Surgery.
| | - Daniel Gustavo Miquelin
- São Jose do Rio Preto Medical School, Department of Surgery, Division of Vascular and Endovascular Surgery
| | - Fernando Reis Neto
- São Jose do Rio Preto Medical School, Department of Surgery, Division of Vascular and Endovascular Surgery
| | - Luiz Fernando Reis
- São Jose do Rio Preto Medical School, Department of Surgery, Division of Vascular and Endovascular Surgery
| | - Andre Rodrigo Miquelin
- São Jose do Rio Preto Medical School, Department of Surgery, Division of Vascular and Endovascular Surgery
| | - Jose Maria Pereira Godoy
- São Jose do Rio Preto Medical School, Department of Surgery, Division of Vascular and Endovascular Surgery
| | - Edwaldo Edner Joviliano
- University of São Paulo, Ribeirão Preto Medical School, Department of Surgery and Anatomy, Division of Vascular and Endovascular Surgery
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Isernia G, Simonte G, Gallitto E, Bertoglio L, Fargion A, Melissano G, Chiesa R, Lenti M, Pratesi C, Faggioli G, Gargiulo M. Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry. J Endovasc Ther 2024; 31:697-705. [PMID: 36408661 DOI: 10.1177/15266028221137498] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes. METHODS Data from all consecutive patients treated during the 2008-2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up. RESULTS Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7-45 months]). CONCLUSION Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks. CLINICAL IMPACT Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification.
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Affiliation(s)
- Giacomo Isernia
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Lenti
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Frese JP, Walter C, Carstens J, Bürger M, Greiner A, Assadian A, Kapahnke S, Falkensammer J. Technical Aspects and Outcome of Multi-Staged and Single-Staged Thoracoabdominal Fenestrated Endovascular Aortic Repair. J Endovasc Ther 2024:15266028241255533. [PMID: 38804508 DOI: 10.1177/15266028241255533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
PURPOSE In some cases of endovascular thoracoabdominal or juxtarenal aortic aneurysm repair, a thoracic endograft in combination with a fenestrated renovisceral device may be needed in order to create a sufficient proximal landing zone. This study aimed to evaluate the technical aspects and postoperative morbidity of a single- or 2-stage approach. METHODS Eighty-seven consecutive patients undergoing thoracic endovascular aortic repair (TEVAR) in combination with elective fenestrated repair (fenestrated endovascular aortic repair [FEVAR]; fenestrated Anaconda device) from 2015 to 2022 were included in this retrospective bicentric study. Underlying pathologies, aortic morphology, technical details, and postoperative morbidity were recorded. RESULTS Single-staged ("1S," n=61) and 2-staged ("2S," n=26) interventions were compared. Indications were thoracoabdominal aneurysms (TAAAs) (Crawford I-IV) (n=56, 64%) and juxtarenal aneurysms (n=31, 36%). In 2S, the proportion of TAAA was higher than in 1S (2S: 77%, 1S: 59%; p=0.001). In 2S, the covered length of the descending aorta was longer (1S: 128±60 mm, 2S: 202±64 mm; p=0.003). Temporary aneurysm sack perfusion (TASP) was established in 11 (18%) of 1S and 1 (4%) of 2S patients (p=0.079), as well as cerebrospinal fluid (CSF) drainage catheter in 48 (79%) of 1S and 19 (73%) of 2S. The rate of spinal cord ischemia (SCI) and the severity of SCI were not different in both groups, with a total of 3 cases of persisting paraplegia. The rate of access complications was higher in 2S (n=6, 23%) than in 1S (n=4, 7%; p=0.027). Postoperative 30 day morbidity did not significantly differ in both groups and neither did 30 day mortality (4.6% in 1S vs 3.8% in 2S; p=0.083). CONCLUSION The combination of TEVAR and FEVAR using a fenestrated endograft is feasible and safe. Aortic morphology does not change significantly after endovascular repair. A single-staged strategy is feasible with excellent results, especially in Crawford IV, Crawford V, or juxtarenal aneurysms. Two-staged repair is recommended in cases with long aortic coverage and a higher American Society of Anesthesiologists (ASA) class. Follow-up data are needed to evaluate the long-term stability of the TEVAR/FEVAR interconnection. CLINICAL IMPACT Our study has revealed the safety and efficacy of the combination of TEVAR and FEVAR in the treatment of TAAAs and juxtarenal aneurysms with compromised supravisceral landing zones. A single-staged concept is not necessary in all cases. Staged procedures may reduce postoperative morbidity in cases with long aortic coverage and higher ASA class.
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Affiliation(s)
- Jan Paul Frese
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Jan Carstens
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Bürger
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jürgen Falkensammer
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
- Department of Vascular Surgery, Konventhospital der Barmherzigen Brüder Linz, Linz, Austria
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Fouad F, Saleem BR, Tielliu IFJ, Pegorer MA, Bellosta R, Esposito D, Fargion AT, Zeebregts CJ, de Vries JPPM, Schuurmann RCL. Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated Endovascular Aortic Repair: A Multicenter, Retrospective Cohort Study. J Endovasc Ther 2024:15266028241248600. [PMID: 38708986 DOI: 10.1177/15266028241248600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
PURPOSE The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic repair (FEVAR) and to determine and visualize BECS-associated complications. METHODS This multicenter retrospective study included patients who underwent FEVAR between 2018 and 2022 in 3 vascular centers participating in the VBX Expand Registry. Patients with at least one visceral artery treated with the VBX and with availability of 2 post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU] 1: 0-6 months; FU2: 9-24 months) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software. RESULTS In total, 90 VBX BECS were analyzed in 43 FEVAR patients. The median CTA FU for FU1 and FU2 was 35 days (interquartile range [IQR], 29-51 days) and 14 months (IQR, 13-15 months), respectively. The mean flare-to-fenestration distance was 5.6±2.0 mm on FU1 and remained unchanged at 5.7±2.0 mm on FU2 (p=.417). The flare-to-fenestration diameter ratio was 1.19±0.17 on FU1 and remained unchanged at 1.21±0.19 (p=.206). The mean apposition length was 18.6±5.3 mm on FU1 and remained 18.6±5.3 mm (p=.550). The flare angle was 31°±15° on FU1 and changed to 33°±16° (p=.009). On FU1, the BECS-associated complication rate was 1%, and the BECS-associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3%, and the BECS-associated reintervention rate was 1%. CONCLUSIONS The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up in this study. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions, but this should be confirmed in a larger study including enough patients and BECS to compare complicated and uncomplicated cases. CLINICAL IMPACT The three-dimensional flare geometry of the Gore Viabahn VBX BECS was assessed on the first and second postoperative CTA scans, and geometrical changes during this period were identified. For BECS that were diagnosed with a type 3c endoleak or occlusion, the BECS geometry was analyzed to detect geometrical components that were related to the complication. Geometric analysis of the flare may help to better detect and identify the cause of such complications.
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Affiliation(s)
- Fatima Fouad
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ben R Saleem
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ignace F J Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Matteo A Pegorer
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Richte C L Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Hofmann A, Mlekusch I, Wickenhauser G, Walter C, Falkensammer J, Assadian A, Taher F. Ultrasound Coded-Excitation Imaging for Endoleak Detection After Complex Endovascular Aortic Repair. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:429-437. [PMID: 37972197 DOI: 10.1002/jum.16374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Several imaging modalities have been suggested for surveillance after fenestrated endovascular aortic repair in general and endoleak detection in specific. In the present project a coded excitation-based ultrasound (B-Flow) was investigated for endoleak detection after complex endovascular aortic repair. METHODS Patients post complex endovascular aortic repair (FEVAR or T/FEVAR) undergoing follow-up appointments including ultrasonography of the aorta at a vascular and endovascular surgery outpatient center were included in the study. B-Flow was compared with computed tomography angiography (CTA), Duplex ultrasound (DUS), and contrast-enhanced ultrasound (CEUS) regarding agreement and reliability for endoleak detection and characterization. RESULTS In total, 47 follow-ups were included. They accumulated in a total of 149 imaging investigations. Endoleaks were discovered in 44.7% of B-Flow studies and a majority of these endoleaks were classified as type II. Agreement between B-Flow and other imaging modalities was good (>80.0%) in general. However, with B-Flow 6 and 2 endoleaks would have been missed compared with CEUS and CTA, respectively. Regarding endoleak classification, B-Flow had a strong agreement (94.5%) with CEUS in detected cases. Furthermore, in a limited subset analysis, imaging findings were externally validated using findings from angiography. CONCLUSIONS Ultrasonography allows for endoleak detection and characterization without an invasive procedure or the use of potentially nephrotoxic contrast medium and can reduce radiation exposure. While CEUS mitigates issues of radiation and nephrotoxicity it still requires the intravenous application of contrast enhancers. Ultrasound coded-excitation imaging such as B-Flow could therefore further simplify endoleak surveillance after fenestrated endovascular aortic repair.
