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Karaolanis GI, Papazoglou DD, Donas KP, Helfenstein F, Kotelis D, Makaloski V. Physician-modified versus chimney endografting for pararenal aortic aneurysms: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:124-131. [PMID: 38635285 DOI: 10.23736/s0021-9509.24.12995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
INTRODUCTION We performed a systematic review and meta-analysis to assess the existing published evidence regarding the safety and efficacy of the endovascular aortic repair with chimney technique (ch-EVAR) and physician-modified stent-grafts (PMSGs) for the treatment of pararenal aortic aneurysm repair. EVIDENCE ACQUISITION A systematic search of all relevant studies reported until October 2023 according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. The pooled 30-day mortality, peri- and postoperative complication rates were estimated using fixed or random effect methods. EVIDENCE SYNTHESIS A total of 679 study titles were identified by the initial search strategy, of which 16 were considered eligible for inclusion in the meta-analysis. A total of 1094 patients (ch-EVAR N.=861 and PMSG N.=233) (90% male) were identified. The pooled 30-day mortality rate was 3.4% for ch-EVAR and 2.6% for PMSG. The major adverse events (MAE) in the early period was 14.7% for ch-EVAR and 18.5% PMSG, respectively. Higher occlusion rate was observed of the chimney stents grafts (8.2%) than the bridging stents (1.4%) during the follow-up period. CONCLUSIONS Ch-EVAR and physician-modified technology are safe with low 30-day mortality in elective settings for pararenal aortic aneurysms repair. No significant differences were seen between the two surgical methods regarding the early major adverse events rate. However, higher occlusion rate for the chimneys can be expected over time.
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Affiliation(s)
- Georgios I Karaolanis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland -
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece -
| | - Dimitrios D Papazoglou
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Konstantinos P Donas
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Wiesbaden, Seligenstadt, Germany
| | | | - Drosos Kotelis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Juszczak M, Mann H, Riste M, Woodhouse A, Sörelius K, Claridge M, Adam DJ. Complex Endovascular Repair of Paravisceral Infective Native Aortic Aneurysms. J Endovasc Ther 2024; 31:223-231. [PMID: 36062747 DOI: 10.1177/15266028221119333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the early and mid-term outcome of complex endovascular repair (EVAR) for paravisceral infective native aortic aneurysms (INAA). METHODS Interrogation of a prospectively maintained database identified consecutive patients who underwent non-elective complex EVAR for paravisceral INAAs in a single institution between December 2013 and June 2020. All patients were considered to have definite INAAs based on diagnostic criteria. Patients who had prior aortic repair were excluded. RESULTS A total of 26 patients (19 men; mean age 67 years [SD = 11.4]; median diameter 60 mm [IQR: 55-73]) with acute symptomatic (n = 24) or contained ruptured (n = 2) aneurysms underwent surgeon-modified fenestrated EVAR (SM-FEVAR; n = 24) or chimney-periscope EVAR (CHIMPS; n = 2). Median observed follow-up was 36.2 months (18.3-53.5). Nine patients had positive venous blood cultures and a further seven had recent or concomitant infection. All patients received pre- and post-operative antibiotic therapy and rifampicin-soaked endografts. A total of 95 vessels were targeted for preservation and 86 were stent-grafted. One vessel occluded intra-operatively and a further 3 occluded within 30 days. The 30-day/in-hospital mortality was 11.5% (n = 3), and the estimated 1- and 3-year survival (±SD) was 85% ± 7%. Infection-related complications (IRCs) occurred in two patients: both developed new INAA within 30 days of index repair and were treated by EVAR with no mortality. Estimated 3-year freedom from late re-intervention was 100%. One patient required infrarenal EVAR for a non-infective aneurysm at 43 months. CONCLUSION Complex EVAR for paravisceral INAAs is associated with acceptable early and mid-term outcomes and is an acceptable alternative to open surgery. We propose that these patients are managed with long-term antimicrobials, impregnation of graft material with rifampicin, and rigorous post-operative surveillance. CLINICAL IMPACT A multi-disciplinary approach is required to deliver the best possible outcome for patients with this challenging aortic pathology.
