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Santos-Venâncio M, Rocha-Neves J, Spath P, Oliveira-Pinto J. Complications and Technical Success on Upper Limb Vascular Access for Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:433-443. [PMID: 39059630 DOI: 10.1016/j.avsg.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Catheterization of target vessels (TV) represented by renal visceral vessels are the crucial aspect during fenestrated and branched endovascular repair. This study aims to assess the efficacy and complications associated with upper limb catheterization during complex aneurysm endovascular surgery repair. METHODS A systematic review was conducted after Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, involving a search across PubMed, Cochrane CENTRAL, and Web of Science. Primary endpoint was represented by 30-day stroke. Secondary endpoints were target vessels' (TVs) technical success, 30-day mortality, and local access-related complications. Meta-analyses were performed using a random-effects model. RESULTS Sixteen observational studies encompassing 4,137 patients were included. The 30-day stroke incidence for upper limb access was 1.4% (95% CI 1.0-1.8%), which was slightly higher than lower limb, despite not statistically significant. Mortality varied between 0 and 6.8%, and local access-related complications occurred in 3.2% (95% CI 1.9-4.4%). Technical success in TV catheterization was 99.2% (95% CI 98.4-100.0%). CONCLUSIONS This systematic review and meta-analysis demonstrate the safety and efficacy of upper limb access for Fenestrated and Branched Endovascular Aortic Repair (f/b-EVAR), with low stroke risk, mortality rates, and minimal local complications. Despite the risk of bias, the findings suggest that upper limb access may be beneficial, especially in bailout situations when femoral access fails, offering valuable insights for clinical decision-making.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; RISE@Health, Porto, Portugal.
| | - Paolo Spath
- Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy; Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Ludwig-Maximilians-Universitat Munchen, Vascular Surgery Marchionisteße Munchen, Bayern, Germany
| | - José Oliveira-Pinto
- RISE@Health, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Sarhan DYA, Kölbel T, Grandi A, Nana P, Torrealba JI, Behrendt CA, Panuccio G. The Role of Downsizing of Large-Bore Percutaneous Femoral Access for Pelvic and Lower Limb Perfusion in Transfemoral Branched Endovascular Aortic Repair. J Clin Med 2024; 13:5375. [PMID: 39336864 PMCID: PMC11432116 DOI: 10.3390/jcm13185375] [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: 08/19/2024] [Revised: 09/07/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Transfemoral access (TFA) is a valuable alternative to upper extremity access (UEA) for branched endovascular aortic repair (bEVAR). However, TFA requires large introducer sheaths, which can reduce blood flow to lower limbs and the pelvis. This study aimed to evaluate the efficacy of sheath downsizing to maintain lower limb perfusion during TFA-bEVAR. Methods: A single-center retrospective review was conducted including patients managed with TFA-performed bEVAR between December 2020 and May 2021. Intra-operative lower limb perfusion was assessed using non-invasive ankle blood pressure measurements and great toe pulse oximetry, with measurements being taken prior to puncture (baseline), one minute after 10F-sheath insertion, three minutes after the main body delivery system insertion, and three minutes after downsizing to a 14F sheath. Outcomes included the incidence of limb perfusion reduction (LPR), defined as a drop in the ankle-brachial index (ABI) < 0.5 or peripheral oxygen saturation (SpO2) < 90%. Results: Out of 47 patients, 24 met the inclusion criteria. LPR occurred in 4.2% of cases after 10F-sheath placement, and 87.5% after main body delivery system placement, and decreased to 12.6% after downsizing to a 14F sheath. No periprocedural major bleeding occurred. Two patients required revision for inadequate hemostasis post-operatively. SCI occurred in 16% of patients, all recovered by discharge. Pre-operative hypogastric artery occlusion was related to persistent LPR after downsizing (100% vs. 16%, p = 0.009). Conclusions: Downsizing the introducer sheath during bEVAR is feasible and safe to restore lower limb and pelvic perfusion. Further research is needed to clarify the access downsizing value during bEVAR.
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Affiliation(s)
- Daour Yousef Al Sarhan
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Alessandro Grandi
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Petroula Nana
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - José I Torrealba
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Christian-Alexander Behrendt
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
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Dias NV, Karelis A, Oderich GS, Sonesson B. Double-Cuff Bidirectional Branch in Endovascular Aortic Repair: A New Way of Increasing the Flexibility of Inner Branch Endografting. J Endovasc Ther 2024; 31:548-551. [PMID: 36482664 DOI: 10.1177/15266028221139200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE The purpose of the study was to describe the design and implantation of a branched stent-graft during endovascular aortic repair incorporating double-cuff bidirectional inner branch. TECHNIQUE A new double-cuff bidirectional antegrade and retrograde inner branched stent-graft with large diamond-shaped fenestration was designed for incorporation of a splenic artery. The inner cuffs of the branch were accessible using brachial and/or femoral access. The splenic artery was originating from an aortic segment with narrow inner aortic luminal diameter in a patient with extent IV thoracoabdominal aortic aneurysm with bilobed configuration. The retrograde, more distal inner cuff of the branch was extended into the splenic artery using a self-expandable bridging stent-graft from the femoral approach, whereas the antegrade, more proximal inner cuff of the branch was intentionally occluded using an endovascular plug. The recovery was uneventful and a computed tomography angiography 30 days postoperatively showed patency of all the target vessels without signs of endoleaks. CONCLUSION This is the first design of a double-cuff bidirectional inner branched stent-graft. The technique can potentially expand the applications of directional branches to patients with more difficult anatomy in the thoracoabdominal or aortic arch segments. Potential indications are patients with target arteries that are not ideally suited for caudally-oriented branches, patients with accessory vessels, or targets with early branch bifurcations. CLINICAL IMPACT This report describes the use of a branched endograft with a new double-cuff bidirectional branch that can potentially address many of the limitations of current BEVAR solutions, such as early bifurcations, double arteries with adjacent origins and arteries with less favorable trajectories for the traditional caudally-oriented branches.
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Affiliation(s)
- Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Angelos Karelis
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Division of Vascular and Endovascular Surgery, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
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Torrealba JI, Kölbel T, Rohlffs F, Spanos K, Panuccio G. Branched Endovascular Aortic Repair After a Migrated EVAR Bypassing a Severely Kinked Previous Endograft. J Endovasc Ther 2024; 31:533-540. [PMID: 36342138 DOI: 10.1177/15266028221134888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To describe a novel technique to repair a juxtarenal abdominal aortic aneurysm (JAAA) after failed endovascular aortic repair (EVAR) with severely kinked anatomy. TECHNIQUE We present a patient who underwent an EVAR with a Medtronic Talent device 15 years ago and a proximal cuff extension 3 years earlier for an abdominal aortic aneurysm. Computed tomography (CT) done for a known gastritis showed a 12 cm JAAA, with a migrated endograft and a type Ia endoleak (EL). Endovascular repair was performed, accessing and navigating the aneurysmal sac outside the previous graft. The type I EL was reached and the suprarenal aorta catheterized. A 4-vessel inner-branched EVAR device was deployed in the distal thoracic aorta and their target vessels bridged through femoral access. A distal bifurcated component was deployed and both iliac limbs were extended to the native distal iliac arteries. Completion angiogram as well as early and 12-month CT showed a fully patent straight course branched EVAR with no ELs. CONCLUSION Complex aortic reinterventions in the presence of previous EVAR can be performed by choosing a straighter course along and parallel to the previous endograft. Several technical aspects must be considered to successfully perform this type of reinterventions. CLINICAL IMPACT We present a technique of a complex endovascular aortic repair in a failed EVAR with kinked anatomy, navigating through the thrombosed aneurysmal sac, outside the previously placed endograft and thus obtaining a straighter path for a new branched endograft. The novelty lies in a different approach to repair a failed EVAR with a branched graft through an uncommon access on the side of the previous endograft, avoiding repeated displacement or occlusion of the new endograft. We exemplify the feasibility of such a complex procedure and highlight important steps to perform it, whether in the abdominal or even thoracic Aorta.
