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Kwiecinski J, Uberoi R, Hadi M, Cheng CP, You Z. In vitro quantification of stent-graft behaviour during chimney thoracic endovascular aortic repair. Vascular 2024:17085381241260910. [PMID: 39033502 DOI: 10.1177/17085381241260910] [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: 07/23/2024]
Abstract
OBJECTIVE To quantify dynamic gutter phenomena and endograft deformations during double chimney thoracic endovascular aortic repair (ch-TEVAR) in a physiological model of the thoracic aorta subjected to pulsatile haemodynamic conditions. METHODS Two in vitro procedures revascularizing the brachiocephalic trunk and left common carotid artery were performed representing both balloon-expandable (BE, Ankura-BeGraft) and self-expandable (SE, Ankura-Viabahn) double ch-TEVAR configurations. Retrospectively gated computed tomography (CT) was used to evaluate endograft behaviour. Device interactions were characterised according to gutter volume, gutter surface deviation, and endograft deformation (D-ratio) at end-diastolic and peak-systolic aortic pressure. RESULTS Use of BE chimney grafts resulted in three times total gutter volume compared to SE chimney grafts. Gutter volumes were observed to vary dynamically between the end-diastolic and peak-systolic phases of the cardiac cycle, with the most substantial change associated with the BE configuration. Chimney graft deformations were dependent on device type, with SE devices exhibiting up to twice the deformation as BE devices. When adjacent, SE chimney grafts were observed to support each other, and thus tended towards a more consistently circular shape. CONCLUSION Gutter and chimney graft behaviour were dependent on device type, and exhibited both spatial and temporal variability. This study emphasises notable differences between BE and SE double ch-TEVAR configurations which should be considered when evaluating risk of endoleak. The findings reported here also support the use of gated CT to better identify device-related complications with ch-TEVAR, and can be used in the design of next generation devices.
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Affiliation(s)
- Jakub Kwiecinski
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Raman Uberoi
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Mohammed Hadi
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Zhong You
- Department of Engineering Science, University of Oxford, Oxford, UK
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Chen B, Huang K, Zhuang X, Wang Z, Wei M. Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study. Front Cardiovasc Med 2024; 11:1360830. [PMID: 38798922 PMCID: PMC11116717 DOI: 10.3389/fcvm.2024.1360830] [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: 12/24/2023] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Objective Inadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up. Methods Data were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact. Results The study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group. Conclusion The staged reintervention strategy for treating RAD is safe and provides promising early results.
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Affiliation(s)
- Bailang Chen
- Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Kunpeng Huang
- Department of Medicine, Shenzhen University, Shenzhen, Guangdong, China
| | - Xianmian Zhuang
- Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zanxin Wang
- Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Minxin Wei
- Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
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Giagtzidis I, Theologou M, Papoutsis I, Karkos C, Papazoglou K. Cleaning Up the Chimney: Early Renal Stent Graft Thrombosis Following Endovascular Treatment of a Juxtarenal Aortic Aneurysm With the Chimney Technique. Cureus 2024; 16:e54669. [PMID: 38523961 PMCID: PMC10960231 DOI: 10.7759/cureus.54669] [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] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
The endovascular management of juxtarenal aortic aneurysms with the chimney technique (ch-EVAR) has gained popularity in recent years. It provides an alternative to open repair, allowing treatment of challenging anatomies with devices readily available in any vascular suite. The primary drawback persists as the occurrence of type-Ia endoleak from gutters and renal stent thrombosis. We present two cases of early renal stent graft thrombosis following chimney endovascular aneurysm repair. The first patient was an 80-year-old man who underwent single ch-EVAR and came back on the fifth post-op day with renal stent graft thrombosis. He was re-operated for recanalization and additional stenting of his chimney graft. The patient recovered well with no complications. The second case involved a 72-year-old man with a juxtarenal aneurysm, treated with ch-EVAR on both renal arteries. Unfortunately, on the 10th post-op day, he was referred to our department due to lumbar pain and acute renal failure due to chimney graft thrombosis bilaterally. The left renal chimney graft was recanalized by endovascular means. On the contrary, despite efforts of the endovascular and open approach, the right chimney graft and the right renal artery remained occluded. While ch-EVAR is a viable and off-the-shelf solution for urgent and complex juxtarenal aortic aneurysms, it should be performed with awareness of the potential for graft thrombosis and persistent endoleaks. Despite these complications, the chimney technique can still be a viable treatment option. A better understanding of the indications and advancements in the devices used can lead to better long-term results.
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Affiliation(s)
- Ioakeim Giagtzidis
- 5th Surgical Department, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Marios Theologou
- 5th Surgical Department, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioakeim Papoutsis
- Vascular Surgery, 5th Surgical Department, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Christos Karkos
- Vascular Surgery, 5th Surgical Department, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Konstantinos Papazoglou
- Vascular Surgery, 5th Surgical Department, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
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4
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Meekel JP, Tran BL, van Schaik TG, Donas KP, Taneva GT, Jongkind V, Yeung KK. What we have learned from in-vitro studies of the chimney endovascular technique for treatment of complex abdominal aortic aneurysms: A systematic review. Vascular 2023; 31:1051-1060. [PMID: 35578179 DOI: 10.1177/17085381221095294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A considerable number of patients with abdominal aortic aneurysms (AAA) is not eligible for standard endovascular repair. These complex cases require alternative surgical approaches including the readily available chimney graft endovascular aneurysm repair (Ch-EVAR) or sealing (Ch-EVAS). The optimal configuration for Ch-EVAR or Ch-EVAS is important for success but not yet known. OBJECTIVE The aim of the present study was to analyze current data of the outcomes of in-vitro chimney graft treatment in complex AAA. METHODS A systematic review following PRISMA guidelines was conducted including studies reporting on gutter size, main graft compression, and chimney graft compression in in-vitro configurations. RESULTS The search resulted in 285 articles. 11 studies considering 219 individual tests could be included. Gutter size was comparable between Ch-EVAR and Ch-EVAS configurations. In Ch-EVAR set-ups, the deployed BECG were Advanta V12, VIABAHN®, and BeGraft. One type of SECG was used: VIABAHN®. The four types of main grafts (MG) deployed were: Endurant™ I/II; EXCLUDER Conformable AAA Endoprosthesis and AAA Endoprosthesis, and AFX™ Endovascular AAA Delivery System. In the EVAS-configurations, the Nellix® EVAS system was deployed. In general, SECG presented smaller gutters with higher chimney graft compression. 30% main grafts oversizing seems to give the smallest gutters without high risk of infolding of MG. Oversizing, EndoAnchors, and secondary endobag filling (in Ch-EVAS) reduced gutter sizes. CG ballooning during the entire polymer injection in Ch-EVAS prevented CG compression. CONCLUSION In-vitro investigations provide insight in optimal Ch-EVAR and Ch-EVAS configurations for simulated complex AAA repair. The findings above might aid physicians in their planning to potential CG set-ups and can be used in future research to refine the most optimal configuration for chimney graft technique in complex AAA.
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Affiliation(s)
- Jorn P Meekel
- Department of Surgery, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Bich L Tran
- Department of Surgery, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
| | - Theodorus G van Schaik
- Department of Surgery, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Konstantinos P Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Gergana T Taneva
- Department of Vascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Vincent Jongkind
- Department of Surgery, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kak K Yeung
- Department of Surgery, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam UMC, Amsterdam, The Netherlands
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5
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Berczeli M, Sonesson B, Karelis A, Oderich GS, Dias NV. Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair. J Endovasc Ther 2023:15266028231208656. [PMID: 37902446 DOI: 10.1177/15266028231208656] [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: 10/31/2023]
Abstract
PURPOSE To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). TECHNIQUE A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. CONCLUSIONS Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. CLINICAL IMPACT Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).
