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Malkoc A, Gnanadev R, Shoemaker HB, Alach A, Vo TD, Behseresht J, Tayyarah M, Andacheh I, Hsu JH. The Use of Advanced Three-Dimensional Computed Tomography During Simple and Complex Endovascular Aortic Aneurysm Repairs. Ann Vasc Surg 2024; 106:90-98. [PMID: 38754579 DOI: 10.1016/j.avsg.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/10/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) success depends on imaging technology both in the planning and operative phases. Endovascular repair requires intravenous contrast and radiation exposure to the patient as well as radiation exposure to the operator. Recent developments in imaging technology attempt to merge preoperative imaging with intraoperative imaging to improve the efficiency and accuracy of EVAR. The Cydar 3-dimensional (3D) imaging system combines the preoperative and intraoperative imaging during the operation. We aim to investigate the use of the Cydar 3D imaging system during EVAR compared to conventional methods. METHODS Retrospective review of all patients undergoing an EVAR at a single quaternary vascular center from 2019-2023 was collected. This cohort was divided into 2 groups: (1) repair using Cydar 3D imaging or (2) repair without Cydar 3D imaging. Overall, 138 unique patients were identified with 27 operations using Cydar 3D imaging and 111 operations without Cydar 3D imaging. We performed a 1-to-1 propensity score-matched analysis using nearest-neighbor matching for variables including age, case urgency, and if the case was performed in the operative room or interventional radiology room. A match occurred when a patient in the Cydar 3D imaging group had an estimated score within 0.01 standard deviations of a patient in the control group. From this, we paired 27 from each cohort for a total of 54 patients. Demographic data included length of stay in days, contrast volume (mL), fluoroscopy time (min), procedure length (mins), mortality, and blood loss (mL). Univariate analyses were performed and a P value less than 0.05 was considered statistically significant. RESULTS A total of 54 vascular patients were analyzed: 27 without the Cydar 3D imaging and 27 with the Cydar 3D imaging. In the univariate analysis, there was no statistical difference in the average length of stay (6.4 days ± 11.76 vs. 4.1 ± 6.03, P = 0.372), aneurysm size (5.9 ± 1.4 vs. 5.9 ± 1.2, P = 0.88), contrast volume in mL (91.3 ± 47.0 vs. 91.1-33.49, P = 9.88), fluoroscopy time in mins (20.2 ± 17.2 vs. 19.5 ± 19.4, P = 0.89), procedure length (299.3 ± 177.9 vs. 353 ± 191.98, P = 0.279), and blood loss in mL (513.8 ± 791 vs. 353 ± 191.98, P = 0.594). There was an increase in reintervention for endoleaks in the group with use of Cydar 3D imaging (0 vs. 6, P = 0.043). A subanalysis of patients undergoing physician-modified EVARs did show a 15% reduction in the contrast volume used. CONCLUSIONS The use of 3D imaging technology has the potential to increase the safety of EVAR to both patients and operators. In our study, we did not find any difference in standard EVARs; however, there was a contrast use decrease in physician-modified EVARs. Further studies will need to be performed to determine the realized benefit from performing EVARs using this new technology.
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Affiliation(s)
- Aldin Malkoc
- Department of General Surgery, Arrowhead Regional Medical Center, Colton, CA.
| | - Raja Gnanadev
- Department of General Surgery, Arrowhead Regional Medical Center, Colton, CA
| | - Hailey B Shoemaker
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Ahmad Alach
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Trung D Vo
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Jason Behseresht
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Majid Tayyarah
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Iden Andacheh
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Jeffrey H Hsu
- Department of Vascular Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Gallitto E, Faggioli G, Austermann M, Kölbel T, Tsilimparis N, Dias N, Melissano G, Simonte G, Katsargyris A, Oikonomou K, Mani K, Pedro LM, Cecere F, Haulon S, Gargiulo M. Urgent endovascular repair of juxtarenal/pararenal aneurysm by off-the-shelf multibranched endograft. J Vasc Surg 2024:S0741-5214(24)01500-3. [PMID: 38992807 DOI: 10.1016/j.jvs.2024.07.005] [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: 05/14/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE To report outcomes of urgent juxtarenal/pararenal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch). METHODS In this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter of >70 mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI), and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions, and target artery instability (TAI) were evaluated during follow-up. RESULTS Overall, 197 patients (J-AAAs, n = 64 [33%]; P-AAAs, n = 95 [48%]; previous failed endovascular aneurysm repair (EVAR), n = 38 [19%]) were analyzed. The mean age and aneurysm diameter was 75 ± 8 years and 76 ± 4 mm, respectively. The American Society of Anesthesiologists score was 3 and 4 in 118 (60%) and 79 (40%) patients. Rupture, symptoms, and diameter of >70 mm were present in 51 (26%), 110 (56%), and 53 (27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28 cases (14%). The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154 ± 49 mm. Single-stage repair and cerebrospinal fluid drainage were reported in 144 (73%) and 53 (27%) cases, respectively. TS was achieved in 182 (92%) cases (rupture, 84% vs no rupture, 95%; P = .02). Failures consist of TA loss (11 [6%]: renal artery, 9; celiac trunk, 2), type I to III endoleaks (2 [1%]), and 24-h mortality (2 [1%]). Rupture was a risk factor for technical failure (P = .02; odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-12.1). Overall, 15 patients (8%) had persistent SCI (rupture, 14% vs no rupture, 5%) with 11 (6%) , of paraplegia (rupture, 10% vs no rupture, 5%; P = .001). Rupture (P = .04; OR, 3.1; 95% CI, 1.1-8.9) and adjunctive proximal thoracic endograft (P = .01; OR, 4.1; 95% CI, 1.3-12.9) were risk-factors for SCI. Twenty-two patients (11%) died within 30 days or during a prolonged hospitalization. Previous failed EVAR (P = .04; OR, 3.6; 95% CI, 1.1-12.3), paraplegia (P < .001; OR, 9.9; 95% CI, 1.6-62.2) and postoperative mesenteric complications (P = .03; OR, 10.4; 95% CI, 1.2-93.3), as well as cardiac (P = .03; OR, 8.2; 95% CI, 2.0-33.0) and respiratory (P < .001; OR, 10.1; 95% CI, 2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19 ± 5 months. The estimated 3-year survival and freedom from reinterventions was 58% and 77%, respectively. TAI occurred in 27 patients (14%) (occlusion, 15; endoleak, 14) with an estimated 3-year freedom from TAI of 72%. CONCLUSIONS Urgent repair of J/P-AAAs by T-branch is feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a non-negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed EVAR and postoperative mesenteric complications, as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and should be subjected to more research for the purposes of improving outcomes.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Martin Austermann
- Department of Vascular and Endovascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Nikolas Tsilimparis
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nuno Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Germano Melissano
- Division of Vascular Surgery, Vita - Salute University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | | | - Kyriakos Oikonomou
- Vascular and Endovascular Surgery, University Hospital and Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Luis Mendes Pedro
- Department of Vascular Surgery, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina da Universidade de Lisboa, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
| | - Fabrizio Cecere
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy
| | - Stephan Haulon
- Vascular Surgery, Hospital Marie Lannelongue, Paris, France
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
