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

One-year results of the Flowdynamics Dense Mesh Stent for residual dissection after proximal repair of stanford type A or type B aortic dissection: a multicenter, prospective, and randomized study

OBJECTIVE

Negative remodeling of the distal aorta following proximal repair for acute aortic dissection has garnered growing attention. This clinical scenario has spurred the development of techniques and devices. A multicenter, prospective, and randomized controlled study was conducted with the aim of confirming the safety and effectiveness of a newly-designed flowdynamics dense mesh stent for the treatment of residual dissection after proximal repair.

METHODS

Patients with nonchronic residual dissection affecting visceral branches were prospectively enrolled at three centers and randomly allocated to either the FDMS group or the control group. Primary endpoints encompassed all-cause and aortic-related mortality, while the patency of branch arteries is indeed a key focal metric. Morphological changes (diameter, area, and volume) were analyzed to demonstrate the therapeutic effect.

RESULTS

One hundred twelve patients were recruited in the clinical trial, and 103 patients completed the 12-month follow-up. The rate of freedom from all-cause and aortic-related death in the FDMS group was 94.64 and 100%, respectively. All visceral branches remained patent. The FDMS group exhibited a substantial expansion in TL and a notable shrinkage in FL at the planes below renal arteries (ΔArea TL : FDMS vs. Control, 0.74±0.46 vs. 0.34±0.66 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.72±1.26 vs. -0.12±0.86 cm, P =0.01) and 5 cm below renal arteries (ΔArea TL : FDMS vs. Control, 1.06±0.75 vs. 0.16±0.63 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.53±1.43 vs. -0.25±1.00 cm, P =0.27). Meanwhile, the FDMS group demonstrated an increase of 22.55±11.14 cm 3 in TL ( P <0.001) and a corresponding reduction of 21.94±11.77 cm 3 in FL ( P =0.08).

CONCLUSIONS

This newly-designed FDMS for endovascular repair of residual dissection following the proximal repair is demonstrated to be safe and effective at 12 months.

Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft

OBJECTIVE

The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion).

METHODS

Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months.

RESULTS

Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year.

CONCLUSIONS

The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.

Innovation in pathogenesis and management of aortic aneurysm

Aortic aneurysm (AA) refers to the persistent dilatation of the aorta, exceeding three centimeters. Investigating the pathophysiology of this condition is important for its prevention and management, given its responsibility for more than 25000 deaths in the United States. AAs are classified based on their location or morphology. various pathophysiologic pathways including inflammation, the immune system and atherosclerosis have been implicated in its development. Inflammatory markers such as transforming growth factor β, interleukin-1β, tumor necrosis factor-α, matrix metalloproteinase-2 and many more may contribute to this phenomenon. Several genetic disorders such as Marfan syndrome, Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease. Recent years has seen the investigation of novel management of AA, exploring the implication of different immune suppressors, the role of radiation in shrinkage and prevention, as well as minimally invasive and newly hypothesized surgical methods. In this narrative review, we aim to present the new contributing factors involved in pathophysiology of AA. We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Early outcomes from the pivotal trial of a four-branch off-the shelf solution to treat complex abdominal and type IV thoracoabdominal aortic aneurysms

BACKGROUND

This study reports the 30-day outcomes of the primary arm of the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE) pivotal trial for complex abdominal aortic aneurysm repair.

METHODS

This multicenter, nonrandomized, prospective study of the TAMBE device included patients enrolled in the primary study arm of extent IV thoracoabdominal aortic aneurysms and pararenal aneurysms. Technical success and major adverse events were analyzed per the Society for Vascular Surgery guidelines.

RESULTS

The 102 patients of the primary arm who underwent endovascular repair using the TAMBE device were a mean age of 73 ± 6.4 years (range, 58-82 years) and 84 (84.2%) were male. The mean body mass index was 28.3 ± 5.0 kg/m2. Fifty-nine patients (57.8%) were treated for extent IV and 43 (42.2%) pararenal aneurysms; the mean maximum diameter of the aneurysms was 59.4 ± 7.8 mm. A prophylactic cerebral spinal fluid drain was used in 10 patients (9.8%). Technical success was achieved in 99% of patients, with the single failure owing to unsuccessful cannulation of the left renal artery. Mean procedure time was 315 ± 103 minutes (range, 163-944 minutes), estimated blood loss was 300 ± 296 mL (range, 10-2000 mL), and contrast administration was 153.6 ± 73.5 mL (range, 16-420 mL). The intensive care unit length of stay was 58.7 ± 52.7 hours (range, 1-288 mL). In 28 patients (27.5%), a total of 32 additional endovascular components were deployed to manage procedural complications including aortic and target vessel dissections and injuries not related to access. Bridging stent grafts were deployed to incorporate 407 target vessels (mean 1.6/per vessel; range, 1-4). Postoperative transfusion was required in 14 patients (13.7%). Major adverse events occurred in seven patients (6.9%) through 30 days. Events included respiratory failure (n = 2), disabling stroke (n = 1), new-onset renal failure requiring dialysis (n = 2), and paraplegia (n = 2). At 30 days, there was one patient with intraoperative rupture; no severe bowel ischemia or lesion-related/all-cause mortality were reported. The Core lab-reported patency was 100% in the aortic component, superior mesenteric artery, and celiac artery, and 95.9% in the left renal and 99.0% in the right renal branch components through 30 days of follow-up. Reinterventions through 30 days were performed in 9 of 96 patients (9.4%) and were all minor.

CONCLUSIONS

Early TAMBE device outcomes demonstrate a high technical success rate, no 30-day lesion-related mortality, and a low rate of safety events within 30 days of the index procedure.

National trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms

INTRODUCTION

Custom-branched/fenestrated grafts are widely available in other countries, but in the United States, they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEGs). We therefore sought to determine how widespread the use of these grafts is.

METHODS

We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the Vascular Quality Initiative from 2014 to 2022 to examine temporal trends.

RESULTS

A total of 5826 repairs were performed during the study period: 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7 ± 0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256) and nearly twofold for juxtarenal repairs. In three-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFENs (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P < .001). The differences in PMEG use were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEGs and ZFENs. However, surgeons in the highest quartile of volume performed a median of 18 (interquartile range: 10-21) PMEGs/y, but only 1.6 (interquartile range: 0.8-3.4) ZFENs/y. The number of physician-sponsored investigational device exemption trials of PMEGs has expanded from 1 in 2012 to 8 currently enrolling. As those data are not included in the Vascular Quality Initiative, the true number of PMEGs is likely substantially higher.