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Affiliation(s)
- Marton Berczeli
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Angelos Karelis
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Division of Vascular and Endovascular Surgery, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Mulatti GC, Joviliano EE, Pereira AH, Fioranelli A, Pereira AA, Brito-Queiroz A, Von Ristow A, Freire LMD, Ferreira MMDV, Lourenço M, De Luccia N, Silveira PG, Yoshida RDA, Fidelis RJR, Boustany SM, de Araujo WJB, de Oliveira JCP. Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm. J Vasc Bras 2023; 22:e20230040. [PMID: 38021279 PMCID: PMC10648059 DOI: 10.1590/1677-5449.202300402] [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: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.
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Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Ribeirão Preto, SP, Brasil.
| | - Adamastor Humberto Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | - Alexandre Araújo Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | - André Brito-Queiroz
- Universidade Federal da Bahia - UFBA, Hospital Ana Nery, Salvador, BA, Brasil.
| | - Arno Von Ristow
- Pontifícia Universidade Católica do Rio de Janeiro - PUC-Rio, Rio de Janeiro, RJ, Brasil.
| | | | | | | | - Nelson De Luccia
- Universidade de São Paulo - USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | | | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil.
| | | | - Sharbel Mahfuz Boustany
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
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7
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Annuvolo PA, Pascucci F, Minelli F, Natola M, Donati T, Tshomba Y. Chimney endovascular aneurysm repair-induced mesenteric ischemia: a report of an extremely rare complication. J Vasc Surg Cases Innov Tech 2023; 9:101259. [PMID: 37577034 PMCID: PMC10413130 DOI: 10.1016/j.jvscit.2023.101259] [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: 04/11/2023] [Accepted: 06/05/2023] [Indexed: 08/15/2023] Open
Abstract
The chimney endovascular aneurysm repair (Ch-EVAR) technique has progressively increased in popularity in the treatment of complex aortic aneurysms. However, the long-term results of this technique still must be assessed, especially in comparison to custom-made solutions. The patency of chimney grafts has always been one of the important issues with the Ch-EVAR technique. However, interactions between nonstented aortic side branches and chimney stent grafts have rarely been discussed. In the present case report, we describe a rare case of mesenteric ischemia due to superior mesenteric artery ostium coverage by the misalignment of a renal stent graft in a Ch-EVAR.
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Affiliation(s)
- Pierfrancesco Antonio Annuvolo
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Pascucci
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabrizio Minelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Natola
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Donati
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
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8
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Taneva GT, Usai MV, Pitoulias GA, Donas KP. In Vitro Radiological Evaluation of Different Types of Chimney Stents Using a Silicon Flow Model with Adjustable Physiological Simulating Conditions. Eur J Vasc Endovasc Surg 2023; 66:270-277. [PMID: 37172689 DOI: 10.1016/j.ejvs.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/20/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate in vitro the performance of in vivo published covered or bare metal chimney stents (ChSs) in combination with the Endurant II abdominal endograft (Medtronic) as the only CE approved main graft (MG) in the treatment of juxtarenal abdominal aortic aneurysms with the chimney endovascular aneurysm repair (chEVAR) technique. METHODS Bench top experimental study. A silicon flow model with adjustable physiological simulating conditions and patient based anatomy was used to test nine different MG-ChS combinations: Advanta V12 (Getinge); BeGraft+ (Bentley); VBX (Gore & Associates Inc.); LifeStream (Bard Medical); Dynamic (Biotronik); Absolute Pro (Abbott); double Absolute Pro; Viabahn (Gore) lined with Dynamic; and Viabahn lined with EverFlex (Medtronic). Angiotomography was performed after each implantation. DICOM data were analysed blindly twice per observer by three independent experienced observers. Each blinded evaluation was performed at one month intervals. The main analysed parameters were the area of gutters, MG and ChS maximum compression, and the presence of infolding. RESULTS Bland-Altman analysis confirmed adequate results correlation (p < .05). Each employed ChS showed significantly different performance favouring the balloon expandable covered stent (BECS). The smallest gutter area was seen in the combination with Advanta V12 (0.26 cm2). MG infolding was observed in all tests. The lowest ChS compression was observed in the combination with BeGraft+ (compression 4.91%, D ratio 0.95). In our model, BECSs showed higher angulations than bare metal stents (BMSs) (p < .001). CONCLUSION This in vitro study shows the variability of performance with each theoretically possible ChS and explains the divergent ChS outcomes in the published literature. BECS in combination with the Endurant abdominal device confirms their superiority vs. BMS. The presence of MG infolding in each test underlines the need for prolonged kissing ballooning. Angulation evaluation and comparison with other in vitro and in vivo publications demands the need for further investigation in transversely or upwardly oriented target vessels.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular Surgery and Angiology, Puerta de Hierro and Montepríncipe University Hospitals, Madrid, Spain.
| | - Marco V Usai
- Department of Vascular Surgery, St Franziskus Hospital Münster, Münster, Germany
| | - Georgios A Pitoulias
- 2nd Department of Surgery, Division of Vascular Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos P Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, Langen, Germany, and Department of Vascular Surgery, University Hospital Bern, Bern, Switzerland
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9
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Taneva GT, Mirgolbabaee H, Groot Jebbink E, Reijnen MMPJ, Donas KP. Systematic Review of the Current In Vitro Experience of the Endovascular Treatment of Juxtarenal Abdominal Aortic Aneurysms by Fenestrated and Parallel Endografting. J Endovasc Ther 2023; 30:8-17. [PMID: 35114834 DOI: 10.1177/15266028221075242] [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: 01/25/2023]
Abstract
OBJECTIVE To identify and analyze the published in vitro benchtop experiments for the assessment of endovascular techniques used for the treatment of juxtarenal abdominal aortic aneurysms (jAAAs). DATA SOURCES Scopus, PubMed, and Web of Science. REVIEW METHODS A systematic literature search was carried out throughout March 2021 following PRISMA guidelines. Two investigators independently performed title and abstract screening to reveal all benchtop testing evaluating the endovascular treatment of jAAA. RESULTS A total of 19 studies were included, 8 evaluating fenestrated (FEVAR) and 11 parallel grafts (PGs). FEVAR studies used different custom testing apparatus (n=7) or 3D-printed models (n=1) to analyze dislodgement and migration resistance, misalignment consequences and causation, and bridging stents' radial force, flareability, fatigue, and fracture resistance. All PG studies used silicone-based models to analyze optimal oversizing, sealing length, gutter behavior, and possible reduction. Test evaluation in FEVAR in vitro testing was based on pullout force analysis (N=5), photo evaluation (n=1), fluoroscopy (n=1), X-rays (n=4), CT analysis (n=3), macro- and microscopic evaluation (n=4), water permeability (n=1), and fatigue simulator testing (n=1), while it was based on CT analysis in all PG studies adding ECG-gate in one study. The most frequently tested devices were Zenit (Cook) (n=7), Endurant (Medtronic) (n=5), and Excluder (Gore) (n=5) as main grafts, and Advanta V12 (n=14) as the bridging device. CONCLUSIONS This systematic review presents a broad analysis of the current in vitro methods evaluating the endovascular treatment of jAAA. Fundamental issues have been benchtop tested in both FEVAR and PGs. The analysis of the included studies allowed to recommend an optimal testing design. In vitro testing is a potential tool to further elucidate points of attention hard to investigate in vivo to finally enhance the endovascular treatment outcomes. Future in vitro studies are needed to evaluate the in vitro performance of all indistinctively used devices in the clinical practice.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Hadi Mirgolbabaee
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Erik Groot Jebbink
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel M P J Reijnen
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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10
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Hu J, Li F, Qiu P, Wu X, Pu H, Zhao Z, Qin J, Liu G, Jin S, Lu X, Liu X. Clinical Validation of the Impact of Branch Stent Extension on Hemodynamics in ISF-TEVAR Involving LSA Reconstruction. Front Cardiovasc Med 2022; 9:911934. [PMID: 35770224 PMCID: PMC9234204 DOI: 10.3389/fcvm.2022.911934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe study of hemodynamics regarding thoracic endovascular aortic repair (TEVAR) is helpful to improve the surgical efficacy.ObjectiveCorrelations between hemodynamic changes and branch stent extension length and interference factors for branch stent extension length of in situ fenestration TEVAR (ISF-TEVAR) involving the left subclavian artery (LSA) were evaluated.Materials and MethodsThis study retrospectively analyzed 196 patients with Stanford type B aortic dissection who received in situ laser fenestrated thoracic endovascular aortic repair with LSA fenestration from April 2014 to March 2021. Branch stent extension to the main stent graft was evaluated by the computed tomographic angiography (CTA). Hemodynamic change of LSA was defined as a 20 mmHg interbrachial systolic pressure difference. The factors affecting the extension of the branch stent were also evaluated.ResultsAll patients underwent ISF-TEVAR with LSA fenestration, and there was no recurrence during the follow-up. The mean length of the branch stent extension was 10.37 ± 0.34 mm, which was used to divide the patients into long and short groups. Asymptomatic hemodynamic changes (defined as a 20 mmHg interbrachial systolic pressure difference) in LSA were observed in 61 patients undergoing ISF-TEVAR involving LSA fenestration. The Spearman correlation analysis showed extension length of a branch stent >1.5 cm elevated the risk of hemodynamic changes.ConclusionOverall, we conclude that branch stent extension length >1.5 cm induced LSA hemodynamic changes. Appropriate shortening of the stent extension length can improve the curative effect of ISF-TEVAR, especially when faced with a type II/III aortic arch and stent angles of <30 degrees.