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Affiliation(s)
- Maciej Juszczak
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Harvinder Mann
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Riste
- Department of Infectious Disease, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Woodhouse
- Department of Infectious Disease, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Claridge
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Chen G, Qi X, Wu W, Fu D, Qin L, Yang C. Current status and future development of aortic stent fenestration-assisted techniques. Chin Med J (Engl) 2024; 137:752-754. [PMID: 38321812 PMCID: PMC10950130 DOI: 10.1097/cm9.0000000000003036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Gezheng Chen
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Xiaoyu Qi
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Wanying Wu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Dongsheng Fu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliate Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Li Qin
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Chao Yang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
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Adam DJ, Juszczak M, Vezzosi M, Claridge M, Quinn D, Senanayake E, Clift P, Mascaro J. The Complementary Roles of Open and Endovascular Repair of Extent I - III Thoraco-abdominal Aortic Aneurysms in a United Kingdom Aortic Centre. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00190-4. [PMID: 38403184 DOI: 10.1016/j.ejvs.2024.02.031] [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: 04/20/2023] [Revised: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE A multidisciplinary approach offering both open surgical repair (OSR) and complex endovascular aortic repair (cEVAR) is essential if patients with thoraco-abdominal aortic aneurysms (TAAAs) are to receive optimal care. This study reports early and midterm outcomes of elective and non-elective OSR and cEVAR for extent I - III TAAA in a UK aortic centre. METHODS Retrospective study of consecutive patients treated between January 2009 and December 2021. Primary endpoint was 30 day/in hospital mortality. Secondary endpoint was Kaplan-Meier estimates of midterm survival. Data are presented as median (interquartile range [IQR]). RESULTS In total, 296 patients (176 men; median age 71 years [IQR 65, 76]; median aneurysm diameter 66 mm [IQR 61, 75]) underwent repair (222 elective, 74 non-elective). OSR patients (n = 66) were significantly younger with a higher incidence of heritable disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher prevalence of coronary, pulmonary, and renal disease. Overall, in hospital mortality after elective and non-elective repair was 3.2% (n = 7) and 23.0% (n = 17), respectively, with no significant difference between treatment modalities (elective OSR 6.5% vs. cEVAR 2.3%, p = .14; non-elective OSR 25.0% vs. cEVAR 20.3%, p = .80). Major non-fatal complications occurred in 15.3% (33/215) after elective repair (OSR 39.5%, 17/43, vs. cEVAR 9.3%, 16/172; p < .001) and 14% (8/57) after non-elective repair (OSR 26.7%, 4/15, vs. cEVAR 9.5%, 4/42; p = .19). Median follow up was 52 months (IQR 23, 78). Estimated survival ± standard error at 1, 3, and 5 years for the entire cohort was 89.6 ± 2.0%, 76.6 ± 2.9%, and 69.0% ± 3.2% after elective repair, and 67.6 ± 5.4%, 52.1 ± 6.0%, and 41.0 ± 6.2% after non-elective repair. There was no difference in 5 year survival comparing modalities after elective repair for patients younger than 70 years and those with post-dissection aneurysms. CONCLUSION A multidisciplinary approach offering OSR and cEVAR can deliver comprehensive care for extent I - III TAAA with low early mortality and good midterm survival. Further studies are required to determine the optimal complementary roles of each treatment modality.
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Affiliation(s)
- Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Quinn
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Eshan Senanayake
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Clift
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jorge Mascaro
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mahmood DN, Rocha R, Ouzounian M, Teng Tan K, Forbes SM, Chung JCY, Lindsay TF. Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe. J Endovasc Ther 2024:15266028241229005. [PMID: 38339966 DOI: 10.1177/15266028241229005] [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: 02/12/2024]
Abstract
PURPOSE The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. MATERIALS AND METHODS A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. RESULTS Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. CONCLUSION Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. CLINICAL IMPACT This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, ON, Canada
| | - Samantha M Forbes
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Dias-Neto M, Vacirca A, Huang Y, Baghbani-Oskouei A, Jakimowicz T, Mendes BC, Kolbel T, Sobocinski J, Bertoglio L, Mees B, Gargiulo M, Dias N, Schanzer A, Gasper W, Beck AW, Farber MA, Mani K, Timaran C, Schneider DB, Pedro LM, Tsilimparis N, Haulon S, Sweet MP, Ferreira E, Eagleton M, Yeung KK, Khashram M, Jama K, Panuccio G, Rohlffs F, Mesnard T, Chiesa R, Kahlberg A, Schurink GW, Lemmens C, Gallitto E, Faggioli G, Karelis A, Parodi E, Gomes V, Wanhainen A, Habib M, Colon JP, Pavarino F, Baig MS, Gouveia E Melo RECD, Crawford S, Zettervall SL, Garcia R, Ribeiro T, Alves G, Gonçalves FB, Kappe KO, Mariko van Knippenberg SE, Tran BL, Gormley S, Oderich GS. Outcomes of Elective and Non-elective Fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms. Ann Surg 2023; 278:568-577. [PMID: 37395613 DOI: 10.1097/sla.0000000000005986] [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: 07/04/2023]
Abstract
OBJECTIVE To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). BACKGROUND FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. METHODS Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. RESULTS A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001). CONCLUSIONS Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.
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Affiliation(s)
- Marina Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | | | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Tilo Kolbel
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Jonathan Sobocinski
- Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM U1008, CHU Lille, France
| | - Luca Bertoglio
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
- Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Nuno Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | | | - Warren Gasper
- University of California San Francisco, San Francisco, CA
| | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Kevin Mani
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Carlos Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - 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 (CCUL@RISE), Lisbon, Portugal
| | | | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Emília Ferreira
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | | | - Fiona Rohlffs
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Thomas Mesnard
- Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM U1008, CHU Lille, France
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, Vita Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | - Geert Willem Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Charlotte Lemmens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna-DIMEC, Italy, and Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Angelos Karelis
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Vivian Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Anders Wanhainen
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Mohammed Habib
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jesus Porras Colon
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Felipe Pavarino
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Mirza S Baig
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Ryan Eduardo Costeloe De Gouveia E Melo
- Department of Vascular Surgery, Centro Hospitalar Universitário Lisboa Norte; Faculdade de Medicina da Universidade de Lisboa; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Lisbon, Portugal
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich
| | - Sean Crawford
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Rita Garcia
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Tiago Ribeiro
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Gonçalo Alves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Frederico Bastos Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - Kaj Olav Kappe
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | | | - Bich Lan Tran
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Sinead Gormley
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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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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9
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Becker D, Ali A, Prendes C, Stavroulakis K, Stana J, Tsilimparis N. Physician Modification of a Custom-Made Fenestrated Endograft By Closure of a Fenestration With Bovine Patch. J Endovasc Ther 2023:15266028231187749. [PMID: 37464749 DOI: 10.1177/15266028231187749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
PURPOSE Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration. TECHNIQUE In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively. CONCLUSION In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique. CLINICAL IMPACT The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.