CONCLUSIONS

PMEGs have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of investigational device exemptions. The field of endovascular aortic surgery and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes, and comparisons to custom-manufactured grafts.

Off the Shelf Multibranched Endograft for Thoraco-Abdominal and Pararenal Abdominal Aortic Aneurysms: a Prospective, Single Centre Study of the G-Branch Endograft

OBJECTIVE

To investigate outcomes of a novel, off the shelf multibranched endovascular stent graft for the treatment of thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA).

METHODS

A prospective, single centre study including 15 patients (mean age, 63.4 ± 10.7 years; 13 male) with TAAA or PAAA treated from October 2019 to March 2021 with a G-Branch endograft (Lifetech Scientific, Shenzhen, China) featuring a mixed multibranch design with two inner and two outer branches for reconstruction of the visceral and bilateral renal arteries, respectively. Follow up assessments were scheduled before discharge and at 30 days, six and 12 months after the index procedure. Annual telephone interviews were performed beyond the initial 12 months. The Kaplan-Meier method was used to estimate cumulative mortality and morbidity rates after endovascular repair.

RESULTS

Technical success was achieved in all 15 patients. Nine patients (60%) had TAAA and six (40%) had PAAA (mean maximum aneurysm diameter, 73.7 ± 15.8 mm). The median follow up was 31.4 months (range, 10.1 - 44.0 months). At 30 days, there was no death and 7% morbidity (one case of temporary spinal cord ischaemia on Day 4). At one year, the mortality rate was 7% (one death from stroke at 10 months) and morbidity was 13% (one other case of renal function decline at six months). There were no aneurysm dilatations, re-interventions, or access related complications, and two (13%) persistent type II endoleaks. The one year primary branch patency rate was 100% for the four renovisceral arteries in all 13 patients who underwent computed tomography examinations. One patient died of hepatocellular carcinoma 29 months post-operatively, resulting in an estimated three year mortality rate of 13%.

CONCLUSION

The G-Branch endograft yielded high technical success with good early and midterm outcomes for the treatment of TAAA and PAAA. A large multicentre study is warranted.

Preoperative predictors of nonhome discharge after fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

BACKGROUND

Nonhome discharge (NHD) has significant implications for patient counseling and discharge planning and is frequently required following fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA). We aimed to identify preoperative predictors of NHD after elective FB-EVAR for CAAA and TAAA and develop a risk calculator able to predict NHD.

METHODS

A retrospective review of prospectively collected data on all patients undergoing FB-EVAR between January 2007 and December 2021 at a single institution was performed. Exclusion criteria were admission from a nonhome setting, emergency and repeat FB-EVAR, and discharge to an unknown destination. The cohort was randomly split into separate development (70% of patients) and validation (30%) cohorts to develop a predictive calculator for NHD. Independent variables associated with NHD were assessed in a series of logistic regression analyses from 100 bootstrapped samples of the development set, and a model was developed using the most predictive variables. Resulting parameter estimates were applied to data in the validation set to assess model discrimination and calibration.

RESULTS

From the initial cohort of 712 FB-EVAR patients, 644 were included in the study (74% male; mean age, 75.4 ± 7.6 years), including 452 with CAAA (70%) and 192 with TAAA (30%). Early mortality occurred in eight patients (1.2%; 5 in CAAA and 3 in TAAA) and the median hospital stay was 5 days (4 for CAAA and 7 for TAAA). Ninety-seven patients (15%) had a NHD. On multivariable analysis, older age (per year, odds ratio [OR], 1.08; P < .001), female gender (OR, 3.03; P < .001), smoking (OR, 2.86; P = .01), congestive heart failure (OR, 3.05; P = .004), peripheral artery disease (OR, 1.81; P = .07), and extent I (OR, 3.17), II (OR, 2.84), and III (OR, 2.52; all P = .08) TAAAs were associated with an increased likelihood of NHD in the development set. Based on these factors, the risk calculator was developed which accurately predicts NHD in the validation set with an area under the curve of 0.7.

CONCLUSIONS

Older, female smokers with congestive heart failure and peripheral artery disease and more extensive aneurysms are at highest risk of NHD after FB-EVAR. Using only preoperative factors, our risk calculator can predict accurately who will have a NHD, allowing enhanced preoperative patient counselling and accelerated hospital discharge.

Techniques and Limitations of Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) for Type 1A Endoleak After Failed Endovascular Aortic Repairs

PURPOSE

Endovascular aortic aneurysm repair (EVAR) is the dominant treatment modality over open repair for abdominal aortic aneurysms. However, a higher rate of reinterventions remains the Achilles heel of EVAR. Although type 1A endoleak from proximal seal zone failure of EVAR remains one of the leading causes for reintervention, fenestrated branched devices suitable for proximal extension of failed EVAR are not widely available in the United States. Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is an off-the-shelf investigational device that provides supraceliac seal by incorporating 4 visceral and renal arteries via preloaded inner branches.

CASE REPORT

In this article, we describe 2 cases of type 1A endoleak from previous EVAR devices repaired using TAMBE. Both cases were performed under the Food and Drug Administration (FDA) compassionate use exemption. Considerations on the case planning and implantation techniques of TAMBE specific to previous EVAR devices are reviewed.

CONCLUSIONS

Gore TAMBE can be utilized to repair a type 1A endoleak of a previous infrarenal EVAR device. Greater supraceliac coverage necessary for TAMBE relative to the minimal seal zone should be considered when applying this device for a type 1A endoleak.

CLINICAL IMPACT

This report demonstrates the feasibility of applying off-the-shelf TAMBE device to treat one of the most common failure modes of EVAR, type1A endoleak.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

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.

Gore thoracoabdominal branched endoprosthesis: early results and impressions

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.

Suitability of current off-the-shelf devices for endovascular TAAA repair: a systematic review

INTRODUCTION

The aim of the present study is to perform a systematic review of published papers regarding the suitability of the current off-the-shelf (OTS) devices for endovascular thoracoabdominal aortic aneurysm (TAAA) repair.

EVIDENCE ACQUISITION

A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed.