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Affiliation(s)
- Jiateng Hu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Fengshi Li
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Zhao
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Guang Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Shanliang Jin
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Shanliang Jin
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
- Xinwu Lu
| | - Xiaobing Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
- Xiaobing Liu
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Ribeiro TF, Camacho N, Ferreira RS, Gonçalves FB, Ferreira ME. Off the Shelf Thoracic Endovascular Aortic Repair with Sandwich Technique for the Treatment of a Thoraco-abdominal Penetrating Aortic Ulcer. EJVES Vasc Forum 2022; 55:61-63. [PMID: 35620415 PMCID: PMC9126946 DOI: 10.1016/j.ejvsvf.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/30/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Penetrating aortic ulcers (PAUs) are the rarest subset of acute aortic syndromes, and a thoraco-abdominal (TA) location is uncommon. Endovascular surgery is considered first line treatment. Custom made branched/fenestrated endografts have been successfully applied in this disease but are unavailable in the urgent setting. Off the shelf solutions may be required in high risk patients. The case of a symptomatic rapidly expanding TA-PAU without a distal seal zone that underwent urgent endovascular repair is described. Report An 81 year old male presented with acute intense thoracic pain. Workup revealed a large TA-PAU. As pain was refractory and computed tomography angiography confirmed rapid expansion, urgent repair was proposed. Due to multiple comorbidities and absence of adequate distal seal zone, an off label endovascular treatment was proposed. The patient underwent successful endovascular repair with two aortic stent grafts (GORE cTAG) with 30% oversize and 50–55 mm overlap between modules, combined with chimney self expanding stent grafts (GORE VIABAHN) to the coeliac trunk and superior mesenteric artery in a sandwich configuration. The post-operative course was uneventful. Follow up at 18 months revealed no endoleaks and patent bridging stent grafts without visceral compromise. Discussion Thoracic endovascular aortic repair (TEVAR) is considered the first treatment option for urgent PAU. However, anatomic requirements limit its use in the thoraco-abdominal aorta. Parallel graft techniques have been described to overcome these anatomic constraints in TA aneurysms. The use of a “sandwich technique” to successfully exclude a PAU without a distal sealing zone for standard TEVAR is described. The advantage was limited aortic coverage compared with a branched device or an “octopus” technique. This solution is particularly useful in urgent situations when patients cannot wait for a custom made device and the morbidity associated with open or hybrid repair is unacceptably high. An off the shelf sandwich technique is a potential safe and long lasting therapeutic option for the urgent treatment of TA-PAU. Endovascular therapy is the standard treatment of aortic PAU. Customized endografts are dependent on a long manufacturing time. Off the shelf techniques can be used in urgent settings in high risk patients. TEVAR with sandwich technique can be used safely for urgent repair TA PAU.
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Affiliation(s)
- Tiago F. Ribeiro
- Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Corresponding author. Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta 50, 1169-024, Lisboa, Portugal.
| | - Nelson Camacho
- Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Rita S. Ferreira
- Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Frederico Bastos Gonçalves
- Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Maria Emília Ferreira
- Serviço de Angiologia e Cirurgia Vascular, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
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12
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Kwiecinski J, Cheng CP, Uberoi R, Hadi M, Hempel P, Degel C, You Z. Thoracic aortic parallel stent-graft behaviour when subjected to radial loading. J Mech Behav Biomed Mater 2021; 118:104407. [PMID: 33740690 DOI: 10.1016/j.jmbbm.2021.104407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/20/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
To manage complex aortic arch disease using minimally invasive techniques, interventionalists have reported the use of multiple stent-graft devices deployed in a parallel configuration. The structural device-device and device-artery interactions arising during aortic arch parallel endografting, also known as chimney thoracic endovascular aortic repair (ch-TEVAR), is not well understood. Through the use of a radial force testing system we sought to characterise both the loading and deformation behaviour of parallel endografts in representative ch-TEVAR configurations. Four commercially available devices (Bentley BeGraft, Gore TAG, Gore Viabahn, and Medtronic Valiant) were subjected to uniform radial load individually, and in six combinations, to quantify loading profiles. Image data collected during testing were analysed to evaluate mechanical deformations in terms of gutters, chimney and main endograft compression, as well as graft infolding. Parallel endografting was found to increase radial loads when compared to standard TEVAR. Chronic outward force during ch-TEVAR was dependent on main endograft manufacturer, with TAG combinations leading to consistently higher loads than Valiant, but independent of chimney graft type. Endograft deformations were dependent on chimney graft type, with Viabahn combinations presenting with lower gutter areas and increased lumen compression than BeGraft. Chimney graft deformations were also influenced by deployment arrangement in the case of double ch-TEVAR. This study emphasizes the significant variability in both radial loads and mechanical deformations between clinically relevant ch-TEVAR configurations.