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Silverberg D, Bar Dayan A, Speter C, Fish M, Halak M. The Use of the Off-the-Shelf Inner Branch E-nside Endograft for the Treatment of Elective and Emergent Complex Aortic Aneurysms-A Single-Center Experience. Ann Vasc Surg 2024; 104:132-138. [PMID: 37495095 DOI: 10.1016/j.avsg.2023.07.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/28/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND The aim of this single-center study was to evaluate the early results of the off-the-shelf inner branch E-nside endograft in the treatment of complex aortic aneurysms and thoracoabdominal aortic aneurysms. METHODS We performed a retrospective analysis of a prospectively maintained database of all patients treated with the E-nside endograft at our institution during the years 2021-2023. Parameters evaluated were technical success, early major adverse events, target vessel patency, and the presence of endoleaks. RESULTS In total 16 patients underwent treatment with the E-nside endograft. Six additional patients were evaluated for the device but were excluded due to anatomical considerations. Mean age was 71 (range 59-84) and 14 (88%) were males. Mean aneurysm diameter was 66 mm (range 54-85). Aneurysms treated included thoracoabdominal in 9 (56%), juxtarenal aneurysms in 5 (31%), postdissection aneurysm in 1 (6%) and a type 1A endoleak after a failed endovascular aneurysm repair in 1 (6%). Five of the treated aneurysms were symptomatic. A total of 58 side branches were placed into target visceral arteries. Mean operative time was 190 min (range 150-360). Technical success was achieved in 15/16 of the patients (94%). At 30 days, 1 perioperative mortality and 3 major adverse events occurred, 2 of them branch related. CONCLUSIONS The E-nside endograft is a feasible option for the treatment of a broad spectrum of aortic pathologies. As it is an off-the-shelf device, it can be used selectively in elective and emergent settings with acceptable 30-day mortality and morbidity. Further follow-up is required to determine the durability of this treatment option and patency of side branches.
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MESH Headings
- Humans
- Male
- Aged
- Female
- Retrospective Studies
- Endovascular Procedures/instrumentation
- Endovascular Procedures/adverse effects
- Blood Vessel Prosthesis
- Middle Aged
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/adverse effects
- Treatment Outcome
- Aged, 80 and over
- Prosthesis Design
- Time Factors
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/physiopathology
- Elective Surgical Procedures
- Databases, Factual
- Stents
- Risk Factors
- Endoleak/etiology
- Endoleak/surgery
- Vascular Patency
- Emergencies
- Postoperative Complications/etiology
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/physiopathology
- Aortic Aneurysm, Abdominal/mortality
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Affiliation(s)
- Daniel Silverberg
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel.
| | - Avner Bar Dayan
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Chen Speter
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Michal Fish
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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4
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Bisdas T, Zambas N, Zertalis M, Theodorides P, Iatrou N, Dimopoulos C, Charalambous N. Real-World Evaluation of the Off-the-Shelf Precannulated Inner-Branched Endograft for Pararenal Aortic Aneurysms. J Endovasc Ther 2024:15266028241241006. [PMID: 38528651 DOI: 10.1177/15266028241241006] [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: 03/27/2024]
Abstract
PURPOSE To analyze the early performance and efficacy of the first commercially available off-the-shelf precannulated multibranched endograft in the endovascular repair of pararenal abdominal aortic aneurysms (PAAAs). The device received European marketing approval in late 2020. MATERIALS AND METHODS Between January 2021 and June 2023, a retrospective analysis of prospectively collected data from all consecutive patients with pAAAs undergoing implantation of the E-nside precannulated inner-branched endograft was conducted in 2 centers. The primary outcome measure was technical success defined as the composite endpoint of successful (1) delivery of the 24F endograft, (2) use of the precannulation tubes, and (3) implantation of the bridging stent-grafts (BSGs) to the target vessels. Main secondary endpoints were mortality, target vessel instability (TVI), absence of type I or III endoleak, reintervention, spinal cord ischemia, and supra-celiac aortic coverage. RESULTS Twenty-one patients (20 men, mean age: 71 years) were included in this study with a mean follow-up of 14±7.7 months. Nine patients had a symptomatic aneurysm (43%). Technical success amounted to 95% (in one patient, an iliofemoral conduit was necessary to advance the device). One out of 112 BSGs (1%, right renal artery) occluded at 30 days, resulting in freedom from TVI and reintervention rate at 12 months of 95%. No type I or III endoleaks were identified during follow-up. One patient (5%) died at 13 months due to non-aneurysm-related death, and 1 patient (5%) developed spinal cord ischemia. No other major perioperative complications were observed. Mean supra-celiac aortic coverage reached 52±8%. CONCLUSIONS Given the imperative need for an off-the-shelf endograft tailored to address PAAAs, the E-nside stent-graft demonstrated encouraging outcomes in this study. Nevertheless, it is essential to emphasize that the extent of aortic coverage mandates the production of a truncated variant. CLINICAL IMPACT The endovascular repair of urgent pararenal aortic aneurysms remains still an unsolved problem in the endovascular era since there are no available off-the-shelf dedicated fenestrated or branched endografts. This paper confirms the safety and efficacy of the off-the-shelf precannulated inner branched endograft for this specific indication.
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Affiliation(s)
- Theodosios Bisdas
- Clinic of Vascular Surgery III, Athens Medical Group, Athens, Greece
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Neophytos Zambas
- Department of Vascular and Interventional Radiology, Aretaeio Hospital, Nicosia, Cyprus
| | - Marios Zertalis
- University of Nicosia Medical School, Nicosia, Cyprus
- Department of Vascular and Interventional Radiology, Aretaeio Hospital, Nicosia, Cyprus
| | | | - Nikolaos Iatrou
- Clinic of Vascular Surgery III, Athens Medical Group, Athens, Greece
| | | | - Nikolas Charalambous
- University of Nicosia Medical School, Nicosia, Cyprus
- Department of Vascular and Interventional Radiology, Aretaeio Hospital, Nicosia, Cyprus
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5
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Gomes VC, Farber MA, Parodi FE. Gore thoracoabdominal branched endoprosthesis: early results and impressions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:481-487. [PMID: 37255496 DOI: 10.23736/s0021-9509.23.12717-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The remarkable advances in technology and devices in the last two decades have made possible the endovascular repair of complex abdominal (cAAA) and thoracoabdominal (TAAA) aortic aneurysms with challenging anatomy. To date, despite the creation of multiple fenestrated/branched endografts intended to treat these difficult cases, in the USA, many of them remain available only under physician sponsored investigational device exemption (PSIDE) protocols in few institutions. The Gore Thoracoabdominal Branched Endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) investigational device is a four-branched off-the-shelf (OTS) endograft that concluded an early feasibility study in 2016 and is currently finalizing a pivotal trial in pursuit of approval from the Food and Drug Administration. This article discusses the TAMBE early feasibility multicenter study results, the most relevant features of this device, its anatomical feasibility, and the impressions about this endograft as an OTS option for the treatment of CAAA and TAAA.