EVIDENCE SYNTHESIS

A total of 19 studies were published between 2014 and 2023. Thirteen clinical studies and six theoretical feasibility studies were included. Eleven studies reported the clinical outcomes of the t-Branch stent-graft, one detailed the observational results of the use of the E-nside endoprosthesis, and one described the TAMBE stent-graft results. The following data primarily involve the t-Branch device outcomes. A total of 1131 patients that underwent aneurysm repair using an OTS stent-graft were identified. Among those, 1002, 116 and 13 patients received a t-Branch, E-nside, and TAMBE stent-grafts, respectively. A total of 767 (67.8%) were men, with a mean age of 71.6±7.4 years old, and a mean Body Mass Index (BMI) of 26.3±3.8 kg/m2. Technical success ranged from 64% to 100%. A total of 4172 target visceral vessels (TVV) were planned for bridging, with a success rate ranging from 92 to 100%. The total of early and late reinterventions reported were 64 and 48, respectively, mainly due to endoleaks and visceral branch occlusions. Among the theoretical feasibility studies, six described the feasibility of the t-Branch device in a total of 661 patients, two described the E-nside and the TAMBE devices feasibility comprising 351 patients for each stent-graft. The overall feasibility of the t-Branch device varied from 39% to 88%, the E-nside from 43% to 75%, and the TAMBE stent-graft ranged from 33% to 94%.

CONCLUSIONS

This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA.

Aortic hemodynamic and morphological analysis before and after repair of thoracoabdominal aortic aneurysm using a G-Branch endograft

Background and objective: The G-Branch endograft is a novel multibranched "off-the-shelf" device used to repair thoracoabdominal aortic aneurysms (TAAAs). This report describes the hemodynamic and morphological performance of the G-Branch endograft in a human patient with TAAA. Materials and methods: We retrospectively reviewed the computed tomography angiography scans and clinical data of a woman in whom TAAA was treated using a G-Branch endograft. Patient-specific three-dimensional models were reconstructed, and computational fluid dynamics and morphological and hemodynamic indicators were analyzed before and after implantation of the device. Results: From a morphological perspective, there was an increase in cross-sectional area in the G-Branch endograft and all bridging stent grafts over time. Blood flow was redistributed among the renovisceral arteries, with a decrease in flow rate in the celiac artery and an increase in the left renal artery. Laminar blood flow was smoother and more rapid after implantation of the G-Branch device and remained stable during follow-up. In the bridging stent grafts, flow recirculation zones were found in the bridging zones of the celiac artery and superior mesenteric artery as well as the distal sealing zones of both renal arteries. Furthermore, higher time-averaged wall shear stress and a lower oscillatory index and relative resident time were found in the G-Branch endograft and bridging stent grafts. Quantitative analysis showed obvious reduction in the surface area ratio of the elevated time-averaged wall shear stress area and surface area ratio of the relative resident time after G-branch implantation. Conclusion: The revascularization of branch vessels occurred following G-branch implantation, with improvements arising not only from morphological changes but also from hemodynamic alterations. The long-term performance of the G-Branch endograft needs further investigation and clinical validation.

Effect of bridging stent graft selection for directional branches on target artery outcomes of fenestrated-branched endovascular aortic repair in the United States Aortic Research Consortium

OBJECTIVE

The purpose of this study was to evaluate the effect of directional branches (DBs) bridging stent choice on target artery (TA) outcomes during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms.

METHODS

Patients enrolled in nine prospective physician-sponsored investigational device exemption studies in the United States between 2005 and 2020 were analyzed. All patients who had at least one TA incorporated by DB using either self-expandable (SESGs), balloon-expandable (BESGs), or hybrid stent graft combinations (HSGs). Endpoints were TA patency and freedom from TA endoleak, instability, and reintervention.

RESULTS

There were 800 patients with 2426 renal-mesenteric arteries incorporated by DBs. DB stent selection was SESGs in 1205 TAs (50%), BESGs in 1095 TAs (45%), and HSGs in 126 TAs (5%). SESGs were predominantly used in the first three quartiles of the study period, whereas BESGs comprised 75% of all stents between 2017 and 2020. The median follow-up was 15 months (interquartile range, 6-35 months). At 5 years, BESGs had significantly lower freedom from TA instability (78% ± 4% vs 88% ± 1% vs 96% ± 2%; log-rank P =.010), freedom from TA endoleaks (87% ± 3% vs 97% ± 1% vs 99% ± 1%; log-rank P < .001), and freedom from TA reintervention (83% ± 4% vs 95% ± 1% vs 99% ± 2%; log-rank P <.001) compared with SESGs or HSGs, respectively. For renal arteries, there was no difference in freedom from TA instability for BESGs, SESGs, or HSGs. However, freedom from TA endoleaks and reintervention were lower for renal arteries targeted by BESGs compared with DBs targeted by SESGs and HSGs (83% ± 6% vs 98% ± 1% vs 100%; log-rank P < .001; and 70% ± 10% vs 92% ± 1% vs 96% ± 4%; log-rank P = .022). For mesenteric arteries, DBs targeted by BESGs had lower freedom from TA instability, endoleak, and reintervention than SESGs or HSGs. In stent-specific analysis, iCAST BESGs had the lowest freedom from TA instability either for renal or mesenteric arteries, primarily due to higher rates of TA endoleaks. There was no difference in patency in any scenario. Independent predictors of TA instability were age (+1-year: hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.94-0.99), stent diameter (+1 mm: HR, 0.67; 95% CI, 0.57-0.80), and BESG (HR, 1.8; 95% CI, 1.1-2.9).

CONCLUSIONS

DBs incorporated using BESGs had lower freedom from TA instability, TA endoleak, and TA reintervention compared with SESGs and HSGs. The patency of DBs was not affected by the type of stent construction. The observed performance disadvantage associated with BESGs appears to have largely been driven by iCAST usage.

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.

Additional Aortic Coverage With an Off The Shelf, Multibranched Endograft Compared With Custom Made Devices For Endovascular Repair of Pararenal Abdominal Aortic Aneurysms

OBJECTIVE

Pararenal abdominal aortic aneurysms (p-AAA) require complex endovascular aortic repair or open surgical repair with suprarenal clamping. Custom made devices (CMD), including fenestrated and branched endovascular aortic repair (F/B-EVAR) or off the shelf (OTS) multibranched devices, are available treatment options. The aim of this study was to determine the additional healthy aortic coverage using an OTS multibranched endograft vs. a CMD for the treatment of p-AAAs.