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Affiliation(s)
- Amun Hofmann
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Irene Mlekusch
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Georg Wickenhauser
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | | | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Fadi Taher
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
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Gallitto E, Faggioli G, Logiacco A, Mascoli C, Spath P, Palermo S, Pini R, Gargiulo M. Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair. Vascular 2023; 31:833-840. [PMID: 35513794 DOI: 10.1177/17085381221097304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. MATERIALS AND METHODS All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. RESULTS Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70 mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). CONCLUSION Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70 mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Manunga J, Pedersen C, Selle B, Stephenson E, Skeik N. Feasibility and outcome of partial open surgical fenestrated stent graft explantation, radical debridement, and in situ reconstruction for late graft infection. J Vasc Surg Cases Innov Tech 2023; 9:101175. [PMID: 37333865 PMCID: PMC10273282 DOI: 10.1016/j.jvscit.2023.101175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/15/2023] [Indexed: 06/20/2023] Open
Abstract
Aortic stent graft infection is a rare, but potentially lethal, complication of endovascular aortic aneurysm repair. Definitive treatment is complete stent graft explanation with in-line or extra-anatomical reconstruction. However, several factors can render such an operation unsafe, including the patient's overall fitness for surgery and partial incorporation of graft with a resulting robust inflammatory process, especially around the visceral vessels. We present the case of a 74-year-old man with a history of an infected fenestrated stent graft that was managed with partial explantation, wide debridement, and in situ reconstruction using a rifampin-soaked graft and a 360° omental wrap with good results.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
- Minneapolis Heart Institute Foundation, Minneapolis, MN
| | - Christopher Pedersen
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
| | - Benjamin Selle
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
| | - Elliot Stephenson
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
- Minneapolis Heart Institute Foundation, Minneapolis, MN
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
- Minneapolis Heart Institute Foundation, Minneapolis, MN
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Cloud-based fusion imaging improves operative metrics during fenestrated endovascular aneurysm repair. J Vasc Surg 2023; 77:366-373. [PMID: 36181994 DOI: 10.1016/j.jvs.2022.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Endovascular treatment of complex aortic pathology has been associated with increases in procedural-related metrics, including the operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased the radiation dose and iodinated contrast use during endovascular aneurysm repair. The aim of the present study was to report our institutional experience with the use of a cloud-based fusion imaging platform during fenestrated endovascular aneurysm repair (FEVAR). METHODS A retrospective review of a prospectively maintained aortic database was performed to identify all patients who had undergone FEVAR with commercially available devices (Zenith Fenestrated; Cook Medical Inc, Bloomington, IN) between 2013 and 2020 and all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVARs performed with overlay map guidance. The patient demographic, clinical, and procedure metrics were analyzed, with a comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from comparative analysis if the data were incomplete in the dataset or they had a documented history of prior open or endovascular abdominal aortic aneurysm repair. RESULTS During the 7-year study period, 191 FEVARs had been performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVARs. A complete dataset was available for 137 FEVARs. With exclusion to select for de novo FEVAR, a comparative analysis was performed of 53 FEVAR without and 63 with Cydar EV imaging guidance. The cohorts were similar in patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between the two groups for major adverse postoperative events, length of stay, or length of intensive care unit stay. The use of Cydar EV resulted in nonsignificant decreases in the mean fluoroscopy time (69.3 ± 28 minutes vs 66.2 ± 33 minutes; P = .598) and operative time (204.4 ± 64 minutes vs 186 ± 105 minutes; P = .278). A statistically significant decrease was found in the iodinated contrast volume (105 ± 44 mL vs 83 ± 32 mL; P = .005), patient radiation exposure using the dose area product (1,049,841 mGy/cm2 vs 630,990 mGy/cm2; P < .001) and cumulative air kerma levels (4518 mGy vs 3084 mGy; P = .02) for patients undergoing FEVAR with Cydar EV guidance. CONCLUSIONS At our aortic center, we have observed a trend toward shorter operative times and significant reductions in both iodinated contrast use and radiation exposure during FEVAR using the Cydar EV intelligent maps. Intelligent map guidance improved the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.
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Reinterventions after physician-modified endovascular grafts for treatment of juxtarenal aortic aneurysms are non-detrimental to long-term survival. J Vasc Surg 2023; 77:1367-1374.e2. [PMID: 36626956 DOI: 10.1016/j.jvs.2022.12.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Reintervention after endovascular aortic aneurysm repair is common. However, their frequency and impact on mortality after physician-modified endografts (PMEGs) is unknown. This study aims to describe reinterventions after PMEG for treatment of juxtarenal aneurysms and their effect on survival. METHODS Data from a prospective investigational device exemption clinical trial (Identifier #NCT01538056) from 2011 to 2022 were used. Reinterventions after PMEG were categorized as open or percutaneous and major or minor by Society for Vascular Surgery reporting standards and as high or low magnitude based on physiologic impact. Reinterventions were also categorized by timing, based on whether they occurred within 30 days of PMEG as well as within 1 week of PMEG. Survival was compared between patients who did and did not undergo reintervention and between reintervention subcategories. RESULTS A total of 170 patients underwent PMEG, 50 (29%) of whom underwent a total of 91 reinterventions (mean reinterventions/patient, 1.8). Freedom from reintervention was 84% at 1 year and 60% at 5 years. Reinterventions were most often percutaneous (80%), minor (55%), and low magnitude (77%), and the most common reintervention was renal stenting (26%). There were 10 early reinterventions within 1 week of PMEG. Two aortic-related mortalities occurred after reintervention. There were no differences in survival between patients who underwent reintervention and those who did not. However, survival differed based on the timing of reintervention. After adjusted analysis, reintervention within one week of PMEG was associated with an increased risk of mortality both compared with late reintervention (hazard ratio, 11.1; 95% confidence interval, 2.7-46.5) and no reintervention (hazard ratio, 5.2; 95% confidence interval, 1.6-16.8). CONCLUSIONS Reinterventions after PMEG were most commonly percutaneous, minor, and low magnitude procedures, and non-detrimental to long-term survival. However, early reinterventions were associated with increased mortality risk. These data suggest that a modest frequency of reinterventions should be expected after PMEG, emphasizing the critical importance of lifelong surveillance.
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Chen Z, Fu D, Liu C, Jin Y, Pan C, Mamateli S, Lv X, Qiao T, Liu Z. Risk factors for target vessel endoleaks after physician-modified fenestrated or branched endovascular aortic arch repair: A retrospective study. Front Cardiovasc Med 2023; 10:1058440. [PMID: 37025680 PMCID: PMC10070968 DOI: 10.3389/fcvm.2023.1058440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Objective Fenestrated or branched endovascular aortic arch repair (fb-arch repair) is an effective option for treating complex aortic arch lesions, including thoracic aortic aneurysms and aortic dissections. However, the relatively high rate of re-intervention due to target vessel (TV)-related endoleaks have raised concerns. This study aimed to determine risk factors for TV-related endoleaks after fb-arch repair. Methods This was a retrospective analysis of all patients undergoing fb-arch repair between 2017 and 2021in nanjing drum tower hospital of China. All the patients underwent computed tomography angiography (CTA) before surgery; at discharge; and at 3 months, 6 months, and yearly post-discharge. All procedures are performed with physician modified grafts. Two experienced vascular surgeons used CTA and vascular angiography data to assess endoleaks. The study endpoints were mortality, aneurysm rupture, and emergence of and re-intervention for TV-related endoleaks. Results During the follow-up period, 218 patients underwent fb-arch repair. There were seven perioperative deaths and four deaths during follow-up (two myocardial infarctions and two malignancies). There were nine additional patients who were excluded from the study (two strokes, three with abnormal aortic arch anatomy, and four with insufficient clinical data). Among the 198 patients considered (mean age, 59 ± 13.3 years; 85% male), 309 branch arteries were revascularized. A total of 35 TV-related endoleaks were identified in 28 patients during a mean follow-up of 23 ± 14 months (median 23, IQR 26.3): six type Ic, 4 type IIIb, and 20 type IIIc endoleaks. Patients in the endoleak group had greater aortic arch segment diameters (43.1 ± 5.1 vs. 40.3 ± 4.7; P = 0.004) and a greater number of TVs revascularized (2.0 ± 0.8 vs. 1.5 ± 0.8; P = 0.004) than those in the non-endoleak group. However, the morphological classification of the aortic arch did not seem to affect the occurrence of TV endoleaks (13%, 14%, and 15% for type І, II, and III aortic arches, respectively; P = 0.957). Pre-sewing branch stents in the fenestration position reduced the risk of TV endoleaks (5% vs. 14%; P = 0.037). Additionally, in TVs affected by aortic aneurysm or dissection, the risk of endoleaks increased after reconstruction (17% vs. 8%; P = 0.018). The incidence of secondary TV-related endoleaks after fb-arch repair was 14.1%. Conclusion The data from this study showed that the incidence of secondary target vessel related endoleaks after fb-arch repair is approximately 14.1%. Additionally, patients with a larger aortic arch diameter or more revascularized arteries during surgery were at increased risk TV-related endoleaks. The target vessels originating from the false lumen or aneurysm sac are more prone to endoleaks after reconstruction. Finally, prefabricated branch stents reduced risk of TV-related endoleaks.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Zhao Liu
- Correspondence: Tong Qiao Zhao Liu
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11
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Lima GBB, Dias-Neto M, Tenorio ER, Baghbani-Oskouei A, Oderich GS. Endovascular Repair of Complex Aortic Aneurysms. Adv Surg 2022; 56:305-319. [PMID: 36096574 DOI: 10.1016/j.yasu.2022.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fenestrated-branched endovascular aortic repair (FB-EVAR) has gained widespread acceptance in patients with complex aortic aneurysms. It has evolved from an alternative to treat elderly and higher risk patients to the first line of treatment in most patients with suitable anatomy, independent of the clinical risk. Currently, these devices are available off-the-shelf (ready to use) and tailored to the patient anatomy with the options of fenestrated, branched and mixed fenestrated, and branched designs. Reports from single and multicenter experiences and systematic reviews have shown lower mortality and morbidity for FB-EVAR compared with historical results of open surgical repair. The main advantages are noted on mortality, respiratory complications, acute kidney injury, and length of hospital stay. The purpose of this article is to review the advances in the endovascular repair of complex aortic aneurysms exploring the indications for treatment, preoperative evaluation, patient selection, device design, and implantation technique.