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Affiliation(s)
- D Becker
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
| | - A Ali
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
| | - C Prendes
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
| | - K Stavroulakis
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
| | - J Stana
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
| | - N Tsilimparis
- Department of Vascular Surgery-Vascular and Endovascular Surgery, University Hospital, Ludwig Maximillian University Munich, Munich, Germany
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Chan HL, Papazoglou DD, Jungi S, Weiss S, Becker D, Kotelis D, Makaloski V. Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms. J Clin Med 2023; 12:4708. [PMID: 37510822 PMCID: PMC10416159 DOI: 10.3390/jcm12144708] [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: 05/23/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. METHODS Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. RESULTS Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. CONCLUSION Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.
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11
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Alberga AJ, de Bruin JL, Bastos Gonçalves F, Karthaus EG, Wilschut JA, van Herwaarden JA, Wever JJ, Verhagen HJM. Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms. J Endovasc Ther 2023; 30:419-432. [PMID: 35311414 PMCID: PMC10209502 DOI: 10.1177/15266028221083460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
PURPOSE Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. METHODS All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. RESULTS The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8). CONCLUSION Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
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Affiliation(s)
- Anna J. Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jorg L. de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederico Bastos Gonçalves
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário de Lisboa Central, NOVA Medical School, Lisboa, Portugal
| | - Eleonora G. Karthaus
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Janneke A. Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | | | - Jan J. Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hence J. M. Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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12
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Le Houérou T, Álvarez-Marcos F, Gaudin A, Bosse C, Costanzo A, Vallée A, Haulon S, Fabre D. Midterm Outcomes of Antegrade In Situ Laser Fenestration of Polyester Endografts for Urgent Treatment of Aortic Pathologies Involving the Visceral and Renal Arteries. Eur J Vasc Endovasc Surg 2023; 65:720-727. [PMID: 36731765 DOI: 10.1016/j.ejvs.2023.01.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/20/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Aortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for the emergency repair of complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article was to evaluate the midterm results of LFEVAR performed with polyester endografts. METHODS From August 2015 to December 2020, all consecutive LFEVAR performed for non-deferrable treatment of complex AAA were analysed. Polyester endografts were deployed and subsequently fenestrated using an atherectomy laser probe; the fenestrations were enlarged using cutting and semicompliant balloons before implantation of balloon expandable bridging stents into the target vessels. Prospectively collected midterm survival, patency, and re-intervention rates were analysed. RESULTS Forty four procedures were performed for 11 type 1a endoleaks, five thoraco-abdominal aneurysms, 20 pararenal aneurysms, four segmental renal artery (RA) preservations, three anastomotic aneurysms, and one aortic dissection. One hundred and eight laser fenestrations were performed (26 for the superior mesenteric artery [SMA], 13 for the coeliac trunk, 33 and 31 for the right and left RA, respectively). The median ischaemia duration was 7, 48, 48, and 45 minutes, respectively. The technical success rate was 97%, with no open surgical conversions. The 30 day mortality was 4.5% (n = 2). No spinal cord ischaemia events were observed nor early stent related complications. Kaplan-Meier overall survival at two years was 73%, the aortic related re-intervention free survival was 70%, and the stent related re-intervention free survival was 90.6%. Four target vessel thromboses were detected, of which three were rescued. Three type IIIc endoleaks, one RA false aneurysm, and one SMA stenosis, required re-intervention during a median follow up of 24.7 months. CONCLUSION Antegrade LFEVAR is feasible, safe, and provides satisfactory early and midterm outcomes for non-deferrable treatment of aortic pathologies involving the visceral segment. Long term data are mandatory to confirm the usefulness of this promising off label technique.
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Affiliation(s)
- Thomas Le Houérou
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Francisco Álvarez-Marcos
- Vascular Surgery Department, Hospital Universitario Central de Asturias (HUCA), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Antoine Gaudin
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Côme Bosse
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Alessandro Costanzo
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Aurélien Vallée
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphan Haulon
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Dominique Fabre
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France.
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13
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Adam DJ, Claridge MWC. Back Table Or In Situ? Select Your Window. Eur J Vasc Endovasc Surg 2023; 65:728. [PMID: 36682402 DOI: 10.1016/j.ejvs.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Donald J Adam
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Martin W C Claridge
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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14
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Brown A, Wooster M. Enlarging Paravisceral Aortic Aneurysm Treated With In Situ Laser Fenestration of Physician-Modified Stent Graft for Preservation of Accessory Renal Arteries. J Endovasc Ther 2023:15266028221147452. [PMID: 36609172 DOI: 10.1177/15266028221147452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE In situ laser fenestration (LISF) was performed as a bailout procedure to ensure renal perfusion during complex aortic aneurysm repair. CASE REPORT A 69 year-old male patient with previous repair of abdominal aortic aneurysm who presented with increasing lower back pain and an enlarging, 6-cm, perivisceral aortic aneurysm that required urgent repair. Given potential complications and risks of redo open repair, we performed endovascular repair via deployment of a 5-vessel fenestrated physician modified stent graft (PMEG) with stent placement to the celiac, superior mesenteric, right renal, and 2 of the larger 3 left renal arteries. The renal artery planned for sacrifice was found intraoperatively to be perfusing a large portion of the kidney. Subsequently, LISF was used to cannulate and salvage perfusion to the third renal artery. Completion aortogram demonstrated patency of all renal visceral vessels with no vessel leak. Follow-up CT angiogram 1 year later demonstrated aortic graft with all visceral stents patent, no endoleak, and a reduction in residual aneurysm sac. CONCLUSION Even with careful planning and design of a physician modified stent graft, in situ laser fenestration provides an option to successfully create additional stents intraoperatively in order to preserve perfusion to critical visceral organs. CLINICAL IMPACT In situ laser fenestration will provide surgeons with a valuable intra-operative method to create additional stents when organ perfusion would otherwise be lost. As more surgeons develop this technical ability and more long-term outcomes are studied, this method has the possibility to not only be used for urgent and emergent cases but may one day be an acceptable variation to standard practice.
