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Ulsaker H, Halvorsen H, Braaten AO, Dorenberg E, Rikken Lindberg B, Nordhus KC, Jakobsen Ø, Brekken R, Seternes A, Manstad-Hulaas F. Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study. SCAND CARDIOVASC J 2024; 58:2335906. [PMID: 38613333 DOI: 10.1080/14017431.2024.2335906] [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: 11/16/2023] [Accepted: 03/24/2024] [Indexed: 04/14/2024]
Abstract
Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
| | | | | | - Eric Dorenberg
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | | | - Øyvind Jakobsen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North, Norway
| | - Reidar Brekken
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Health Research, SINTEF, Trondheim, Norway
| | - Arne Seternes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St. Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Radiology, St. Olavs University Hospital, Trondheim, Norway
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Isernia G, Simonte G, Gallitto E, Bertoglio L, Fargion A, Melissano G, Chiesa R, Lenti M, Pratesi C, Faggioli G, Gargiulo M. Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry. J Endovasc Ther 2024; 31:697-705. [PMID: 36408661 DOI: 10.1177/15266028221137498] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes. METHODS Data from all consecutive patients treated during the 2008-2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up. RESULTS Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7-45 months]). CONCLUSION Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks. CLINICAL IMPACT Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification.
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Affiliation(s)
- Giacomo Isernia
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Lenti
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Gallitto E, Faggioli G, Austermann M, Kölbel T, Tsilimparis N, Dias N, Melissano G, Simonte G, Katsargyris A, Oikonomou K, Mani K, Pedro LM, Cecere F, Haulon S, Gargiulo M. Urgent endovascular repair of juxtarenal/pararenal aneurysm by off-the-shelf multibranched endograft. J Vasc Surg 2024:S0741-5214(24)01500-3. [PMID: 38992807 DOI: 10.1016/j.jvs.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE To report outcomes of urgent juxtarenal/pararenal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch). METHODS In this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter of >70 mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI), and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions, and target artery instability (TAI) were evaluated during follow-up. RESULTS Overall, 197 patients (J-AAAs, n = 64 [33%]; P-AAAs, n = 95 [48%]; previous failed endovascular aneurysm repair (EVAR), n = 38 [19%]) were analyzed. The mean age and aneurysm diameter was 75 ± 8 years and 76 ± 4 mm, respectively. The American Society of Anesthesiologists score was 3 and 4 in 118 (60%) and 79 (40%) patients. Rupture, symptoms, and diameter of >70 mm were present in 51 (26%), 110 (56%), and 53 (27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28 cases (14%). The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154 ± 49 mm. Single-stage repair and cerebrospinal fluid drainage were reported in 144 (73%) and 53 (27%) cases, respectively. TS was achieved in 182 (92%) cases (rupture, 84% vs no rupture, 95%; P = .02). Failures consist of TA loss (11 [6%]: renal artery, 9; celiac trunk, 2), type I to III endoleaks (2 [1%]), and 24-h mortality (2 [1%]). Rupture was a risk factor for technical failure (P = .02; odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-12.1). Overall, 15 patients (8%) had persistent SCI (rupture, 14% vs no rupture, 5%) with 11 (6%) , of paraplegia (rupture, 10% vs no rupture, 5%; P = .001). Rupture (P = .04; OR, 3.1; 95% CI, 1.1-8.9) and adjunctive proximal thoracic endograft (P = .01; OR, 4.1; 95% CI, 1.3-12.9) were risk-factors for SCI. Twenty-two patients (11%) died within 30 days or during a prolonged hospitalization. Previous failed EVAR (P = .04; OR, 3.6; 95% CI, 1.1-12.3), paraplegia (P < .001; OR, 9.9; 95% CI, 1.6-62.2) and postoperative mesenteric complications (P = .03; OR, 10.4; 95% CI, 1.2-93.3), as well as cardiac (P = .03; OR, 8.2; 95% CI, 2.0-33.0) and respiratory (P < .001; OR, 10.1; 95% CI, 2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19 ± 5 months. The estimated 3-year survival and freedom from reinterventions was 58% and 77%, respectively. TAI occurred in 27 patients (14%) (occlusion, 15; endoleak, 14) with an estimated 3-year freedom from TAI of 72%. CONCLUSIONS Urgent repair of J/P-AAAs by T-branch is feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a non-negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed EVAR and postoperative mesenteric complications, as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and should be subjected to more research for the purposes of improving outcomes.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Martin Austermann
- Department of Vascular and Endovascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Nikolas Tsilimparis
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nuno Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Germano Melissano
- Division of Vascular Surgery, Vita - Salute University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | | | - Kyriakos Oikonomou