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Affiliation(s)
- Guilherme B B Lima
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Marina Dias-Neto
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Emanuel R Tenorio
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Gustavo S Oderich
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
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Forsythe RO, Eng C, Roy C, Cafferkey J, Clinch D, Ventham N, Tambyraja AL, Burns PJ, Falah O, Chalmers RTA. Open extent IV thoracoabdominal aneurysm repair: 22-year experience of the Scottish National Service. Br J Surg 2022; 109:711-716. [PMID: 35716129 PMCID: PMC10364699 DOI: 10.1093/bjs/znac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/17/2021] [Accepted: 01/26/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Since 1999, the Scottish National Service for Thoracoabdominal Aneurysms has offered repair of thoracoabdominal aneurysms (TAAAs) to a population of 5.5 million people. The open operation most commonly performed by the service is the extent IV TAAA repair. METHODS All extent IV open TAAA repairs performed at the Scottish National Service for TAAAs from June 1999 until April 2021 were evaluated for clinical features, technical details, and clinical outcomes. The primary outcome measure was 30-day mortality; secondary outcomes included short-term (90 days, 6 months, 1 and 2 years) and long-term (5 and 10 years) survival, perioperative complications, and reintervention. Survival was assessed using Kaplan-Meier analysis. RESULTS Some 248 patients underwent extent IV TAAA repair, with elective surgery in 204 (82.3 per cent). A totally abdominal transperitoneal approach was used for all patients, with a median visceral ischaemia time of 40 (i.q.r. 35-48) min. Overall, 18 patients (7.3 per cent) died within 30 days. The proportion of patients surviving at 90 days, 6 months, 1, 2, 5, and 10 years was 0.91, 0.90, 0.89, 0.85, 0.72, and 0.41, respectively. Ten patients (4.0 per cent) required a reintervention while in hospital, four (1.6 per cent) experienced permanent spinal cord ischaemia, 19 (7.9 per cent) required temporary renal replacement therapy (RRT), and four (1.6 per cent) required permanent RRT. CONCLUSION Open extent IV TAAA repair performed in a high-volume national centre is associated with favourable short- and long-term survival, and acceptable complication rates.
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Affiliation(s)
- Rachael O Forsythe
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Calvin Eng
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe Roy
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John Cafferkey
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Darja Clinch
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas Ventham
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew L Tambyraja
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Phillipa J Burns
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Orwa Falah
- Correspondence to: Orwa Falah, Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK (e-mail: )
| | - Roderick T A Chalmers
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
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Uijtterhaegen G, VAN Langenhove K, Moreels N, VAN Herzeele I, Vermassen F. Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:317-327. [PMID: 35142459 DOI: 10.23736/s0021-9509.22.11964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility. METHODS This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR. RESULTS One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak. CONCLUSIONS This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.
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Affiliation(s)
- Gilles Uijtterhaegen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium -
| | - Karen VAN Langenhove
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Kapahnke S, Bürger M, Torsello GF, Omran S, Hinterseher I, Greiner A, Frese JP. Cannulation of visceral vessels using a steerable sheathin fenestrated and branched aortic endografts. Ann Vasc Surg 2022; 85:305-313. [PMID: 35271960 DOI: 10.1016/j.avsg.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/18/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A critical step in the endovascular treatment of complex aortic aneurysm is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR). METHODS Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or non-challenging TV. RESULTS Fifty-three patients (median age 73 (Q1, Q3 (68 - 80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n = 26; 49%), juxtarenal aneurysms (n = 23; 43.5%) and penetrating aortic ulcers (PAU) (n = 4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of three TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus non-challenging TV (p = 0.457). One patient died within 30 days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36 months, the survival rate was 87%, 87%, and 81%, respectively Primary patency after 12 months was 98.6%, and 97.9% of vessels remained FFR during follow-up. CONCLUSION Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.
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Affiliation(s)
- Sebastian Kapahnke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Matthias Bürger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Giovanni Federico Torsello
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Irene Hinterseher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane - Campus Neuruppin, Vascular Surgery; Fehrbelliner Str. 38, 16816 Neuruppin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan Paul Frese
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
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Long-term Outcomes after FEVAR for Juxtarenal Aortic Aneurysm. J Vasc Surg 2021; 75:1164-1170. [PMID: 34838610 DOI: 10.1016/j.jvs.2021.11.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Fenestrated endovascular aortic repair (FEVAR) for juxtarenal aortic aneurysm (jAAA) disease is safe and effective with good short- and mid-term outcomes. Durability issues focus mainly on proximal and distal seal as well as target vessel (TV) instability, and long-term data is scarce. In previous publications we have reported short-term outcomes after FEVAR while comparing early- and late-experience patient groups, as well as long-term results for the early cohort. In this series we provide long-term outcome in the late experience cohort treated with FEVAR in Vascular Center Malmö. METHODS Consecutive patients treated in Vascular Center Malmö with FEVAR for jAAA between 2007 and 2011 were included. Data was collected retrospectively from medical- and imaging records. Follow up consisted of a clinical examination 1 month post-operatively, and computed tomography angiography combined with plain abdominal X-ray at 1 and 12 months, and annually thereafter. Primary endpoints were TV instability, reinterventions and survival. Changes in aneurysm diameter and renal function as well as endoleaks were also analyzed. RESULTS 94 patients were treated. Median follow-up time was 89 (range 0-152) months. 280 fenestrations or scallops were employed of which 205 were stented. Technical success was 89.4%. Primary TV patency was 94% ± 1 % at 1year, 90% ± 2% at 3 years and 89% ± 2% at 5 years. 37 (39.4%) patients needed a total of 70 reinterventions and mean time to first reintervention was 21 ± 3.97 months. 5 (5.3%) patients died of aneurysm related causes and overall survival was 95.7% ± 2.1% at 1 year, 87.1% ± 3.5% at 3 years and 71.0 ± 4.7% at 5 years. A stable or decreasing aortic diameter after treatment was seen in 91% of cases. Mean glomerular filtration rate (GFR) fell from 59.2 ± 14.9 ml/min/1.73m2 pre-operatively to 50.0 ± 18.6 ml/min/1.73 m2 at end of follow-up. CONCLUSION Long-term results after treatment of jAAA with FEVAR remain good and the treatment is safe and effective. Although the need for reintervention remains high, long-term renal function and survival support the use of FEVAR as a valid treatment option for jAAA disease.
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Klein A, Guild J, Xi Y, Chamseddin K, Shih M, Siah M, Timaran C, Kirkwood M. Use of a 2 Dimensional Vessel Navigator Roadmap Decreases Patient Radiation Dose Compared to Standard 3D Mapping for Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2021; 80:250-255. [PMID: 34748947 DOI: 10.1016/j.avsg.2021.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE For fenestrated endovascular aneurysm repair (FEVAR), the implementation of the VesselNavigator (Philips Healthcare, Best, The Netherlands) to provide a 3-dimensional vessel roadmap has been shown to reduce patient radiation exposure. Unfortunately, FEVAR radiation doses remain substantial despite utilization of this technology. Traditionally, registration of the live fluoroscopy with the pre-operative CTA is performed via the acquisition of a low-dose cone-beam CT scan. However, this registration can also be accomplished with the acquisition of 2D X-rays using the c-arm in 2 different projection angles. We hypothesized that the 2D image acquisition for vessel roadmap development would result in a significant reduction in patient radiation dose in comparison to the 3D CT registration without compromising image quality or increasing procedural length. METHODS This single-center, retrospective study included FEVARs performed from January 2015 to May 2019. For patient data, the cumulative reference air kerma (RAK) was presented as geometric mean and standard deviation. A general linear model with log-normal distribution was used to test the difference in patient RAK between 2D X-ray and 3D CT VesselNavigator registration after adjusting for BMI and the number of vessel fenestrations (1 to 2 vs. 3 to 4). Fluoroscopy time was recorded and used as a surrogate for case complexity. All analyses were done in SAS 9.4 (SAS Institute, Inc., Cary, North Carolina). RESULTS One hundred and sixty four FEVARs were performed on a Philips Allura Xper FD 20 fluoroscopy system equipped with clarity technology. The VesselNavigator registration was completed using 3D CT mapping in 99 cases and 2D X-rays in 65 procedures. On average, utilization of 2D mapping versus 3D mapping for the VesselNavigator resulted in a 20.4% reduction in patient RAK after controlling for BMI and number of vessel fenestrations, P = 0.0135. There was no significant difference in fluoroscopy time between the 2 study groups (P= 0.81) suggesting that image quality was not compromised by the use of 2D mapping leading to the need for additional fluoroscopy. CONCLUSION Acquisition of 2D films rather than a 3D CT scan for VesselNavigator registration allows for a significant reduction in patient radiation dose during FEVAR without increasing the case complexity or compromising image quality.
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Affiliation(s)
- Andrea Klein
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX.
| | - Jeffrey Guild
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Khalil Chamseddin
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Michael Shih
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Michael Siah
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Carlos Timaran
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Melissa Kirkwood
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
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How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study. Eur J Vasc Endovasc Surg 2021; 62:849-856. [PMID: 34686454 DOI: 10.1016/j.ejvs.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/03/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort. METHODS This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes. RESULTS In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay. CONCLUSION In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.
