Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair

Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study

Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.

Expert-Based Narrative Review on Contemporary Use of an Off-The-Shelf Multibranched Endograft for Endovascular Treatment of Thoracoabdominal Aortic Aneurysms: Device Design, Anatomical Suitability, Technical Tips, Perioperative Care, Clinical Applications, and Real-World Experience

Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm patients have anatomic limitations to fenestrated stent-grafts given a large lumen, that is, the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, IN), which has been commercially available in Europe to treat thoracoabdominal aortic aneurysm since June 2012, represents a feasible off-the-shelf alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior endovascular aneurysm repair), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been carried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

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.

Systematic Review and Meta-analysis of Short-term and Mid-term Outcomes After Use of t-Branch Off-the-shelf Multibranched Endograft for Elective and Urgent Treatment of Thoracoabdominal Aortic Aneurysms

OBJECTIVE

To conduct a meta-analysis to assess the safety and efficacy of t-Branch off-the-shelf multibranched endograft for the treatment of thoracoabdominal aortic aneurysm (TAAA).

DATA SOURCES

PubMed, Embase, and Web of Science.

REVIEW METHODS

Online databases were searched from June 2012 to March 2023. The data were pooled together using a random-effects model of proportions. The outcomes overall included technical success, spinal cord ischemia, target vessel occlusion, type I or III endoleak, reintervention, early mortality (30-day), and mid-term outcomes. Subgroup meta-analyses and meta-regression were performed to explore variation among studies.

RESULTS

A total of 15 studies containing 1238 patients were included in the meta-analysis. The overall study quality assessment was found to be moderate to good. The pooled technical success was 97.0% (95% confidence interval [CI]=95.5-98.6, I2=53.01%, 1185/1238 cases, 15 studies). Overall, early mortality was 7.3% (95% CI=4.4-10.1, I2=74.48%, 124/1238 cases, 15 studies). Early spinal cord ischemia was 13.4% (95% CI=9.6-17.2, I2=67.24%, 160/1238 cases, 15 studies), and early type I or III endoleak was 6.0% (95% CI=3.4-8.5, I2=53.71%, 68/1032 cases, 9 studies). Mid-term outcomes showed target vessel occlusion was 4% (95% CI=1.4-6.5, I2=65.18%, 28/528 cases, 10 studies, 5-21.2 months), type I or III endoleak was 4.7% (95% CI=2-7.5, I2=49.74%, 38/512 cases, 10 studies, 5-21.2 months), reintervention was 11.2% (95% CI=8.1-14.3, I2=31.06%, 85/650 cases, 10 studies, 5-21.2 months), and pooled mortality was 13.9% (95% CI=7.2-20.7, I2=76.32%, 84/550 cases, 11 studies, 5-21.2 months). Meta-regression found a significant linear association between higher technical success and earlier publication year (p=0.014) and studies with anatomic inclusion criteria (p=0.037). Urgent patients (p=0.021) and later publication year (p=0.048) were significantly associated with higher early mortality.

CONCLUSION

The use of the off-the-shelf t-Branch multibranched endograft for elective or urgent endovascular TAAA repair is associated with high technical success rates and proved to be safe and effective at early and mid-term follow-up. However, the heterogeneity between the included studies is high, and prospective, randomized studies along with future larger studies with long-term follow-up are needed.

CLINICAL IMPACT

The Zenith t-Branch (Cook Medical, Bloomington, Ind) was approved as a commercially available device in Europe in June 2012. Although a decade has past, the outcomes of t-Branch have rarely been synthesized at the global level. This meta-analysis included 15 studies containing 1238 patients. The meta-analyses included technical success, major adverse events, reintervention, early mortality, and mid-term outcomes. The outcome was very meaningful and representative for the use of t-Branch. It is helpful for endovascular surgeons to make decisions on the treatment of TAAA patients.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Stent-Graft Fabrics Incorporating a Specific Corona Ready to Fenestrate

In situ fenestration of endovascular stent-grafts has become a mainstream bailout technique to treat complex emergent aneurysms while maintaining native anatomical visceral and aortic arch blood supplies. Fabric tearing from creating the in situ fenestration using balloon angioplasty may extend beyond the intended diameter over time. Further tearing may result from the physiologic pulsatile motion at the branching site. A resultant endoleak at the fenestrated sites in stent-grafts could ultimately lead to re-pressurization of the aortic sac and, eventually, rupture. In an attempt to address this challenge, plain woven fabrics were designed. They hold a specific corona surrounding a square-shaped cluster with a plain weave fabric structure, a 2/2 twill, or a honeycomb. The corona was designed to stop potential further tearing of the fabric caused by the initial balloon angioplasty and stent or later post-implantation motion. The cluster within the corona was designed with relatively loose fabric structures (plain weave, 2/2 twill weave, and honeycomb) to facilitate the laser fenestration. Two commercial devices, Anaconda (Vascutek, Terumo Aortic) and Zenith TX2 (Cook), were selected as controls for comparison against this new design. All the specimens were characterized by morphology, thickness, and water permeability. The results demonstrated that all specimens with a low thickness and water permeability satisfied the requirements for a stent graft material that would be low profile and resistant to endoleaks. The in situ fenestrations were performed on all fabrics utilizing an Excimer laser followed by balloon angioplasty. The fabrics were further observed by light microscopy and scanning electron microscopy. The dimension of the fenestrated apertures was smaller than the balloon's diameter. The tearing was effectively confined within the corona. The clinical acceptability of this concept deserves additional bench testing and animal experimentation.