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Affiliation(s)
- Jakub Kwiecinski
- Department of Engineering Science, University of Oxford, Oxford, UK.
| | | | - Raman Uberoi
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Mohammed Hadi
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | | | - Zhong You
- Department of Engineering Science, University of Oxford, Oxford, UK
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13
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Fazzini S, Martinelli O, Torsello G, Austermann M, Pipitone MD, Torsello GF, Irace L, Donas KP. The PROTAGORAS 2.0 Study to Identify Sizing and Planning Predictors for Optimal Outcomes in Abdominal Chimney Endovascular Procedures. Eur J Vasc Endovasc Surg 2021; 61:591-602. [PMID: 33573913 DOI: 10.1016/j.ejvs.2020.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/18/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim was to identify predictors of adequate pre-operative sizing and planning for chimney endovascular aortic repair (ChEVAR) in order to reduce the incidence of persistent type Ia endoleaks (IaELs) without influencing chimney graft (CG) patency. METHODS Consecutive patients who underwent ChEVAR between January 2009 and December 2017 at a single centre were evaluated retrospectively. Included were patients treated with one device combination (Medtronic Endurant mated with Getinge Advanta V12/iCast) and placement of single or double CG. The freedom from IaEL related re-interventions and primary CG patency was estimated by measuring aortic stent graft oversizing (OS), total neck length (TNL), and a composite parameter (L-OS: TNL [mm] + OS [%]). RESULTS Seventy-three patients who underwent placement of 101 CGs (45 single, 28 double) met the inclusion criteria. The median radiological follow up was 25.5 (interquartile range [IQR] 12-48) months. Freedom from IaEL related re-intervention was achieved in 94.6% with a median OS of 38.5% (IQR 30%-44%, p = .004), TNL 19 mm (16-25 mm, p = .62), and L-OS 59 (51-65, p = .018). Primary CG patency was achieved in 95% of the cases with a median OS of 36% (29%-42%, p = .008), TNL 19 mm (15.5-26 mm, p = .91), and L-OS 57 (50-64, p = .005). By using the receiver operating characteristic curve, an optimal cut off to prevent IaEL related re-interventions was identified by an OS of 30% (p < .001; L-OS 55, p = .006) and to avoid CG stenosis/occlusions by OS 42% (p < .001; L-OS 65, p < .001). In multivariable analysis, aortic endograft OS was the only independent parameter preventive for IaEL related re-intervention (odds ratio, 0.78; 95% confidence interval, 0.61-0.99). CONCLUSION With the Endurant-Advanta V12/iCast combination, an aortic stent graft OS of at least 30% (range 30%-42%) should be used to avoid type Ia endoleaks and likewise to ensure CG patency.
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Affiliation(s)
- Stefano Fazzini
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany; Unit of Vascular Surgery, Department of Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy.
| | - Ombretta Martinelli
- Unit of Vascular Surgery, Department of Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Giovanni Torsello
- Institute for Vascular Research, St. Franziskus Hospital, Münster, Germany
| | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Marco D Pipitone
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Giovanni F Torsello
- Department of Radiology, Charité Campus Virchow-Klinikum, Charité University Medicine, Berlin, Germany
| | - Luigi Irace
- Unit of Vascular Surgery, Department of Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Konstantinos P Donas
- Department of Vascular Surgery and Research Vascular Centre, Asclepios Clinic Langen, University of Frankfurt, Langen, Hessen, Germany
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14
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Experimental in vitro study of parallel stent technique in endovascular repair of complex abdominal aortic aneurysms. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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15
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Taneva GT, Lee JT, Tran K, Dalman R, Torsello G, Fazzini S, Veith FJ, Donas KP. Long-term chimney/snorkel endovascular aortic aneurysm repair experience for complex abdominal aortic pathologies within the PERICLES registry. J Vasc Surg 2020; 73:1942-1949. [PMID: 33259893 DOI: 10.1016/j.jvs.2020.10.086] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/29/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The early and short-term efficacy of the snorkel/chimney technique for endovascular aortic aneurysm repair (ch-EVAR) have been previously reported. However, long-term ch-EVAR performance, vessel patency, and patient survival remain unknown. Our study evaluated the late outcomes to identify possible predictors of failure within the PERICLES (performance of the chimney technique for the treatment of complex aortic pathologies) registry. METHODS Clinical and radiographic data from patients who had undergone ch-EVAR from 2008 to 2014 in the PERICLES registry were updated with an extension of the follow-up. Regression models were used to evaluate the relevant anatomic and operative characteristics as factors influencing the late results. We focused on patients with ≥30 months of follow-up (mean, 46.6 months; range, 30-120 months). RESULTS A total of 517 patients from the initial PERICLES registry were included in the present analysis, from which the mean follow-up was updated from 17.1 months to 28.2 months (range, 1-120 months). All-cause mortality at the latest follow-up was 25.5% (n = 132), with an estimated patient survival of 87.6%, 74.4%, and 66.1% at 1, 3, and 5 years, respectively. A subgroup of 244 patients with 387 chimney grafts placed (335 renal arteries, 42 superior mesenteric arteries, 10 celiac arteries) and follow-up for ≥30 months was used to analyze specific anatomic and device predictors of adverse events. In the subgroup, the technical success was 88.9%, and the primary patency was 94%, 92.8%, 92%, and 90.5% at 2.5, 3, 4, and 5 years, respectively. The mean aneurysm sac regression was 7.8 ± 11.4 mm (P < .0001). Chimney graft occlusion had occurred in 24 target vessels (6.2%). Late open conversion was required in 5 patients for endograft infection in 2, persistent type Ia endoleak in 2, and endotension in 1 patient. The absence of an infrarenal neck (odds ratio, 2.86; 95% confidence interval, 1.32-6.19; P = .007) was significantly associated with long-term device-related complications. A sealing zone diameter >30 mm was significantly associated with persistent or late type Ia endoleak (odds ratio, 4.86; 95% confidence interval, 1.42-16.59; P = .012). CONCLUSIONS The present analysis of the PERICLES registry has provided the missing long-term experience for the ch-EVAR technique, showing favorable results with more than one half of the patients surviving for >5 years and a chimney graft branch vessel patency of 92%. The absence of an infrarenal neck and treatment with a sealing zone diameter >30 mm were the main anatomic long-term limits of the technique, requiring adequate preoperative planning and determination of the appropriate indication.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany; Department of Vascular and Endovascular Surgery, Puerta de Hierro University Hospital, Madrid, Spain.
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif
| | - Kenneth Tran
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif
| | - Ronald Dalman
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, Münster, Germany
| | - Stefano Fazzini
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY; Division of Vascular Surgery, The Cleveland Clinic, Cleveland, Ohio
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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16
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Kuo HS, Tsai KC, Chen JS. Endovascular Aortic Arch Reconstruction with Parallel Grafts: A Dilemma of Excessive Endograft Oversizing. ACTA CARDIOLOGICA SINICA 2020; 36:351-359. [PMID: 32675927 DOI: 10.6515/acs.202007_36(4).20200109a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Preservation of supra-aortic branches in thoracic endovascular aortic repair plays a role in associated neurological outcomes, and the strategy varies. Objectives This study aimed to evaluate the safety and efficacy of a parallel graft technique to reconstruct the aortic arch. Methods From August 2014 to July 2018, a total of 25 patients with thoracic aortic pathologies requiring arch reconstruction were included. All patients underwent thoracic aortic endovascular repair (TEVAR) with a zone 1 landing aortic stent graft, a chimney graft to preserve the left common carotid artery, and a periscope graft to preserve the left subclavian artery. The associated outcomes and complications were reported. Results Eighteen patients presented with aortic dissection, 4 with a thoracic aortic aneurysm, 1 with a penetrating aortic ulcer, 1 with a traumatic aortic injury, and 1 case of re-TEVAR. The technical success rate was 96% (24/25), but the case of immediate failure died of retrograde type A dissection. Over a mean follow-up of 32.33 months, another retrograde type A aortic dissection was detected in 1 month, and a case of early failure (< 1 year) and 3 cases of late failure (> 1 year) whose primary aortic problems recurred were detected. Conclusions This study demonstrates a total endovascular approach to preserve supra-aortic branches with a parallel graft technique. However, the dilemma of excessive graft oversizing was disclosed due to the risk of retrograde type A dissections and an unsatisfactory durability in this small series.