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Affiliation(s)
| | - Tilo Kölbel
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
| | - Fiona Rohlffs
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
| | - Konstantinos Spanos
- Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Giuseppe Panuccio
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
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Ruiter Kanamori L, Tenorio ER, Babocs D, Savadi S, Baghbani-Oskouei A, Huang Y, Figueroa A, Tanenbaum M, Costa Filho JE, Baig M, Macedo TA, Timaran CH, Oderich GS. Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections. J Vasc Surg 2024:S0741-5214(24)01660-4. [PMID: 39074740 DOI: 10.1016/j.jvs.2024.07.089] [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: 04/19/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Endovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. METHODS We reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). RESULTS Among 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. CONCLUSIONS TES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.
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Affiliation(s)
- Lucas Ruiter Kanamori
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Dora Babocs
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andres Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose Eduardo Costa Filho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mirza Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thanila A Macedo
- Department of Diagnostic Radiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
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Piazza M, Squizzato F, Ferri M, Pratesi G, Gatta E, Orrico M, Giudice R, Antonello M. Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft. J Vasc Surg 2024:S0741-5214(24)01235-7. [PMID: 38908806 DOI: 10.1016/j.jvs.2024.05.056] [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: 04/15/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). METHODS Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. RESULTS Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. CONCLUSIONS The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Matteo Orrico
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Enzmann FK, Grandi A, Panuccio G, Torrealba JI, Kluckner M, Nana P, Rohlffs F, Kölbel T. Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair. J Endovasc Ther 2024:15266028241251985. [PMID: 38708984 DOI: 10.1177/15266028241251985] [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: 05/07/2024]
Abstract
PURPOSE The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.
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Affiliation(s)
- Florian K Enzmann
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - José Ignacio Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Kluckner
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Mesnard T, Vacirca A, Baghbani-Oskouei A, Sulzer TAL, Savadi S, Kanamori LR, Tenorio ER, Mirza A, Saqib N, Mendes BC, Huang Y, Oderich GS. Prospective evaluation of upper extremity access and total transfemoral approach during fenestrated and branched endovascular repair. J Vasc Surg 2024; 79:1013-1023.e3. [PMID: 38141739 DOI: 10.1016/j.jvs.2023.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Total transfemoral (TF) access has been increasingly used during fenestrated-branched endovascular aortic repair (FB-EVAR). However, it is unclear whether the potential decrease in the risk of cerebrovascular events is offset by increased procedural difficulties and other complications. The aim of this study was to compare outcomes of FB-EVAR using a TF vs upper extremity (UE) approach for target artery incorporation. METHODS We analyzed the clinical data of consecutive patients enrolled in a prospective, nonrandomized clinical trial in two centers to investigate the use of FB-EVAR for treatment of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA) between 2013 and 2022. Patients were classified into TF or UE access group with a subset analysis of patients treated using designs with directional branches. End points were technical success, procedural metrics, 30-day cerebrovascular events defined as stroke or transient ischemic attack, and any major adverse events (MAEs). RESULTS There were 541 patients (70% males; mean age, 74 ± 8 years) treated by FB-EVAR with 2107 renal-mesenteric TAs incorporated. TF was used in175 patients (32%) and UE in 366 patients (68%) including 146 (83%) TF and 314 (86%) UE access patients who had four or more TAs incorporated. The use of a TF approach increased from 8% between 2013 and 2017 to 31% between 2018 and 2020 and 96% between 2021 and 2022. Compared with UE access patients, TF access patients were more likely to have CAAAs (37% vs 24%; P = .002) as opposed to TAAAs. Technical success rate was 96% in both groups (P = .96). The use of the TF approach was associated with reduced fluoroscopy time and procedural time (each P < .05). The 30-day mortality rate was 0.6% for TF and 1.4% for UE (P = .67). There was no early cerebrovascular event in the TF group, but the incidence was 2.7% for UE patients (P = .035). The incidence of MAEs was also lower in the TF group (9% vs 18%; P = .006). Among 237 patients treated using devices with directional branches, there were no significant differences in outcomes except for a reduced procedural time for TF compared with UE access patients (P < .001). CONCLUSIONS TF access was associated with a decreased incidence of early cerebrovascular events and MAEs compared with UE access for target artery incorporation. Procedural time was decreased in TF access patients irrespective of the type of stent graft design.
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Affiliation(s)
- Thomas Mesnard
- 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
| | - 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
| | - Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem Mirza
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Naveed Saqib
- 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
| | - 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
| | - 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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Goyal A, Fatima L, Mushtaq F, Tariq MD, Kamran A, Sohail AH, Chunawala Z, Sulaiman SA, Shrestha AB, Sheikh AB, Belur AD. Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta-analysis. Catheter Cardiovasc Interv 2024; 103:982-994. [PMID: 38584518 DOI: 10.1002/ccd.31048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access-site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random-effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40-0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38-0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32-0.53, p < 0.00001], and shortens fluoroscopy time [SMD: -0.62; 95% CI: -1.00 to -0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: -0.33; 95% CI: -0.61 to -0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30-day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large-scale randomized controlled trials are warranted to confirm and strengthen these findings.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Laveeza Fatima
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Fiza Mushtaq
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan
| | - Aemen Kamran
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Zainali Chunawala
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Samia Aziz Sulaiman
- Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | | | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Agastya D Belur
- Department of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
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10
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Torrealba JI, Panuccio G, Rohlffs F, Nana P, Toader RI, Arulrajah K, Kölbel T. The Electrified Wire Technique in Complex Aortic Interventions: A Case Series. J Endovasc Ther 2024:15266028241245341. [PMID: 38597263 DOI: 10.1177/15266028241245341] [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: 04/11/2024]
Abstract
OBJECTIVES Electrosurgery has been long used in endovascular procedures, with only case reports in the aortic field. Our aim is to present a case series with the use of an electrified wire to perform catheter-based electrosurgery by applying external current through an electrocautery pen. METHODS Single-center retrospective case series of all patients undergoing complex aortic surgery from October 2020 to August 2023, in whom the electrified wire technique was used: (1) Perforation of a dissection flap or left subclavian artery (LSA) in situ endograft fenestration-a 0.014" polytetrafluoroethylene (PTFE) insulated guidewire is detached from the insulation with a scalpel at the end and a cautery pen is here attached with a clamp. A curved tip catheter or sheath is positioned against the aortic flap or the endograft (through a left brachial access in this case) and the wire pushed, crossing the flap by activating the electrocautery pen and (2) slicing a dissection flap ("powered cheese-wire technique")-after same preparation as above, the middle section of the 0.014 guidewire is removed from the PTFE and bent into a V-shape. Once in the aorta, the guidewire crosses from the true lumen (TL) to the false lumen (FL) and a through-and-through access is obtained. Sheaths are positioned against the flap from both sides and moved up or down while the electricity is activated, slicing the flap and communicating both lumens. Technical success and technical-related complications were evaluated. RESULTS Eleven cases concerning aortic dissections and 1 case of aortic atresia were treated. Four patients presented urgently, whereas the rest were planned procedures. Seven cases underwent perforation of a dissection flap, 2 cases underwent the powered cheese-wire technique, in 2 cases for an LSA in situ fenestration, and in 1 case to cross an aortic atresia at the aortic isthmus. The technique was in all cases successfully applied. No complications related to the technique occurred. CONCLUSIONS The "electrified wire" technique is a feasible and ready-available tool that can be safely used in complex aortic interventions, especially to perforate aortic tissue like dissection flaps or to perform in situ fenestrated repairs by perforation of the endograft fabric. CLINICAL IMPACT The electrified wire technique described herein is a straightforward technique that uses readily available tools to perform electrosurgery. We present its use in complex aortic procedures. However, it could be envisioned for any vascular procedure that requires crossing of the vessel or even prosthetic material. As we have described in this series, when used along with an adequate properative planning, it can be a safe tool of great utility, as has already been demonstarted in the field of the interventional cardiology.