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Affiliation(s)
- Vivian C Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA -
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Federico E Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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6
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Khoury MK, Lancaster E, Eagleton MJ, Gasper WJ. Update of T-branch use from the US Aortic Research Consortium. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:470-474. [PMID: 37389548 DOI: 10.23736/s0021-9509.23.12737-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Aortic endograft evolution has altered our approach to treating patients with both standard and complex aortic disease. In particular, fenestrated and branched aortic endografts have allowed for the expansion of therapy to include those patients with extensive thoracoabdominal aortic aneurysms (TAAAs). The fenestrations and branches allow for the aortic endografts to achieve a seal in the proximal and distal aspects of the aorto-iliac tree, to exclude the aneurysm, while maintaining perfusion to the renal and visceral vessels. Historically, many of the grafts used for this purpose are custom made devices designed for a specific patient based on their preoperative computed tomography imaging. One downside to this approach is the time it takes to construct these grafts. Given this, much effort has been directed towards developing "off-the-shelf" grafts which may be applicable to many patients in an immediate-need bases. The Zenith T-Branch device offers an off-the-shelf graft with four directional branches. Its utilization is not applicable to all patients, but can be applied to many patients with TAAAs. Large reported series on outcomes for these devices is limited to centers in Europe as well as within the United States Aortic Research Consortium. While early outcomes appear excellent, long-term outcomes related to aneurysm exclusion, branch patency, and freedom from reintervention are needed and will be forthcoming.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Lancaster
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA -
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
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7
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Gallitto E, Faggioli G, Logiacco A, Mascoli C, Spath P, Palermo S, Pini R, Gargiulo M. Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair. Vascular 2023; 31:833-840. [PMID: 35513794 DOI: 10.1177/17085381221097304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. MATERIALS AND METHODS All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. RESULTS Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70 mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). CONCLUSION Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70 mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
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8
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Gomes VC, Parodi FE, Motta F, Pascarella L, McGinigle KL, Marston WA, Wood J, Farber MA. Outcome Analysis Comparing Asymptomatic Juxtarenal Aortic Aneurysms Treated with Custom-Manufactured Fenestrated-Branched Devices and the "Off-The-Shelf" Zenith p-Branch Device. Ann Vasc Surg 2023; 96:207-214. [PMID: 37003359 DOI: 10.1016/j.avsg.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/17/2023] [Accepted: 03/18/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Numerous endovascular options have been used for the repair of juxtarenal aortic aneurysms (JRAAs) over the last 15 years. This study aims to compare the performance between the Zenith p-branch device and custom-manufactured fenestrated-branched devices (CMD) for the treatment of asymptomatic JRAA. METHODS A single-center retrospective analysis of prospectively collected data was performed. Patients with a diagnosis of JRAA submitted to endovascular repair between July 2012 and November 2021 were included in the study, being divided into 2 groups: CMD and Zenith p-branch. The following variables were analyzed: preoperative information: demographics, comorbidities, and maximum aneurysm diameter; procedural data: contrast volume, fluoroscopy time, radiation dose, estimated blood loss, and technical success; and postoperative data: 30-day mortality, duration of intensive care unit and hospital stay, major adverse events, secondary interventions, target vessel instability, and long-term survival. RESULTS From a total of 373 physician-sponsored investigational device exemption (Cook Medical devices) cases performed at our institution, 102 patients presented the diagnosis of JRAA. Of these, 14 patients were treated with the p-branch device (13.7%) and 88 (86.3%) with a CMD. Both groups presented similar demographic composition and maximum aneurysm diameter. All devices were successfully deployed, with no type I or III endoleaks observed at procedure completion. The contrast volume (P = 0.023) and radiation dose (P = 0.001) were significantly higher in the p-branch group. No significant difference was observed between the groups for the remaining intraoperative data. No paraplegia or ischemic colitis has been observed during the first 30 days after the surgical procedures. There was no 30-day mortality in either group. One major cardiac adverse event was registered in the CMD group. Early outcomes were similar in both groups. No significant difference was found between the groups with respect to the presence of type I or III endoleaks during the follow-up. From a total of 313 target vessels stented in the CMD group (mean of 3.55 per patient) and 56 in the p-branch group (mean of 4 per patient), 4.79% and 5.35% presented instability, respectively, with no difference observed between the groups (P = 0.743). Secondary interventions were required in 36.4% of the CMD cases and 50% of the p-branch group, but this was not statistically different (P = 0.382). In the p-branch cohort, 2 of 7 reinterventions (28.5%) were target vessel-related and in the CMD group, 10 of 32 secondary interventions (31.2%) were target vessel-related. CONCLUSIONS Comparable perioperative outcomes were obtained when appropriately selected patients were treated with either the off-the-shelf p-branch or CMD for JRAA. The long-term target vessel instability does not appear impacted by the presence of pivot fenestrations in comparison to other target vessel configurations. Given these outcomes, delay in CMD production time should be considered when treating patients with large juxtarenal aneurysms.