- Vascular and Endovascular Surgery, University Hospital and Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Luis Mendes Pedro
- Department of Vascular Surgery, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina da Universidade de Lisboa, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
| | - Fabrizio Cecere
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy
| | - Stephan Haulon
- Vascular Surgery, Hospital Marie Lannelongue, Paris, France
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
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Doering A, Nana P, Torrealba JI, Panuccio G, Trepte C, Chindris V, Kölbel T. Intra- and Early Post-Operative Factors Affecting Spinal Cord Ischemia in Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair. J Clin Med 2024; 13:3978. [PMID: 38999542 PMCID: PMC11242175 DOI: 10.3390/jcm13133978] [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: 06/11/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Spinal cord ischemia (SCI) is a severe complication after fenestrated/branched endovascular repair (f/bEVAR). The underlying causes of SCI are still under investigation. This study aimed to evaluate intra- and early post-operative parameters that may affect SCI evolution. Methods: A single-center retrospective analysis was conducted including SCI patients with complete anesthesiologic records (1 January 2011 to 31 December 2023). Values of intra-operative glucose, hemoglobin, lactate, activated clotting time (ACT), and the need for transfusion were collected. The cohort was compared to a matched cohort of non-SCI patients. Results: Fifty-one patients with SCI and complete anesthesiologic records were included (mean age: 69.8 ± 6.2 years; 39.2% male). Intra-operative glucose value < 110 mg/dL (AUC: 0.73; sensitivity 91%, specificity of 83%) and hemoglobin value > 8.5 mg/dL (AUC: 0.61; sensitivity 83%, specificity 78%) were protective for Grade 3 SCI. Twenty-three patients with SCI were matched to 23 patients without SCI. SCI patients presented significantly higher glucose levels intra-operatively (glucose mean value: SCI 150 ± 46 mg/dL vs. non-SCI: 122 ± 30 mg/dL, p = 0.005). ACT (SCI 259 ± 31 svs. non-SCI 288 ± 28 s, p = 0.001), volume input (SCI 4030 ± 1430 mL vs. non-SCI 3020 ± 113 mL, p = 0.009), and need for transfusion (SCI: 52.5% vs. 4.3%, p < 0.001) were related to SCI. Higher glucose levels were detected among patients with SCI, at 24 (SCI: 142 ± 30 mg/dL vs. non-SCI: 118 ± 26 mg/dL, p=0.004) and 48 h (SCI: 140 ± 29 mg/dL vs. non-SCI: 112 ± 20 mg/dL, p < 0.001) post-operatively. Conclusions: SCI is a multifactorial complication after f/bEVAR. Intra-operative and early post-operative glucose levels may be related to SCI evolution. Targeted glucose < 110 mg/dL may be protective for Grade 3 SCI.
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Affiliation(s)
| | - Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, 20251 Hamburg, Germany; (A.D.); (J.I.T.); (G.P.); (C.T.); (V.C.); (T.K.)
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Lu C, Duan W, Li Z, Wang C, Yang P, Liu Y, Zuo J, Hu J. One-year results of the Flowdynamics Dense Mesh Stent for residual dissection after proximal repair of stanford type A or type B aortic dissection: a multicenter, prospective, and randomized study. Int J Surg 2024; 110:4151-4160. [PMID: 38597396 PMCID: PMC11254268 DOI: 10.1097/js9.0000000000001440] [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: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Negative remodeling of the distal aorta following proximal repair for acute aortic dissection has garnered growing attention. This clinical scenario has spurred the development of techniques and devices. A multicenter, prospective, and randomized controlled study was conducted with the aim of confirming the safety and effectiveness of a newly-designed flowdynamics dense mesh stent for the treatment of residual dissection after proximal repair. METHODS Patients with nonchronic residual dissection affecting visceral branches were prospectively enrolled at three centers and randomly allocated to either the FDMS group or the control group. Primary endpoints encompassed all-cause and aortic-related mortality, while the patency of branch arteries is indeed a key focal metric. Morphological changes (diameter, area, and volume) were analyzed to demonstrate the therapeutic effect. RESULTS One hundred twelve patients were recruited in the clinical trial, and 103 patients completed the 12-month follow-up. The rate of freedom from all-cause and aortic-related death in the FDMS group was 94.64 and 100%, respectively. All visceral branches remained patent. The FDMS group exhibited a substantial expansion in TL and a notable shrinkage in FL at the planes below renal arteries (ΔArea TL : FDMS vs. Control, 0.74±0.46 vs. 0.34±0.66 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.72±1.26 vs. -0.12±0.86 cm, P =0.01) and 5 cm below renal arteries (ΔArea TL : FDMS vs. Control, 1.06±0.75 vs. 0.16±0.63 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.53±1.43 vs. -0.25±1.00 cm, P =0.27). Meanwhile, the FDMS group demonstrated an increase of 22.55±11.14 cm 3 in TL ( P <0.001) and a corresponding reduction of 21.94±11.77 cm 3 in FL ( P =0.08). CONCLUSIONS This newly-designed FDMS for endovascular repair of residual dissection following the proximal repair is demonstrated to be safe and effective at 12 months.