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Affiliation(s)
- Jose I Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Radu-Ionut Toader
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Kugarajah Arulrajah
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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11
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Nana P, Panuccio G, Rohlffs F, Torrealba JI, Tsilimparis N, Kölbel T. Early and midterm outcomes of fenestrated and branched endovascular aortic repair in thoracoabdominal aneurysms types I through III. J Vasc Surg 2024; 79:457-468.e2. [PMID: 38453660 DOI: 10.1016/j.jvs.2023.10.043] [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: 08/24/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Fenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs. METHODS A single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes. RESULTS F/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution. CONCLUSIONS Endovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany.
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Jose I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | | | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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12
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Nana P, Koelemay MJW, Leone N, Brodis A, van den Berg JC, de Bruin JL, Geelkerken RH, Spanos K. A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2023; 66:632-643. [PMID: 37451604 DOI: 10.1016/j.ejvs.2023.07.011] [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: 03/16/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Mark J W Koelemay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Konstantinos Spanos
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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13
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Patel RJ, Sibona A, Malas MB, Lane JS, Al-Nouri O, Barleben AR. Upper Extremity Access Has Worse Outcomes in F/BEVAR Using the VQI Dataset. Ann Vasc Surg 2023; 97:184-191. [PMID: 37574045 PMCID: PMC10841218 DOI: 10.1016/j.avsg.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Physician-modified endografts and custom-manufactured devices use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally, many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity (UEM) access from a transfemoral approach. Single-institution studies have demonstrated increased risks of access site complications and stroke when UEM access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed UEM access. METHODS This study is an analysis of the Vascular Quality Initiative for all patients who underwent F/BEVAR from 2014 to 2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction (MI), and perioperative death. Secondary outcomes included access site hematoma, occlusion or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed. RESULTS Three thousand one hundred forty six patients underwent an F/BEVAR: 2,309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 vs. 297 min, P < 0.001) and fluoroscopy time (62 vs. 80 min, P < 0.001) in the TTF group and no difference in technical success between groups (96% vs. 97%, P = 0.159). Finally, there was a decrease in access site hematoma 2.54% vs. 4.31% (P = 0.013), access site occlusion 0.61% vs. 1.91% (P = 0.001), and extremity embolization 2.17% vs. 3.58% (P = 0.026) in the TTF versus UEM group. CONCLUSIONS This study using Vascular Quality Initiative data demonstrates that patients who undergo an F/BEVAR using UEM access have an increased risk of perioperative MI, death, and stroke compared to TTF access.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Agustin Sibona
- Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA.
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14
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Torrealba J, Grandi A, Nana P, Panuccio G, Rohlffs F, Kölbel T. Transfemoral Access to Implant Iliac Branch Devices After Previous Aortic Grafts. J Endovasc Ther 2023:15266028231208657. [PMID: 37902437 DOI: 10.1177/15266028231208657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
OBJECTIVE To report on the outcomes of patients undergoing an iliac branch device implantation after previous open or endovascular aorto-biliac repair, using exclusively femoral access for catheterization and delivery of the covering stent to the hypogastric artery. METHODS Single-center retrospective study in which all patients in whom an iliac branch device was implanted after previous open or endovascular aorto-biliac repair were identified. Patients in whom the hypogastric artery catheterization and delivery of the bridging cover stent were achieved via exclusive femoral access were included. Different techniques were used based on surgeon preference. Technical success and access-related complications, as well as iliac branch device endoleak or occlusions during follow-up, were evaluated. RESULTS From 2015 to 2021, 28 patients with a prior open or endovascular aorto-biliac repair underwent 34 iliac branch device implantations. Most (71%) had juxtarenal or thoracoabdominal aortic aneurysms, 82% had common iliac artery aneurysms, and 25% had hypogastric artery aneurysms. Bilateral iliac branch device implantations were performed in 21% of the patients, and in 26% of cases, landing in the superior gluteal artery was obtained. An "up-and-over" technique from the contralateral groin was used in 65% of the cases, and a steerable sheath in 35%. Technical success was 94%, with no complications related to access or technique to catheterize and deliver the stents in the hypogastric artery. The cohort had 20% of major complications, with 3 perioperative deaths. Kaplan-Meier estimated an iliac branch device freedom from occlusion and endoleak was 92% and 83% at 2 years. CONCLUSIONS The implantation of an iliac branch device over previous aortic or open endografts involving the aortic bifurcation is feasible and safe. We suggest using a femoral approach as the primary access of choice. CLINICAL IMPACT In this study we present 28 patients with previous aortoiliac grafts in which iliac branch devices were performed as a subsequent step.We demonstrated the feasibility of the technique despite the difficulty of crossing a neobifurcation, with a steep angle, without complications associated with the technique. Based on our experience, we recommend transfemoral access as the first option for bypassing the hypogastric artery stent, preserving upper extremity access and its possible complications.
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Affiliation(s)
- Jose Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
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15
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Grandi A, Gronert C, Panuccio G, Rohlffs F, Yousef Al Sarhan D, Kölbel T. Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access. J Endovasc Ther 2023:15266028231197972. [PMID: 37688485 DOI: 10.1177/15266028231197972] [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: 09/11/2023]
Abstract
PURPOSE To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. TECHNIQUE Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. CONCLUSION Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. CLINICAL IMPACT A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.