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Affiliation(s)
- Adam Brown
- Medical University of South Carolina, Charleston, SC, USA
| | - Mathew Wooster
- Medical University of South Carolina, Charleston, SC, USA
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15
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Shalan A, Tenorio ER, Mascaro JG, Juszczak MT, Claridge MW, Melloni A, Bertoglio L, Chiesa R, Oderich GS, Adam DJ. Fenestrated-branched endovascular repair for distal thoraco-abdominal aortic pathology after total aortic arch replacement with frozen elephant trunk. J Vasc Surg 2022; 76:867-874. [PMID: 35697307 DOI: 10.1016/j.jvs.2022.04.035] [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: 01/25/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET). METHODS Interrogation of prospectively-maintained databases from four high volume aortic centres identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. Primary endpoint was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, mid-term survival and freedom from re-intervention. Data are presented as median (IQR). RESULTS 39 patients [21 men; median age, 73 years (67-75)] with degenerative (n=22) and post-dissection TAAAs (n=17) [median diameter 71 mm (61-78)] were identified. Distal FBEVAR was intended in 27 patients [median interval 9.8 months (6.2-16.6)], anticipated in seven and unexpected in five. 31 patients had a two (n=24) or three (n=7) stage distal FBEVAR. Reno-visceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. 30-day mortality was 2.6% [n=1; respiratory failure and spinal cord ischaemia (SCI)]. Six survivors also developed SCI which was associated with complete (n=4), or partial recovery (n=2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7). Eleven patients required 16 late re-interventions. Estimated 3-year survival and freedom from re-intervention were 84±6% and 63±10%, respectively. CONCLUSIONS Distal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Mid-term patient survival is favourable but there remains a high requirement for late re-intervention. FBEVAR represents an acceptable alternative to distal open TAAA repair.
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Affiliation(s)
- Ahmed Shalan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emanuel R Tenorio
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Jorge G Mascaro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Maciej T Juszczak
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin W Claridge
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gustavo S Oderich
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Donald J Adam
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Biggs JH, Tenorio ER, DeMartino RR, Oderich GS, Mendes BC. Outcomes Following Urgent Fenestrated-Branched Endovascular Repair For Pararenal And Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2022; 85:87-95. [PMID: 35595206 DOI: 10.1016/j.avsg.2022.05.003] [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: 07/06/2021] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients considered high-risk for open repair. METHODS A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and one year aortic related outcomes. RESULTS Thirty-two patients (23 male, mean age 74±9 years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and eighteen patients underwent urgent repair for symptomatic, mycotic or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and eight patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%) and two double-wide scallops (2%). 30-day mortality was 6%, with one patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. MAEs otherwise occurred in sixteen patients (50%) including minor stroke in three patients, transient paraparesis and heart failure in one patient each, and early return to the operating room in six patients. Mean follow up was 24±22 months. At 1- year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70%±8%, 94%±3 and 83%±7, respectively. CONCLUSIONS Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow up is needed to assess durability of repair and device-related complications.
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Affiliation(s)
- Joedd H Biggs
- From the Advanced Endovascular Aortic Research Program Mayo Clinic, 200 1(st) St NW, Rochester, MN 55905
| | - Emanuel R Tenorio
- From the Advanced Aortic Research Program University of Texas Health Science, 7000 Fannin St #1200, Houston, TX 77030
| | - Randall R DeMartino
- From the Advanced Endovascular Aortic Research Program Mayo Clinic, 200 1(st) St NW, Rochester, MN 55905
| | - Gustavo S Oderich
- From the Advanced Aortic Research Program University of Texas Health Science, 7000 Fannin St #1200, Houston, TX 77030
| | - Bernardo C Mendes
- From the Advanced Endovascular Aortic Research Program Mayo Clinic, 200 1(st) St NW, Rochester, MN 55905.