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Affiliation(s)
- Huey-Shiuan Kuo
- Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, New Taipei City
| | - Kun-Cheng Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Saint Paul's Hospital, Taoyaun City
| | - Jer-Shen Chen
- Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, New Taipei City.,Department of Healthcare Administration, Oriental Institute of Technology, New Taipei City, Taiwan
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17
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Ferrari E, Wang C, Berdajs D, von Segesser LK. Chimney grafts in renal arteries: a clinical model for coronary perfusion in future transcatheter aortic root repair techniques. J Cardiothorac Surg 2020; 15:132. [PMID: 32517779 PMCID: PMC7285528 DOI: 10.1186/s13019-020-01184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 06/03/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Given the similarities between coronary ostia and renal arteries, chimney grafts (CG) for kidney perfusion during abdominal endovascular aneurysm repair (EVAR) can be considered for coronary perfusion in future transcatheter aortic root repair (TARR) techniques. We analysed the results of renal CG and compared anatomic and technical details with root and coronary anthropometric data. METHODS Current status of kidney perfusion with CG was reviewed from literature. Anatomic details, technical data, CG performance and clinical outcome were collected and analysed. Anatomic details of aortic landing zone and renal arteries were compared with human anthropometric data of aortic root, ascending aorta and coronary ostia. RESULTS Seventeen articles reported 430 patients (mean age:74.5 ± 2.9 years) treated with renal CG. Mean length and diameter of proximal landing zone were 2.0 ± 2.0 mm and 26.4 ± 4.3 mm, respectively (anthropometric correspondence: ascending aorta diameter of 29.3 mm). Aortic endograft mean diameter was 26.4 ± 7.3 mm with reported oversize of 19.5 ± 6.0%. In total, 590 renal arteries were treated (left:325; right:265; bilateral:139 cases). Mean left and right renal artery diameters were 5.7 ± 0.6 mm and 5.8 ± 0.7 mm, respectively (anthropometric correspondence: coronary ostia diameters of 4.8 mm (left) and 3.7 mm (right)) with reported CG oversize of 19.75 ± 6% (left) and 18.1 ± 5.1% (right). Mean follow-up time was 16.5 ± 8.5 months, CG occlusion rate was 3.2% and endoleak I or II was reported in 83 patients (19.3%), requiring 7 procedures. CONCLUSIONS CG provides satisfactory results in patients with suitable renal artery diameter. Based on aortic root and coronary anthropometric data, CG can be considered in future TARR technologies for coronary perfusion but further tests for flow evaluations are mandatory.
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Affiliation(s)
- Enrico Ferrari
- Cardiac Surgery, Cardiocentro Ticino, Via Tesserete 48, 6900, Lugano, Switzerland.
- Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
| | - Changtian Wang
- Cardiovascular Surgery, Nanjing Jinling Hospital, Nanjing, China
| | - Denis Berdajs
- Cardiovascular Surgery, University Hospital of Basel, Basel, Switzerland
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18
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Touma J, Caradu C, Sylvestre R, Settembre N, Schneider F, Moia A, Ben Ahmed S, Lebas B, Gaudric J, Alsac JM, Warein E, Coscas R. Multicentre Experience with the Chimney Technique for Abdominal Aortic Aneurysms in French University Hospitals. Eur J Vasc Endovasc Surg 2020; 59:776-784. [PMID: 32273159 DOI: 10.1016/j.ejvs.2020.01.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/04/2020] [Accepted: 01/30/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The chimney technique (ChEVAR) allows for proximal landing zone extension for endovascular repair of complex aortic aneurysms. The aim of the present study was to assess ChEVAR national outcomes in French university hospital centres. METHODS All centres were contacted and entered data into a computerised online database on a voluntary basis. Clinical and radiological data were collected on all consecutive ChEVAR patients operated on in 14 centres between 2008 and 2016. Patients were deemed unfit for open repair. Factors associated with early (30 day or in hospital) mortality and type 1 endoleak (Type I EL) were calculated using multivariable analysis. RESULTS In total, 201 patients with 343 target vessels were treated. There were 94 juxtarenal (46.8%), 67 pararenal (33.3%), 10 Crawford type IV thoraco-abdominal (5%) aneurysms, and 30 (15.1%) proximal failures of prior repairs. The pre-operative diameter was 66.8 ± 16.7 mm and 28 (13.9%) ChEVAR were performed as an emergency, including six (2.9%) ruptures. There were 23 (11.7%) unplanned intra-operative procedures, mainly related to access issues. The rate of early deaths was 11.4% (n = 23). The elective mortality rate was 9.8% (n = 17). Nine patients (4.5%) presented with a stroke. The rate of early proximal Type I EL was 11.9%. Survival was 84.6%, 79.4%, 73.9%, 71.1% at 6, 12, 18, and 24 months, respectively. The primary patency of chimney stents was 97.4%, 96.7%, 95.2%, and 93.3% at 6, 12, 18, and 24 months, respectively. Performing unplanned intra-operative procedures (OR 3.7, 95% CI 1.3-10.9) was identified as the only independent predictor of post-operative death. A ChEVAR for juxtarenal aneurysm was independently associated with fewer post-operative Type I ELs (OR 0.17, 95% CI 0.05-0.58). CONCLUSION In this large national ChEVAR series, early results were concerning. The reasons may lie in heterogeneous practices between centres and ChEVAR use outside of current recommendations regarding oversizing rates, endograft types, and sealing zones. Future research should focus on improvements in pre-operative planning and intra-operative technical aspects.
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Affiliation(s)
- Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Caroline Caradu
- Department of Vascular Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Raphaelle Sylvestre
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
| | - Nicla Settembre
- Department of Vascular Surgery, Nancy University Hospital, University of Lorraine, Nancy, France
| | - Fabrice Schneider
- Department of Vascular Surgery, University Hospital of Poitiers, Poitiers, France
| | - Alessia Moia
- Department of Vascular and Endovascular Surgery, Edouard Herriot Hospital, University Hospital of Lyon, Lyon, France
| | - Sabrina Ben Ahmed
- Department of Vascular Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoit Lebas
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpétrière University Hospital, AP-HP, Paris, France
| | - Jean-Marc Alsac
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Edouard Warein
- Department of Vascular Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France.
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Ahn S. Adjunctive Procedures for Challenging Endovascular Abdominal Aortic Repair: When Needed and How Effective? Vasc Specialist Int 2020; 36:7-14. [PMID: 32274372 PMCID: PMC7119153 DOI: 10.5758/vsi.2020.36.1.7] [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: 03/06/2020] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/20/2022] Open
Abstract
Endovascular aneurysm repair (EVAR) is now considered the first choice treatment modality for abdominal aortic aneurysm (AAA) treatment. Advocates for endovascular strategies will try to treat all AAA by EVAR, regardless if the anatomy is conducive for treatment or not. However, the long-term outcomes of EVAR outside the instructions for use (IFU) due to a hostile aneurysmal neck or iliac artery anatomy are known to be poor. The EVAR procedures can be classified according to the technical difficulty, IFU, and need for visceral revascularization: standard, adjunctive, and complex EVAR. The situation required for adjunctive procedures can be classified as the following four steps: a hostile neck (i.e., short or severely angled); large inferior mesenteric or lumbar artery; tough iliac artery anatomy, such as a short common iliac artery and stenotic external iliac artery; and limitations in vascular access. This article will discuss the adjunctive procedures to overcome hostile aneurysm neck and unsuitable iliac artery anatomy.