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Affiliation(s)
- Chen Lu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi Province
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, People’s Republic of China
| | - Chenhao Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Yu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Jian Zuo
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi Province
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan
- Department of Cardiothoracic Surgery, West China Guang'an Hospital, Sichuan University, Guang’an, Sichuan Province
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Banks CA, Novak Z, Zheng X, Mao J, Sutzko DC, Scali S, Beck AW, Spangler EL. Readmissions Following Endovascular Thoracic and Thoracoabdominal Aortic Repairs in The Vascular Implant Surveillance and Interventional Outcomes Network (VISION). Ann Vasc Surg 2024:S0890-5096(24)00285-1. [PMID: 38942375 DOI: 10.1016/j.avsg.2024.05.007] [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: 03/05/2024] [Revised: 05/30/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90-days post-operatively after elective endovascular thoracic and thoracoabdominal aortic repair overall and by extent of coverage. METHODS A cohort of index elective non-traumatic endovascular thoracic and thoracoabdominal aortic cases from 2010-2018 was derived from the Vascular Implant Surveillance and Interventional Outcomes Network. Cohort readmissions within 90-days postoperative were examined both overall and by Crawford extent (CE) of aortic coverage. Postoperative mortality was examined by reason for readmission and CE. RESULTS The cohort consisted of 2,093 patients who underwent endovascular thoracic and thoracoabdominal aortic repair (1,541 CE 0A/0B; 240 CE 1-3; 312 CE 4-5). Cumulative risk for 90-day readmission was 34.3% in CE 0A/0B repairs, 33.4% in CE4-5 repairs and 47.4% in CE 1-3 repairs. Compared to CE 0A/B, patients with CE 1-3 repairs experienced an increased risk of readmission within 90 days postoperatively after adjusting for preoperative factors (aHR 1.27(1.00,1.61) while the readmission risk for CE 4-5 repairs did not differ significantly (aHR 0.83 (0.64,1.06). Significant risk factors for 90-day readmission included COPD, dialysis dependence, limited ambulation, visceral/spinal ischemia, and in-hospital stroke. Discharge to home was protective against readmission (HR 0.65, CI 0.54-0.79). Patients with a readmission within 90-days had a 7.89-fold increase in 90-day mortality (HR 7.84; 5.17, 11.9) compared to those not readmitted. CONCLUSIONS Increasing extent of endovascular thoracic and thoracoabdominal aortic repair was associated with higher 90-day readmission rates. Readmission for all CE was associated with near 8-fold increased risk of mortality. Risk factors associated with increased risk for readmission included pulmonary insufficiency, renal disease, and poor functional status. These findings can inform stakeholders about investment of resources to improve processes of care that both target prevention and mitigate risk of readmission after elective endovascular thoracic and thoracoabdominal aortic repair.
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Affiliation(s)
- C Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, US
| | - Z Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, US
| | - X Zheng
- Weill Cornell Medical College, New York, NY, US
| | - J Mao
- Weill Cornell Medical College, New York, NY, US
| | - D C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, US
| | - S Scali
- University of Florida Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL, US
| | - A W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, US
| | - E L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, US;.
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Mendes D, Machado R, Almeida R. Kidney autotransplantation as a key solution for a BEVAR type IIIb endoleak. Vascular 2024; 32:541-545. [PMID: 36719859 DOI: 10.1177/17085381231155672] [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: 02/01/2023]
Abstract
OBJECTIVES Target vessel endoleaks are one of the most common causes of revision procedures after a fenestrated or branched endovascular aneurysm repair. Usually, a redo stenting is an effective therapy, however, not always feasible. We present a case of a hybrid treatment for a type IIIb endoleak using the renal autotransplantation technique. METHODS A 60-year-old man with a thoracoabdominal aortic aneurysm has been treated with a custom-made branched endoprosthesis. Occlusion of the bridging stent to the right renal artery with total infarction of the right kidney was identified one week later and conservatively managed. After four years, a type IIIb endoleak was identified. Endovascular treatment was attempted unsuccessfully. So, the endoleak was corrected using a hybrid strategy with the kidney autotransplantation technique. RESULTS A left kidney autotransplantation followed by an aortic stent-graft relining with a tubular graft has been done uneventfully, in a phased manner. Postoperative computed tomography angiography confirmed the patency of vascular reconstructions with no endoleaks. No adverse events occurred during one year of follow-up. CONCLUSION Our case highlights kidney autotransplantation as a viable solution for a hybrid treatment of target vessel endoleaks and shows that this technique can assist complex endovascular aortic reconstructions.