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes of Directional Branches of the T-Branch Off-the-Shelf Multi-Branched Stent-Graft

Background: A controversy on bridging covered stent (BCS) choice, between self-expanding (SECS) and balloon-expandable (BECS) stents, still exists in branched endovascular repair. This study aimed to determine the primary target vessel (TV) patency in patients treated with the t-Branch device and identify factors impairing the outcomes. Methods: A retrospective study was undertaken, including patients treated with the t-Branch (Cook Medical, Bloomington, IN, USA) between 2014 and 2019 (early 2014–2016; late 2017–2019). The endpoint was the primary patency (CT: celiac trunk, SMA, superior mesenteric artery, RRA: right renal artery, LRA: left renal artery) during the follow-up. Any branch instability event was assessed. The factors affecting the patency were determined using multivariable regression models and Kaplan–Meier analyses. Results: In total, 2018 TVs were analyzed; 1542 SECSs and 476 BECSs. The CT patency was 99.8% (SE 0.2%) at the 1st month, with no other event. The SMA patency was 97.8% (SE 1) at the 12th month. The RRA patency was 96.7% (SE 2) at the 24th month. The LRA patency was 99% (SE 0.4) at the 6th month. Relining was the only factor independently associated with the SMA patency (OR 8.27; 95% CI 1.4–4.9; p = 0.02). The freedom from instability was 62% (SE 4.3%) and 45% (SE 5.4%) at the 24th month and 36th month. No significant difference was identified between the BECSs and SECSs in the early or late experience. Conclusion: BCS for the t-Branch branches performed with a good primary patency during the short-term follow-up. The type of BCS did not influence the patency. Relining might be protective for SMA patency.

[Status of the Inner Branches in Complex Endovascular Aortic Repair]

Complex endovascular therapy of the aorta with fenestrated and branched endografts plays an essential role in modern vascular medicine. Innovative solutions for demanding aortic pathologies are therefore being constantly developed by the medical industry. The aim of this manuscript is to illustrate the growing importance of the inner branches in complex aortic repair and to show the advantages and limits of this technique with an overview of the current literature. The inner branches (iBEVAR) were therefore compared to the standard treatment options (fenestrations; [FEVAR], outer branches [BEVAR]) and the technical advantages of all platforms were evaluated. The widespread use of iBEVAR in the aortic arch stands in contrast to the thoracoabdominal aorta, which is mirrored by the scarce evidence for the thoracoabdominal inner branches. The published experience is based on smaller retrospective studies with a 1-year follow-up. The E-nside (Artivion, Hechingen, Germany) thoracoabdominal off-the-shelf inner-branch-based endograft was released 2 years ago. Its widespread deployment may increase the use of the inner branches in the thoracoabdominal aorta. Moreover, an ongoing industry-funded registry may provide new insights into the long-term durability of this innovative technique.

Outcomes of multibranched off-the-shelf stent graft in elective and urgent/emergent repair of complex aortic aneurysms with narrow internal aortic lumen

OBJECTIVES

To assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft (Cook Medical, Bloomington, IN, USA) in the treatment of complex aortic aneurysms with narrow internal aortic lumen.

METHODS

Between 2016 and 2020, 48 patients (mean age 73 years) underwent elective or urgent/emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in 2 Italian vascular centers. Among these, 20 patients presented a paravisceral/pararenal luminal diameter < 25 mm. Major clinical and radiological outcomes of patients with narrow aortic lumen were compared with patients with larger lumen in a multicenter, non-randomized, retrospective fashion.

RESULTS

The in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range 1 - 63), late t-Branch procedure-related mortality and the need for re-intervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (Group 1) with patients with small lumen (Group 2), no significant difference was found regarding fluoroscopy time (p = 0.3), technical success (p = 1), early (p = 0.4) and late (p = 1) mortality, spinal cord ischemia (p = 0.2), bowel ischemia (p = 0.5), renal (p = 0.7), cardiac (p = 1), and respiratory complications (p = 1), re-intervention rate (p = 1), and primary patency rate of stented target vessels (p = 1).

CONCLUSION

The use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible also when maneuverability is reduced, with low mortality and morbidity, and acceptable re-intervention need. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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.

Endovascular treatment of thoracoabdominal aortic aneurysms

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

Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms

OBJECTIVE

Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed.

METHODS

The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI.

RESULTS

A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS).

CONCLUSIONS

For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.

Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair

OBJECTIVE

The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair.

METHODS

Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency.

RESULTS

A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002).

CONCLUSIONS

F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.

Early outcomes of t-Branch off-the-shelf multibranched stent-graft in urgent and emergent repair of thoracoabdominal aortic aneurysms

OBJECTIVE

We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent-graft (Cook Medical, Bloomington, Ind).

METHODS

All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests.

RESULTS

The t-Branch stent-graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively.

CONCLUSIONS

The technical success of TAAA repair using t-Branch stent-graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair

OBJECTIVE

The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms.

METHODS

We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts.

RESULTS

There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD.

CONCLUSIONS

Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.