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17
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Gouveia E Melo R, Prendes CF, Caldeira D, Stana J, Rantner B, Wanhainen A, Oderich GS, Tsilimparis N. Systematic Review and Meta-analysis of Physician Modified Endografts for Treatment of Thoraco-Abdominal and Complex Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2022; 64:188-199. [PMID: 35483575 DOI: 10.1016/j.ejvs.2022.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Perform a systematic review and meta-analysis of the outcomes of physician modified endografts (PMEG) for treatment of thoraco-abdominal (TAAA) and complex abdominal aortic aneurysm (C-AAA) repair. METHODS We searched MEDLINE, CENTRAL, Web of Science Core Collection, Scielo and Open Grey databases from inception to July 2021 for studies reporting on outcomes of PMEGs for TAAA or C-AAA repair. A systematic review was conducted (protocol CRD42021267856) and data were pooled using a random-effects model of proportions. The outcomes analyzed were major adverse events at 30-days [30-day mortality, myocardial infarction, respiratory failure requiring prolonged ventilation (>24h or re-intubation), renal failure requiring dialysis, bowel ischemia requiring surgery, major stroke or definitive paraplegia]; technical success; 30-day mortality; ruptures; spinal cord ischemia; endoleaks; re-interventions and target vessel patency. RESULTS Twenty studies were included. Overall study quality assessment was found to be low. Overall, 909 PMEGs were reported and analyzed. Regarding aneurysm location (n=867), 222 patients had extent I-III TAAAs and 645 had C-AAA or extent IV TAAA. Regarding presentation, 14 studies reported if the patients were treated in an elective or urgent setting (n=782 patients). Overall, 500 (63.9%) patients were treated in an elective setting and 282(36.1%) in an urgent setting. Major adverse events (at thirty-days) occurred in 15.5% of patients (95%CI:10.8;20.8;I2=63%,135/832cases), being 11.6%(95%CI:8.1;15.7;I2=0%,23/280 cases) for elective patients and 24.6% for urgent (95%CI:14.1;36.6;I2=65%,50/192cases). Overall technical success was 97.2%(95%CI:95.4;98.7;I2=0%,587/611cases), being 98.0%(95%CI:92.1;100;I2=0%,106/113cases) for extent I-III TAAAs and 99.4%(95%CI:97.5;100;I2=0%,317/324cases) for C-AAA and extent IV TAAAs. Regarding technique, technical success was 96.1% for FEVAR (95%CI:93.2;98.4;I2=0%,313/329cases) and 99.8% for F/B-EVAR (95%CI:99.8;100;I2=0%,17/18 cases). CONCLUSION Physician modified fenestrated or branched grafts for endovascular aortic repair seems feasible and safe in the short-term follow-up. However, the quality of the available data is low which highlights the need for better and more accurate data regarding this technique.
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Affiliation(s)
- Ryan Gouveia E Melo
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany.
| | | | - Daniel Caldeira
- Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Jan Stana
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
| | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, USA
| | - Nikolaos Tsilimparis
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
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Spinella G, Finotello A, Pisa FR, Conti M, Pratesi G, Pane B, Lanzarone E. Temporary Reperfusion of the Aneurysm Sac as a Prevention of Spinal Cord Ischemia After Endovascular Treatment of Thoracoabdominal Aortic Aneurysm: Systematic Review and Meta-analysis. J Endovasc Ther 2022; 30:323-335. [PMID: 35287499 DOI: 10.1177/15266028221082008] [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: 11/16/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is still a feared complication for patients suffering from thoracoabdominal aortic aneurysm (TAAA) who undergo endovascular treatment. The aims of this work are to review the available literature on different reperfusion methods of the aneurysm sac, and to analyze whether the different reperfusion methods, also in combination with other factors, are effective in reducing SCI risk and if the impact varies with the patient's age. METHODS PubMed/MEDLINE library was searched for studies published until November 2020 concerning TAAA, endovascular repair, and SCI preventive measures. Systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. Primary outcome consisted of correlation between endovascular repair techniques (type A: single step; type B: staged approach with reperfusion branches; type C: staged sequential approach with positioning of the thoracic component). A logistic-weighted regression for each event (SCI, transient, and permanent) was then performed with type of treatment, age, and interaction between them as input factors. Finally, another logistic-weighted regression was performed to analyze the other relevant factors for which observations are available together with the endovascular technique. RESULTS Data from 53 studies with a total of 3095 patients were analyzed. Type A, type B, and type C endovascular strategies were adopted in 75%, 13%, and 12% of studied patients, respectively. Data showed that both type B and type C treatments are associated with lower risk of SCI, with a higher reduction of type C with respect to type B, although this positive trend is limited for elder patients. Moreover, a greater aortic diameter, a reduced aneurysm extent, and the absence of cerebrospinal fluid drainage positioning contribute to lower the risk of SCI. Concerning permanent SCI, both type B and type C are effective in reducing percentages for all ages, with type C treatment more beneficial for younger patients and type B for elder ones. CONCLUSION According to the anatomy and the endovascular repair feasibility criteria, staged endovascular treatment appears to offer relevant advantages over single-step treatment in reducing the risk of SCI, regardless of the reperfusion method adopted.