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Karelis A, Haulon S, Sonesson B, Adam D, Kölbel T, Oderich G, Cieri E, Mesnard T, Verhoeven E, Dias N. Multicentre Outcomes of Redo Fenestrated/Branched Endovascular Aneurysm Repair to Rescue Failed Fenestrated Endografts. Eur J Vasc Endovasc Surg 2021; 62:738-745. [PMID: 34393056 DOI: 10.1016/j.ejvs.2021.06.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/02/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. METHODS Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. RESULTS 18 male patients (76 years old; range 69 - 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 - 69 mm). Median interval between the procedures was 53 (29 - 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 - 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 - 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. CONCLUSION F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.
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Affiliation(s)
- Angelos Karelis
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden.
| | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, INSERM UMR_S 999, Université Paris Saclay, Paris, France
| | - Björn Sonesson
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden
| | - Donald Adam
- Complex Aortic Team, Birmingham Heartlands Hospital and Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Gustavo Oderich
- Health Science Centre, University of Texas, Houston, TX, USA
| | - Enrico Cieri
- Unit of Vascular & Endovascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Thomas Mesnard
- Aortic Centre, University of Lille, Inserm, CHU Lille, U1008, F-Lille, France
| | - Eric Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Nuno Dias
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden
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Chisci E, Michelagnoli S, Masciello F, Turini F, Panci S, Troisi N. Benefits and Role of Carbon Dioxide Angiography in Case of Misalignment Between Fenestration and Target Vessel During Fenestrated Endovascular Aneurysm Repair. J Endovasc Ther 2021; 29:7-10. [PMID: 34369173 DOI: 10.1177/15266028211032955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report the benefits and the role of carbon dioxide (CO2) angiography in case of misalignment between fenestration and target vessel during fenestrated endovascular aneurysm repair (F-EVAR). TECHNIQUE During F-EVAR, misalignment between fenestration and target vessel is a potentially catastrophic complication. In 2 patients, we experienced that one of the target vessels were not visible during standard angiography in different projections after positioning a fenestrated graft and even after cannulation of the corresponding fenestration. In both cases, the graft was sealed to the aortic wall but not in the predictable position. Consequently, acute occlusion of the target vessel was hypothesized. However, CO2 angiography was useful to evaluate patency of the target vessel clarifying the relative position of the fenestration versus the target vessel. Rescue maneuvers were feasible under the guidance of CO2 angiography in order to obtain the cannulation of both renal arteries. In both cases, the procedure was successfully accomplished. CONCLUSION In case of misalignment of a fenestration during F-EVAR and non-visualization of the target vessel with standard angiography, CO2 angiography could have the unique and complementary role of clarifying the patency and position of the target vessel. In addition, CO2 could guide the rescue maneuvers.
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Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Fabrizio Masciello
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Filippo Turini
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Simone Panci
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Nicola Troisi
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
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20
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E G, G F, G M, A F, G I, M L, C P, R C, M G. Pre and postoperative predictors of clinical outcome of fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms in an Italian multicenter registry. J Vasc Surg 2021; 74:1795-1806.e6. [PMID: 34098004 DOI: 10.1016/j.jvs.2021.04.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Complex aortic aneurysms (juxtarenal j-AAA, pararenal p-AAAs, thoracoabdominal TAAAs) are treated with increasing frequency through fenestrated and branched endovascular repair (F/B-EVAR), however the outcome of these procedures is usually reported separately by single experiences and wider overviews are not frequent. The aim of this study was therefore to report an Italian experience analyzing the results obtained in 4 academic centers in order to evaluate predictors of outcome. METHODS Between 2008 and 2019, all consecutive patients undergoing F/B-EVAR in 4 Italian university centers were prospectively recorded and retrospectively analyzed. Preoperative comorbidities and postoperative complications were classified according with the SVS-reporting standard. Postoperative complications and 30-day / in-hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions (FFRs) and target visceral vessels (TVVs) patency were assessed as follow-up outcomes by Kaplan-Meier analysis. Risk factors for 30-day / in-hospital mortality and spinal cord ischemia (SCI) were determined by multivariate analysis. Risk factors for follow-up mortality and reinterventions were evaluated by Cox-regression model. RESULTS Five hundred and ninety-six patients underwent F/B-EVAR for 124(21%) j-AAAs, 121(20%) p-AAAs and 351(59%) TAAAs. Elective and urgent procedures were performed in 520(87%) and 76(13%) cases, respectively. Postoperative cardiac, pulmonary and renal complications were reported in 41(7%), 50(8%) and 80(13%) patients, respectively. Seven (1%) bowel ischemia and 23(4%) cerebrovascular complications occurred. Forty-seven (8%) patients suffered SCI with 17(3%) cases of permanent paraplegia. Crawford's extent I-II-III TAAAs (OR:13.41; 95%CI:1.77-101.65; P=.012) and postoperative renal complications (OR:3.84; 95%CI:1.70-8.69; P=.001) independently predicted SCI. Thirty-two (5%) patients died in the perioperative period. Preoperative chronic renal failure (OR:7.81; 95%CI:7.81-26.31; P=.001), postoperative bowel ischemia (OR:26.97; 95%CI:3.37-215.5; P=.002), cardiac (OR:5.77; 95%CI:1.41-23.64; P=<.001),cerebrovascular (OR:28.63; 95%CI:5.20-157.5; P:<.001) complications and SCI (OR:5.99; 95%CI:1.12-32.5; P=.036) were independently correlated with 30-day/hospital mortality. The mean follow-up was 25+7months. Freedom from TVVs occlusion and FFR were 96% and 92% at 1 year and 93% and 85% at 3 years, respectively. TAAAs (HR:3.16; 95%CI:1.68-5.92; P=<.001), post dissection TAAAs (HR:2.20; 95%CI:1.30-4.90; P=.05) and postoperative bowel ischemia (HR:11.98; 95%CI:1.53-93.31; P=.018) were independent predictors of reinterventions. Survival was 88% and 78% at 1 and 3 years, respectively. Preoperative chronic renal failure (HR:2.39; 95%CI:1.59-3.59; P=<.001), urgent repair (HR:1.80; 95%CI:1.03-3.20; P=.039), TAAAs (HR:2.01; 95%CI:1.13-3.56; P=.017),postoperative bowel ischemia (HR:5.55; 95%CI:2.11-14.59; P=.001), cardiac (HR:3.89; 95%CI:2.25-6.71; P=<.001) and pulmonary (HR:1.97; 95%CI:1.56-3.35; P=.013) complications were independent predictors of mortality during follow up. CONCLUSION F/B-EVAR is associated with satisfactory mid-term outcomes in a nationwide experience. A variety of risk factors should be considered in FB-EVAR indication and post-operative patients management in order to reduce the risk of postoperative complications and improve mid-term outcome.
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Affiliation(s)
- Gallitto E
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Faggioli G
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Melissano G
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fargion A
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Isernia G
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti M
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Pratesi C
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Chiesa R
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gargiulo M
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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21
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Karaolanis GI, Antonopoulos CN, Scali S, Koutsias SG, Kotelis D, Donas KP. Systematic review with pooled data analysis reveals the need for a standardized reporting protocol including the visceral vessels during fenestrated endovascular aortic repair (FEVAR). Vascular 2021; 30:405-417. [PMID: 34074168 DOI: 10.1177/17085381211019148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To collect and analyse the available evidence in the outcomes of patients treated with fenestrated endovascular aortic repair (f-EVAR) technique focusing specifically on visceral vessel outcomes. METHODS The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the studies reporting the f-EVAR technique for the management of degenerative pararenal and/or type IV thoracoabdominal aortic aneurysms (TAAA) were considered eligible for inclusion in the study. The main study outcomes (technical success, type I endoleaks, fracture or occlusion of the bridging stents, overall aneurysm-related mortality, and the reintervention rate) were subsequently expressed as proportions and 95% confidence intervals. RESULTS Fourteen studies with a total of 1804 patients were included in a pooled analysis. The technical success of the procedure was 95.97% (95%CI = 92.35-98.60). Intraoperatively, the pooled proportion of reported type I endoleak was 7.6% (95%CI = 2.52-14.60) while during a median follow-up of 41 months (range 11-96) follow-up period the pooled rate of fracture and occlusion of the bridging stents was 2.79% (95%CI = 0.00-8.52) and 4.46% (95%CI = 1.93-7.77), respectively. The overall aneurysm-related mortality was detected to be 0.63% (95%CI = 0.04-1.63), and the pooled estimate for re-intervention rate was 15.69%. CONCLUSIONS Fenestrated endovascular repair for p-AAA is an effective and safe treatment. Target vessel complications and endoleaks remain the two most important concerns for fenestrated endovascular procedures, contributing to most of the secondary interventions. The lack of computed tomography angiography follow-up evaluation does not allow us to draw robust conclusions about the complication rates for the superior mesenteric artery during f-EVAR. Due to the potential implications of SMA complications on aneurysm-related mortality, standardized reporting of short- and long-term target visceral vessel outcomes is required.