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Affiliation(s)
- Vivian Carla Gomes
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Federico Ezequiel Parodi
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Fernando Motta
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jacob Wood
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
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9
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Wu H, Zhang L, Li M, Wei S, Zhang C, Bai H. Systematic Review and Meta-Analysis of Published Studies on Endovascular Repair of Abdominal Aortic Aneurysm With the p-Branch. Front Surg 2022; 9:879682. [PMID: 35574550 PMCID: PMC9098825 DOI: 10.3389/fsurg.2022.879682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Endovascular treatment of juxtarenal or pararenal abdominal aortic aneurysms is more popular than open surgery, mainly because it reduces perioperative mortality and morbidity. The custom-made fenestrated devices need to be tailored to each patient, so these devices require extra manufacturing and shipping time. The increased wait time may increase the risk of aneurysm rupture in some patients. In some situations, “Off-the-shelf” (OTS) fenestrated grafts can be used. The Cook Zenith p-Branch device (William Cook Australia, Brisbane, Australia) is a relatively common OTS. This study aimed to systematically evaluate all published experiences with p-Branch. Methods We searched PubMed, Embase, and Cochrane to find works of literature that reported on the outcomes of patients treated with the p-Branch stent-grafts. Then we conducted an assessment of quality and meta-analysis of the results. The primary endpoints were the application rate of p-Branch stent-graft (type A, B), technical success rate, and early re-intervention rate. We estimated pooled proportions and 95% CIs. Results Initial search of the literature included 111 articles, of which 7 studies were included in the end. A total of 260 patients were enrolled in these studies, and 218 patients were eventually treated with p-Branch. The pooled application rate of type A devices was 48% (95% CI, 29–67%), and pooled application rate of type B devices was 30% (95% CI, 16–44%). The pooled technical success rate was 87% (95% CI, 75–98%). The early re-intervention rate was 10% (95% CI, 3–17%). Midterm renal infarct rate (after 30 days) was 3% (95% CI, 0–6%). Midterm re-intervention rate (after 30 days) was 30% (95% CI, 3–57%). Midterm renal failure rate (after 30 days) was 6% (95% CI, 2–10%). Conclusions This pooled analysis indicated an acceptable technical success rate after p-Branch stent-graft implantation, with early and midterm re-intervention rate and renal failure rate that cannot be ignored. The p-Branch repair of juxtarenal abdominal aortic aneurysms may be an appropriate and safe option, especially in emergency situations.
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Affiliation(s)
- Haoliang Wu
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Zhengzhou, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cong Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hualong Bai
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Zhengzhou, China
- *Correspondence: Hualong Bai ;
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10
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Midterm Outcomes of a Prospective, Nonrandomized Study to Evaluate Endovascular Repair of Complex Aortic Aneurysms Using Fenestrated-Branched Endografts. Ann Surg 2021; 274:491-499. [PMID: 34132698 DOI: 10.1097/sla.0000000000004982] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the midterm outcomes of fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs). SUMMARY BACKGROUND DATA FB-EVAR has been associated with decreased morbidity compared to open repair, but there is limited midterm data. METHODS A total of 430 patients (302 males, mean age 74 ± 8 years) treated by FB-EVAR were enrolled in a prospective, nonrandomized investigational device exemption study. Endpoints included 30-day mortality and major adverse events (MAEs), freedom from all cause and aortic-related mortality, target vessel patency, and freedom from secondary intervention and target vessel instability. RESULTS There were 133 PRAs and 297 TAAAs with 1673 renal-mesenteric arteries incorporated by fenestrations or directional branches (3.9 ± 0.5 vessels/patient). At 30 days or within the hospital stay if longer than 30 days, there were 4 (0.9%) deaths. MAEs included new-onset dialysis in 8 patients (2%), permanent paraplegia or stroke in 10 patients each (2%), and respiratory failure requiring tracheostomy in 2 patients (0.5%). After a mean follow-up of 26 ± 20 months, there were 3 (0.7%) aortic-related deaths from SMA stent occlusion, gastrointestinal hemorrhage, or complications of open arch repair. At 5 years, freedom from all-cause and aortic-related mortality were 57% ± 5% and 98% ± 1%, respectively. Freedom from secondary intervention was 64% ± 4%, primary target vessel patency was 94% ± 1%, and freedom from target vessel instability was 89% ± 2% at same interval. One patient (0.2%) had nonfatal aneurysm treated using endovascular repair. CONCLUSION FB-EVAR is safe and effective for treatment of PRA and TAAAs with low rate of aortic-related mortality and aneurysm rupture on midterm follow-up.
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11
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Evolution of fenestrated/branched endovascular aortic aneurysm repair complexity and outcomes at an organized center for the treatment of complex aortic disease. J Vasc Surg 2021; 73:1148-1155.e2. [PMID: 33766243 DOI: 10.1016/j.jvs.2020.07.100] [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: 02/01/2020] [Accepted: 07/24/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fenestrated/branched endovascular aneurysm repair (F/BEVAR) volume has increased rapidly, with favorable outcomes at centers of excellence. We evaluated changes over time in F/BEVAR complexity and associated outcomes at a single-center complex aortic disease program. METHODS Prospectively collected data of all F/BEVAR (definition: requiring ≥1 fenestration/branch), procedures performed in an institutional review board-approved registry and/or physician-sponsored investigational device exemption trial (IDE# G130210), were reviewed (11/2010-2/2019). Patients were stratified by surgery date into thirds: early experience, mid experience, and recent experience. Patient and operative characteristics, aneurysm morphology, device types, perioperative and midterm outcomes (survival, freedom from type I or III endoleak, target artery patency, freedom from reintervention), were compared across groups. RESULTS For 252 consecutive F/BEVARs (early experience, n = 84, mid experience, n = 84, recent experience, n = 84), 194 (77%) company-manufactured custom-made devices, 11 (4.4%) company-manufactured off-the-shelf devices, and 47 (19%) physician-modified devices, were used to treat 5 (2.0%) common iliac, 97 (39%) juxtarenal, 31 (12%) pararenal, 116 (46%) thoracoabdominal, and 2 (0.8%) arch aneurysms. All patients had follow-up for 30-day events. The mean follow-up time for the entire cohort was 589 days (interquartile range, 149-813 days). On 1-year Kaplan-Meier analysis, survival was 88%, freedom from type I or III endoleak was 91%, and target vessel patency was 92%. When stratified by time period, significant differences included aneurysm extent (thoracoabdominal, 33% early experience, 40% mid experience, and 64% recent experience; P < .001) and target vessels per case (four-vessel case, 31% early experience, 39% mid experience, and 67% recent experience; P < .0001). There was no difference, but a trend toward improvement, in composite 30-day events (early experience, 39%; mid experience, 23%; recent experience, 27%; P = .05). On Kaplan-Meier analysis, there was no difference in survival (P = .19) or target artery patency (P = .6). There were differences in freedom from reintervention (P < .01) and from type I or III endoleak (P = .02), with more reinterventions in the early experience, and more endoleaks in the recent period. CONCLUSIONS Despite increasing repair complexity, there has been no significant change in perioperative complications, overall survival, or target artery patency, with favorable outcomes overall. Type I or III endoleaks remain a significant limitation, with increased incidence as the number of branch arteries incorporated into the repairs has increased.
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12
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Mees BME. Off the Shelf Fenestrated Stent Grafts: "Mind The Gap?". Eur J Vasc Endovasc Surg 2021; 61:559. [PMID: 33642137 DOI: 10.1016/j.ejvs.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/05/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Barend M E Mees
- Vascular Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands.