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Affiliation(s)
- Giovanni Spinella
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Alice Finotello
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy.,Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Fabio Riccardo Pisa
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Bianca Pane
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
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Georgakarakos E, Karaolanis GI, Argyriou C, Papatheodorou N, Karangelis D, Georgiadis GS. Update on the TREO endograft device: overview of its safety and efficacy. Expert Rev Med Devices 2022; 19:31-35. [PMID: 34913785 DOI: 10.1080/17434440.2022.2020093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The TREO abdominal aortic stent graft system (Terumo Aortic, Sunrise, Fla) is a low-profile, trimodular endovascular endoprosthesis for the endovascular repair of abdominal aortic aneurysm (AAA). The objective of the present study was to collect and discuss all the available modern data of this device highlighting especially its mid-and long-term clinical results. AREAS COVERED This updated review article presents the most current results from great-scale clinical studies and the RATIONALE registry involving also angulated neck anatomies and challenging AAA geometries, reflecting the real-world experience. EXPERT OPINION The global, multicenter RATIONALE registry prospectively enrolled 202 patients (mean age 73.0 ± 7.8 years) who underwent EVAR. Technical success, primary clinical success and assisted primary patency rate was 96%, 92.2% and 97%, respectively. The clinical success at 1 year was 96%. Another multicenter, non-randomized, clinical trial confirmed also high technical and clinical success. Additionally, a comparative study comparing favorable and hostile necks in AAA, demonstrated a comparable technical success (95.2%), achieving proper sealing and technical success in the hostile neck group. TREO endograft seems to be safe and effective for EVAR, especially in hostile neck anatomies. Long-term outcomes from ongoing registries are awaited to complete these results.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina, School of Medicine, Ioannina, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Papatheodorou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimos Karangelis
- Department of Cardiac Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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Spanos K, Kölbel T, Heidemann F, Debus ES, Rohlffs F, Tsilimparis N. Early and mid-term durability of surgeon-modified and custom-made fenestrated devices for the treatment of complex aortic pathology. Ann Vasc Surg 2021; 83:212-221. [PMID: 34954035 DOI: 10.1016/j.avsg.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (F-EVAR) has allowed successful treatment of patients with complex aortic aneurysms. Custom-made devices (CMDs) are manufactured by companies and tailored to the patient's anatomy to incorporate target vessels, while there is also the "off label" alternative with the devices modified by a surgeon in the operating room: surgeon-modified FEVAR (sm-FEVAR). This study aims to present and compare technical durability of CMDs- and sm-FEVAR for complex abdominal and thoracoabdominal aortic pathologies. METHODS A retrospective cohort study was undertaken including all consecutive patients treated with sm- or CMD-FEVAR during a 3-year period in a single centre. Only cases with at least three reno-visceral target vessels were included. Primary outcomes were technical success, and freedom from endoleak (EL) (Ia or III; all branch related) and re-intervention during follow-up period. Mortality and morbidity were also recorded. RESULTS 32 sm-FEVAR patients (81,3% male) and 79 CMD-FEVAR patients (77,2% male) were included. Indication for sm-FEVAR was exclusively urgent, while all CMD- FEVAR were elective. Technical success was similar in sm-FEVAR (100%) and CMD-FEVAR (98,7%) (p=0.523). Mean follow-up was 16.3±13 and 20±17.3 months for sm-FEVAR and CMD- FEVAR, respectively (p=0.28). The freedom from EL Ia rate was 91.7% [standard error (SE) 5.7%] at 12 months in sm-FEVAR, while it was 97.7% (SE 2.2%) and 92.3% (SE 4.3%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.69). The freedom from EL III rate was 95.5% (SE 4.4%) and 88% (SE 8.2%) at 12 and 24 months, respectively in sm-FEVAR, while it was 92.1% (SE 3.8%) and 89.2% (SE 4.7%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.68). The freedom from re-intervention rate was 91.6% (SE 5.7%) and 84.6% (SE 8.6%) at 12 and 24 months, respectively in sm-FEVAR, while it was 91.7% (SE 4%) and 83.4% (SE 5.9%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.90). The survival rate was 87.5% (5.8%) and 76.3% (7.9%) at 1 and 12 months, respectively in sm-FEVAR, while it was 93.7% (2.7%) at 1 month in CMD-FEVAR without any other death during FU period. No bridging stent occlusions were noted during follow up period in any patient. CONCLUSION Sm-FEVAR offers good technical success and mid-term clinical outcomes in urgent cases of complex aortic pathologies. Its durability is acceptable and comparable to CMD-FEVAR with a relatively low re-intervention rate.
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Affiliation(s)
- Kostantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - E Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany; Department of Vascular Surgery, Hospital, LMU Munich, Munich, Germany
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21
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Kapetanios D, Stana J, Prendes CF, Stavroulakis K, Koelbel T, Rantner B, Tsilimparis N. [Acute Complex Endovascular Aortic Repair - Off-the-shelf vs. Surgeon-modified Stent Grafts]. Zentralbl Chir 2021; 146:521-527. [PMID: 34666365 DOI: 10.1055/a-1647-3549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Treatment of complex abdominal and thoracoabdominal aortic aneurysms is challenging. Open surgical repair is a high-risk operation, especially in emergency cases. Endovascular aneurysm repair with a patient-specific custom-made stent graft in patients with symptomatic or ruptured complex aortic aneurysms is not possible, due to the manufacturing time required. In such cases, alternative endovascular techniques can be used. RESULTS The "off-the-shelf" and "surgeon-modified" stent grafts are valid options for the endovascular treatment of complex aneurysms in urgent and emergent patients. The former are standardised commercially manufactured fenestrated or branched stent grafts, which are available off-the-shelf with an anatomical feasibility in 50 - 80% of the patients. The "surgeon-modified" stent grafts refer to a technique, in which a commercially available stent graft is modified by the surgeon under sterile conditions directly before the implantation, in order to add the required fenestrations, scallops and/or branches. The modification takes approximately 60 - 120 min and haemodynamic stability of the patient is mandatory. Because of the off-label use of the commercial stent graft, detailed patient consent about the modification complications and risks should be performed whenever possible. A comparison of results on mortality and morbidity between "off-the-shelf" and "surgeon-modified" stent grafts has been published, although a direct comparison would be unfair for several reasons (different design, lack of extensive outcomes reports, long learning curve and different modification techniques). CONCLUSION The "surgeon-modified" and "off-the-shelf" fenestrated/branched stent grafts are used in the treatment of high-risk patients with symptomatic or contained ruptured complex aneurysms. The outcomes of the two techniques are good, although the long-term durability of the former should be further investigated.