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Affiliation(s)
- Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University of Ioannina, and of School of Medicine, Ioannina, Greece
| | - Constantine N Antonopoulos
- Cardiothoracic and Vascular Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Salvatore Scali
- Division of Vascular Surgery, University of Florida, Gainesville, FL, USA
| | - Stylianos G Koutsias
- Vascular Unit, Department of Surgery, University of Ioannina, and of School of Medicine, Ioannina, Greece
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Research Vascular Centre, Asclepios Clinic Langen, University of Frankfurt, Germany
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22
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Gallitto E, Faggioli G, Pini R, Logiacco A, Mascoli C, Fenelli C, Abualhin M, Gargiulo M. Reinterventions after fenestrated and branched endografting for degenerative aortic aneurysms. J Vasc Surg 2021; 74:1808-1816.e4. [PMID: 34087395 DOI: 10.1016/j.jvs.2021.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Fenestrated/branched endovascular abdominal aortic aneurysm repair (F/B-EVAR) is widely accepted technique to treat juxta/pararenal abdominal aortic aneurysms (J/P-AAAs) and thoracoabdominal aortic aneurysms (TAAAs) for patients at high-surgical risk. However, the follow-up results should be carefully evaluated, especially in terms of the reintervention rate. The aim of the present study was, therefore, to evaluate the early and mid-term reinterventions after FB-EVAR for J/P-AAAs and TAAAs and their effects on follow-up survival. METHODS From 2006 to 2019, all consecutive patients who had undergone F/B-EVAR for J/P-AAAs or TAAAs were prospectively enrolled. Cases requiring reinterventions were retrospectively analyzed. Patients with aortic dissection were excluded from the present analysis. Reinterventions were classified as follows: access related, aortoiliac related, or target visceral vessel (TVV) related. Freedom from reintervention and survival were assessed using the Kaplan-Meier method, and univariate and multivariate analyses were used to determine the risk factors. RESULTS Overall, 221 F/B-EVAR procedures were performed for 111 J/P-AAAs (50.3%) and 110 TAAAs (49.7%) in an elective (182; 82%) or urgent (39; 18%) setting. The median follow-up was 27 months (interquartile range, 13 months). Overall, 41 patients had undergone 52 reinterventions (single, 30 [14%]; multiple, 11 [5%]; access related, 17 [33%]; aortoiliac related, 6 [12%]; TVV related, 29 [55%]). Of the 52 reinterventions, 32 (62%) and 20 (38%) had occurred within and after 30 days, respectively. Eight reinterventions (15%) had been were performed in an urgent setting. Endovascular and open reinterventions were performed in 32 (62%) and 20 (38%) cases, respectively. Open reinterventions were frequently access related (access, 16; no access, 4; P ≤ .001). Technical success was 95% (39 patients); failures consisted of one splenic artery rupture and one renal artery loss. Patients undergoing reintervention had more frequently undergone a primary urgent F/B-EVAR (urgent, 12 of 39 [31%]; elective, 29 of 182 [16%]; P < .001) and had had TAAAs (TAAAs, 34 of 41 [83%]; J/P-AAAs, 7 of 41 [17%]; P < .001). The patients with TAAAs had had a greater incidence of TVV-related reintervention (TAAAs, 26 of 28 [93%]; J/P-AAAs, 2 of 28 [7%]; P < .001) and multiple reinterventions (TAAAs, 9 of 11 [82%]; J/P-AAAs, 2 of 11 [18%]; P = .03) compared with those with J/P-AAAs. Survival at 3 years was 75%. Freedom from reintervention was 81% at 3 years. Patients who had undergone reinterventions had lower 3-year survival (reintervention, 61%; no reintervention, 77%; P = .02). Preoperative chronic renal failure (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .02), TAAAs (HR, 2.3; 95% CI, 1.1-4.8; P = .03), and urgent primary F/B-EVAR procedures (HR, 2.5; 95% CI, 1.2-4.9; P = .01) were independent predictors of late mortality. CONCLUSIONS Reinterventions after F/B-EVAR are not uncommon and were related to TVVs in only one half of cases. Most of them can be performed in an elective setting using endovascular techniques. The technical success rate was excellent. Reinterventions were more frequent after TAAAs and urgent F/B-EVAR procedures and had a significant effect on overall survival in these situations.
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Affiliation(s)
- Enrico Gallitto
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy.
| | - Gianluca Faggioli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonino Logiacco
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Chiara Mascoli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Cecillia Fenelli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Mohammahad Abualhin
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi, Bologna, Italy
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Patel SR, Roy IN, McWilliams RG, Brennan JA, Vallabhaneni SR, Neequaye SK, Smout JD, Fisher RK. Characterising the incidence and mode of visceral stent failure after fenestrated endovascular aneurysm repair (FEVAR). JRSM Cardiovasc Dis 2021; 10:20480040211012503. [PMID: 34211706 PMCID: PMC8217896 DOI: 10.1177/20480040211012503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/20/2021] [Accepted: 04/01/2021] [Indexed: 12/05/2022] Open
Abstract
Background In FEVAR, visceral stents provide continuity and maintain perfusion between
the main body of the stent and the respective visceral artery. The aim of
this study was to characterise the incidence and mode of visceral stent
failure (type Ic endoleak, type IIIa endoleak, stenosis/kink, fracture,
crush and occlusion) after FEVAR in a large cohort of patients at a
high-volume centre. Methods A retrospective review of visceral stents placed during FEVAR over 15 years
(February 2003-December 2018) was performed. Kaplan-Meier analyses of
freedom from visceral stent-related complications were performed. The
outcomes between graft configurations of varying complexity were compared,
as were the outcomes of different stent types and different visceral
vessels. Results Visceral stent complications occurred in 47/236 patients (19.9%) and 54/653
stents (8.3%). Median follow up was 3.7 years (IQR 1.7–5.3 years). There was
no difference in visceral stent complication rate between renal, SMA and
coeliac arteries. Visceral stent complications were more frequent in more
complex grafts compared to less complex grafts. Visceral stent complications
were more frequent in uncovered stents compared to covered stents. Visceral
stent-related endoleaks (type Ic and type IIIa) occurred exclusively around
renal artery stents. The most common modes of failure with SMA stents were
kinking and fracture, whereas with coeliac artery stents it was external
crush. Conclusion Visceral stent complications after FEVAR are common and merit continued and
close long-term surveillance. The mode of visceral stent failure varies
across the vessels in which the stents are located.
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Affiliation(s)
- Shaneel R Patel
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Iain N Roy
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard G McWilliams
- Department of Interventional Radiology, Royal Liverpool University Hospital, Liverpool, UK
| | - John A Brennan
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Simon K Neequaye
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Jonathan D Smout
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert K Fisher
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
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Flanagan CP, Crawford AS, Arous EJ, Aiello FA, Schanzer A, Simons JP. Preoperative functional status predicts 2-year mortality in patients undergoing fenestrated/branched endovascular aneurysm repair. J Vasc Surg 2021; 74:383-395. [PMID: 33548435 DOI: 10.1016/j.jvs.2020.12.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is a minimally invasive alternative for patients at high risk of open repair of complex aortic aneurysms. Nearly all investigative study protocols evaluating F/BEVAR have required a predicted life expectancy of >2 years for study inclusion. However, accurate risk models for predicting 2-year survival in this patient population are lacking. We sought to identify the preoperative predictors of 2-year survival for patients undergoing F/BEVAR. METHODS The prospectively collected data for all consecutive F/BEVAR procedures, performed in an institutional review board-approved registry and/or a physician-sponsored investigational device exemption (IDE) trial (IDE no. G130210), were reviewed (November 2010 to February 2019). We assessed 44 preoperative patient characteristics, including comorbidities, preoperative functional status, aneurysm morphologies, and repair techniques. Preoperative functional status was defined as totally dependent (any impairment in activities of daily living or residing in a skilled nursing facility), partially dependent (any impairment in instrumental activities of daily living), or independent (no impairment in activities of daily living or instrumental activities of daily living). Using the results of univariate analysis (P < .2), a Cox proportional hazards model was constructed to identify the independent predictors of 2-year all-cause mortality. RESULTS For the 256 consecutive patients who had undergone F/BEVAR (6 common iliac [2.3%], 94 juxtarenal [41%], 35 pararenal [14%], 119 thoracoabdominal [47%], and 2 arch [0.8%] aneurysms), the 2-year mortality was 18%. On Cox modeling, the only independent preoperative predictor contributing to 2-year mortality was functional status (totally dependent: hazard ratio [HR], 5.4; 95% confidence interval [CI], 1.8-16; P = .0024; partially dependent: HR, 4.5; 95% CI, 2.4-8.7; P < .0000019). A history of an implanted anti-arrhythmic device was protective (HR, 0.4; 95% CI, 0.2-0.99; P = .0495). Factors such as age, congestive heart failure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, aneurysm extent, and previous aortic surgery, were not significant. The 2-year mortality for the independent (n = 176; 69%), partially dependent (n = 69; 27%), and totally dependent (n = 10; 3.9%) groups was 11%, 33%, and 40%, respectively. CONCLUSIONS For patients undergoing F/BEVAR, decreased preoperative functional status was the strongest predictor of 2-year mortality, with totally dependent patients experiencing poor survival. The traditional risk factors were not independently significant, perhaps reflecting the high prevalence of severe chronic illness in these high-risk patients participating in an IDE trial. For the independent patients, the 2-year F/BEVAR survival rate was 89%, equivalent to patient survival after infrarenal EVAR. Therefore, for independent patients, it would be reasonable to expand the indication for F/BEVAR to low-risk patients.
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Affiliation(s)
- Colleen P Flanagan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, Calif
| | - Allison S Crawford
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Edward J Arous
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Francesco A Aiello
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, Mass.