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Affiliation(s)
- Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Gronert
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daour Yousef Al Sarhan
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Vacirca A, Wong J, Baghbani-Oskouei A, Tenorio ER, Huang Y, Mirza A, Saqib N, Sulzer T, Mesnard T, Mendes BC, Oderich GS. Outcomes of fenestrated-branched endovascular aortic repair in patients with or without prior history of abdominal endovascular or open surgical repair. J Vasc Surg 2023; 78:278-288.e3. [PMID: 37080442 DOI: 10.1016/j.jvs.2023.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/21/2023] [Accepted: 04/02/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE The aim of this study was to compare outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) in patients with or without prior history of abdominal open surgical (OSR) or endovascular aortic repair (EVAR). METHODS The clinical data of consecutive patients enrolled in a prospective, non-randomized study to evaluate FB-EVAR for treatment of CAAAs and TAAAs was reviewed. Clinical outcomes were analyzed in patients with no previous aortic repair (Controls), prior EVAR (Group 1), and prior abdominal OSR (Group 2), including 30-day mortality and major adverse events (MAEs), patient survival and freedom from aortic-related mortality (ARM), secondary interventions, any type II endoleak, sac enlargement (≥5 mm), and new-onset permanent dialysis. RESULTS There were 506 patients (69% male; mean age, 72 ± 9 years) treated by FB-EVAR, including 380 controls, 54 patients in Group 1 (EVAR), and 72 patients in Group 2 (abdominal OSR). FB-EVAR was performed on average 7 ± 4 and 12 ± 6 years after the index EVAR and abdominal OSR, respectively (P < .001). All three groups had similar clinical characteristics, except for less coronary artery disease in controls and more TAAAs and branch stent graft designs in Group 2 (P < .05). Aneurysm extent was CAAA in 144 patients (28%) and TAAA in 362 patients (72%). Overall technical success, mortality, and MAE rate were 96%, 1%, and 14%, respectively, with no difference between groups. Mean follow up was 30 ± 21 months. Patient survival was significantly lower in Group 2 (P = .03), but there was no difference in freedom from ARM and secondary interventions at 5 years between groups. Group 1 patients had lower freedom from any type II endoleak (P = .02) and sac enlargement (P < .001), whereas Group 2 patients had lower freedom from new-onset permanent dialysis (P = .03). CONCLUSIONS FB-EVAR was performed with high technical success, low mortality, and similar risk of MAEs, regardless of prior history of abdominal aortic repair. Patient survival was significantly lower in patients who had previous abdominal OSR, but freedom from ARM and secondary interventions were similar among groups. Patients with prior EVAR had lower freedom from type II endoleak and sac enlargement. Patients with prior OSR had lower freedom from new-onset dialysis.
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Affiliation(s)
- Andrea Vacirca
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Joshua Wong
- Department of Cardiothoracic and 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 and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic and 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 and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem Mirza
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Naveed Saqib
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Titia Sulzer
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic and 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
| | - Gustavo S Oderich
- Department of Cardiothoracic and 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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Mario D, Alessandro G, Giovanni P, Gianbattista P, Rocco G, Mauro G, Nicola M, Roberto C, Sandro L, Luca B. Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry. J Endovasc Ther 2023:15266028231179864. [PMID: 37326371 DOI: 10.1177/15266028231179864] [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: 06/17/2023]
Abstract
OBJECTIVE The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. MATERIALS AND METHODS The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). RESULTS Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. CONCLUSIONS A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. CLINICAL IMPACT Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.
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Affiliation(s)
- D'Oria Mario
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Grandi Alessandro
- Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pratesi Giovanni
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Parlani Gianbattista
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giudice Rocco
- UOC di Chirurgia Vascolare, Dipartimento Cardiovascolare, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Gargiulo Mauro
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Mangialardi Nicola
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Lepidi Sandro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
- Division of Vascular Surgery, Department of Surgical and Clinical Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
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18
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Piazza M, Squizzato F, Pratesi G, Tshomba Y, Gaggiano A, Gatta E, Simonte G, Piffaretti G, Frigatti P, Veraldi GF, Silingardi R, Antonello M. Editor's Choice - Early Outcomes of a Novel Off the Shelf Preloaded Inner Branch Endograft for the Treatment of Complex Aortic Pathologies in the ItaliaN Branched Registry of E-nside EnDograft (INBREED). Eur J Vasc Endovasc Surg 2023; 65:811-817. [PMID: 36871927 DOI: 10.1016/j.ejvs.2023.02.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/02/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the early outcomes of a novel off the shelf pre-loaded inner branched thoraco-abdominal endograft (E-nside) in the treatment of aortic pathologies. METHODS Data from a physician initiated national multicentre registry on patients treated with the E-nside endograft, were prospectively collected and analysed. Pre-operative clinical and anatomical characteristics, procedural data, and early outcomes (90 days) were recorded in a dedicated electronic data capture system. The primary endpoint was technical success. Secondary endpoints were early mortality (90 days), procedural metrics, target vessel patency, endoleak rate, and major adverse events (MAEs) at 90 days. RESULTS In total, 116 patients from 31 Italian centres were included. Mean ± standard deviation (SD) patient age was 73 ± 8 years and 76 (65.5%) were male. Aortic pathologies included degenerative aneurysm in 98 (84.5%), post-dissection aneurysm in five (4.3%), pseudoaneurysm in six (5.2%), penetrating aortic ulcer or intramural haematoma in four (3.4%), and subacute dissection in three (2.6%). Mean ± SD aneurysm diameter was 66 ± 17 mm; aneurysm extent was Crawford I - III in 55 (50.4%), IV in 21 (19.2%), pararenal in 29 (26.7%), and juxtarenal in four (3.7%). The procedure setting was urgent in 25 (21.5%) patients. Median procedural time was 240 minutes (interquartile range [IQR] 195, 303), with a median contrast volume of 175 mL (IQR 120, 235). The endograft's technical success rate was 98.2% and the 90 day mortality rate was 5.2% (n = 6; 2.1% for elective repair and 16% for urgent repair). The 90-days cumulative MAE rate was 24.1% (n = 28). At 90 days, there were 10 (2.3%) target vessel related events (nine occlusions and one type IC endoleak) and one type 1A endoleak requiring re-intervention. CONCLUSION In this real life, non-sponsored registry, the E-nside endograft was used for the treatment of a broad spectrum of aortic pathologies, including urgent cases and different anatomies. The results showed excellent technical implantation safety and efficacy, as well as early outcomes. Longer term follow up is needed to better define the clinical role of this novel endograft.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Paolo Frigatti
- Division of Vascular Surgery, Azienda Sanitaria Universitaria Friuli Centrale, S. Maria della Misericordia University Hospital of Udine, Udine, Italy
| | | | - Roberto Silingardi
- Division of Vascular Surgery, University Hospital of Modena and Reggio Emilia, Baggiovara (MO), Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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19
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Grandi A, Melloni A, D'Oria M, Lepidi S, Bonardelli S, Kölbel T, Bertoglio L. Emergent endovascular treatment options for thoracoabdominal aortic aneurysm. Semin Vasc Surg 2023; 36:174-188. [PMID: 37330232 DOI: 10.1053/j.semvascsurg.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
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.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy.