METHODS

This was a retrospective single centre analysis of prospectively collected data. Consecutive patients with p-AAAs requiring a proximal landing zone above the coeliac artery (CA), planned and treated with CMDs (Zenith Fenestrated) between January 2017 and December 2021 were included in this study. Treatment with supracoeliac coverage using available OTS multibranched devices was simulated using available pre-operative images: T-Branch; E-nside; and TAMBE. Study endpoints included the need for additional proximal aortic coverage, and the number of the segmental arteries additionally covered proximally from the CA for OTS devices compared with CMDs.

RESULTS

Eighty three patients with p-AAAs were treated with CMDs (all FEVAR), including juxtarenal AAAs (n = 46; 56%), suprarenal AAAs (n = 20; 24%), and short neck AAAs (n = 17; 20%). In this study, treatment with 249 (3 × 83) OTS endografts was simulated. When compared with CMDs, OTS devices required a mean of 74 ± 19 mm of additional proximal healthy aortic coverage from the CA (CMD: 33 ± 19 mm vs. OTS: 108 ± 6 mm; p ≤ .001), as well as an average sacrifice of 2.5 additional segmental arteries (CMD: 1.3 ± 0.8 vs. OTS: 3.8 ± 0.9; p ≤ .001). In 94% of patients, at least one of the available multibranched endografts could have been implanted in accordance with instructions for use.

CONCLUSION

Despite not requiring customisation time, OTS endografts for the treatment of p-AAA lead to more extensive healthy aortic coverage, as well as an average sacrifice of 2.5 additional segmental arteries, compared with CMDs. When compared with OTS devices, CMDs appear to limit the extent of unnecessary aortic coverage and the theoretical subsequent risk of spinal cord ischaemia.

Treatment of a type Ia endoleak following EVAR using a custom-made inner branch device

OBJECTIVES

We represent two cases of late proximal type I endoleak following EVAR with aneurysm expansion that were treated with a custom-made graft with inner branches.

METHODS

Two patients of 87 and 82 years old were operated by EVAR 6 and 8 years ago for abdominal aortic aneurysm. Both had proximal type I endoleak with aneurysm sac expansion. Open surgery had a high risk, and a proximal aortic extension with a simple aortic cuff was not possible neither because previous EVAR grafts were already at the level of the renal arteries. A custom-made endograft with inner branches was planned as a fenestrated graft was not technically possible.

RESULTS

We successfully treated both patients using a custom-made graft with four inner branches from Jotec (Cryolife, Kennesaw, GA). Three months' follow-up CT scan did not show any endoleaks. All target vessels were patent with good conformability of the bridging stents.

CONCLUSION

The treatment of proximal type I endoleak using inner branches' endografts is feasible. This novel technology might broaden the indications for complex aortic repair in a group of patients where fenestrated endografts are not possible.

Single-Center Experience with the Femoral-to-Brachial Preloaded Delivery System for Fenestrated-Branched Endovascular Repair of Complex Aortic Aneurysms

PURPOSE

To assess technical aspects and outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using a femoral-to-brachial (FTB) preloaded delivery system (PDS) with two separate configurations.

METHODS

Clinical data of all consecutive patients enrolled in a prospective study to evaluate FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms (CAAAs & TAAA) between 2013 and 2020 were reviewed. Patients treated with FTB-PDS were included. The two configurations included 4 trans-brachial preloaded wires (4BR) or 2 trans-brachial and 2 transfemoral preloaded wires (2BR-2FE). Outcome measures included technical success, procedural metrics, 30-day or in-hospital mortality, major adverse events (MAEs), and target-vessel outcomes.

RESULTS

There were 115 patients with a mean age of 73.8 ± 8 years, treated with FTB-PDS. Of these, 62 patients (54%) had 4BR and 53 patients (46%) had 2BR-2FE FTB-PDS. There were 106 TAAA (92%) and 9 CAAAs (8%). Technical success, defined as successful implantation of the stent-graft and all intended target-vessel stents without type I or III endoleak, was 97%, with no differences in total operating time, endovascular time, and radiation dose between groups. There were 3 deaths (3%) at 30 days. MAEs were noticed in 21 patients (18%) with no difference between groups, including new-onset dialysis (2% vs. 4%, P = 0.59), and paraplegia (7% vs. 11%, P = 0.51), for 4BR and 2BR-2FE, respectively. Patient survival and freedom from aortic-related mortality at 2-years were 79 ± 5% and 97 ± 1.7%, respectively, with no difference between groups.

CONCLUSION

The use of FTB-PDS for FB-EVAR is safe with high technical success and a reasonable rate of MAEs. Each configuration provides specific benefits based on patient anatomy, while having similar procedural metrics and clinical outcomes.

Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3

Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.

Comparative Early Results of In-Situ Fenestrated Endovascular Aortic Repair and Other Emergent Complex Endovascular Aortic Repair Techniques for Ruptured Suprarenal and Thoracoabdominal Aortic Aneurysms at a Regional Aortic Center

INTRODUCTION

Emergent endovascular repair of suprarenal (SRAAA) and thoracoabdominal aortic aneurysms (TAAA) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting (PG), physician modified endografts (PMEG), double-barrel/reversed iliac branch device (DB/rIBE), and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAA and TAAA.

METHODS

A retrospective review of patients who underwent endovascular repair of ruptured SRAAA and TAAAs from July 2014 - March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared to those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia.

RESULTS

Forty-two patients underwent endovascular repair for ruptured SRAAA and TAAA, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive prior to surgery, compared to 46% of the patients who underwent repair using non-ISF techniques (PMEG, PG, or DB/rIBE). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs. 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures, and 25% for ruptures with hypotension. Compared to the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs. 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P =.048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly utilized technqiue later in the study period.

CONCLUSIONS

While emergent endovascular repair of ruptured SRAAA/TAAA remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a 5-fold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up is needed to validate these initial results and assess durability.

Protocol for GUo's renovisceral Artery reconstruction-1: a prospective, multicentre, single-arm clinical trial to evaluate the safety and efficacy of a multibRANched sTEnt graft systEm for thoracoabdominal aortic aneurysm (GUARANTEE study)

INTRODUCTION

The multibranched off-the-shelf stent graft is a promising treatment option for thoracoabdominal aortic aneurysm (TAAA). A commercially available, multibranched, off-the-shelf endograft called the t-Branch stent graft has demonstrated favourable midterm outcomes. Another two investigational off-the-shelf endografts, the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis and E-nside multibranch stent graft system, are still being developed. However, these three endografts have an unsatisfactory anatomic feasibility rate in patients with TAAA. Based on the concept of Guo's renovisceral artery reconstruction-1, a novel, multibranched, off-the-shelf endograft with different configurations has been developed.