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13
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Sveinsson M, Sonesson B, Dias N, Björses K, Kristmundsson T, Resch T. Five Year Results of Off the Shelf Fenestrated Endografts for Elective and Emergency Repair of Juxtarenal Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2021; 61:550-558. [PMID: 33455820 DOI: 10.1016/j.ejvs.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 11/22/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is a well established treatment for complex abdominal aortic aneurysms (AAAs). FEVAR with custom made devices (CMDs) has limitations in both the emergency and elective settings due to time consuming manufacture. "Off the shelf" (OTS) fenestrated stent grafts are a potential solution. The primary goal was to evaluate the five year outcome of the COOK Zenith p-Branch OTS device at a single centre. METHODS Patients with juxtarenal AAA meeting the inclusion criteria for the COOK Zenith p-Branch device were enrolled in a prospective, non-randomised, non-comparative trial from July 2012 to September 2015. Demographic, anatomical, procedure related, and five year follow up data were collected, analysed, and adjudicated by a core laboratory. The primary aims were to assess intervention free survival and overall survival at five years. RESULTS Twenty-three patients were treated and 21 completed follow up. Mean time to p-Branch implantation after patient presentation was 28 hours (range 0-122 hours) in emergency cases and 67 days (range 20-112 days) in elective cases. Median procedure time was 283 minutes (range 161-475 minutes) and technical success was 91%. Mean follow up was 45 months (standard deviation ± 24.4 months). The most common adverse events were renal injuries. Primary target vessel patency was 96.4% and 94.0% after one and five years respectively. Mean time to first re-intervention was 469 days (range 0-1 567 days). Survival during the follow up period was 76%, with no aneurysm related deaths. CONCLUSION FEVAR with the COOK Zenith p-Branch device is safe and effective for juxtarenal AAA in a selected patient population, in both elective and emergency settings. Long term outcomes are acceptable although inferior to CMDs. Mid and long term outcomes emphasise the p-Branch as a possible endovascular treatment for juxtarenal aortic pathology where CMD is not an option. Further innovation to address target vessel complications is needed, as these seem more prevalent than after repair with CMDs.
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Affiliation(s)
- Magnus Sveinsson
- Helsingborg Regional Hospital, Helsingborg, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Nuno Dias
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | | | | | - Timothy Resch
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Rigshospitalet University Hospital, Copenhagen, Denmark.
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Silverberg D, Bar-Dayan A, Hater H, Khaitovich B, Halak M. Short-term outcomes of inner branches for endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms. Vascular 2020; 29:644-651. [PMID: 33292087 PMCID: PMC8564222 DOI: 10.1177/1708538120977279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS A retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates. RESULTS Twenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up. CONCLUSIONS Inner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.
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Affiliation(s)
- Daniel Silverberg
- Department of Vascular Surgery, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv, Israel
| | - Avner Bar-Dayan
- Department of Vascular Surgery, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv, Israel
| | - Haitam Hater
- Department of Vascular Surgery, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv, Israel
| | - Boris Khaitovich
- Division of Interventional Radiology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Moshe Halak
- Department of Vascular Surgery, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv, Israel
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15
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Timaran CH, Oderich GS, Tenorio ER, Farber MA, Schneider DB, Schanzer A, Beck AW, Sweet MP. Expanded Use of Preloaded Branched and Fenestrated Endografts for Endovascular Repair of Complex Aortic Aneurysms. Eur J Vasc Endovasc Surg 2020; 61:219-226. [PMID: 33262091 DOI: 10.1016/j.ejvs.2020.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 10/18/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to report the expanded use of preloaded catheters and wires of fenestrations and directional branches to facilitate access to renal and mesenteric target arteries during endovascular repair of complex aortic aneurysms. METHODS This was an observational retrospective cohort multicentre study. Prospectively collected data from six physician sponsored investigational device exemption studies at US centres were analysed. Patients were treated with fenestrated and branched aortic endografts for pararenal and thoraco-abdominal aortic aneurysms (TAAAs) between 2012 and 2017. Technical success was defined as successful intra-operative catheterisation and stenting of all intended target visceral arteries. Univariable and stratified analyses were performed to identify differences in outcomes between repairs using preloaded and standard devices. RESULTS There were 564 patients (73% men, mean age 73 ± 8 years) treated for 168 pararenal aortic aneurysms (29.8%), 216 type IV TAAAs (38.3%), and 180 type I - III TAAAs (31.9%). Preloaded grafts (PGs) were used in 387 (68.6%) patients and standard grafts (SGs) in 177 (31.4%). PGs were used preferentially for type IV TAAAs (45% vs. 24%; p < .001), whereas standard devices were used more frequently among patients with type I - III TAAAs (24% vs. 49%; p < .001). The majority of custom made devices were preloaded (95% vs. 21%; p < .001). A total of 2 157 target arteries were incorporated (mean 3.9/patient) utilising 1 469 fenestrations (68.1%), 603 directional branches (27.9%), and 85 double wide scallops (3.9%). Most PGs included fenestrations (80% vs. 43%; p < .001), whereas directional branches were more frequent in standard devices (17% vs. 53%; p < .001). Contrast volume, fluoroscopy time, radiation dose, and operative time were not significantly different between preloaded and standard devices. Upper extremity access was more frequent for PGs (87% vs. 72%; p < .001). Overall technical success was 98.8% and comparable for both preloaded and standard grafts (99.5% vs. 97.2%; p = .022). The 30 day stroke rate was similar for PGs and SGs (2.3% and 1.7%%, respectively). The 30 day mortality rate was 1.9%, and low for both PGs and SGs (0.8% vs. 4.5%; p = .003). CONCLUSION Endovascular repair of complex aortic aneurysms is safe and effective. The expanded use of preloaded catheters and wires of fenestrations and directional branches for target artery incorporation is associated with a high technical success and low early mortality.