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20
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Bertoglio L, Oderich G, Melloni A, Gargiulo M, Kölbel T, Adam DJ, Di Marzo L, Piffaretti G, Agrusa CJ, Van den Eynde W. Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures. Eur J Vasc Endovasc Surg 2023; 65:729-737. [PMID: 36740094 DOI: 10.1016/j.ejvs.2023.01.046] [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: 06/16/2022] [Revised: 09/08/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. METHODS A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. RESULTS Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p < .001). CONCLUSION AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gustavo Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Luca Di Marzo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University, Rome, Italy
| | - Gabriele Piffaretti
- Vascular Surgery and Interventional Radiology, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Centre, New York, NY, USA
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
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21
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Chamseddin K, Timaran CH, Oderich GS, Tenorio ER, Farber MA, Parodi FE, Schneider DB, Schanzer A, Beck AW, Sweet MP, Zettervall SL, Mendes B, Eagleton MJ, Gasper WJ. Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair. J Vasc Surg 2023; 77:704-711. [PMID: 36257344 DOI: 10.1016/j.jvs.2022.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access. METHODS Prospectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality. RESULTS Among 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43). CONCLUSIONS In the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach.
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Affiliation(s)
- Khalil Chamseddin
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Mark A Farber
- Division of Vascular and Endovascular Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular and Endovascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts, Worcester, MA
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Bernardo Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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22
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Rogers RT, Lemmens CC, Tenorio ER, Schurink GWH, DeMartino RR, Oderich GS, Mees BME, Mendes BC. Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease. J Vasc Surg 2023; 77:722-730. [PMID: 36372375 DOI: 10.1016/j.jvs.2022.10.049] [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: 05/06/2022] [Revised: 07/01/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. METHODS We performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. RESULTS There were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. CONCLUSIONS Although challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.
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Affiliation(s)
- Richard T Rogers
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Charlotte C Lemmens
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Geert Willem H Schurink
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Barend M E Mees
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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23
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Shirasu T, Akai A, Motoki M, Kato M. Modified adaption of iliac branch endografts in rare congenital anomaly of proximal origin of bilateral internal iliac arteries. J Vasc Surg Cases Innov Tech 2023; 9:101119. [PMID: 36970131 PMCID: PMC10033981 DOI: 10.1016/j.jvscit.2023.101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
We report a case of 55 mm abdominal aortic aneurysm coinciding with a rare congenital anomaly of proximal origin of bilateral internal iliac arteries (IIAs). Because renal to iliac bifurcation lengths were bilaterally short (129 mm and 125 mm), a trunk-ipsilateral leg and an iliac leg were deployed before iliac branch component insertion into the iliac leg. With help of a pull-through wire, internal iliac component was delivered without migration of the main body. The left IIA was embolized, but the right IIA was successfully preserved with commercially available iliac branch endoprosthesis only from femoral approaches, and the patient fully recovered without any complication.
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Affiliation(s)
- Takuro Shirasu
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
- Correspondence: Takuro Shirasu, MD, PhD, Department of Cardiovascular Surgery, Morinomiya Hospital, 2-1-88, Morinomiya, Joto-ku, Osaka, Japan 536-0025
| | - Atsushi Akai
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Manabu Motoki
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
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Panuccio G, Schanzer A, Rohlffs F, Heidemann F, Wessels B, Schurink GW, van Herwaarden JA, Kölbel T. Endovascular navigation with Fiber Optic RealShape technology. J Vasc Surg 2023; 77:3-8.e2. [PMID: 35963458 DOI: 10.1016/j.jvs.2022.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/20/2022] [Accepted: 08/03/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Fiber Optic RealShape (FORS) technology has recently been introduced as an adjunctive guidance technology that allows real-time three-dimensional visualization of dedicated endovascular devices while avoiding radiation exposure. It consists of equipment which sends pulses of light through hair-thin optical fibers that run within a dedicated hydrophilic wire and selective catheters. The purpose of the study was to report the observed benefits and limitations related to the first edition of FORS technology. METHODS Data were collected prospectively from the first 50 patients undergoing FORS-guided endovascular repair at a single center between February 2020 and February 2021 as part of the global multicenter FORS Learn registry. All consecutive, elective procedures with one or more navigation tasks attempted with FORS were included. Factors related to FORS navigation task success were assessed. The time required for the catheterization of each task as well as the amount of radiation exposure (fluoroscopy time, dose area product, and estimated skin dose) were collected. A per-task analysis was conducted. End points included the success rate in achieving a stable FORS-guided catheterization, catheterization time, and radiation dose during catheterization. RESULTS During the study period from February 2020 to February 2021, 50 patients were treated using FORS technology. Forty-five patients were treated for aortic aneurysm, 4 for iliac artery aneurysm, and 1 for splenic artery aneurysm. Overall, 201 navigation tasks were completed for these procedures and FORS was used in 186 tasks (92.5%). No FORS-related complication was recorded and a success rate of 60.2% (n = 116) was observed. Target vessel (TV) angle of 45° or greater, TV stenosis, and the renal arteries as navigation tasks (compared with celiac artery or superior mesenteric artery) were associated with a lower success rate. Catheterization of a TV through a branch more frequently required a standard catheter in combination with the FORS-enabled guidewire. Successful task catheterization using FORS guidance was associated with a shorter catheterization time 6 minutes (interquartile range, 3-11 minutes) versus 16 minutes (interquartile range, 10-24 minutes) (P < .001) and lower radiation exposure compared with unsuccessful catheterization (dose area product, 4.4 cGy/cm2 vs 12.5 cGy/cm2; P < .001). CONCLUSIONS FORS technology was implemented successfully as a new guidance technology in a complex endovascular aortic repair program and was associated with an encouraging success rate and a high potential for radiation reduction.
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Affiliation(s)
- Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University hospital Eppendorf UKE, Hamburg, Germany.