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Affiliation(s)
- Daniel Mendes
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Rui Machado
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
- School of Medicine and Biomedical Sciences - ICBAS, University of Porto, Oporto, Portugal
| | - Rui Almeida
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
- School of Medicine and Biomedical Sciences - ICBAS, University of Porto, Oporto, Portugal
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Frese JP, Walter C, Carstens J, Bürger M, Greiner A, Assadian A, Kapahnke S, Falkensammer J. Technical Aspects and Outcome of Multi-Staged and Single-Staged Thoracoabdominal Fenestrated Endovascular Aortic Repair. J Endovasc Ther 2024:15266028241255533. [PMID: 38804508 DOI: 10.1177/15266028241255533] [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: 05/29/2024]
Abstract
PURPOSE In some cases of endovascular thoracoabdominal or juxtarenal aortic aneurysm repair, a thoracic endograft in combination with a fenestrated renovisceral device may be needed in order to create a sufficient proximal landing zone. This study aimed to evaluate the technical aspects and postoperative morbidity of a single- or 2-stage approach. METHODS Eighty-seven consecutive patients undergoing thoracic endovascular aortic repair (TEVAR) in combination with elective fenestrated repair (fenestrated endovascular aortic repair [FEVAR]; fenestrated Anaconda device) from 2015 to 2022 were included in this retrospective bicentric study. Underlying pathologies, aortic morphology, technical details, and postoperative morbidity were recorded. RESULTS Single-staged ("1S," n=61) and 2-staged ("2S," n=26) interventions were compared. Indications were thoracoabdominal aneurysms (TAAAs) (Crawford I-IV) (n=56, 64%) and juxtarenal aneurysms (n=31, 36%). In 2S, the proportion of TAAA was higher than in 1S (2S: 77%, 1S: 59%; p=0.001). In 2S, the covered length of the descending aorta was longer (1S: 128±60 mm, 2S: 202±64 mm; p=0.003). Temporary aneurysm sack perfusion (TASP) was established in 11 (18%) of 1S and 1 (4%) of 2S patients (p=0.079), as well as cerebrospinal fluid (CSF) drainage catheter in 48 (79%) of 1S and 19 (73%) of 2S. The rate of spinal cord ischemia (SCI) and the severity of SCI were not different in both groups, with a total of 3 cases of persisting paraplegia. The rate of access complications was higher in 2S (n=6, 23%) than in 1S (n=4, 7%; p=0.027). Postoperative 30 day morbidity did not significantly differ in both groups and neither did 30 day mortality (4.6% in 1S vs 3.8% in 2S; p=0.083). CONCLUSION The combination of TEVAR and FEVAR using a fenestrated endograft is feasible and safe. Aortic morphology does not change significantly after endovascular repair. A single-staged strategy is feasible with excellent results, especially in Crawford IV, Crawford V, or juxtarenal aneurysms. Two-staged repair is recommended in cases with long aortic coverage and a higher American Society of Anesthesiologists (ASA) class. Follow-up data are needed to evaluate the long-term stability of the TEVAR/FEVAR interconnection. CLINICAL IMPACT Our study has revealed the safety and efficacy of the combination of TEVAR and FEVAR in the treatment of TAAAs and juxtarenal aneurysms with compromised supravisceral landing zones. A single-staged concept is not necessary in all cases. Staged procedures may reduce postoperative morbidity in cases with long aortic coverage and higher ASA class.
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Affiliation(s)
- Jan Paul Frese
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Jan Carstens
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Bürger
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jürgen Falkensammer
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
- Department of Vascular Surgery, Konventhospital der Barmherzigen Brüder Linz, Linz, Austria
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Simonte G, Gatta E, Vento V, Parlani G, Simonte R, Montecchiani L, Isernia G. Partial Deployment to Save Space for Vessel Cannulation When Treating Complex Aortic Aneurysms with Narrow Paravisceral Lumen Is Also Feasible Using Inner-Branched Pre-Cannulated Endografts. J Clin Med 2024; 13:3060. [PMID: 38892771 PMCID: PMC11172520 DOI: 10.3390/jcm13113060] [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: 04/13/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction: The aim of this paper is to propose a sequential deployment technique for the E-nside off-the-shelf endograft that could potentially enhance target visceral vessel (TVV) cannulation and overstenting in narrow aortic anatomies. Methods: All data regarding patients consecutively treated in two aortic centers with the E-nside graft employing the partial deployment technique were included in the study cohort and analyzed. To execute the procedure with partial endograft deployment, the device should be prepared before insertion by advancing, under fluoroscopy, all four dedicated 400 cm long 0.018″ non-hydrophilic guidewires until their proximal ends reach the cranial graft's edge. Anticipating this guidewire placement prevents the inability to do so once the endograft is partially released, avoiding potentially increased friction inside the constricted pre-loaded microchannels. The endograft is then advanced and deployed in the standard fashion, stopping just after the inner branch outlets are fully expanded. Tip capture is released, and the proximal end of the device is opened. Visceral vessel bridging is completed from an upper access in the desired sequence, and the graft is fully released after revascularizing one or more arteries. Preventing the distal edge of the graft from fully expanding improves visceral vessel cannulation and bridging component advancement, especially when dealing with restricted lumina. Results: A total of 26 patients were treated during the period December 2019-March 2024 with the described approach. Procedure was performed in urgent settings in 14/26 cases. The available lumen was narrower than 24 mm at the origin of at least one target vessel in 11 out of 26 cases performed (42.3%). Technical success was obtained in 24 out of 26 cases (92.3%), with failures being due to TVVs loss. No intraoperative death or surgical conversion was recorded, and no early reintervention was needed in the perioperative period. Clinical success at 30 days was therefore 80.7%. Conclusions: The described technique could be considered effective in saving space outside of the graft, allowing for safe navigation and target vessel cannulation in narrow visceral aortas, similar to what has already been reported for outer-branched endografts.