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Affiliation(s)
- Dimitrios Kapetanios
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Tilo Koelbel
- Gefäßchirurgie, Universitäres Herzzentrum, Hamburg, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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22
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Juszczak M, Vezzosi M, Nasr H, Claridge M, Adam DJ. Fenestrated-Branch Endovascular Repair After Prior Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 62:728-737. [PMID: 34474963 DOI: 10.1016/j.ejvs.2021.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/03/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report the outcome of fenestrated and branch endovascular aortic repair (FEVAR-BEVAR) for asymptomatic and acute symptomatic proximal aortic pathology in patients with prior open (OSR) or endovascular (EVAR) abdominal aortic aneurysm (AAA) repair. METHODS This was a single centre retrospective study of consecutive patients with non-ruptured (asymptomatic and acute symptomatic) proximal aortic pathology after prior OSR or EVAR treated between December 2007 and February 2020. The primary endpoint was 30 day/in hospital mortality. Secondary endpoints were technical success, primary clinical success, and Kaplan-Meier estimates of medium term survival and freedom from re-intervention. Data are presented as median (interquartile range [IQR]). The effect of covariates on medium term survival was estimated using multivariable (Cox proportional hazards model) analysis. A p value < .05 was considered to be statistically significant. RESULTS Ninety-two patients (83 men; median age 75 years [IQR 71 - 80 years]; median diameter 73 mm [IQR 64 - 89 mm]; 82 elective, 10 acute) underwent FEVAR-BEVAR after prior OSR (n = 47) or EVAR (n = 45). Indications for intervention were aneurysmal degeneration with or without type 1a endoleak (n = 57; four juxtarenal [JR] AAA, 21 extent II/III, 32 extent IV thoraco-abdominal aortic aneurysms); type 1a endoleak alone (n = 27) and to create a more durable repair after acute infrarenal EVAR (n = 8; JRAAA). In total, 348 renovisceral vessels were targeted for preservation and 324 were stent grafted. Twenty-four unstented vessels comprised one bypass, 11 scallops and six fenestrations intentionally not stent grafted, two vessels occluded before graft implantation, and four vessels occluded intra-operatively. Primary technical success was 95.6%. The thirty day mortality rate was 1.1% and one patient each (1.1%) required permanent dialysis or developed temporary spinal cord ischaemia. Early primary clinical success was 94.6%. Median follow up was 36 months (IQR 23 - 64 months). Estimated overall survival (± standard error) at one, two, and three years was 86% ± 4%, 85% ± 4%, and 70% ± 5%, respectively. Multivariable analysis did not demonstrate any independent predictors of survival. Four target vessels occluded during follow up. Nineteen patients underwent 28 late re-interventions, with almost half performed for issues arising distal to the FEVAR-BEVAR. Patients treated with a cuff were statistically significantly more likely to require distal re-intervention compared with those treated by relining (9/49 vs. 1/43, p = .018 [odds ratio 9.3, 95% confidence interval 1.2 - 423]). In patients with prior EVAR alone, this did not reach statistical significance (cuff 7/25 vs. relining 1/20, p = .059 [odds ratio 7.1, 95% confidence interval 0.8 - 350]). Estimated freedom from re-intervention at one, two, and three years was 88% ± 3%, 81% ± 4%, and 81% ± 4%, respectively. CONCLUSION FEVAR-BEVAR after prior OSR or EVAR is associated with low peri-operative morbidity and mortality, and acceptable medium term survival and freedom from re-intervention. Treatment with a FEVAR-BEVAR cuff is associated with a higher requirement for distal re-intervention than relining of the original repair.
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Affiliation(s)
- Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hosaam Nasr
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Jungi S, Sangalli Z, Schmidli J, Makaloski V. Surgeon-modified fenestrated endovascular aortic repair for ruptured anastomotic aneurysm after open thoracoabdominal repair. J Vasc Surg Cases Innov Tech 2021; 7:484-487. [PMID: 34381932 PMCID: PMC8339120 DOI: 10.1016/j.jvscit.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
We report the case of a 60-year-old female patient with a contained rupture of a proximal anastomotic pseudoaneurysm after previous open repair of a type IV thoracoabdominal aneurysm. A repeat open repair was considered to be too risky. We performed an urgent endovascular repair with a thoracic stent-graft and a surgeon-modified fenestrated aortic cuff with two fenestrations. The final angiogram and postoperative imaging studies showed complete aneurysm exclusion without any endoleak. Surgeon-modified fenestrated endovascular aortic repair is a feasible treatment option for emergency cases for which repeat open repair or custom-made complex endovascular repair is not an option.