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Affiliation(s)
| | | | | | | | - Darren B Schneider
- Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | | | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL, USA
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16
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Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 2020; 73:4S-52S. [PMID: 32615285 DOI: 10.1016/j.jvs.2020.06.011] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022]
Abstract
Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
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18
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Learning curve of fenestrated and branched endovascular aortic repair for pararenal and thoracoabdominal aneurysms. J Vasc Surg 2020; 72:423-434.e1. [PMID: 32081482 DOI: 10.1016/j.jvs.2019.09.046] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/15/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study was to review the learning curve for fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). METHODS We reviewed the clinical data of 334 consecutive patients (255 males, mean age 75 ± 7 years) who underwent F-BEVAR between 2007 and 2016 in a single institution. Outcomes were analyzed in four quartiles of experience (Q1-Q4). Study outcomes included trends in patient characteristics, device design, procedural variables, 30-day mortality, and major adverse events (MAEs). RESULTS There were 178 patients (53%) treated for pararenal aneurysms and 156 (47%) for TAAAs. During the study period, there was a statistically significant increase in the proportion of TAAAs and in the number of vessels incorporated. Despite this, there was a steady decrease in 30-day mortality (6% in Q1 to 0% in Q4; P < .04) and in the rate of MAEs (60% in Q1 to 29% in Q4; P<.001). By linear regression analysis, there was significant decline in estimated blood loss (1358 ± 1517 mL in Q1 to 486 ± 520 mL in Q4; P < .001), total operating time (325 ± 116 minutes in Q1 to 248 ± 92 minutes in Q4; P < .001), total fluoroscopy time (121 ± 59 minutes in Q1 to 85 ± 39 minutes in Q4; P < .001), contrast volume (201 ± 92 mL in Q1 to 160 ± 61 mL in Q4; P = .002), and radiation dose (4141 ± 2570 mGy in Q2 to 2543 ± 1895 mGy in Q4; P < .001). Independent predictors of MAEs were total operating time (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.8; P < .001), Society for Vascular Surgery total score (OR, 1.1; 95% CI, 1.02-1.2; P = .009), and quartile 1 (OR, 3.0; 95% CI, 1.7-5.2; P < .001). CONCLUSIONS This study demonstrates significant improvement in perioperative mortality, MAEs, procedural variables, and secondary interventions in patients treated by F-BEVAR, despite the increase in complexity of aneurysm pathology during the study period. Also, better patient selection contributed to improve outcomes.
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Mohamed N, Galyfos G, Anastasiadou C, Sachmpatzidis I, Kikiras K, Papapetrou A, Giannakakis S, Kastrisios G, Papacharalampous G, Geroulakos G, Maltezos C. Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review. Ann Vasc Surg 2020; 63:399-408. [DOI: 10.1016/j.avsg.2019.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 12/20/2022]
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20
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Farber MA, Oderich GS, Timaran C, Sanchez LA, Dawson Z. Results from a prospective multicenter feasibility study of Zenith p-Branch stent graft. J Vasc Surg 2019; 70:1409-1418.e3. [PMID: 31255472 DOI: 10.1016/j.jvs.2019.03.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/12/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the Cook Zenith p-Branch stent graft (William A. Cook Australia, Brisbane, Queensland, Australia) for the treatment of patients with asymptomatic juxtarenal or pararenal abdominal aortic aneurysms in a prospective, nonrandomized, multicenter, feasibility study conducted in the United States. METHODS The off-the-shelf p-Branch endograft incorporates a celiac scallop, superior mesenteric artery (SMA) fenestration, and two conical-shaped pivot renal fenestrations. Patients were eligible if the aneurysm did not extend above the distal margin of the SMA and the anatomy of renal and visceral arteries were compatible with one of the two p-Branch configurations (configuration A, renal fenestrations at the same longitudinal position; configuration B, offset renal fenestration). RESULTS A total of 30 patients (93% men; mean age, 73 years; mean aneurysm diameter, 64.7 ± 11.4 mm) were enrolled from January 2013 to June 2015. The mean follow-up period was 28.7 ± 12.5 months (as of October 2017). The technical success rate was 93% (28/30), with technical failure occurring in the first two study cases (device deliberately repositioned below the renal arteries because of difficulty in cannulating the renal arteries in one and an inability to place a renal stent in the other; both patients survived the procedure and withdrew from the study before the 12-month follow-up visit). No additional technical failures occurred after these first two cases, when an updated physician training and proctoring program was implemented. No 30-day mortality occurred. Of the remaining 28 patients, three died during the follow-up period; none within 30 days and none related to the device or procedure as determined by Clinical Events Committee adjudication. No treated aneurysm ruptures, conversion, or core laboratory-reported migration, or stent fracture were reported. The primary renal artery patency (interval to occlusion or reintervention for stenosis) rate was 88.6% ± 4.4% at 1 and 2 years. Two patients (7%) developed renal insufficiency secondary to a right renal artery stenosis in one patient and progression of chronic renal insufficiency in one patient. No patient required dialysis or developed mesenteric ischemia. Of the 28 patients, nine (32%) had undergone 13 secondary interventions for renal artery occlusion (n = 2), SMA occlusion (n = 1), renal or SMA stenosis (5 interventions in 4 patients), renal stent kinking (n = 1), lower extremity claudication (n = 2 in the same patient), type III endoleak between the p-Branch and renal stent (n = 1), and type II endoleak (n = 1). CONCLUSIONS These early and intermediate results, which incorporated physician learning curves, support the safety and feasibility of the off-the-shelf Zenith p-Branch device. Follow-up examinations through 5 years will continue to assess the long-term results.
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Affiliation(s)
- Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC.
| | | | - Carlos Timaran
- Division of Vascular Surgery, University of Texas Southwestern, Dallas, Tex
| | - Luis A Sanchez
- Division of Vascular Surgery, Washington University Medical Center, St. Louis, Mo
| | - Zach Dawson
- Cook Research Incorporated, West Lafayette, Ind
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Nguyen TT, Simons JP, Schanzer A. Use of fenestrated-branched endovascular aneurysm repair to treat Carrel patch aneurysmal degeneration after open thoracoabdominal aortic aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:117-121. [PMID: 31193425 PMCID: PMC6529688 DOI: 10.1016/j.jvscit.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/11/2018] [Indexed: 10/28/2022]
Abstract
Two patients with a history of open type II thoracoabdominal aortic aneurysm repair presented with saccular aneurysmal degeneration of the Carrel patch. The degenerated segments measured 6.2 cm and 7.4 cm, respectively, and involved the celiac artery, superior mesenteric artery, and right renal artery. Both patients successfully underwent a custom fenestrated-branched endovascular aneurysm repair with downgoing branches to the celiac artery, superior mesenteric artery, and right renal artery and a stented fenestration to the left renal artery. Completion angiography demonstrated no endoleak and patent visceral-renal segments. Both patients were discharged home on postoperative day 2.
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Affiliation(s)
- Tammy T Nguyen
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
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Comparison of commercially available versus customized branched-fenestrated devices in the treatment of complex aortic aneurysms. J Vasc Surg 2019; 69:645-650. [DOI: 10.1016/j.jvs.2018.05.215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/10/2018] [Indexed: 11/18/2022]
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O'Donnell TFX, Patel VI, Deery SE, Li C, Swerdlow NJ, Liang P, Beck AW, Schermerhorn ML. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative. J Vasc Surg 2019; 70:369-380. [PMID: 30718110 DOI: 10.1016/j.jvs.2018.11.021] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices. METHODS We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality. RESULTS During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 ± 0.8, with PMEGs involving the most arteries (3.3 ± 0.8 for PMEG vs 2.5 ± 0.6 for FEVAR and 1.9 ± 0.9 for chimney/snorkel; P < .001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P = .13) and AKI (17% vs 18% vs 19%; P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P = .03) and MACEs (6.1% vs 5.4% vs 11.7%; P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P = .015), myocardial infarction (OR, 18.7 [2.6-136.8]; P = .004), and MACEs (OR, 11.1 [2.1-58.9]; P = .005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis. CONCLUSIONS The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, NewYork-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sarah E Deery
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Kougias P, Branco BC, Braun J, Sharath S, Younes H, Barshes NR, Mills JL. Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair. J Vasc Surg 2019; 70:23-30. [PMID: 30626551 DOI: 10.1016/j.jvs.2018.10.094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR. METHODS Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis. RESULTS We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment. CONCLUSIONS LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.