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Affiliation(s)
- Gioele Simonte
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia University Hospital, 06132 Perugia, Italy (R.S.)
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, 60126 Ancona, Italy; (E.G.); (V.V.); (L.M.); (G.I.)
| | - Vincenzo Vento
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, 60126 Ancona, Italy; (E.G.); (V.V.); (L.M.); (G.I.)
| | - Gianbattista Parlani
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia University Hospital, 06132 Perugia, Italy (R.S.)
| | - Rachele Simonte
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia University Hospital, 06132 Perugia, Italy (R.S.)
| | - Luca Montecchiani
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, 60126 Ancona, Italy; (E.G.); (V.V.); (L.M.); (G.I.)
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, 60126 Ancona, Italy; (E.G.); (V.V.); (L.M.); (G.I.)
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10
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Becker D, Sikman L, Ali A, Mosbahi S, F. Prendes C, Stana J, Tsilimparis N. Analysis of Target Vessel Instability in Fenestrated Endovascular Repair (f-EVAR) in Thoraco-Abdominal Aortic Pathologies. J Clin Med 2024; 13:2898. [PMID: 38792439 PMCID: PMC11122549 DOI: 10.3390/jcm13102898] [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: 04/04/2024] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: The aim of this study was to evaluate the influence of target vessel anatomy and post-stenting geometry on the outcome of fenestrated endovascular aortic repair (f-EVAR). Methods: A retrospective review of data from a single center was conducted, including all consecutive fenestrated endovascular aortic repairs (f-EVARs) performed between September 2018 and December 2023 for thoraco-abdominal aortic aneurysms (TAAAs) and complex abdominal aortic aneurysms (cAAAs). The analysis focused on the correlation of target vessel instability to target vessel anatomy and geometry after stenting. The primary endpoint was the cumulative incidence of target vessel instability. Secondary endpoints were the 30-day and follow-up re-interventions. Results: A total of 136 patients underwent f-EVAR with 481 stented target vessels. A total of ten target vessel instabilities occurred including three in visceral and seven instabilities in renal vessels. The cumulative incidence of target vessel instability with death as the competing risk was 1.4%, 1.8% and 3.4% at 1, 2 and 3 years, respectively. In renal target vessels (260/481), a diameter ≤ 4 mm (OR 1.21, 95% CI 1.035-1.274, p = 0.009) and an aortic protrusion ≥ 5.75 mm (OR 8.21, 95% CI 3.150-12-23, p = 0.027) was associated with an increased target vessel instability. In visceral target vessels (221/481), instability was significantly associated with a preoperative tortuosity index ≥ 1.25 (HR 15.19, CI 95% 2.50-17.47, p = 0.045) and an oversizing ratio of ≥1.25 (HR 7.739, CI % 4.756-12.878, p = 0.049). Conclusions: f-EVAR showed favorable mid-term results concerning target vessel instability in the current cohort. A diameter of ≤4 mm and an aortic protrusion of ≥5.75 mm in the renal target vessels as well as a preoperative tortuosity index and an oversizing of the bridging stent of ≥1.25 in the visceral target vessels should be avoided.
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Affiliation(s)
- Daniel Becker
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
| | - Laura Sikman
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
| | - Ahmed Ali
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
- Department of Vascular Surgery, Cardiovascular and Vascular Surgery Center, University Hospital, Mansoura University, Mansoura 35516, Egypt
| | - Selim Mosbahi
- Department of Cardiac Sugery, University Hospital, Inselspital Bern, 3010 Bern, Switzerland;
| | - Carlota F. Prendes
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
| | - Jan Stana
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.B.); (L.S.); (A.A.); (C.F.P.); (J.S.)