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Affiliation(s)
- Sanghyun Ahn
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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20
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Koike Y, Date K, Kiss B. Chimney Endografting for Zone 2 Thoracic Endovascular Aortic Repair Using The Reorientation Technique. INTERVENTIONAL RADIOLOGY 2020; 5:89-93. [PMID: 36284658 PMCID: PMC9550391 DOI: 10.22575/interventionalradiology.2019-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/29/2020] [Indexed: 11/15/2022]
Abstract
The purpose of this report was to describe the reorientation of the chimney graft technique to downsize brachial artery access during thoracic endovascular aortic repair and thus preserve left subclavian artery flow. In the case described herein, the chimney graft was advanced not from the brachial or axillary artery, but from the common femoral artery, over a brachiofemoral pull-through wire. The chimney graft was then turned out into the ascending aorta by balloon dilatation via percutaneous brachial access (“reorientation”). Despite the use of a large-diameter chimney graft, the chimney technique with percutaneous brachial access was successfully performed using the reorientation technique.
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Affiliation(s)
- Yuya Koike
- Department of Interventional Radiology, Yokohama Nanbu Hospital
- Department of Interventional Radiology, Yokohama Rosai Hospital
| | - Kazuma Date
- Department of Cardiovascular Surgery, Yokohama Rosai Hospital
| | - Borbala Kiss
- Department of Radiology, Yokohama Rosai Hospital
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Riambau V, Blanco Amil C, Capoccia L, Mestres G, Yugueros X. FEVAR/BEVAR have limitations and do not always represent the preferred option for juxtarenal reconstruction. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:10-17. [PMID: 31755680 DOI: 10.23736/s0021-9509.19.11181-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Following the definition given by the recent ESVS guidelines, juxtarenal abdominal aortic aneurysm (JAAA) is defined as an aneurysm extending up to but not involving the renal arteries, necessitating suprarenal aortic clamping for open surgery, i.e. a short neck (<10 mm). JAAA repair always represents a challenge intervention, either by open or endovascular means, mostly related to the renal arteries involvement. Concerning endovascular repair, different options can be considered. Among them, fenestrated endografts (FEVAR) should be considered as a first option1, due to their reported safety and efficacy. However, when the anatomy is not favorable or when FEVAR devices are not available in an emergency setting for instance, other alternatives can be considered like parallel graft or chimney technique (ChEVAR). Do nothing is the last alternative when medical and anatomical circumstances are absolutely poor. In the following pages, we will review the limitations of FEVAR and branched endografts, the better indications and anatomical conditions for a successful repair with ChEVAR technique and its current clinical results reported in the literature.
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Affiliation(s)
- Vincent Riambau
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain -
| | - Carla Blanco Amil
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Capoccia
- Division Vascular and Endovascular Surgery, "Paride Stefanini" Department of Surgery, Umberto I Plyclinic, Sapienza University, Rome, Italy
| | - Gaspar Mestres
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Xavier Yugueros
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Taneva GT, Donas KP, Torsello GB, Seifarth H, de Azevedo FM, Austermann M, Torsello GF. In Vitro Evaluation of Balloon-Expandable Chimney Grafts in the Renal Arteries Combined With the Endurant Endograft. J Endovasc Ther 2019; 26:865-870. [DOI: 10.1177/1526602819872498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare balloon-expandable covered stents (BECS) available for use as renal chimney grafts to the Advanta V12 approved for use with the Endurant endograft. Materials and Methods: A silicone model was manufactured based on preoperative computed tomography angiography (CTA) scans of a patient with a 7-cm juxtarenal aneurysm treated with an Endurant bifurcated endograft and an Advanta V12 covered stent for the 6-mm-diameter right renal artery. The model was placed in a flow box filled with a 37°C blood-mimicking solution equipped with a pulsatile pumping system (140/60 mm Hg). The tested BECS were the Advanta V12, the VBX, and the BeGraft+. A 36-mm-diameter Endurant II endograft with a 16-mm-diameter contralateral limb and a 6×59-mm BECS chimney graft were used in 9 consecutive tests (3 for each combination). After each implantation, the model was placed in the CT scanner, and 2 radiologists blinded to the test device independently measured the gutter areas and the patent chimney graft lumen at the level of the Endurant’s suprarenal stent, at the level of the chimney’s maximum curvature, and 10 mm inside the renal artery. The intraclass correlation coefficients (ICC) were calculated to assess interreader reliability. Results: The mean gutter areas were 19.3±7, 20.2±8, and 22.3±8 mm2 for the Advanta, VBX, and BeGraft+, respectively (all p>0.05). At the level of the aortic endograft’s suprarenal stent struts, the mean diameter of the Advanta V12, VBX, and BeGraft+ were 4.46±0.3, 4.12±0.4, and 4.12±0.3 mm, respectively (all p>0.05). At the level of the maximum chimney graft angulation, the mean diameters were 3.77±0.3, 4.16±0.1, and 3.74±0.3 mm, respectively (all p>0.05). In the right renal artery, the mean diameters were 3.91±0.2, 4.05±0.9, and 4.3±0.4 mm, respectively (all p>0.05). The ICCs varied between 0.7 and 0.9, indicating good agreement between readers. Conclusion: These in vitro findings showed comparable results between the Advanta V12 and the available BECS used in conjunction with the Endurant endograft according to the instructions for use. Further clinical evaluation is needed to confirm these results.
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Affiliation(s)
- Gergana T. Taneva
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | | | | | - Harald Seifarth
- Clinic for Diagnostic and Interventional Radiology, Klinikum Esslingen, Esslingen, Germany
| | | | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Giovanni Federico Torsello
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Charité Campus Virchow-Klinikum, Charité University Medicine Berlin, Germany
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23
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Spampinato B, Settembrini AM, Romagnoli S, D'Alessio I, Domanin M, Gabrielli L. Concomitant Renal Artery and Aortic Aneurysm: Is Endovascular Surgery the Correct Approach? Ann Vasc Surg 2019; 61:473.e1-473.e5. [PMID: 31394217 DOI: 10.1016/j.avsg.2019.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 11/17/2022]
Abstract
Our case illustrates the concomitant presence of a giant aneurysm of the left renal artery at the ostium and an abdominal aortic aneurysm, in presence of a complex aortic anatomy. Type of approach and timing of the treatment is still not well established for the rare coexistence of these 2 pathologies. In case of surgical high-risk patients, endovascular therapy is considered now the best choice to exclude arterial and aortic aneurysms although there are chances to do further interventions in the follow-up. For this reason, we simultaneously treated both the aneurysms through an embolization with plugs and coils of renal aneurysm and endovascular exclusion of aortic aneurysm; in the follow-up, renal function of the patient worsened until hemodialysis and we saw the reperfusion of renal aneurysm and the onset of endoleak I type A from above the aortic and renal aneurysm and B from iliac legs of the previous endograft. We performed a parallel graft technique on visceral vessels to exclude the refilling of both aneurysms and preserve visceral vascularization. Follow-up at 12 months showed the complete exclusion of the aneurysms and the patency of stents in celiac trunk and superior mesenteric artery.