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Sveinsson M, Sonesson B, Dias N, Björses K, Kristmundsson T, Resch T. Five Year Results of Off the Shelf Fenestrated Endografts for Elective and Emergency Repair of Juxtarenal Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2021; 61:550-558. [PMID: 33455820 DOI: 10.1016/j.ejvs.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 11/22/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is a well established treatment for complex abdominal aortic aneurysms (AAAs). FEVAR with custom made devices (CMDs) has limitations in both the emergency and elective settings due to time consuming manufacture. "Off the shelf" (OTS) fenestrated stent grafts are a potential solution. The primary goal was to evaluate the five year outcome of the COOK Zenith p-Branch OTS device at a single centre. METHODS Patients with juxtarenal AAA meeting the inclusion criteria for the COOK Zenith p-Branch device were enrolled in a prospective, non-randomised, non-comparative trial from July 2012 to September 2015. Demographic, anatomical, procedure related, and five year follow up data were collected, analysed, and adjudicated by a core laboratory. The primary aims were to assess intervention free survival and overall survival at five years. RESULTS Twenty-three patients were treated and 21 completed follow up. Mean time to p-Branch implantation after patient presentation was 28 hours (range 0-122 hours) in emergency cases and 67 days (range 20-112 days) in elective cases. Median procedure time was 283 minutes (range 161-475 minutes) and technical success was 91%. Mean follow up was 45 months (standard deviation ± 24.4 months). The most common adverse events were renal injuries. Primary target vessel patency was 96.4% and 94.0% after one and five years respectively. Mean time to first re-intervention was 469 days (range 0-1 567 days). Survival during the follow up period was 76%, with no aneurysm related deaths. CONCLUSION FEVAR with the COOK Zenith p-Branch device is safe and effective for juxtarenal AAA in a selected patient population, in both elective and emergency settings. Long term outcomes are acceptable although inferior to CMDs. Mid and long term outcomes emphasise the p-Branch as a possible endovascular treatment for juxtarenal aortic pathology where CMD is not an option. Further innovation to address target vessel complications is needed, as these seem more prevalent than after repair with CMDs.
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Affiliation(s)
- Magnus Sveinsson
- Helsingborg Regional Hospital, Helsingborg, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Nuno Dias
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | | | | | - Timothy Resch
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Rigshospitalet University Hospital, Copenhagen, Denmark.
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26
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Mezzetto L, Scorsone L, Silingardi R, Gennai S, Piffaretti G, Mantovani A, Bush RL, Haulon S, Veraldi GF. Bridging Stents in Fenestrated and Branched Endovascular Aneurysm Repair: A Systematic REVIEW. Ann Vasc Surg 2021; 73:454-462. [PMID: 33359330 DOI: 10.1016/j.avsg.2020.10.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Concern exists about durability of stent grafts used to bridge aortic grafts to visceral and renal arteries during fenestrated and branched endovascular aneurysm repair (F/B-EVAR). There are no guidelines regarding the ideal technique for joining target vessels (TVs). METHODS We systematically reviewed data published from 2014 to 2019 using PRISMA guidelines and PICO models. Keywords were searched in MEDLINE, EMBASE, and Cochrane Library. All articles were screened by two authors (a third author in case of discrepancies). Only original articles regarding F/B-EVAR in complex aortic aneurysm, reporting the number and type of TVs mated, the onset of bridging stent complications, and reinterventions on TVs were included. Analysis included quality assessment scoring, types of stent grafts, and complications related to bridging stents. RESULTS 19 studies were included with 2,796 patients and 9556 TV; 4,797 renal arteries (50.2%), 4,174 visceral arteries (43.6%), and undefined TV (n = 585; 6.1%) were bridged. Balloon-expandable stent-grafts (B-EXP) were used in 40.9% and self-expandable (S-EXP) in 22.7% and undefined stents in 36.3%. The included studies had quality assessment scores ranging between 11/15 and 15/15, with high grade of accordance on reporting general results, but a low grade of accordance on reporting detailed data. Despite study heterogeneity, high-volume analysis confirmed a higher rate of complication in renal arteries than visceral arteries, 6% (95% CI 4-8) vs. 2% (95% CI 1-3), respectively. The rate of reinterventions was similar, 3% (95% CI 2-4) and 2% (95% CI 1-3). S-EXP versus B-EXP stent complication was 4% (95% CI 2-7) vs. 3% (95% CI 2-5), respectively. CONCLUSIONS This systematic review underlines the low grade of accordance in reporting detailed data of bridging stents in F/B-EVAR. Renal TVs were more prone to complications, with an equivalent reintervention rate to visceral TVs. As to B-EVAR, the choice of B-EXP over S-EXP is still uncertain.
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Affiliation(s)
- Luca Mezzetto
- Vascular Surgery, University Hospital of Verona, Italy.
| | | | - Roberto Silingardi
- Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Stefano Gennai
- Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | | | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University Hospital of Verona, Italy
| | - Ruth L Bush
- Vascular Surgery, University of Houston College of Medicine, Houston, TX, USA
| | - Stephan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Université Paris Sud, France
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Proximal Aortic Coverage and Clinical Results of the Endovascular Repair of Juxta-/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom-made Fenestrated Endografts. Ann Vasc Surg 2021; 73:397-406. [PMID: 33412242 DOI: 10.1016/j.avsg.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Juxta-renal (JAAA)/para-renal (PAAA) and type IV-thoracoabdominal (TAAA) aneurysms can be repaired by custom-made fenestrated endografts (CM-FEVAR). Differently from open repair, a relatively long segment of healthy proximal aorta needs to be covered to achieve a durable sealing, and this may be considered a disadvantage of the endovascular approach. We aimed to quantify the additional proximal aortic coverage in JAAAs, PAAAs, and type-IV TAAAs treated with CM-FEVAR and to evaluate its impact on early/follow-up clinical outcomes. METHODS Between 2006 and 2018, preoperative, intraoperative, and postoperative data of JAAAs, PAAAs, and type-IV TAAAs submitted to CM-FEVAR were collected. The length of proximal healthy aortic coverage was evaluated on the preoperative endograft planning as the distance between the top of the CM-FEVAR endograft and the hypothetical level of aortic cross-clamping in case of open repair (type-IV TAAA-above the celiac trunk; PAAA-above the superior mesenteric artery; JAAA-above the lowest renal artery). Spinal cord ischemia (SCI), bowel ischemia (BI), renal function worsening (RFW) (estimated glomerular filtration rate reduction > 25% of the baseline level - RFW), and mortality were assessed at 30-day. Survival, target visceral vessel (TVV) patency, and freedom from reinterventions (FFRs) were assessed during follow-up by Kaplan-Meier analysis R2. RESULTS One hundred forty-seven cases were submitted to CM-FEVAR, for 72 (49%) JAAAs, 46 (31%) PAAAs, and 29 (20%) type IV-TAAAs, with 1(4-3%), 2 (28-19%), 3 (48-33%), and 4 (67-45%) fenestrations. JAAAs required a fenestration + bridging stent graft for the superior mesenteric artery and celiac trunk, in 46(64%) and 24(33%) cases, respectively. Nineteen (41%) PAAAs required a fenestration + bridging stent graft for the celiac trunk. The mean proximal additional aortic coverage was 48 ± 2 mm with no differences among JAAAs (52 ± 1 mm), PAAAs (42 ± 2 mm), and type IV-TAAAs (50 ± 2 mm) (P.09). Technical success, defined as correct endograft deployment, with TVV patency, absence of type I-III endoleaks, iliac leg stenosis/occlusions, open surgical conversion, and 24-hour mortality, was achieved in 98% of cases. Failures occurred for 1 type-III endoleak (type-IV TAAA) and 2 renal artery losses (PAAA and type IV-TAAA). The only case of SCI (0.7%) occurred in a type-IV TAAA where the proximal healthy aortic coverage was 80 mm. One BI was caused by acute thrombosis of the bridging stent graft for the superior mesenteric artery at 24 hours in 1 type IV-TAAA (0.7%). Thirty-five patients (24%) suffered postoperative RFW and required hemodialysis in 1 (0.7%) JAAA with severe preoperative chronic renal failure. There was no difference of proximal additional aortic coverage between patients with (49 ± 29 mm) and without (48 ± 23 mm) RFW (P.2). The 30-day mortality was 1.4%. The mean follow-up was 37 ± 2 months with no cases of aneurysm-related late mortality. Survival was 94%, 89%, and 75% at 1, 2, and 5 years, respectively. TVV patency was 97%, 97%, and 93% at 1, 2, and 5 years, respectively. FFR was 98%, 95%, and 87% at 1, 2, and 5 years, respectively. CONCLUSIONS Custom-made FEVAR requires a mean proximal additional aortic coverage of 48 ± 2 mm above the level of hypothetical aortic cross-clamping in case of open repair. This aspect should be considered for CM-FEVAR indication in JAAAs, PAAAs, and type-IV TAAAs; nevertheless, it does not appear to be associated with negative early and follow-up clinical sequelae.
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George J, Tadros RO, Rao A, Png CYM, Han DK, Ilonzo N, Faries PL, McKinsey JF. Duplex Ultrasound Can Successfully Identify Endoleaks and Renovisceral Stent Patency in Patients Undergoing Complex Endovascular Aneurysm Repair. Vasc Endovascular Surg 2020; 55:234-238. [PMID: 33317440 DOI: 10.1177/1538574420980605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Efficacy of duplex ultrasound (DU) surveillance of complex EVAR such as FEVAR and ChEVAR has not been studied. All patients undergoing FEVAR or ChEVAR at a single multihospital institution were retrospectively reviewed. Postoperative surveillance included DU at 1 month and CTA at 3 months. 82 patients met inclusion criteria including 39 (47.6%) ChEVAR and 43 (52.4%) FEVAR cases. DU identified endoleak with aneurysm sac enlargement in 3 cases requiring reintervention. CTA at 3 months detected 2 new endoleaks without growth and 1 renal artery stent occlusion. Replacement of initial postoperative imaging with DU did not result in any missed endoleaks, deaths, ruptures, or branch occlusions.