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Affiliation(s)
- Panos Kougias
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
| | - Bernardino C Branco
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Jonathan Braun
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Sherene Sharath
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Houssam Younes
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Neal R Barshes
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Joseph L Mills
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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Technical aspects and 30-day outcomes of the prospective early feasibility study of the GORE EXCLUDER Thoracoabdominal Branched Endoprosthesis (TAMBE) to treat pararenal and extent IV thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 70:358-368.e6. [PMID: 30612825 DOI: 10.1016/j.jvs.2018.10.103] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study reports the technical aspects and 30-day outcomes of the prospective, multicenter early feasibility study designed to evaluate the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz). METHODS Thirteen patients with pararenal or extent IV thoracoabdominal aortic aneurysms were prospectively enrolled at five U.S sites and one non-U.S. site from 2014 to 2016. The TAMBE included four portals with either retrograde or antegrade renal portal configuration and used GORE VIABAHN Balloon-Expandable Endoprosthesis (W. L. Gore & Associates) for stenting of the renal and mesenteric arteries. The primary end point was procedural safety at 30 days, defined by absence of major adverse events, including any-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, severe acute kidney injury (>50% decline in estimated glomerular filtration rate), dialysis, and procedural blood loss >1000 mL. RESULTS There were 11 male and two female patients with a mean age of 69 ± 8 years. Mean aneurysm diameter was 61 ± 13 mm. A total of 52 renal and mesenteric arteries were incorporated (4 vessels/patient). Technical success was achieved in 12 patients (92%). One patient had inadvertent occlusion of a right renal artery due to dissection. There was no mortality, aneurysm rupture, conversion to open repair, dialysis, or spinal cord injury. Mean length of hospital stay was 5 ± 3 days. At 30 days, four patients (31%) had major adverse events, all due to procedural blood loss >1000 mL. One patient had a type I endoleak at the distal renal branch, which was successfully treated by placement of an additional renal stent before dismissal. Computed tomography angiography at 30 days showed patent target vessels and no type I or type III endoleak. CONCLUSIONS This study confirms the early feasibility of the TAMBE for treatment of pararenal and extent IV thoracoabdominal aortic aneurysms. The high technical success, no mortality, and low morbidity rate support continuation of clinical investigation in a larger population of patients.
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Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent graft. J Vasc Surg 2019; 69:296-302.e1. [DOI: 10.1016/j.jvs.2018.09.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
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Asakura T. Recent Development and Long-Term Results of Open vs EVAR for Pararenal Abdominal Aortic Aneurysms. Ann Vasc Dis 2018; 11:458-463. [PMID: 30636999 PMCID: PMC6326061 DOI: 10.3400/avd.ra.18-00126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this article, I would like to discuss on the two different treatment options (Open vs EVAR) for pararenal abdominal aortic aneurysm (the term "PRAAA" is not clearly defined and classified). Recently, complex endovascular treatment [Fenestrated EVAR (F-EVAR), Chimney (Snorkel) EVAR (C-EVAR, S-EVAR), Branched EVAR (B-EVAR)] have been developed and applied in selected patients, with encouraging early results; however, the high rate for secondary reinterventions and long-term results remain uncertain. This article introduce new devices and a new concept with endovascular aneurysm sealing (EVAS) are currently available on the market for the treatment of PRAAA. Open repair of PRAAA can be performed with low mortality and long-term survival is favorable from single-center experience in the real world and others. We conclude that open repair remains the golden standard treatment in most centers for PRAAA. However, EVAR of PRAAA may represent an alternative option in high-risk patients. Because the indications and circumstances for PRAAA vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons should be familiar with both treatment strategies and tailor-made strategy for improved long-term results for PRAAA. (This is a translation of Jpn J Vasc Surg 2018; 27: 303-308.).
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Affiliation(s)
- Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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Patient and operating room staff radiation dose during fenestrated/branched endovascular aneurysm repair using premanufactured devices. J Vasc Surg 2018; 68:1281-1286. [PMID: 30369410 DOI: 10.1016/j.jvs.2018.02.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/17/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Fenestrated endovascular aneurysm repair (FEVAR) is the highest radiation dose procedure performed by vascular surgeons. We sought to characterize the radiation dose to patients and staff during FEVAR procedures with different premanufactured devices. METHODS A single-center prospective study of FEVARs was performed over 24 months. Three FEVAR devices were included: off-the-shelf (OTS; t-Branch, p-Branch), Zenith Fenestrated (ZFen), and investigational custom-made devices (CMDs). Radiation doses to the surgeon, trainee, anesthesiologist, and scrub/circulating nurses were measured using a personal dosimetry system (DoseAware, Philips Healthcare, Amsterdam, The Netherlands). Procedure type, patient body mass index (BMI), reference air kerma (RAK), and kerma area product (KAP) were recorded. RAK and KAP were corrected for BMI based on an exponential fit of fluoroscopy dose rate and the dose per radiographic frame. Operator dose was corrected for BMI by the ratio of corrected to actual KAP. A one-sided Wilcox rank-sum test was used to compare personnel radiation doses, RAKs, and KAPs between procedure types. Statistical significance was set at P ≤ .05. RESULTS There were 80 FEVARs performed by a single surgeon on a Philips Allura XperFD20 fluoroscopy system equipped with Clarity technology. Average BMI was 27 kg/m2. Sixty CMDs (36 four-, 21 three-, and 3 two-vessel fenestrations), 11 ZFens (8 three- and 3 two-vessel fenestrations), and 9 OTS devices (4 p-Branch, 5 t-Branch) were included. ZFens had significantly lower patient (1800 mGy vs 2950 mGy; P = .004), operator (120 μSv vs 370 μSv; P = .004), assistant (60 μSv vs 210 μSv; P = .003), circulator (10 μSv vs 30 μSv; P = .049), and scrub nurse dose (10 μSv vs 40 μSv; P = .02) compared with CMDs. OTS devices had significantly lower operator (220 μSv vs 370 μSv; P = .04), assistant (110 μSv vs 210 μSv; P = .02), and circulator doses (4 μSv vs 30 μSv; P = .001) compared with CMDs. Four-vessel fenestrated devices had significantly higher patient dose (3020 mGy) compared with three-vessel FEVARs (2670 mGy; P = .03) and two-vessel FEVARs (1600 mGy; P = .0007), and significantly higher operator dose (440 μSv) compared with three-vessel FEVARs (170 μSv; P = .0005). Patient dose was lowest with ZFens. Operating room personnel dose was lower with ZFens and OTS devices compared with CMDs. Four-vessel fenestrations required significantly more radiation compared with those involving three-vessel fenestrations; however, the dose increase was only 12% and should not preclude operators from extending coverage, if anatomically required. CONCLUSIONS Overall, patient and personnel radiation doses during FEVAR with all devices were within acceptable limits and lower in our series than previously reported.