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University hospital Eppendorf UKE, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University hospital Eppendorf UKE, Hamburg, Germany
| | - Bart Wessels
- Philips Medical Systems Nederland, Best, The Netherlands
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University hospital Eppendorf UKE, Hamburg, Germany
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Sotir A, Klopf J, Wolf F, Funovics MA, Loewe C, Domenig C, Kölbel T, Neumayer C, Eilenberg W. Monoplane versus biplane fluoroscopy in patients undergoing fenestrated/branched endovascular aortic repair. J Vasc Surg 2022; 77:1359-1366.e2. [PMID: 36587811 DOI: 10.1016/j.jvs.2022.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) with fenestrated (F-EVAR) or branched (B-EVAR) endografts represents an indispensable tool of modern patient care in vascular surgery. The purpose of this retrospective study was to evaluate the center's initial experience of F/B-EVAR procedures performed under biplane angiography guidance compared with a historical control group. METHODS From January 2020 to March 2022, 80 consecutive patients underwent F/B-EVAR under general anesthesia at a single institution. As from January 2021, the deployment of complex stent grafts was performed using an alternative intraoperative imaging modality-a biplane fluoroscopy and angiography. The cohort was divided into monoplane (MPA) and biplane (BPA) groups according to the imaging modality applied. The end points were operation time, fluoroscopy time, radiation exposure, dose of contrast agent, and technical success. RESULTS The MPA group included 59 patients (78% male; median age; 74 years; interquartile range [IQR], 66-78 years) and the BPA group 21 patients (85.7% males; median age, 75 years; IQR, 69-79 years). Operation time (median, 320 minutes; IQR, 266-376 minutes) versus (median, 275 minutes; IQR, 216-333 minutes) was significantly lower in the BPA group (P = .006). The median fluoroscopy time (median, 82 minutes; IQR, 57-110 minutes vs median, 68 minutes; IQR, 54-92 minutes), contrast agent volume applied (median, 220 mL; IQR, 179-250 mL vs median, 200 mL; IQR, 170-250 mL), and radiation dose (dose-area product, median, 413 Gy × cm2; IQR, 249-736 Gy × cm2; vs median, 542 Gy × cm2; IQR, 196-789 Gy × cm2) were similar in both groups. Technical success of 96.6% (57/59 cases) versus 100% (21/21 cases) could be achieved in MPA and BPA group, respectively. CONCLUSIONS F/B-EVAR procedures performed under BPA guidance were associated with a significant decrease in operation time.
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Affiliation(s)
- Anna Sotir
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Klopf
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Wolf
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christoph Domenig
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, Hamburg, Germany
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
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Gatta E, Berretta P, Vento V, Di Eusanio M. Arch vessels' switch in frozen elephant trunk: a new technique to facilitate the second-stage endovascular thoraco-abdominal aorta repair. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6965026. [PMID: 36579884 DOI: 10.1093/ejcts/ezac588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022]
Abstract
In patients with extensive thoraco-abdominal aortic disease, staged hybrid repair involving open total aortic arch replacement and endovascular thoraco-abdominal aorta repair with branched stent graft has emerged as a valuable treatment option. However, total arch replacement with the available branched vascular grafts often results in acute angulation between the reimplanted vessels and the aortic arch hampering antegrade catheterization of the thoraco-abdominal aorta during the second endovascular stage. Here, we present our 'switch technique' for arch vessels' reimplantation to facilitate antegrade aortic catheterization of the thoraco-abdominal aorta and visceral vessels.
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Affiliation(s)
- Emanuele Gatta
- Vascular Surgery Unit, Aortic Team, Lancisi Cardiovascular Center, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Aortic Team, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Vento
- Vascular Surgery Unit, Aortic Team, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Aortic Team, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Gallitto E, Faggioli G, Melissano G, Fargion A, Isernia G, Bertoglio L, Simonte G, Lenti M, Pratesi C, Chiesa R, Gargiulo M. Fenestrated and Branched Endografts for Post-Dissection Thoraco-Abdominal Aneurysms: Results of a National Multicentre Study and Literature Review. Eur J Vasc Endovasc Surg 2022; 64:630-638. [PMID: 35764243 DOI: 10.1016/j.ejvs.2022.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 05/27/2022] [Accepted: 06/19/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Fenestrated and branched endografting (F/B-EVAR) has been proposed as an endovascular solution for chronic post-dissection thoraco-abdominal aneurysms (PD-TAAAs). The aim of this study was to analyse the experience of four high volume centres nationwide and the current available literature. METHODS Data on patients undergoing F/B-EVAR in four Italian academic centres between 2008 and 2019 were collected, and those from patients with PD-TAAAs were analysed retrospectively. Peri-operative morbidity and mortality were assessed as early outcomes. Survival, freedom from re-intervention (FFR), target visceral vessel (TVV) patency, and aortic remodelling were assessed as follow up outcomes. A MEDLINE search was performed for studies published from 2008 to 2020 reporting on F/B-EVAR in PD-TAAAs. RESULTS Among 351 patients who underwent F/B-EVAR for TAAAs, 37 (11%) had PD-TAAAs (Crawford's extent I-III: 35% - 95%). Overall, 135 TVVs (from true lumen 120; false lumen seven; both true and false lumen eight) were accommodated by fenestrations (96% - 71%) and branches (39% - 29%). Technical success (TS) was achieved in 34 (92%) cases with three failures due to endoleaks (Ia: 1; Ic: 1; III: 1). There were no 30 day deaths. No cases of permanent spinal cord ischaemia (SCI) were recorded and six (16%) patients suffered from transient deficits. Renal function worsening (eGFR < 30% than baseline) and pulmonary complications were reported in two (5%) and four (11%) cases, respectively. From the Kaplan-Meier analysis, three year survival, FFR, and TVV patency were 81%, 66%, and 97%, respectively. Radiological imaging was available for 30 (81%) patients at 12 months with complete false lumen thrombosis in 26 (87%). Two hundred and fifty-six patients were reported in seven published papers with TS, 30 day mortality, and SCI ranging from 99% to 100%, 0 to 6%, and 0 to 16%, respectively. The mean follow up ranged from 12 to 26 months, with estimated two year survival between 81% and 90% and a re-intervention rate between 19% and 53%. CONCLUSION F/B-EVAR is effective to treat PD-TAAAs. A high re-intervention rate is necessary to complete the aneurysm exclusion and promote aortic remodelling successfully.
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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
| | - Germano Melissano
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, 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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Witheford M, Roche-Nagle G. Commentary on tightrope technique for facilitating complex endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:875-876. [PMID: 36568953 PMCID: PMC9768233 DOI: 10.1016/j.jvscit.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Miranda Witheford
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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We Can Go Up, and We Can Go Down, But Does It Really Matter Anyway? Eur J Vasc Endovasc Surg 2022; 64:339. [PMID: 35964889 DOI: 10.1016/j.ejvs.2022.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023]
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Mandigers TJ, Lomazzi C, Domanin M, Piffaretti G, van Herwaarden JA, Trimarchi S. Vascular Access Challenges in Thoracic Endovascular Aortic Repair: A Literature Review. Ann Vasc Surg 2022. [PMID: 37534575 DOI: 10.1016/j.avsg.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This review aims to comprehensively summarize access challenges in thoracic endovascular aortic repair (TEVAR) by describing vascular access routes, associated risks, outcomes, and complications. METHODS A literature search was conducted utilizing the PubMed (Medline), Scopus, and Web of Science databases. Qualitative and quantitative data from selected studies are extracted and discussed according to available standards for narrative reviews. RESULTS In total, there were 109 eligible studies based on predefined inclusion- and exclusion criteria. There were 39 original articles or reviews and 57 case series or case reports. This article summarizes the evidence from these studies and discusses traditional retrograde access routes and techniques for TEVAR via a femoral or iliac route, with or without the use of conduits. Next, alternative antegrade access routes and techniques via a brachial, axillary, carotid, ascending aorta, transapical, transcaval, or another route are discussed. Vascular access complications are presented with specific attention to the importance of gender and alternative antegrade access routes. CONCLUSIONS Multiple access routes and techniques are currently available to overcome access challenges associated with TEVAR, based on low grade evidence from heterogeneous studies. Future research that compares different access routes and techniques might help in the development of a tailored access protocol for specific patients with challenging TEVAR access.