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Affiliation(s)
- Justin George
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami O Tadros
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit Rao
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Y Maximilian Png
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Ilonzo
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L Faries
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F McKinsey
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Gallitto E, Faggioli G, Vacirca A, Pini R, Mascoli C, Fenelli C, Logiacco A, Abualhin M, Gargiulo M. The benefit of combined carbon dioxide automated angiography and fusion imaging in preserving perioperative renal function in fenestrated endografting. J Vasc Surg 2020; 72:1906-1916. [DOI: 10.1016/j.jvs.2020.02.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/29/2020] [Indexed: 11/25/2022]
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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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Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms. J Vasc Surg 2020; 72:866-872. [DOI: 10.1016/j.jvs.2019.10.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/01/2019] [Indexed: 11/22/2022]
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Steerable Sheath for Cannulation and Bridging Stenting of Challenging Target Visceral Vessels in Fenestrated and Branched Endografting. Ann Vasc Surg 2020; 67:26-34. [DOI: 10.1016/j.avsg.2019.11.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
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Gallitto E, Faggioli G, Spath P, Pini R, Mascoli C, Ancetti S, Stella A, Abualhin M, Gargiulo M. The risk of aneurysm rupture and target visceral vessel occlusion during the lead period of custom-made fenestrated/branched endograft. J Vasc Surg 2020; 72:16-24. [DOI: 10.1016/j.jvs.2019.08.273] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 08/31/2019] [Indexed: 10/25/2022]
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Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-Renal Aortic Aneurysms. Ann Vasc Surg 2020; 66:132-141. [DOI: 10.1016/j.avsg.2019.10.077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 11/21/2022]
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Rouer M, Monnot A, Bubenheim M, Fuda M, Godier S, Lebras M, Thomas P, Benadiba L, Elleboode B, Plissonnier D. Early Postoperative Renal Dysfunction Predicts Long-Term Renal Function Degradation after Type IV Thoracoabdominal Aortic Aneurysm Surgical Repair. Ann Vasc Surg 2020; 68:316-325. [PMID: 32439519 DOI: 10.1016/j.avsg.2020.04.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/10/2019] [Accepted: 04/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Type IV thoracoabdominal aortic aneurysm surgical repair is often complicated by postoperative acute kidney injury. The aim was to evaluate early renal injury influence on long-term renal function. METHODS All type IV thoracoabdominal surgical repair performed between January 2000 and January 2014 in our tertiary hospital were included in this retrospective observational study. All procedures were performed through a retroperitoneal approach with at least suprarenal aortic cross-clamping. Cold Ringer Lactate was used to perfuse the kidneys. Serum creatinine (Scr.) and glomerular filtration rate (GFR) were recorded preoperatively, daily until discharge and at least annually during follow-up. Postoperative renal dysfunction was classified using the RIFLE score. Predictors of long-term renal decline were identified by logistic regression and a Cox model. RESULTS Of total, 80 patients were included. Aortic clamping level was suprarenal (10%), supramesenteric (37%) or supracoeliac (53%). Ischemic durations were 29 ± 9 min for the gastrointestinal tract and the right kidney, 54 ± 28 min for the left kidney. Three patients died postoperatively. At discharge, 31 (38.8%) patients did not have a postoperative renal impairment (RIFLE-), compared with 49 (61.2%) who had a renal dysfunction (RIFLE+). GFR was 89 ± 29 ml/min vs 68 ± 37 ml/min, respectively (P < 0.01). In the RIFLE + group, Scr. was increased by x1.5 (Risk) for 22 patients, x2 (Injury) for 19 patients, and ×3 (Failure) for 8 patients. Mean follow-up was 59 months. Eighteen patients died, and 2 patients started permanent dialysis at 46 and 118 months during follow-up. The only predictive factor of long-term GFR degradation was a postoperative GFR below 45 ml/min (OR: 16.5; 95%; P < 0.001). CONCLUSIONS Postoperative renal dysfunction was a frequent complication, associated with long-term renal function degradation.
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Affiliation(s)
- Martin Rouer
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
| | - Antoine Monnot
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Michael Bubenheim
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Michelangelo Fuda
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Sylvie Godier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Marie Lebras
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Pascale Thomas
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Laurent Benadiba
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | | | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
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Overeem S, Schuurmann R, Schumacher M, Jolink F, Ketel M, Nijendijk B, Slump K, Versluis M, de Vries JP. Validation of a Novel Methodology to Evaluate Changes in the Flare Geometry of Renovisceral Bridging Stent-Grafts After Fenestrated Endovascular Aneurysm Repair. J Endovasc Ther 2020; 27:436-444. [DOI: 10.1177/1526602820915932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To validate a novel method to evaluate changes in the geometry of renovisceral bridging stent-grafts (BSGs) in patients undergoing fenestrated endovascular aneurysm repair (fEVAR). Materials and Methods: Retrospective analysis was conducted of serial computed tomography angiograms (CTAs) of 10 fEVAR patients (31 BSGs) with at least 2 years of CTA follow-up. Centerline reconstructions were made through the fenestrated stent-graft (FSG) and each BSG. Flare geometry was reconstructed based on marker coordinates and a mesh of the aortic lumen. The shortest distance was calculated from the top of the flare circumference to the FSG fabric. The amount of flaring was assessed with the flare to fenestration diameter ratio and BSG compression to diameter ratio (D-ratio). All measurements were performed by 2 observers. Interobserver variability was assessed; results are presented as the intraclass correlation coefficient (ICC) and repeatability coefficient (RC). Results: Excellent interobserver agreement was achieved for BSG diameter and flare to fenestration distance calculations (ICC 0.865 and 0.944; RC 2.2% and 4.5%, respectively). Six patients had BSG-related complications during follow-up: 2 type IIIc endoleaks and 4 BSG occlusions. Five of the 6 BSGs with complications showed a considerable change in the D-ratio compared with the first postoperative CTA. Conclusion: Precise assessment of the geometry of visceral BSGs in fEVAR is feasible with the presented method. Geometrical changes that may precede later complications can be detected, which could aid in localization of the origin, but a larger series of patients is necessary to define its true clinical merit.
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Affiliation(s)
- Simon Overeem
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Multimodality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Richte Schuurmann
- Multimodality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, the Netherlands
| | - Michiel Schumacher
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Floortje Jolink
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirte Ketel
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Bob Nijendijk
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Kees Slump
- Robotics and Mechatronics, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Michel Versluis
- Physics of Fluids Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Jean-Paul de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, the Netherlands
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Pini R, Faggioli G, Gallitto E, Mascoli C, Fenelli C, Ancetti S, Vacirca A, Gargiulo M. The different effect of branches and fenestrations on early and long-term visceral vessel patency in complex aortic endovascular repair. J Vasc Surg 2020; 71:1128-1134. [DOI: 10.1016/j.jvs.2019.07.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/16/2019] [Indexed: 10/25/2022]
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Liang NL, Mohapatra A, Avgerinos ED, Katsargyris A. Acute Kidney Injury after Complex Endovascular Aneurysm Repair. Curr Pharm Des 2020; 25:4686-4694. [DOI: 10.2174/1381612825666191129095829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022]
Abstract
Background:
Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative
morbidity than standard infrarenal endovascular repair.
Objective:
This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular
repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.
Methods:
A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal,
and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further
analyzed by the level of anatomic complexity and method of repair.
Results:
52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017.
The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19%
(temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute
kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency
did not demonstrate any associations with the outcome.
Conclusion:
Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively
associated factors other than increasing anatomic complexity and operative time. Further study is
needed for the identification of predictors related to postoperative acute kidney injury.
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Affiliation(s)
- Nathan L. Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Abhisekh Mohapatra
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Efthymios D. Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
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Gargiulo M, Gallitto E, Pini R, Giordano J, Mascoli C, Sonetto A, Logiacco A, Ancetti S, Faggioli G. Fenestrated endografting is the preferred option for juxta-renal aortic aneurysm reconstruction. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:2-9. [PMID: 31833736 DOI: 10.23736/s0021-9509.19.11185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to report early/mid-term-up outcomes of fenestrated endografting (FEVAR) for juxta-renal aneurysms (j-AAAs). METHODS Between 2008 and 2019, all consecutive j-AAAs treated by FEVAR were prospectively collected and retrospectively analyzed. Early endpoints were technical success, renal function worsening and 30-day mortality. Follow-up endpoints were survival, freedom from re-interventions (FFRs) and target visceral vessels (TVVs) patency. RESULTS Among 240 cases of FB-EVAR, 98(41%) were j-AAAs. Endografts with 1,2,3,4 and 5 fenestrations were planned in 3(3%), 25(26%), 35(36%), 33(34%) and 2(1%) cases, respectively. Overall, 360 TVVs were treated by fenestrations and scallops. Technical success was achieved in 97(99%) cases. The only failure was 1 type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening was reported in 22(22%) and 12(12%) cases at 24-hour and 30-day, respectively. One patient required hemodialysis and died within 30-day (1%). This was the only case of 30-day mortality. The mean follow-up was 36±32months. Aneurysm sac shrinkage or stability was observed in 55(56%) and 41(42%) cases, respectively. Two (2%) patients with persistent type II endoleak had sac enlargement and required re-interventions. Freedom from reinterventions at 5-year was 86%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24-month in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. TVVs-patency was 96% at 5-year. Renal function worsening was reported in 10(10%) patients during follow-up. Survival at 5-year was 73%, with no j-AAA related mortality. Chronic obstructive pulmonary disease (COPD) (P=0.007; OR:4.8; 95% CI: 1.5-15.3) and postoperative renal function worsening (P=0.028; OR:1,1; 95% CI: 1.1-1.2) were independent predictor for mortality at the multivariate analysis. CONCLUSIONS FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with these results, it could be proposed as the first line treatment in high risk patients if anatomically fit. Long term survival is reduced in the presence of preoperative COPD and postoperative renal function worsening.