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Lucatelli P, Cini M, Benvenuti A, Saba L, Tommasino G, Guaccio G, Munneke G, Neri E, Ricci C. Custom-Made Endograft for Endovascular Repair of Thoraco-Abdominal Aneurysm and Type B Dissection: Single-Centre Experience. Cardiovasc Intervent Radiol 2018; 41:1174-1183. [PMID: 29725810 DOI: 10.1007/s00270-018-1975-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/23/2018] [Indexed: 02/04/2023]
Abstract
AIMS To report a series of patients treated with the Jotec custom-made endograft for thoraco-abdominal aneurysms and dissections and identify predictive factors for re-intervention. METHODS We retrospectively analysed 49 patients unsuitable for surgery, treated between 2011 and 2017 (71.3 ± 9.5 years; 15 females). Indications included Crawford type 4 aneurysm in 25 patients, type 3 in 13, type 2 in 4, type 1 in 2 and chronic aneurysmal dilatation of the false lumen following dissection in 5 cases. Mean aneurysm diameter was 58.7 ± 8.4 mm. The study aims were to assess procedural success, complications rate, mortality and long-term follow-up. We also analysed factors that predicted the need for re-intervention. RESULTS The endograft was successfully deployed in all patients, catheterization of the fenestration and/or branches was achieved in 152/156 (97.4%) vessels. Early complications occurred in 10 patients (3 paraplegia, 3 haemorrhages, pancreatitis, aortic rupture, iliac artery rupture, 2 strokes). Thirty-day mortality was 10.2% and 180-day mortality 14.3%; two non procedure related deaths occurred. Mean follow-up was 23.6 ± 29.9 months [range 1-80]. No patients needed surgical explantation or developed significant renal impairment. Endoleak rate was 34.6% and re-intervention rate 9.7%. The aneurysm sac reduced or was stable in 36/49, and enlarged in 9/49 patients prompting re-intervention. Primary, primary-assisted and secondary patency of fenestrations/branches at 80 months was 90, 96 and 100%. Re-intervention was required more frequently in braches than in fenestrations, most commonly the external type branches. CONCLUSIONS The results of the Jotec endograft are comparable to other devices, with acceptable complication and re-intervention rates. Fenestration and inner-branch should be preferred due to lower re-intervention rates.
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Affiliation(s)
- Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Viale Mario Bracci, 16, 53100, Siena, Italy. .,Vascular and Interventional Radiology Unit, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy.
| | - Marco Cini
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Antonio Benvenuti
- Cardiac and Great Vessels Surgery Unit, University of "Siena", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (AOU), di Cagliari - Polo di Monserrato s.s. 554, 09045, Monserrato (Cagliari), Italy
| | - Giulio Tommasino
- Cardiac and Great Vessels Surgery Unit, University of "Siena", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Giulia Guaccio
- Cardiac and Great Vessels Surgery Unit, University of "Siena", Viale Mario Bracci, 16, 53100, Siena, Italy
| | | | - Eugenio Neri
- Cardiac and Great Vessels Surgery Unit, University of "Siena", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Carmelo Ricci
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Viale Mario Bracci, 16, 53100, Siena, Italy
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Abstract
Abdominal aortic aneurysm (AAA) is most commonly defined as a maximal diameter of the abdominal aorta in excess of 3 cm in either anterior-posterior or transverse planes or, alternatively, as a focal dilation ≥ 1.5 times the diameter of the normal adjacent arterial segment. Risk factors for the development of AAA include age > 60, tobacco use, male gender, Caucasian race, and family history of AAA. Aneurysm growth and rupture risk appear to be associated with persistent tobacco use, female gender, and chronic pulmonary disease. The majority of AAAs are asymptomatic and detected incidentally on various imaging studies, including abdominal ultrasound, and computed tomographic angiography. Symptoms associated with AAA may include abdominal or back pain, thromboembolization, atheroembolization, aortic rupture, or development of an arteriovenous or aortoenteric fistula. The Screening Abdominal Aortic Aneurysms Efficiently (SAAAVE) Act provides coverage for a one-time screening abdominal ultrasound at age 65 for men who have smoked at least 100 cigarettes and women who have family history of AAA disease. Medical management is recommended for asymptomatic patients with AAAs < 5 cm in diameter and focuses on modifiable risk factors, including smoking cessation and blood pressure control. Primary indications for intervention in patients with AAA include development of symptoms, rupture, rapid aneurysm growth (> 5 mm/6 months), or presence of a fusiform aneurysm with maximum diameter of 5.5 cm or greater. Intervention for AAA includes conventional open surgical repair and endovascular aortic stent graft repair.
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Bertoglio L, Cambiaghi T, Ferrer C, Baccellieri D, Verzini F, Melissano G, Chiesa R, Tshomba Y. Comparison of sacrificed healthy aorta during thoracoabdominal aortic aneurysm repair using off-the-shelf endovascular branched devices and open surgery. J Vasc Surg 2018; 67:695-702. [DOI: 10.1016/j.jvs.2017.08.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/15/2017] [Indexed: 11/26/2022]
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Youssef M, Deglise S, Szopinski P, Jost-Philipp S, Jomha A, Vahl CF, Koshty A. A Multicenter Experience With a New Fenestrated-Branched Device for Endovascular Repair of Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2018; 25:209-219. [DOI: 10.1177/1526602817752147] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Marwan Youssef
- Department of Cardiothoracic and Vascular Surgery, Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Sebastien Deglise
- Department of Vascular Surgery, University Hospital of Lausanne, Switzerland
| | - Piotr Szopinski
- Department of Vascular Surgery, Institution of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Amer Jomha
- Department of Vascular Surgery, Hospital of Bad-Hersfeld, Germany
| | - Christian F. Vahl
- Department of Cardiothoracic and Vascular Surgery, Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Ahmed Koshty
- Department of Vascular Surgery, Hospital of Diakonie-Jung-Stilling, Siegen, Germany
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