METHODS AND ANALYSIS

This prospective, multicentre, single-arm, cohort study will enrol 73 patients with TAAA. Preoperative and postoperative clinical data, as well as CT angiography images at each follow-up timepoint, will be analysed to evaluate the safety and efficacy of this novel, multibranched, off-the-shelf endograft for the treatment of TAAA. The primary safety end point is the major adverse event rate within 30 days after index endovascular aortic repair, including all-cause death, hepatic failure, bowel necrosis, renal failure, stroke, permanent paraplegia, cardiac infarction and respiratory failure. The primary efficacy end point is the successful treatment rate within 12 months after procedure, which is a composite of immediate technical success and no secondary surgical intervention related to TAAA within 12 months after the procedure.

ETHICS AND DISSEMINATION

The protocol has been reviewed and approved by the ethics committee of Chinese PLA General Hospital (reference number: 2021-NO.-007) and each participating hospital. The findings of this study will be disseminated through conference presentations, peer-reviewed journal publications and social media.

TRIAL REGISTRATION NUMBER

NCT05054985.

Meta-analysis of Comparative Studies Between Self- and Balloon-Expandable Bridging Stent Grafts in Branched Endovascular Aneurysm Repair

PURPOSE

Currently there is no robust evidence which type of bridging stent graft provides better outcomes after branched endovascular aortic repair (BEVAR). Self-expanding (SESG) and balloon-expandable (BESG) stent grafts are both commonly used to connect branches to their respective target vessels (TV). The aim of the current review was to evaluate the impact of the type of bridging stent grafts on TV outcomes during the mid-term follow-up after BEVAR.

MATERIALS AND METHODS

The study protocol was registered to the PROSPERO (CRD42021274766). A search of the English literature was conducted, using PubMed and EMBASE databases via Ovid and Cochrane database via CENTRAL, from inception to June 30, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Only comparative studies on BEVAR reporting TV outcomes related to BESG vs SESG were considered eligible. Individual studies were assessed for risk of bias using the Newcastle Ottawa Scale. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcomes were primary patency, freedom from endoleak, TV instability, and re-intervention between BESG and SESG, used as bridging stents in branches. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis.

RESULTS

Five out of 609 articles published from 2016 to 2020 were included in the analysis. In total, 1406 TV were revascularized, 547 (38.9 %) with BESGs and 859 with SESGs. The overall pooled primary patency (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.29-1.09; p=.256, I²=4.24%) and freedom from branch-related endoleak (OR, 0.65; 95% CI, 0.17-1.48; p<.122, I²=0.18%) did not differ between the stent types during the available follow-up (17 months, range = 12-35 months). In 4 studies (619 TV), SESG required fewer secondary interventions (OR, 1.04; 95% CI, 0.23-1.83; p=.009, I²=0%) and TV instability rate was lower (OR, 0.99; 95% CI, 0.33-1.65; p=.003, I²=0%) compared with BESG during the available follow-up.

CONCLUSION

BESG and SESG seem to perform similarly in terms of primary patency and branch-related endoleak during the mid-term follow-up. Current data from retrospective studies suggest that overall TV instability and re-intervention rates are favorable for SESG as bridging stent grafts in BEVAR.

Endovascular treatment of thoracoabdominal aortic aneurysms

Endovascular repair of thoracoabdominal aneurysms using fenestrated and/or branched stent grafts is technically feasible and efficacious but carries a steep learning curve. This innovative surgical approach is associated with less perioperative morbidity than traditional open repair and its early and mid-term outcomes are very favorable. Spinal cord ischemia remains a devastating complication after these procedures, hence the importance of various neuroprotective strategies. Widespread applicability remains limited in the United States, as no custom-made or off-the-shelf endografts are commercially available. Access to these devices remains limited to physician-sponsored or industry-sponsored clinical trials, but results from the Cook p-Branch and Gore Thoracoabdominal Branch Endoprosthesis trials are on the horizon.

Factors Affecting the Visceral Suitability of a Multibranched off-the-Shelf Endograft for the Treatment of Thoraco-Abdominal Aortic Aneurysms

BACKGROUND

To assess the factors affecting visceral suitability of the use of the Zenith T-branch^TM system in a group of patients with thoraco-adbominal aortic aneurysms (TAAAs).

METHODS

Computer tomography angiography (CTA) of patients who presented a TAAA from 01/2015 to 12/2019 were retrospectively examined. Multi-Planar Reconstructions were performed on CTA images to assess the anatomic suitability of the Zenith T-branch in the visceral district. In particular, the branch deviation angle (BDA), and the branch-length were computed for each target vessel.

RESULTS

Fifty-four CTA were examined. In 33.3% of these patients the presence of either a common origin of the superior mesenteric artery and the celiac trunk, or the diameter of 1 or more visceral/renal artery limited the visceral suitability of the device. All patients except 1 (97.9%) fitted the BDA criterion when the graft was placed in a position in which the BDA for the SMA was 5 degrees to the left. The branch-length criteria was met in all patients, except for 1 (97.9%), when the graft was placed in the center of the aorta. The eccentrical placement of the endograft decreased the suitability to 93.7%.

CONCLUSIONS

The Zenith T-branch system can be suitable in the visceral district for about 67% of patients. The target artery diameter was the most limiting criterion. The central location of the graft within the aortic lumen significantly affected the branch-length distance criteria.

Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.

[Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR - complementary or competitive?]

The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.

Use of Inner Branches During Physician-Modified Endografting for Complex Abdominal and Thoracoabdominal Aortic Aneurysms

OBJECTIVES

Endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms have been performed widely in an increasing number of centers, utilizing custom-manufactured or physician-modified stent grafts containing fenestrations and side-arm branches for visceral and renal artery incorporation. Alternatively, inner branch configurations may be useful in complex anatomy, where application of fenestrations or side-arm branches can be challenging. Our study aims to evaluate the incidence of target vessel instability when incorporated with inner branch configurations, and report clinical outcomes of patients who underwent fenestrated/branched endovascular aortic repairs (F-BEVAR) containing one or more inner branches.

METHODS

We reviewed patients who underwent F-BEVAR with at least one inner branch configuration for complex abdominal or thoracoabdominal aortic aneurysms at Keck Hospital of University of Southern California from 2014 to 2020. Endpoints were mortality, major adverse events (MAE), technical success, and target vessel instability. Target vessel instability was assessed using follow-up computed tomography (CT) and duplex imaging.