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11
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Banks CA, Novak Z, Spangler EL, Schanzer A, Farber MA, Sweet MP, Oderich G, Timaran CH, Lee A, Schneider DB, Eagleton MJ, Gasper W, Beck AW. Preoperative risk factors for 1-year mortality in patients undergoing fenestrated endovascular aortic aneurysm repair in the US Aortic Research Consortium. J Vasc Surg 2024:S0741-5214(24)01089-9. [PMID: 38718849 DOI: 10.1016/j.jvs.2024.04.063] [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: 02/20/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Early survival (1-year) after elective repair of complex abdominal aortic aneurysms (AAA) or thoracoabdominal aortic aneurysms (TAAA) can be used as an indicator of successful repair and provides a reasonable countermeasure to the annual rupture risk based on diameter. We aimed to identify preoperative factors associated with 1-year mortality after fenestrated or branched endovascular aortic repair (F/BEVAR) and develop a predictive model for 1-year mortality based on patient-specific risk profiles. METHODS The US-Aortic Research Consortium database was queried for all patients undergoing elective F/BEVAR for complex AAA (cAAA) or TAAA from 2005 to 2022. The primary outcome was 1-year survival based on preoperative risk profile. Multivariable Cox regression was used to determine preoperative variables associated with 1-year mortality overall and by extent of aortic pathology. Logistic regression was performed to build a predictive model for 1-year mortality based on number of risk factors present. RESULTS A total of 2099 patients met the inclusion criteria for this study (cAAA: n = 709 [34.3%]; type 1-3 TAAA: n = 777 [37.6%]; type 4-5 TAAA: n = 580 [28.1%]). Multivariable Cox regression identified the following significant risk factors associated with 1-year mortality: current smoker, chronic obstructive pulmonary disease, congestive heart failure (CHF), aortic diameter >7 cm, age >75 years, extent 1-3, creatinine >1.7 mg/dL, and hematocrit <36%. When stratified by extent of aortic involvement, multivariable Cox regression revealed risk factors for 1-year mortality in cAAA (CHF maximum aortic diameter >7 cm, hematocrit <36 mg/dL, and current smoking status), type 1-3 TAAA (chronic obstructive pulmonary disease, CHF, and age >75 years), and type 4-5 TAAA (age >75 years, creatinine >1.7 mg/dL, and hematocrit <36 mg/dL). Logistic regression was then used to develop a predictive model for 1-year mortality based on patient risk profile. Appraisal of the model revealed an area under the curve of 0.64 (P < .001), and an observed to expected ratio of 0.85. CONCLUSIONS This study describes multiple risk factors associated with an increase in 1-year mortality after F/BEVAR. Given that elective repair of cAAA or TAAA is offered to some patients in whom future rupture risk outweighs operative risk, these findings suggest that highly comorbid patients with smaller aneurysms may not benefit from repair. Descriptive and predictive models for 1-year mortality based on patient risk profiles can serve as an adjunct in clinical decision-making when considering elective F/BEVAR.
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Affiliation(s)
- Charles A Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Gustavo Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, TX
| | - Carlos H Timaran
- Division of Vascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Anothny Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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12
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Becker D, Sikman L, Ali A, Prendes CF, Stana J, Tsilimparis N. The Impact of Target Vessel Anatomy and Bridging Stent Geometry on Branched Endovascular Aortic Repair Outcomes. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00364-2. [PMID: 38685310 DOI: 10.1016/j.ejvs.2024.04.028] [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: 10/02/2023] [Revised: 03/22/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE This study aimed to evaluate the impact of target vessel anatomy and bridging stent geometry on target vessel instability in branched endovascular aortic repair (B-EVAR). METHODS This retrospective, single centre cohort study included all consecutive B-EVARs performed between September 2018 and December 2022 for thoraco-abdominal aortic aneurysm (TAAA) or complex abdominal aortic aneurysm (CAAA). The primary endpoints were target vessel instability and related re-interventions at 12 months. Secondary endpoints were 30 day results, including target vessel instability and re-interventions. Target vessel instability analysis consisted of assessment of target vessel anatomy, including diameter, aortic trunk to branch angle, and tortuosity. Post-operative parameters included change of clock position/horizontal misalignment, bridging length (gap), sealing length, tortuosity, post-stenting angle, and oversizing ratio. RESULTS A total of 69 patients (TAAA: n = 56, 81%; CAAA: n = 13, 19%) and 271 (133 visceral and 138 renal) target vessels were included. The cumulative incidence of target vessel instability was 4.8%, 6.4%, and 7.9% at one, two, and three years, respectively. In the renal target vessel group, vessel diameter ≤ 4 mm (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.116 - 2.54; p = .022) and a bridging length ≥ 25 mm (HR 1.320, 95% CI 1.066 - 1.636; p = .011) were associated with increased target vessel instability. In visceral vessels, a change in clock position/horizontal misalignment ≥ 70 minutes (HR 1.072, 95% CI 1.026 - 1.121; p = .002) showed a significant association with target vessel instability. CONCLUSION Target vessel diameter, bridging length (gap), and horizontal misalignment seemed to be associated with adverse target vessel outcomes. This may be solved with more customised endograft solutions to reduce the negative impact of the latter parameter.
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Affiliation(s)
- Daniel Becker
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Laura Sikman
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Ahmed Ali
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany; Department of Vascular Surgery, Cardiovascular and Vascular Surgery Centre, University Hospital, Mansoura University, Mansoura, Egypt
| | - Carlota F Prendes
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany.