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Patel RJ, Mathlouthi A, Al-Nouri O, Lane JS, Malas MB, Barleben AR. A Single Center Review of a Total Transfemoral Approach to Upper Extremity Access in Branched and Fenestrated Physician Modified Endografts. Ann Vasc Surg 2022; 86:117-126. [PMID: 35809740 PMCID: PMC10339283 DOI: 10.1016/j.avsg.2022.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches. METHODS Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes. RESULTS Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke. CONCLUSIONS This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA.
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Single-Center Experience with the Femoral-to-Brachial Preloaded Delivery System for Fenestrated-Branched Endovascular Repair of Complex Aortic Aneurysms. Cardiovasc Intervent Radiol 2022; 45:1451-1461. [PMID: 36050563 DOI: 10.1007/s00270-022-03252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/06/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To assess technical aspects and outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using a femoral-to-brachial (FTB) preloaded delivery system (PDS) with two separate configurations. METHODS Clinical data of all consecutive patients enrolled in a prospective study to evaluate FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms (CAAAs & TAAA) between 2013 and 2020 were reviewed. Patients treated with FTB-PDS were included. The two configurations included 4 trans-brachial preloaded wires (4BR) or 2 trans-brachial and 2 transfemoral preloaded wires (2BR-2FE). Outcome measures included technical success, procedural metrics, 30-day or in-hospital mortality, major adverse events (MAEs), and target-vessel outcomes. RESULTS There were 115 patients with a mean age of 73.8 ± 8 years, treated with FTB-PDS. Of these, 62 patients (54%) had 4BR and 53 patients (46%) had 2BR-2FE FTB-PDS. There were 106 TAAA (92%) and 9 CAAAs (8%). Technical success, defined as successful implantation of the stent-graft and all intended target-vessel stents without type I or III endoleak, was 97%, with no differences in total operating time, endovascular time, and radiation dose between groups. There were 3 deaths (3%) at 30 days. MAEs were noticed in 21 patients (18%) with no difference between groups, including new-onset dialysis (2% vs. 4%, P = 0.59), and paraplegia (7% vs. 11%, P = 0.51), for 4BR and 2BR-2FE, respectively. Patient survival and freedom from aortic-related mortality at 2-years were 79 ± 5% and 97 ± 1.7%, respectively, with no difference between groups. CONCLUSION The use of FTB-PDS for FB-EVAR is safe with high technical success and a reasonable rate of MAEs. Each configuration provides specific benefits based on patient anatomy, while having similar procedural metrics and clinical outcomes.
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Marques de Marino P, Hagen M, Katsargyris A, Botos B, Verhoeven EL. Outcomes of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2022; 64:332-338. [PMID: 35963515 DOI: 10.1016/j.ejvs.2022.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study aims to assess the safety of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurologic and local complications as well as reinterventions associated with this technique. METHODS All patients undergoing a F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single-centre study. Endpoints were neurological and access-related complications and reinterventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury and arterial complications. RESULTS 264 patients (192 male, mean age 70 ± 7 years) were included. Upper access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2,2%) patients had early complications related to the arterial access: four with postoperative bleeding and two with acute arm ischaemia. Two patients with postoperative bleeding and both patients with ischaemic complications required reintervention. One of these patients with arm ischaemia died five weeks after the reintervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented transient arm paraesthesia or sensory neurologic deficit postoperatively. The symptoms completely recovered in all cases with no residual deficits. Perioperative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. CONCLUSIONS Upper access with surgical exposure of the axillary artery is a safe method for antegrade catheterization of fenestrations and branches in complex endovascular aneurysm repair.
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Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Maike Hagen
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
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Porras-Colon J, Knowles M, Timaran CH. Outcomes and strategies for utilization of brachial access and preloaded systems during F/BEVAR. Semin Vasc Surg 2022; 35:287-296. [DOI: 10.1053/j.semvascsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/11/2022]
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Mesnard T, Patterson BO, Azzaoui R, Pruvot L, Haulon S, Sobocinski J. Iliac branch device to treat type IB endoleak with a brachial access or an "up-and-over" transfemoral technique. J Vasc Surg 2022; 76:1537-1547.e2. [PMID: 35760243 DOI: 10.1016/j.jvs.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/12/2022] [Accepted: 06/19/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to review the results of secondary IBD (iliac branch device) implantation in patients with type IB endoleak after prior fenestrated and/or branched or infrarenal endovascular aortic repair (F/B-EVAR or EVAR), using either brachial access or an "up-and-over" transfemoral technique. METHODS A retrospective single centre analysis was conducted between Jan 2016 and Oct 2021 including consecutive patients that underwent IBD to correct a type IB endoleak after prior EVAR or F/B-EVAR. Groups were defined by arterial access which was either brachial (group 1) or transfemoral (group 2). All IBD implanted were manufactured by Cook Medical (INC, Bloomington, IN, USA). Demographics, anatomical features, technical success, and 30-day major adverse events (MAE) were recorded according to the current SVS standards. Survival curves according to Kaplan-Meier were calculated. Branch instability was a composite endpoint of any IIA branch-related complication or reintervention indicated to treat endoleak, kink, disconnection, stenosis, occlusion or rupture. RESULTS Overall, 28 patients (93% male, median age 74 years) receiving 32 IBDs were included, with 14 patients in each group. Prior endovascular aortic repairs were 23 EVAR and 5 F/B-EVAR, with time from initial repair being 58 months [48, 70]. Median pre-IBD maximal aneurysm diameter was 63.5 mm [59.0, 78.0]. Patients' baseline characteristics were similar in both groups except for pulmonary status. All procedures were performed in a hybrid operative room. Median total operating time, fluoroscopy time and dose area product were 120 min [86, 167], 23 min [15, 32] and 54 Gy.cm2 [40, 62], respectively. Total operating time was shorter in group 2 (p=0.006). Technical success rate was 100% and no early death reported. One 30-day MAE occurred including a medically treated colonic ischemia (group 2). Aortic-related secondary interventions were required in 7 patients (5 in group 1 and 2 in group 2) including 3 surgical explantations. Median follow-up was 31 months [24, 42] and 6 months [3, 10] in group 1 and 2, respectively. In group 1, 2-year freedom from aortic-related secondary intervention and IIA branch instability were 84.6% [67.1-100] and 92.3% [78.9-100], respectively. In group 2, 6-month freedom from aortic-related secondary intervention and IIA branch instability were 87.5% [67.3-100] and 91.7% [77.3-100], respectively. CONCLUSION The secondary implantation of IBD to correct distal type I endoleak of previous aortic stent-graft is safe with a high technical success rate. The "up-and-over" technique could be considered as an alternative to the brachial access in patients with suitable anatomy.
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Affiliation(s)
- T Mesnard
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, France; Univ. Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - B O Patterson
- Department of Vascular Surgery, University Hospital Southampton, United Kingdom
| | - R Azzaoui
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, France
| | - L Pruvot
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, France
| | - S Haulon
- Service de chirurgie vasculaire, Centre de l'Aorte, Hôpital Marie-Lannelongue, Le Plessis Robinson
| | - J Sobocinski
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, France; Univ. Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France.