RESULTS

Out of the 175 patients who underwent F-BEVAR for complex abdominal and TAAA during the study period, 17 patients had at least one inner branch configuration. All were deemed high-risk for open repair with multiple cardiovascular and/or pulmonary comorbidities. Eight (47%) patients had extent I, II, III thoracoabdominal aortic aneurysms, and 10 (59%) had prior aortic repairs. A total of 68 target vessels were incorporated (mean = 4 vessels/patient, range=1~6), of which 40% were inner branch configurations, most commonly for renal arteries. Technical success was 94.1%. There was one perioperative mortality due to massive myocardial infarction, as well as one patient who needed temporary hemodialysis. No device-related mortalities were observed. At 30 days, primary inner branch patency was 100% with no target vessel instability or reintervention. At mean follow-up of 5.8 months, the overall survival was 94% with one patient who expired from unknown cause. Overall primary inner branch patency was 96.3%, due to occlusion of a long lumbar artery branch with no clinical sequelae.

CONCLUSION

Inner branch configurations can provide a safe alternative technique of branch incorporation during complex endovascular aortic repair.

The Early Outcomes of BeGraft Peripheral Plus in Branched Endovascular Repair of Thoracoabdominal Aneurysms

OBJECTIVE

No bridging stent-graft (BSG) has been specifically designed for branched endovascular aortic repair (BEVAR) and therefore different "off-label" stent-grafts have been used. Recently, a third generation of balloon-expandable stent-graft has become available. Here we evaluate the outcomes of the BeGraft Peripheral Plus (B+) used as a BSG for internal/externalor inner branches during BEVAR.

MATERIALS AND METHODS

Consecutive patients undergoing BEVAR using B+ as a BSG since its release in 2017 were included into the study. The primary endpoints were technical success and target vessel patency during follow-up. Secondary endpoints included the need for adjunct extension and relining of the BSG, branch instability rate, including occlusion, reinterventions for restonosis, kink, fracture, or endoleak (types 1 and 3).

RESULTS

A total of 163 visceral branches in 46 patients were included with a median follow-up 15 months (4-36 months). Primary technical success was achieved in all visceral branches (69 inner branches and 94 internal/external branches) with the exception of 1 BSG that required serial dilatation until full expansion was achieved with overall branch patency was 98% at 2 years. An additional stent-graft was necessary in 35 branches (21%) following deployment of a B+ BSG to cover a longer bridging distance and optimize the distal and proximal sealing. Relining of B+ BSG was not routinely carried out during the index procedure and a self-expanding uncovered nitinol stent was necessary in only 3% of branches to smooth the distal transition zone between the BSG and target vessel. There were 4 events (2.4%) of branch related instability, including 2 occlusions and 2 late reinterventions for a partial in-stent-graft thrombosis.

CONCLUSION

Our study findings show satisfactory early outcomes of B+ as a BSG in BEVAR with low occlusion and reintervention rates. Extensions of BSG might be required to achieve adequate seal in the target vessels but routine relining BSG in branches was not required.

Comparison of anatomic feasibility of three different multibranched off-the-shelf stent-grafts designed for thoracoabdominal aortic aneurysms

OBJECTIVE

We compared the theoretical anatomic feasibility of endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with three off-the-shelf multibranched stent-grafts: t-Branch (Zenith t-Branch; Cook Medical, Bloomington, Ind), Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz), and E-nside (E-nside multibranch stent graft system; Jotec GmbH, Hechingen, Germany).

METHODS

Computed tomography scans of patients with degenerative TAAAs treated from 2007 to 2019 were reviewed, and the anatomic feasibility of the multibranched stent-grafts was assessed according to the manufacturer's instructions for use. The anatomic factors determining the overall feasibility were divided into access feasibility, aortic feasibility, and visceral vessel feasibility.

RESULTS

Degenerative TAAAs in 268 patients were analyzed. The overall feasibility did not differ significantly (TAMBE, 33%; t-Branch, 39%; E-nside, 43%; P = .271). Access, aortic, and visceral vessel feasibility alone excluded 18% to 22%, 35% to 49% and 21% to 26% of the patients respectively. The only significant difference between the devices was in aortic feasibility (P = .005), which was more frequently limited by the proximal aortic neck diameter in the TAMBE cohort and the inner visceral aortic diameter in the t-Branch cohort. The overall treatment feasibility using any of the three devices would have been 58%.

CONCLUSIONS

The new investigational off-the-shelf multibranched stent-grafts did not significantly improve the theoretical applicability in an extensive cohort of patients with TAAAs. Improvements are warranted to increase their overall feasibility.

Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair

OBJECTIVE

Complex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR).

METHODS

All patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined.

RESULTS

A total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm² (range, 8260-55,070 dGycm²). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non-aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months).

CONCLUSIONS

The use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.

Expanded Use of Preloaded Branched and Fenestrated Endografts for Endovascular Repair of Complex Aortic Aneurysms

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.

Anatomical feasibility of a new off-the-shelf inner branch stent graft (E-nside) for endovascular treatment of thoraco-abdominal aneurysms

OBJECTIVES

METHODS

Preoperative computed tomography scans of patients with atherosclerotic TAAA treated between 2007 and 2019 were reviewed, and the anatomical feasibility of the E-nside graft was verified by a retrospective study (clinicaltrials.gov: NCT03959670) based on the investigational manufacturer instructions for use. The anatomical factors determining overall feasibility were divided into vascular access (AC) feasibility, aortic (AO) feasibility and visceral vessels (VV) feasibility.

RESULTS

Two hundred sixty-eight patients with thoraco-abdominal aneurysms were analysed: the overall treatment feasibility was 43%. AC feasibility was 78%, AO feasibility 60% and VV feasibility 79%. An iliac diameter &lt;8.5 mm excluded 21% of the patients. Aortic feasibility was limited by infrarenal aortic diameter (16%) and size of aortic lumen at the level of visceral vessels (14%). Visceral vessels feasibility was mainly limited by inadequate number (8%) or diameter (12%) of target vessels. Height and orientation of target vessels were adequate in 97% of the cases. Overall feasibility was negatively influenced by female gender (Odds ratio: 3.89; 95% confidence interval 2.03–7.44; P &lt; 0.001): the limiting factors in this subgroup being iliac diameter, infrarenal aortic diameter and visceral vessels diameter.