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13
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Gallitto E, Faggioli G, Poliseno C, Cappiello A, Pini R, Vacirca A, Logiacco A, Gargiulo M. Pre-emptive False Lumen Embolization to Prevent Persistent Type II Endoleak in Fenestrated-Branched Endovascular Repair of Post-Dissection Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2024:15266028241246656. [PMID: 38659327 DOI: 10.1177/15266028241246656] [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: 04/26/2024]
Abstract
PURPOSE The purpose was to describe a technique to promote false lumen (FL) thrombosis in post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) managed by fenestrated/branched endografting (F/B-EVAR). TECHNIQUE A 5/6Fr-90 cm length sheath is advanced from the true lumen (TL) to FL through the most distal entry tear of the infrarenal aorta or iliac arteries. It is parked in the most cranial portion of the FL in the thoracic aorta. Aortic endografts are deployed in the TL excluding all the para-visceral/distal entry tears and target visceral vessels bridging stenting is performed. A selective FL angiography is performed through the 5/6Fr sheath to detect the origin of all segmentary arteries. Embolization of FL is performed from above to below by M-reye pushable coils, obtaining the packaging of FL. After completion angiography, the 5/6Fr sheath is retrieved in external iliac artery and molding ballooning of the distal segment of the aortic/iliac endograft is performed. Between 2019 and 2023, this technique was applied in 11cases with a median number of 73 (interquartile range [IQR=12) coils. Out of 8 (72%) patients with available radiological follow-up at 1 year, 7 exhibited complete FL thrombosis. CONCLUSIONS The FL coiling in PD-TAAAs managed by F/B-EVAR is feasible, safe, and effective to promote the complete FL thrombosis. CLINICAL IMPACT Preemptive false lumen embolization is a feasible, safe, and effective technique for preventing persistent type II endoleaks after fenestrated-branched endovascular repair of post-dissection thoracoabdominal aortic aneurysms. This technique may be routinely recommended to promote FL thrombosis and aortic remodeling after FB-EVAR in PD-TAAAs, thereby reducing the incidence of reinterventions during follow-up.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, DIMEC, University of Bologna, Bologna, Italy
| | | | | | | | - Rodolfo Pini
- Vascular Surgery, DIMEC, University of Bologna, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery, DIMEC, University of Bologna, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, DIMEC, University of Bologna, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
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14
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Simmering JA, Koenrades MA, Slump CH, Groot Jebbink E, Zeebregts CJ, Reijnen MMPJ, Geelkerken RH. Renal and Visceral Artery Configuration During the First Year of Follow-Up After Fenestrated Aortic Aneurysm Repair Using the Anaconda Stent-graft: A Prospective Longitudinal Multicenter Study With ECG-Gated CTA Scans. J Endovasc Ther 2023:15266028231209929. [PMID: 37933525 DOI: 10.1177/15266028231209929] [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: 11/08/2023]
Abstract
OBJECTIVE The performance of fenestrated endovascular aortic aneurysm repair (FEVAR) may be compromised by complications related to the dynamic vascular environment. The aim of this study was to analyze the behavior of FEVAR bridging stent configurations during the cardiac cycle and during follow-up to improve our understanding on treatment durability. DESIGN Twenty-one patients presenting with complex abdominal aortic aneurysms (AAAs; 9 juxtarenal/6 pararenal/3 paravisceral/1 thoracoabdominal aortic aneurysm type IV), treated with a fenestrated Anaconda (Terumo Aortic, Inchinnan, Scotland, UK) with Advanta V12 bridging stents (Getinge, Merrimack, NH, USA), were prospectively enrolled in a multicenter observational cohort study and underwent electrocardiogram (ECG)-gated computed tomographic angiography (CTA) preoperatively, at discharge, 7-week, and 12-month follow-ups. METHODS Fenestrated endovascular aortic aneurysm repair stability was assessed considering the following variables: branch angle as the angle between the aorta and the target artery, end-stent angle as the angle between the end of the bridging stent and the native artery downstream from it, curvature and tortuosity index (TI) to describe the bending of the target artery. Body-bridging stent stability was assessed considering bridging stent flare lengths, the distances between the proximal sealing stent-ring and fenestrations and the distance between the fenestration and first apposition in the target artery. RESULTS Renal branch angles significantly increased after FEVAR toward a perpendicular position (right renal artery from median 60.9°, inter quartile range [IQR]=44.2-84.9° preoperatively to 94.4°, IQR=72.6-99.8°, p=0.001 at 12-month follow-up; left renal artery [LRA], from 63.7°, IQR=55.0-73.0° to 94.3°, IQR=68.2-105.6°, p<0.001), while visceral branch angles did not. The mean dynamic curvature only decreased for the LRA from preoperative (3.0, IQR=2.2-3.8 m-1) to 12-month follow-up (1.9, IQR=1.4-2.6 m-1, p=0.027). The remaining investigated variables did not seem to show any changes over time in this cohort. CONCLUSIONS Fenestrated endovascular aortic aneurysm repair for complex AAAs using the Anaconda fenestrated stent-graft and balloon-expandable Advanta V12 bridging stents demonstrated stable configurations up to 12-month follow-up, except for increasing renal branch angles toward perpendicular orientation to the aorta, yet without apparent clinical consequences in this cohort. CLINICAL IMPACT This study provides detailed information on the cardiac-pulsatility-induced (dynamic) and longitudinal geometry deformations of the target arteries and bridging stents after fenestrated endovascular aortic aneurysm repair (FEVAR) up to 12-month follow-up. The configuration demonstrated limited dynamic and longitudinal deformations in terms of branch angle, end-stent angle, curvature, and tortuosity index (TI), except for the increasing renal branch angles that go toward a perpendicular orientation to the aorta. Overall, the results suggest that the investigated FEVAR configurations are stable and durable, though careful consideration of increasing renal branch angles and significant geometry alterations is advised.