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Affiliation(s)
- Silvan Jungi
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Zoe Sangalli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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24
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Canonge J, Jayet J, Heim F, Chakfé N, Coggia M, Coscas R, Cochennec F. Comprehensive Review of Physician Modified Aortic Stent Grafts: Technical and Clinical Outcomes. Eur J Vasc Endovasc Surg 2021; 61:560-569. [PMID: 33589325 DOI: 10.1016/j.ejvs.2021.01.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/01/2021] [Accepted: 01/13/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Physician modified stent grafts (PMSGs) present satisfactory results in selected cases of complex aortic pathologies. However, the technique lacks standardisation and depends on the surgeon and aortic segment. The aim of this article is to review comprehensively the technical details and clinical results of PMSGs related to patients with pathology in all aortic locations. METHODS A MEDLINE search (last search 20 April 2020) identified 20 relevant papers in the English language published over the last 20 years evaluating clinical outcomes after a PMSG and specifying the technical details to design it. RESULTS Seven hundred and eleven patients were included in the analyses, with 59% being operated on as an emergency. Ninety-two per cent of abdominal aortic segment PMSGs (A-PMSGs) were performed either as an emergency or before 2012. The main indications were available in 670 cases; 435 were degenerative aneurysms (64.9%) and 171 were aortic dissections (25.5%). Most of the endografts used were composed of polyethylene terephthalate, except for the Ankura (expanded polytetrafluoroethylene [Lifetech Scientific, Shenzhen, China]; n = 50, 7.5%). The Valiant (Medtronic, Minneapolis, MN, USA) represented 65% (n = 169) of aortic arch PMSGs (aa-PMSGs) and the Zenith platform (Cook Medical, Bloomington, IN, USA) 51% (n = 139) of A-PMSGs. A snare was used to reinforce the fenestration in 458 PMSGs (66%) and a cautery device cut the fenestration in 484 (75%) PMSGs. No bridging stent was used in 47 (7.0%) PMSGs (these aa-PMSGs had large fenestrations). Technical success ranged from 87.5% to 100% and 30 day mortality from 0% to 8%. Primary branch patency ranged from 96.3% to 100% at 12 month follow up. Zero to 14% of patients experienced type 3 or type 1 endoleak at 14.8 month follow up. CONCLUSION PMSG is a useful technique, particularly when validated treatments are not available. However, it is a non-standardised technique and the long term consequences of modifications remain unknown.
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Affiliation(s)
- Jennifer Canonge
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France; Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), Strasbourg, France
| | - Jérémie Jayet
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), Strasbourg, France; Department of Vascular Surgery, Pitié-Salpétrière University Hospital, Paris, France.
| | - Frédéric Heim
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), Strasbourg, France
| | - Nabil Chakfé
- Groupe Européen de Recherche sur les Prothèses Appliquées à la Chirurgie Vasculaire (GEPROVAS), Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, Strasbourg University, Strasbourg, France
| | - Marc Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France; Paris Est Créteil University (UPEC), INSERM-IMRB U955, CEpiA team (Clinical Epidemiology and Ageing), Créteil, France
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25
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Tong YH, Yu T, Zhou MJ, Liu C, Zhou M, Jiang Q, Liu CJ, Li XQ, Liu Z. Use of 3D Printing to Guide Creation of Fenestrations in Physician-Modified Stent-Grafts for Treatment of Thoracoabdominal Aortic Disease. J Endovasc Ther 2020; 27:385-393. [PMID: 32517556 DOI: 10.1177/1526602820917960] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To summarize the experience and outcomes of total endovascular repair of thoracoabdominal aortic disease using 3-dimensional (3D) printed models to guide on-site creation of fenestrations in aortic stent-grafts. Materials and Methods: From April 2018 to March 2019, 34 patients (mean age 58±14 years; 24 men) with thoracoabdominal aortic disease were treated in our department. Nineteen patients had thoracoabdominal aortic dissection and 15 had thoracoabdominal aortic aneurysm. Preoperatively, a 3D printed model of the aorta was made according to computed tomography images. In the operating room, the main aortic stent-graft was completely released in the 3D printed model, and the position of each fenestration or branch was marked on the stent-graft. The fenestrations were then made using an electric pen. Wires were sewn to the edge of the fenestrations using nonabsorbable sutures. After customization, the aortic stent-graft was reloaded into the delivery sheath and deployed. Results: The printing process took ~5 hours (1 hour for image reconstruction, 3 hours for printing, and 1 hour for postprocessing). The physician-modified stent-grafts had a total of 107 fenestrations secured by 102 bridging stent-grafts, including 73 covered stents and 29 bare stents. The average procedure time was 5.6±1.2 hours, including a mean 1.3 hours for stent-graft customization. No renal insufficiency or paraplegia occurred. Two branch arteries were lost during the operation. One patient (3%) died 1 week after surgery from a retrograde dissection rupture. One patient developed a minor cerebral infarction postoperatively. The mean follow-up time was 8.5 months. There was 1 endoleak from a fenestration (coil embolized) and 4 distal ruptures of the aortic dissection (3 treated and 1 observed). Conclusion: Three-dimensional printing can be used to guide creation of fenestrated stent-grafts for the treatment of thoracoabdominal aortic diseases involving crucial branches. This technique appears to be more accurate than the traditional measurement method, with short-term follow-up demonstrating the safety and reliability of the method. However, further research and development are needed.
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Affiliation(s)
- Yuan-Hao Tong
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tong Yu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Min-Jie Zhou
- Biological 3D Printing Institute of Nanjing University, Nanjing, China
| | - Chen Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qing Jiang
- Biological 3D Printing Institute of Nanjing University, Nanjing, China
| | - Chang-Jian Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiao-Qiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Biological 3D Printing Institute of Nanjing University, Nanjing, China
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26
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Georgiadis GS, Koutsoumpelis A, Tsilimparis N. Commentary: Physician-Modified Fenestrated/Branched EVAR and Hybrid Techniques for Acute Thoracoabdominal Aortic Pathologies: Inequality When Comparing Alternative Options With Different Philosophies Does Not Equal Lower Quality. J Endovasc Ther 2020; 27:757-763. [PMID: 32580674 DOI: 10.1177/1526602820934469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Evros, Alexandroupolis, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Evros, Alexandroupolis, Greece
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
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