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Affiliation(s)
- Mauro Gargiulo
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Rodolfo Pini
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Giordano
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Chiara Mascoli
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessia Sonetto
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonino Logiacco
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Ancetti
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Gallitto E, Faggioli G, Pini R, Mascoli C, Sonetto A, Abualhin M, Logiacco A, Ricco JB, Gargiulo M. First/Preliminary Experience of Gore Viabahn Balloon-Expandable Endoprosthesis as Bridging Stent in Fenestrated and Branched Endovascular Aortic Repair. Ann Vasc Surg 2019; 61:299-309. [DOI: 10.1016/j.avsg.2019.04.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
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Motta F, Kalbaugh CA, Luckett DJ, Fine J, Antonescu I, Ohana E, Crowner JR, Farber MA. Renal volumes and estimated glomerular filtration rate changes after fenestrated-branched endovascular aortic repair. J Vasc Surg 2019; 70:1040-1047. [DOI: 10.1016/j.jvs.2018.12.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 12/16/2018] [Indexed: 11/29/2022]
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Jones AD, Waduud MA, Walker P, Stocken D, Bailey MA, Scott DJA. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open 2019; 3:572-584. [PMID: 31592091 PMCID: PMC6773647 DOI: 10.1002/bjs5.50178] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 04/01/2019] [Indexed: 11/12/2022] Open
Abstract
Background Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short- and long-term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms. Methods A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms 'juxta/para/suprarenal' were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30-day/in-hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak. Results Twenty-seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case-control study and a single prospective non-randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively. Conclusion No significant difference was noted in 30-day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long-term durability is a concern, with far higher reintervention rates after FEVAR.
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Affiliation(s)
- A. D. Jones
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - M. A. Waduud
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - P. Walker
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - D. Stocken
- The Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - M. A. Bailey
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - D. J. A. Scott
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
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Endosuture aneurysm repair in patients treated with Endurant II/IIs in conjunction with Heli-FX EndoAnchor implants for short-neck abdominal aortic aneurysm. J Vasc Surg 2019; 70:732-740. [DOI: 10.1016/j.jvs.2018.11.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/07/2018] [Indexed: 11/19/2022]
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Giles KA, Scali ST, Pearce BJ, Huber TS, Berceli SA, Arnaoutakis DJ, Back MR, Fatima J, Upchurch GR, Beck AW. Impact of secondary interventions on mortality after fenestrated branched endovascular aortic aneurysm repair. J Vasc Surg 2019; 70:1737-1746.e1. [PMID: 31420254 DOI: 10.1016/j.jvs.2019.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fenestrated and branched endovascular aortic repair (F/BEVAR) is increasingly used to manage pararenal and thoracoabdominal aortic disease (TAAA). Device-related reintervention after F/BEVAR is common, but little is known about its impact on postoperative mortality. The purpose of this analysis was to describe secondary intervention (SI) after F/BEVAR and determine the impact of these procedures on patient survival. METHODS A single-center review was done on all consecutive F/BEVARs performed from 2010 to 2016. Primary end points were incidence of secondary aortic, branch, and/or access vessel‒related SI, and survival. SI was categorized as minor endovascular (branch restenting, access vessel treatment, or percutaneous coil embolization), major endovascular (new aortic graft placement), or open (bleeding, access vessel, and/or aortic). Kaplan-Meier methodology was used to estimate freedom from SI and survival. Multivariable analysis was used to identify predictors of SI. RESULTS A total of 308 F/BEVAR procedures were performed (75% physician-modified, 18% custom, 7% Zfen), with 1022 vessels revascularized (celiac, 228; superior mesenteric artery [SMA], 263; renal, 525). There were 117 (39%) extent I-III TAAA, 132 (44%) extent IV TAAA/4-vessel pararenal, and 54 (18%) <4-vessel pararenal repairs performed. Any type of SI occurred in 24% (74) of patients during the mean follow-up of 20 ± 21 months. The majority of reinterventions were endovascular (minor, 53% [n = 39]; major, 32% [n = 24]), whereas 12% (n = 9) were open and 3% (n = 2) hybrid. Primary indication for SI included: 22 (29%) with branch-related endoleaks (1C or III); 15 (22%) with proximal or distal aortic degeneration; 8 (12%) with branch vessel thrombosis/stenosis; 10 (11%) with aortic device type III endoleak/loss of overlap; 4 (6%) with postoperative mesenteric or renal bleeding events; 5 (5%) with type II endoleak; 3 (5%) with access vessel complication; and 2 (3%) with graft infection. Most SIs were elective (65%; n = 48) with the remainder occurring emergently (24%; n = 18) or for symptoms/urgently (11%; n = 8). Compared with endovascular remediation, open SI was more likely to be emergent (89%, 8 of 9; P = .001). Freedom from SI was 80 ± 3% and 64 ± 4% at 1 and 3 years, respectively. One- and 5-year survival with or without SI was: 1 year, 88 ± 4% vs 81 ± 3%; 5 years, 76 ± 5% vs 59 ± 4% (log rank test, P = .06). There was no survival difference based on type of SI (log rank test, P = .3). Extent I-III TAAA (HR, 1.6; 95% CI, 0.98-3.3; P = .06) and history of cerebrovascular disease (HR, 1.8; 95% CI, 0.97-2.6; P = .07) were predictive of SI. CONCLUSIONS SIs after F/BEVAR most frequently involve branch vessel or aortic device remediation procedures; however, they do not negatively impact out-of-hospital survival. These results further highlight the crucial role of imaging surveillance after F/BEVAR to maintain durability. Discussions with patients, periprocedural planning, and the next generation of device design must focus on issues surrounding the risk of device-related SI events.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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Gallitto E, Faggioli G, Ancetti S, Pini R, Mascoli C, Sonetto A, Calculli L, Pezzilli R, Gargiulo M. The Clinical Impact of Splanchnic Ischemia on Patients Affected by Thoracoabdominal Aortic Aneurysms Treated with Fenestrated and Branched Endografts. Ann Vasc Surg 2019; 59:102-109. [DOI: 10.1016/j.avsg.2019.01.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/29/2018] [Accepted: 01/19/2019] [Indexed: 11/29/2022]
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Van Calster K, Bianchini A, Elias F, Hertault A, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Risk factors for early and late mortality after fenestrated and branched endovascular repair of complex aneurysms. J Vasc Surg 2019; 69:1342-1355. [DOI: 10.1016/j.jvs.2018.08.159] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/17/2018] [Indexed: 11/27/2022]
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Lindström D, Mani K, Lundberg G, Wanhainen A. Bridging stent grafts in fenestrated and branched endovascular aortic repair: current practice and possible complications. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:476-484. [PMID: 30916523 DOI: 10.23736/s0021-9509.19.10942-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fenestrated and branched endovascular aortic repair (F/B-EVAR) is associated with a high degree of technical and clinical success. Despite this, studies have also reported high reintervention rates, and these are often related to the bridging stent grafts. Often new devices appear on the market before they have been tested in the bridging stent graft position. This review aims to assess the current literature on bridging stent grafts and discuss complications, illustrated by case reports. Complications reported with bridging stent grafts include; endoleak, kink, fracture, migration, occlusion, stenosis and perforation. Some known risk factors for bridging stent occlusions are renal artery stent grafts vs. SMA and celiac artery stent grafts. Some device specific complications have also been reported such as type IIIc endoleak with the Lifestream stent graft (Bard Peripheral Vascular, Tempe, AZ, USA) fractures and type IIId endoleaks with the 1st generation of Begraft (BentleyInnoMed, Hechingen, Germany). In addition, this review also discusses some newer devices with possible relation to complications such as stenosis and target vessel perforation. In conclusion, bridging stent grafts in fenestrated and branched aortic repair have a good midterm patency. Despite this, remaining issues are often related to the bridging stent grafts. Thorough follow-up and attention are needed, especially when new devices are introduced. The endovascular community should work towards a common global feedback system.
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Affiliation(s)
- David Lindström
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden -
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Göran Lundberg
- Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Stackelberg O, Lindström D, Mani K, Lundberg G, Linné A, Delle M, Berger M, Wanhainen A, Gillgren P. Outcomes after endovascular repair of abdominal aortic aneurysm involving the renovisceral arteries: A multi-center follow-up study. Vascular 2019; 27:397-404. [PMID: 30871441 DOI: 10.1177/1708538119836016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Otto Stackelberg
- 1 Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden.,2 Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - David Lindström
- 3 Department of Vascular Surgery, MMK, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
| | - Kevin Mani
- 4 Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Göran Lundberg
- 3 Department of Vascular Surgery, MMK, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
| | - Anneli Linné
- 1 Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden
| | - Martin Delle
- 5 Department of Radiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Martin Berger
- 6 Department of Radiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Anders Wanhainen
- 4 Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Peter Gillgren
- 1 Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden
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Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair. J Vasc Surg 2019; 69:783-791. [DOI: 10.1016/j.jvs.2018.07.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/02/2018] [Indexed: 11/21/2022]
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Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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