CONCLUSIONS

The E-nside off-the-shelf stent graft can be theoretically employed in almost half of the cases from an all-comers cohort of patients with TAAA. Improvement of device profile and creation of a dedicated infrarenal component are warranted to increase overall feasibility. Female gender significantly affects the overall feasibility.

Clinicaltrials.gov

NCT03959670.

Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones

BACKGROUND

The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported.

METHODS

Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n = 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n = 20) or EndoAnchors (Medtronic, Minneapolis, MN [n = 6]).

RESULTS

Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P = .04).

CONCLUSIONS

Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.

Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms

BACKGROUND

First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices.

METHODS

A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization.

RESULTS

Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used.

CONCLUSIONS

Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.

Performance of Viabahn balloon-expandable stent compared with self-expandable covered stents for branched endovascular aortic repair

OBJECTIVE

The objective of this study was to compare the performance between the Viabahn balloon-expandable stent (VBX; Viabahn [W. L. Gore & Associates, Flagstaff, Ariz]) and a covered self-expandable stent (SES; Fluency [Bard Peripheral Vascular, Tempe, Ariz]) used as bridging stents for directional branches during fenestrated or branched endovascular aneurysm repair of complex aortic aneurysms.

METHODS

Patients with thoracoabdominal aortic aneurysms (type I-IV) or pararenal aortic aneurysms either at high risk for open repair or unsuitable for endovascular repair with commercially available devices were prospectively enrolled in a physician-sponsored investigational device exemption trial. Descriptive statistics of the cohort included demographics, risk factors, and anatomic and device characteristics. Individual branches were grouped as either VBX or SES and had data analyzed for primary patency, branch-related type I or type III endoleaks, branch instability, branch-related secondary intervention, and branch-related aortic rupture or death. Categorical variables were expressed as total and percentage, and continuous variables were expressed as median (interquartile range). Kaplan-Meier curves were used to estimate long-term results. Groups were compared with the log-rank test. P value <.05 was considered statistically significant.

RESULTS

During the period from July 2012 through June 2019, there were 263 patients treated for complex aortic aneurysm (thoracoabdominal aortic aneurysm) with fenestrated or branched endografts. The devices used were either custom-manufactured devices or off-the-shelf p-Branch or t-Branch (Cook Medical, Bloomington, Ind) devices. The median age was 71 years (interquartile range, 66-79 years); 70% were male, and 81% were white. The most common cardiac risk factors were smoking (92%), hypertension (91%), hyperlipidemia (78%), and chronic obstructive pulmonary disease (52%). The total number of vessels incorporated into the repair was 977, with branches representing 18.4% (179 branches). Among these 179 branches, the celiac artery, superior mesenteric artery, right renal artery, and left renal artery received 54 (30%), 56 (31%), 38 (21%), and 31 (18%) branches, respectively. VBX and SES groups represented 96 (54%) and 81 (46%) of the branches implanted. The celiac artery, superior mesenteric artery, right renal artery, and left renal artery received VBX as a bridging stent in 40%, 46.7%, 33.8%, and 32.2% respectively. The overall cohort survival rate was 78.5% at 24 months. There was no branch-related rupture or mortality. Primary patency at 24 months (VBX, 98.1%; SES, 98.6%; log-rank, P = .95), freedom from endoleak (VBX, 95.6%; SES, 98.6%; log-rank, P = .66), freedom from secondary intervention (VBX, 94.7%; SES, 98.1%; log-rank, P = .33), and freedom from branch instability (VBX, 95.6%; SES, 97.2%; log-rank, P = .77) were similar between groups.

CONCLUSIONS

This initial experience with VBX stents demonstrated excellent primary patency and similarly low rates of branch-related complications and endoleaks, with no branch-related aortic rupture or death. Our results demonstrate that in a high-volume, experienced aortic center, the VBX stent is a safe and effective bridging stent option during branched endovascular aortic repair. Multicenter studies with a larger cohort and longer follow-up are necessary to validate these findings.

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

OBJECTIVE

Mortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality.

METHODS

The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality.

RESULTS

We included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m²), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003).

CONCLUSIONS

Nearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

Anatomic feasibility of the investigational GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE), off-the-shelf multibranched endograft for the treatment of pararenal and thoracoabdominal aortic aneurysms

OBJECTIVE

The objective of this study was to evaluate the proportion of pararenal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs) that could theoretically be treated with the investigational GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz) off-the-shelf multibranched endograft.

METHODS

The preoperative computed tomography scans of patients with pararenal aortic aneurysms and TAAAs treated at a single institution between 2007 and 2017 were reviewed. This cohort included both open and endovascular repairs performed in either elective or urgent/emergent settings. These studies were included in a retrospective feasibility study to verify anatomic feasibility of the TAMBE graft (with four antegrade portals) employed within the manufacturer's investigational instructions for use during the U.S. pivotal trial. The patient cohort was divided into two groups: extended thoracoabdominal aneurysm (E-TAA)-extent I, II, and III TAAA; and limited pararenal and thoracoabdominal aneurysm (L-TAA)-pararenal aortic aneurysm and extent IV TAAA. The anatomic factors determining the overall theoretical feasibility were further divided into three groups: vascular access feasibility, aortic feasibility, and visceral vessel feasibility.

RESULTS

Computed tomography scans of 227 patients with degenerative aneurysms were analyzed, 166 with E-TAA and 61 with L-TAA. In the L-TAA group, 49% of the cases could have been treated with the TAMBE endograft alone; access feasibility was 85%, aortic feasibility 74%, and visceral vessel feasibility 72%. In the E-TAA group, only 23% of the cases could have been treated with a TAMBE combined with a GORE CTAG proximal thoracic stent graft; access feasibility was 79%, aortic feasibility 48%, and visceral vessel feasibility 63%. The different feasibility rate was related to a difference in aortic feasibility between L-TAA and E-TAA (74% vs 48%; P = .0008) because of the lack of a dedicated tapered thoracic component.

CONCLUSIONS

The TAMBE multibranched endograft can theoretically be employed in half of an all-comers cohort of patients with degenerative L-TAA. Development of a dedicated tapered thoracic component is warranted to increase the feasibility for E-TAA, and comparative studies are required to investigate differences with other available off-the-shelf stent grafts.

A novel physician-assembled endograft for the repair of pararenal, paravisceral, Crawford type IV thoracoabdominal aortic aneurysms, and aneurysms requiring treatment after prior repair

OBJECTIVE

In the present study, we reviewed the 30-day and 1-year clinical results of the use of the investigational unitary manifold (UM) stent graft system (Sanford Health, Sioux Falls SDak) for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm).