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Affiliation(s)
- Benedetta Spampinato
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Alberto M Settembrini
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Silvia Romagnoli
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Ilenia D'Alessio
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Maurizio Domanin
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Department of Clinical and Community Sciences, University of Milan, Milano, Italy
| | - Livio Gabrielli
- Division of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Department of Clinical and Community Sciences, University of Milan, Milano, Italy
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Xu H, Mei Y, Han X, Wei J, Watton PN, Jia W, Li A, Chen D, Xiong J. Optimization schemes for endovascular repair with parallel technique based on hemodynamic analyses. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2019; 35:e3197. [PMID: 30838798 DOI: 10.1002/cnm.3197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/24/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
Endovascular repair with parallel stent-grafts (SG) is a challenging technique that reconstructs the luminal flow pathways by implanting parallel-placed SGs into the vessel. After treatment, occlusion and shifting of the parallel SGs are sometimes reported, which could be fatal and difficult to be re-operated. These issues are highly related to the local hemodynamic conditions in the stented region. In this study, a patient case treated by the octopus endograft technique (a head-SG with three limb-SGs) and experienced limb-SG occlusion is studied. 3-D models are established based on computed tomography (CT) angiography datasets pretreatment and posttreatment as well as during follow-ups. Hemodynamic quantities such as pressure drop, wall shear stress-related parameters, and flow division in limb-SGs and visceral arteries are quantitatively investigated. Optimizations on the length of the head-SG and diameter of the limb-SGs are analyzed based on various scenarios. The results indicate that when reconstructing the flow pathways via octopus stenting, it is important to ensure the flow distribution as physiologically required with this new morphology. Position (or length) of the head-SG and diameter of the limb-SGs play an important role in controlling flow division, and high time average wall shear stress (TAWSS) around the head-SG acts as a main factor for graft immigration. This study, by proposing optimization suggestions with hemodynamic analyses for a specific case, implicates that pretreatment SG scenarios may assist in wise selection and placement of the device and thus may improve long-term effectiveness of this kind of challenging endovascular repair techniques.
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Affiliation(s)
- Huanming Xu
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Yuqian Mei
- Department of Computer Science and INSIGNEO Institute, University of Sheffield, Sheffield, UK
| | - Xiaofeng Han
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianyong Wei
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Paul N Watton
- Department of Computer Science and INSIGNEO Institute, University of Sheffield, Sheffield, UK
| | - Wan Jia
- Department of Vascular Surgery, The Second People's Hospital of Yunnan Province, Kunming, China
| | - Anqiang Li
- Department of Vascular Surgery, Gansu Provincial People's Hospital, Lanzhou, China
| | - Duanduan Chen
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
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25
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Taneva GT, Usai MV, Pitoulias GA, Torsello G, Austermann M, Donas KP. One-year outcomes of the BeGraft stent graft used as chimney graft in conjunction with the Endurant device for the treatment of complex abdominal diseases. Vascular 2019; 27:518-523. [DOI: 10.1177/1708538119843422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim To evaluate the performance of two different flexible devices, the balloon-expandable BeGraft stent as on-label chEVAR use with the Endurant (Medtronic, Santa Rosa, USA) stent graft compared to the self-expandable off-label employment of Viabahn (Gore Flagstaff, Arizona, USA). Methods All patients treated for pararenal aortic pathologies between 2008 and 2017 using Endurant II (Medtronic, Santa Rosa, CA, USA) abdominal endograft in combination with Viabahn (Gore, Flagstaff, AZ, USA) or BeGraft (Bentley, Hechingen, Germany) at our institution were retrospectively analyzed. Patients were divided into two groups according to the employed chimney graft, namely Viabahn (group A) and BeGraft (group B). The primary endpoint was the incidence of type IA endoleak at one month and last follow-up. Secondary endpoints included reintervention rates, primary patency of the chimney graft, and need for additional placement of bare metal stents also known as relining. Results A total of 27 patients (mean age: 76 years) were treated with overall 47 chimney grafts. In particular, 11 patients received 21 Viabahn and 16 patients underwent placement of 26 BeGraft stents. Mean follow-up was 14.3 ± 9.0 months for group A and 13.0 ± 13.7 for group B, p = .451. The mean chimney graft length was 85.1 ± 38.9 mm for group A and 34.9 ± 9.8mm for group B ( p < .001). The oversizing rate at the proximal sealing zone was significantly higher in group B (Group A: 23.1 ± 16.5% vs. Group B: 33.6 ± 7.6%, p = .007). The primary patency rates were similar between groups ( p = .250). The subgroup analysis showed a significantly higher early (9–42.9% vs. 2–7.7%, p = .005) and at last CT follow-up (5–23.8% vs. 0–0.0%, p = .011) type IA endoleak, higher primary relining (14–66.7% vs. 5–19.2%, p = .001) and reintervention rates (5–23.8% vs. 0–0.0%; p = .011) for group A chimney stent grafts. Conclusions Both chEVAR combinations displayed similar patency rate, showing the BeGraft-Endurant composition less need for relining and fewer one-year type IA endoleak and reintervention rates in the subgroup analysis.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Marco V Usai
- Clinic of Vascular and Endovascular Surgery, University of Münster, Münster, Germany
| | - Georgios A Pitoulias
- 2nd Department of Surgery, Division of Vascular Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Martin Austermann
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
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26
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Ducasse E, Caradu C, Brochier C, Midy D, Bérard X, Poirier M, Ottaviani N. Midterm Results with the Open Chimney Technique during Endovascular Aneurysm Repair. J Vasc Interv Radiol 2019; 30:511-520.e1. [PMID: 30876807 DOI: 10.1016/j.jvir.2018.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To report the midterm experience with chimney-endovascular aneurysm repair (Ch-EVAR) with the use of open self-expending stents for branch vessel preservation. MATERIALS AND METHODS From July 2010 to May 2017, 67 patients underwent open Ch-EVAR because their proximal landing zones were adjacent to, or covered, the renal or mesenteric arteries (Zones 7-9), and they were not suitable for standard or fenestrated endovascular aneurysm repair. The proximal landing zone was relocated below the highest renal artery in 46 cases, the superior mesenteric artery in 17 cases, and the celiac artery in 4 cases, using 84 open chimneys (131 stents). A subgroup analysis was performed between an early (2010-2014) and a later (2015-2017) time period. Thirty-two patients were treated during the early period, and 35 were treated during the later period. In the later period, open chimneys were strengthened by a second self-expanding stent. RESULTS The primary technical success rate was 89.6%; the early mortality rate was 9.0%; and the median follow-up duration was 13 months (range, 1-76 months). The estimated actuarial survival rate was 85.7% in year 1 and 79.2% in year 2, and the estimated patency rate of open chimneys reached 95.2% at 2 years. Aneurysm sac regression >5 mm and sac stability rates were 39.0% and 57.6%, respectively. Freedom from aneurysm-related reintervention was lower in the later period (log-rank P = .04), while type Ia endoleaks tended to be twice as likely. CONCLUSIONS Midterm results of open Ch-EVAR show high technical success with acceptable midterm patency and lack of endoleak in appropriately selected patients. The advantages over covered stents are lower-profile delivery systems and maintenance of branch vessel patency in early bifurcations and overlying visceral vessels.