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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Meertens MM, van Herwaarden JA, de Vries JPPM, Verhagen HJM, van der Laan MJ, Reijnen MMPJ, Schurink GWH, Mees BME. Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1150-1159. [PMID: 35709857 DOI: 10.1016/j.jvs.2022.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/10/2022] [Accepted: 04/26/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR). METHODS In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received upper extremity access during complex EVAR were included. Primary outcome was a composite endpoint of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions and incidence of ischemic cerebrovascular events. RESULTS 417 patients underwent 437 UEA for 303 fenestrated/branched EVARs, and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. 413 approaches were performed surgically and 24 percutaneously. Distal brachial access was used in 89 cases, medial brachial in 149, proximal brachial in 140 and axillary access in 59 cases. No significant differences regarding the composite endpoint of access complications were seen (DBA 11.3% vs. MBA 6.7% vs. PBA 13.6% vs. AA 10.2%; p=.29). Postoperative neuropathy occurred most after proximal brachial access (DBA 1.1% vs. MBA 1.3% vs. PBA 9.3 % vs. AA 5.1%; p=.003). There were no differences in cerebrovascular complications between access sides (right 5.9% vs. left 4.1% vs. bilateral 5%; p=.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs. 6.8%; p=.002). In multivariate analysis the risk for access complications after open approach was decreased by male gender (OR 0.27; CI 95% 0.10 - 0.72; p= .009), while an increase in age per year (OR 1.08; CI 95% 1.004 - 1.179; p=.039) and diabetes mellitus type 2 (OR 3.70; CI 95% 1.20 - 11.41; p= .023) increased the risk. CONCLUSION Between the four access localizations, there were no differences in overall access complications. Female gender, diabetes mellitus type 2 and ageing increased the risk for access complications after surgical approach. Furthermore, a percutaneous upper extremity access resulted in higher complication rates than a surgical approach.
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Affiliation(s)
- M M Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - J A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M J van der Laan
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - M M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, and Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - G W H Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany
| | - B M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany.
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Hauck SR, Eilenberg W, Kupferthaler A, Kern M, Dachs TM, Wressnegger A, Neumayer C, Loewe C, Funovics MA. Use of a Steerable Sheath for Completely Femoral Access in Branched Endovascular Aortic Repair Compared to Upper Extremity Access. Cardiovasc Intervent Radiol 2022; 45:744-751. [PMID: 35391546 PMCID: PMC9117381 DOI: 10.1007/s00270-022-03064-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/22/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To compare bridging stent graft (BSG) implantation in downward oriented branches in branched endovascular aortic repair (bEVAR), using a commercially available steerable sheath from an exclusively femoral access (TFA) with traditional upper extremity access (UEA). METHODS In a retrospective cohort study, 7 patients with 19 branches in the TFA cohort received BSG insertion using the Medtronic Heli FX steerable sheath from a femoral access, and 10 patients with 32 branches in the UEA cohort from a brachial approach. Technical success, total intervention time, fluoroscopy time, branch cannulation time, and complication rate were recorded. RESULTS Technical success was 19/19 branches in the TFA and 31/32 in the UEA cohort. The mean branch cannulation time was considerably shorter in the TFA group (17 vs. 29 min, p = 0.003), and total intervention time tended to be shorter (169 vs. 217 min, p = 0.176). CONCLUSION Using a commercially available steerable sheath allowed successful cannulation of all branches in this cohort and was associated with significantly shorter branch cannulation times. Potentially, this technique can lower the stroke and brachial puncture site complication risk as well as reduce total intervention time and radiation dose. LEVEL OF EVIDENCE 2b, retrospective cohort study.
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Affiliation(s)
- Sven R Hauck
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Kupferthaler
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Diagnostic and Interventional Radiology, Ordensklinikum Linz, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
| | - Maximilian Kern
- Department of Radiology, Klinik Floridsdorf, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Alexander Wressnegger
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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Steerable sheath for cannulation of target visceral vessels in complex endoprosthesis. ANGIOLOGIA 2022. [DOI: 10.20960/angiologia.00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6543963. [DOI: 10.1093/ejcts/ezac136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/29/2022] [Accepted: 02/19/2022] [Indexed: 11/13/2022] Open
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Schaefers JF, Murtaja A, Oberhuber A. Retrograde Approach for Antegrade Inner Branches in a Precannulated Off-the-Shelf Multibranch Device. J Endovasc Ther 2021; 29:512-515. [PMID: 34836476 DOI: 10.1177/15266028211059452] [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
PURPOSE The purpose of this technical note was to describe the application of the combination of precannulated branches and a femoral approach for bridging stent graft deployment in branched endovascular aneurysm repair. TECHNIQUE The technique is shown in a 65-year-old woman treated for thoracoabdominal aneurysm type I with endovascular repair using a multibranched device. The stent graft is an off-the-shelf device with 4 precannulated inner branches. Access to the precannulated branches is gained using a steerable sheath from retrograde femoral access instead of using access via the upper extremities. For this purpose, a 0.018" wire introduced to the precannulated tube is snared into the steerable sheath. Next, the steerable sheath is guided into a stable position inside the branch. With this technique, the implantation of this off-the-shelf multibranch device could be completed safe and quickly with a full femoral approach avoiding upper extremity access. CONCLUSION The combination of a precannulated multibranch stent graft with a full femoral approach for target vessel revascularisation is a feasible and quick method for complex endovascular repair.
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Affiliation(s)
| | - Ahmed Murtaja
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
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Zymvragoudakis V, Saha P, Gkoutzios P, Zayed H, Abisi S. Use of the Off-The-Shelf Pre-Cannulated E-Nside Endograft to Overcome Anatomical Challenges in Urgent Complex Endovascular Aortic Repair. Ann Vasc Surg 2021; 79:441.e1-441.e7. [PMID: 34653640 DOI: 10.1016/j.avsg.2021.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/15/2021] [Accepted: 07/30/2021] [Indexed: 11/01/2022]
Abstract
Treatment options for large or symptomatic complex aortic aneurysms that require urgent intervention remain limited. Patient factors and comorbidities often make open surgery unappealing, leading to increasing interest in endovascular solutions that can be employed in the urgent setting, such as off-the-shelf endografts. The E-nsideTM (Jotec GmbH, Hechingen, Germany) is a new off-the-shelf endograft with 4 pre-cannulated inner branches that has recently become available in Europe. We report the urgent treatment of 2 large complex aortic aneurysms using this device and discuss the benefits of this new technology. The E-nside off-the-shelf endograft with inner branches is a useful addition to our treatment options for complex aortic aneurysms, particularly those with a narrow aortic lumen. Pre-cannulation of branches provides consistent access to the branches and a readily available option for establishment of a through and through wire for added stability during cannulation and bridging stent-grafts placement. The design of inner branches provides flexibility during deployment of the endograft and cannulation of the target vessels in varied, challenging anatomies.
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Affiliation(s)
- Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Prakash Saha
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Panos Gkoutzios
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Gloviczki P. Journal of Vascular Surgery – May 2021 Audiovisual Summary. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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