METHODS

The present study was a single-center, multiarm, prospective review of the first 44 patients who had undergone repair of Crawford type IV, pararenal, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) using the physician-modified UM under a physician-sponsored investigational device exemption. The primary end point was freedom from major adverse events at 30 days, including all-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, and renal failure.

RESULTS

Technical success was achieved in all 44 patients (100%), with a large number of these patients having undergone previous aortic repair (20 of 44; 45.5%). All the intended 170 visceral vessels (100%) had been successfully cannulated and stent grafted. No episodes of paraplegia or in-hospital deaths were recorded. One patient had died of aneurysm-related ischemic stroke (2.3%). The rate of transient nonclinically significant spinal cord ischemia was 4.5%. At the last follow-up, one reintervention had been required owing to branch patency from a thrombotic event. Of the 170 bridging stent grafts, 169 have remained patent through a mean follow-up of 8.8 months (range, 0-36 months). No type I or III endoleaks, migration, or component separation in the investigational device has occurred.

CONCLUSIONS

The early and midterm results with the use of the UM suggest it could be a viable option for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) without exposing patients to the increased risk of permanent spinal cord ischemia, renal failure, visceral vessel ischemia, or aneurysm-related mortality that results from open thoracoabdominal aortic aneurysm repair. The high technical success rate, in native and previous repairs, supports the utility of this device as a bail-out technique for failed endovascular aneurysm repair or proximal extension of disease after previous aortic repair. However, experience is limited, and this approach requires further study before widespread adoption.

Acute Kidney Injury after Complex Endovascular Aneurysm Repair

Background:

Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative morbidity than standard infrarenal endovascular repair.

Objective:

This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.

Methods:

A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal, and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further analyzed by the level of anatomic complexity and method of repair.

Results:

52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017. The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19% (temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency did not demonstrate any associations with the outcome.

Conclusion:

Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively associated factors other than increasing anatomic complexity and operative time. Further study is needed for the identification of predictors related to postoperative acute kidney injury.

Endovascular Treatment for Thoracoabdominal Aortic Aneurysm and Complex Abdominal Aortic Aneurysm Using Fenestrated and Branched Grafts

Fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is a less invasive treatment for thoracoabdominal aortic aneurysm (TAAA) and complex abdominal aortic aneurysm. Fenestrated and branched (cuff) grafts facilitate safe and durable repair, and bail-out maneuvers for target vessel cannulation and stenting have been established; however, the available bridging stent grafts have differences. The present article discusses the optimal selection of fenestrated or branched grafts, the cannulation of target vessels that have difficult anatomies, and the advantages and disadvantages of various bridging stents. We review the causes and risk factors of spinal cord injury (SCI), the protocol for prevention of SCI, and the outcomes of target vessel stent grafting, including patency and endoleak.

Although conventional open surgery is the gold standard for the repair of thoracoabdominal aortic aneurysm (TAAA), it is highly invasive. To reduce invasiveness, hybrid surgery that combines open surgery and endovascular therapy has been developed [1, 2], and fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is frequently performed at centers in the USA, Europe, and Japan [3-5]. Additionally, a hostile neck may be an independent factor for sac enlargement after EVAR for abdominal aortic aneurysm (AAA) [6], but a previous study reported that 41% of AAA cases presented with neck lengths outside the range prescribed by the traditional instruction for use [7]. Stark et al. showed that extending the graft above the highest renal artery would create an augmented neck length in 90% of patients with AAA [7]. F/B-EVAR is based on this principle. However, there are some technical tips for, and limitations of, fenestrated and/or branched graft. F/B-EVAR for TAAA and complex AAA will be reviewed in the present article.

Bridging stent grafts in fenestrated and branched endovascular aortic repair: current practice and possible complications

Fenestrated and branched endovascular aortic repair (F/B-EVAR) is associated with a high degree of technical and clinical success. Despite this, studies have also reported high reintervention rates, and these are often related to the bridging stent grafts. Often new devices appear on the market before they have been tested in the bridging stent graft position. This review aims to assess the current literature on bridging stent grafts and discuss complications, illustrated by case reports. Complications reported with bridging stent grafts include; endoleak, kink, fracture, migration, occlusion, stenosis and perforation. Some known risk factors for bridging stent occlusions are renal artery stent grafts vs. SMA and celiac artery stent grafts. Some device specific complications have also been reported such as type IIIc endoleak with the Lifestream stent graft (Bard Peripheral Vascular, Tempe, AZ, USA) fractures and type IIId endoleaks with the 1st generation of Begraft (BentleyInnoMed, Hechingen, Germany). In addition, this review also discusses some newer devices with possible relation to complications such as stenosis and target vessel perforation. In conclusion, bridging stent grafts in fenestrated and branched aortic repair have a good midterm patency. Despite this, remaining issues are often related to the bridging stent grafts. Thorough follow-up and attention are needed, especially when new devices are introduced. The endovascular community should work towards a common global feedback system.

Should endovascular approach be considered as the first option for thoraco-abdominal aortic aneurysms?

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique of open TAAA repair has evolved from the use of "island" patch incorporation to separate branch vessel bypass, from "clamp and go" to routine use of distal perfusion, and towards more extensive repair in patients with connective tissue disorders. Open TAAA repair can be done with excellent results in highly specialized centers. However, these operations continue to carry excessive risk when performed outside large aortic centers, with 30-day mortality estimated on 20% according to statewide and national databases. In octogenarians, the mortality of elective open TAAA repair can be up to 40%. Endovascular repair was introduced as an alternative to open surgical repair in the elderly or higher risk patients using hybrid reconstruction, parallel grafts or fenestrated and branched endografts. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular repair using patient-specific and off-the-shelf devices, offering a minimally invasive alternative to open repair allowing treatment of increasingly older and sicker TAAA patients. During the last decade, improvements in device design, patient selection, spinal cord injury protocols, and perioperative management have contributed to a continued decline in morbidity and mortality of fenestrated-branched endovascular aortic repair, challenging open surgical repair as the new "gold standard" for treatment of TAAAs. Despite the improved results, endovascular repair is a highly technical procedure that requires vast experience, involves a significant risk of complications, and also, has an impact on patients' physical quality of life. In this article, we review the current technical aspects of endovascular TAAA repair with the main focus on the evidence of open versus endovascular outcomes of TAAA repair.