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Affiliation(s)
- Eric Ducasse
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France.
| | - Caroline Caradu
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France
| | - Coline Brochier
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France
| | - Dominique Midy
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France
| | - Xavier Bérard
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France
| | - Mathieu Poirier
- Unit of Vascular Surgery, CH de Mont-de-Marsan, Mont-de-Marsan, France
| | - Nicolas Ottaviani
- Unit of Vascular Surgery, Pellegrin Hospital, University of Bordeaux, Place Amélie Raba Léon, CHU Pellegrin Tripode, Bordeaux, France
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27
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Deployment of stent graft in an excessively higher position above the renal artery induces a flow channel to the aneurysm in chimney endovascular aortic aneurysm repair: an in vitro study. J Artif Organs 2019; 22:200-206. [PMID: 30663032 DOI: 10.1007/s10047-019-01090-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
We aimed to investigate the influences of the sealing length above the renal artery (RA) on gutter formation, non-apposed regions between the aortic wall, stent graft (SG), and chimney graft and incidence of flow channel to the aneurysm in chimney endovascular aortic aneurysm repair (Ch-EVAR) using a juxtarenal abdominal aortic aneurysm model. Neck diameter and length of the silicone model were 24 and 4 mm, respectively. In double Ch-EVAR configuration using Advanta V12, 12 combinations were tested three times with two sizes [28.5 (20%-oversize) and 31 (30%-oversize) mm] of Excluder SG, three sealing lengths above the RA (10, 20, and 30 mm), and two deployment positions (anatomical and cross-leg). Gutter area, non-apposed region, and flow channels to the aneurysm were analyzed using micro-computed tomography. Average gutter area and non-apposed region of 30%-oversize SG were significantly smaller than those of 20%-oversize SG (p = 0.05). Furthermore, the non-apposed region of 30%-oversize SG with a 30-mm sealing length was significantly larger than that of the other sealing lengths. For 20%-oversize SGs, flow channel to the aneurysm was observed, except for the anatomical deployment with the sealing length of 10 mm. For 30%-oversize SGs, flow channel was absent, except for the SG with a 30-mm sealing length in both deployment positions. These flow channels were frequently formed through a valley space, existing in the lower unibody above the two limbs. Our data indicated that the optimal sealing length should be chosen in consideration of the device design difference due to the device diameter in Ch-EVAR.
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28
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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29
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Carter R, Wee IJY, Petrie K, Syn N, Choong AM. Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review. Vascular 2018; 27:204-212. [PMID: 30522411 DOI: 10.1177/1708538118812548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an 'endovascular first' approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising 'off-the-shelf' stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. METHODS We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). RESULTS The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. CONCLUSIONS Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.
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Affiliation(s)
- Rebeca Carter
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,2 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ian Jun Yan Wee
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kyle Petrie
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,2 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicholas Syn
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Mtl Choong
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,4 Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore.,5 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,6 Division of Vascular Surgery, National University Heart Centre, Singapore, Singapore
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30
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Donas KP, Usai MV, Taneva GT, Criado FJ, Torsello GB, Kubilis P, Scali S, Veith FJ. Impact of aortic stent-graft oversizing on outcomes of the chimney endovascular technique based on a new analysis of the PERICLES Registry. Vascular 2018; 27:175-180. [PMID: 30419183 DOI: 10.1177/1708538118811212] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Chimney endovascular aortic aneurysm repair is gaining ever greater acceptance. However, persistent gutters leading to type IA endoleaks represent an unsolved issue. The aim of the current study was to analyze the impact of abdominal endograft oversizing to the occurrence of this phenomenon. METHODS The PERformance of the snorkel/chImney endovascular teChnique in the treatment of compLex aortic PathologiesES registry includes the largest experience with chimney endovascular aortic aneurysm repair from 13 vascular centers in Europe and the U.S. Prospectively collected data from centers with standard use of the Endurant stent-graft and balloon-expandable covered stents as chimney grafts only were included in the present analysis. The parameter which varied was the degree of oversizing of the aortic stent-graft classifying the cohort in two groups, group A (20% and less oversizing) and group B (>20% of oversizing). The primary endpoint was the incidence of persistent type IA endoleak needed reintervention. Secondary endpoints were all-cause mortality and freedom from reintervention. RESULTS Group A included 21 patients while group B 144. The mean preoperative pathology's neck length and diameter was 5.8 mm (±4.4) versus 4.9 mm (±3.8) and 27.6 mm (±4.7) versus 24.9 mm (±3.7) for group A and group B, respectively. The mean length of the new sealing zone after chimney graft placement was similar for both groups (group A versus group B; 17.9 mm versus 18.3 mm, respectively, P = .21). The percentage of oversizing of the aortic stent-graft ranged between 13.8 and 20% versus 22.2 and 30%, for group A and group B, respectively. Patients of group A had more type 1A endoleaks, (14.3%) versus patients of group B (2.1%) based on the first follow-up imaging, P = .02. The incidence of persistent type IA endoleaks needing a reintervention was 14.3 and 1.4% for the group A and group B, respectively, P = .01. The mean volume of contrast medium used was greater in group A versus group B with 239 ml versus150 ml, P = .05. Additionally, 14.3% of patients of group A experienced acute renal failure compared to those in group B which was 1.0%, P = .01. CONCLUSIONS Oversizing of ideally 30% of the Endurant stent-graft is associated with significant lower incidence of type IA endoleaks requiring reintervention for patients treated by chimney endovascular aortic aneurysm repair.
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Affiliation(s)
| | - Marco V Usai
- 2 Clinic of Vascular and Endovascular Surgery, University of Münster, Münster, Germany
| | - Gergana T Taneva
- 1 Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Frank J Criado
- 3 Division of Vascular Surgery, MedStar Union Memorial Hospital, Baltimore, USA
| | | | | | | | - Frank J Veith
- 5 New York University, New York, USA.,6 Cleveland Clinic, Cleveland, USA
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31
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Ronchey S, Fazzini S, Scali S, Torsello G, Kubilis P, Veith F, Donas KP, Pecoraro F, Mangialardi N. Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results. J Endovasc Ther 2018; 25:492-498. [DOI: 10.1177/1526602818782941] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). Overall, 70 visceral vessels were targeted for revascularization. Results: Technical success was achieved in 35 (89.7%) cases; 3 persistent type Ia endoleaks and 1 chimney graft occlusion were detected within the first 30 days. Thirty-day mortality was 2.6%. Two other deaths (not aneurysm related) occurred during a mean follow-up of 21.9 months (0.23–71.3). Primary patency of the chimney grafts was 94.3% at 36 months. In a subgroup analysis comparing Endurant to other stent-grafts, no significant differences were observed regarding persistent endoleak [1/20 (5%) vs 2/19 (11%), p=0.6] or reintervention [1/20 (5%) vs 0/19 (0%)]. Conclusion: The present series demonstrates that chEVAR in the treatment of post-EVAR type Ia endoleaks has satisfactory results independent of the abdominal and chimney graft combinations. Midterm results show that chEVAR is an effective method for treating type Ia endoleaks.
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Affiliation(s)
- Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Fazzini
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
| | - Paul Kubilis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Frank Veith
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- New York University Medical Center, New York, NY, USA
| | | | - Felice Pecoraro
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- University of Palermo, Vascular Surgery Unit, AOUP “P. Giaccone”, Palermo, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, “San Camillo-Forlanini” Hospital, Rome, Italy
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32
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Mestres G. Commentary: The Value of In Vitro Studies in Assessing Chimney Graft Behavior in Endovascular Aneurysm Repair. J Endovasc Ther 2018; 25:395-396. [DOI: 10.1177/1526602818762465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gaspar Mestres
- Vascular Surgery Division, Hospital Clinic, Barcelona, Spain
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Morgan GJ, Ciuffreda M, Spadoni I, DeGiovanni J. Optimus covered stent: Advanced covered stent technology for complex congenital heart disease. CONGENIT HEART DIS 2018; 13:458-462. [DOI: 10.1111/chd.12596] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Gareth J. Morgan
- The Heart Institute; Children's Hospital of Colorado and University Hospital Colorado; Aurora Colorado, USA
| | - Matteo Ciuffreda
- Cardiovascular Department; “Papa Giovanni XXIII” Hospital; Bergamo Italy
| | | | - Joseph DeGiovanni
- Department of Pediatric Cardiology; Birmingham Children's Hospital; Birmingham United Kingdom
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