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Affiliation(s)
- Jaimy A Simmering
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Maaike A Koenrades
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Medical 3D Lab, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Erik Groot Jebbink
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michel M P J Reijnen
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - Robert H Geelkerken
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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15
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Haulon S, Steinmetz E, Feugier P, Magnan PE, Maurel B, Fabre D, Geng B, Doyle M, Twesigye I, Sobocinski J. Two-Year Results on Real-World Fenestrated or Branched Endovascular Repair for Complex Aortic Abdominal Aneurysm in France. J Endovasc Ther 2023:15266028231208653. [PMID: 37902436 DOI: 10.1177/15266028231208653] [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
PURPOSE To describe and compare mid-term outcomes from 2 real-world data collection efforts on fenestrated and branched endovascular aortic repair (fbEVAR) for complex abdominal aortic aneurysms (AAAs) in France and to evaluate the potential of health care databases for long-term post-market surveillance (PMS) and continued reimbursement approval. METHODS Two real-world studies were conducted in France: a retrospective health care database study (SNDS) and a prospective clinical study. In the SNDS study, data from implantation and/or hospital stays occurring during follow-up were extracted for all patients treated with the study devices from April 2012 to December 2018. In the clinical study, high-risk patients undergoing fbEVAR with the study devices were enrolled consecutively at 15 sites in France from December 2016 to November 2018. RESULTS Data from 1073 patients were extracted from SNDS and compared with analogous variables from 186 patients in the clinical study. Most demographic details were similar between studies (SNDS vs clinical: mean age, 71.9 vs 71.8 years; men, 91.0% vs 89.8%), as was 30-day mortality (SNDS: 5.5%, clinical: 4.3%). Patients received custom-made fenestrated or branched devices (SNDS: 80.7%, clinical: 96.2%) or CE-marked Zenith Fenestrated devices (SNDS: 19.3%, clinical: 3.8%). Initial or technical success was above 94% for both studies. Two-year freedom from all-cause mortality was 80.0% (SNDS) and 85.1% (clinical study). Two-year freedom from aneurysm-related mortality was 93.8% (SNDS) and 94.6% (clinical study). Detailed imaging outcomes were not captured within SNDS; however, information on secondary procedures to restore patency was available and used as a surrogate measure for secondary interventions. Two-year freedom from secondary interventions was 73% for the SNDS study. In the clinical study, at 2 years, aneurysm stability or shrinkage was observed in 92.3% of patients, freedom from target vessel primary patency loss was above 95% for all visceral target vessels, and freedom from secondary interventions was 79.1%. CONCLUSION Real-world outcomes from the SNDS and clinical study suggest positive mid-term outcomes in high-risk populations following fbEVAR for complex AAAs. The similarities between these studies suggest that the use of health care databases may be an alternative to prospective clinical studies for long-term follow-up and PMS. CLINICAL IMPACT Positive results following endovascular repair of complex abdominal aortic aneurysms are observed from data extracted from both the French health care database and a post-market clinical study despite initial high-risk patient status and diverse center experience. These outcomes parallel more rigorously designed studies and suggest that with careful study design, real-world data collections have high translatable value to add to the clinical understanding of fenestrated and branched endovascular aortic repair (fbEVAR).
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Affiliation(s)
- Stéphan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | | | | | | | | | - Dominique Fabre
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Bo Geng
- Cook Research Incorporated, West Lafayette, IN, USA
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Chait J, Gilkey GD, Mendes BC, Ramakrishna H. Complex Endovascular Aortic Reconstruction: An Update. J Cardiothorac Vasc Anesth 2023; 37:2125-2132. [PMID: 37344248 DOI: 10.1053/j.jvca.2023.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Jesse Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - George D Gilkey
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Gallitto E, Faggioli G, Vacirca A, Lodato M, Cappiello A, Logiacco A, Feroldi F, Pini R, Gargiulo M. Superior mesenteric artery-related outcomes in fenestrated/branched endografting for complex aortic aneurysms. Front Cardiovasc Med 2023; 10:1252533. [PMID: 37771670 PMCID: PMC10526822 DOI: 10.3389/fcvm.2023.1252533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
Aim Early/follow-up durability of superior mesenteric artery (SMA) stent-grafts is crucial after fenestrated/branched endografting (FB-EVAR) in complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). The study aimed to report early/midterm outcomes of SMA incorporated during FB-EVAR procedures. Methods FB-EVAR procedures performed between 2016 and 2021 in a single institution were reviewed. Anatomical SMA characteristics were analyzed. The SMA configuration was classified into three types according to the angle between the SMA main trunk and the aorta: (A) perpendicular, (B) downward, and (C) upward. SMA-related technical success (SMA-TS: cannulation and stenting, patency at completion angiography without endoleak, stenosis/kinking, dissection, bleeding, and 24-h mortality) and SMA-adverse events (SMA-AEs: one among bowel ischemia, stenosis, occlusion, endoleak, reinterventions, or SMA-related mortality) were assessed. Results Two hundred FB-EVAR procedures with SMA as the target artery were performed. The indication for FB-EVAR was CAAAs and TAAAs in 99 (49%) and 101 (51%) cases, respectively. The SMA configuration was A, B, and C in 132 (66%), 63 (31%), and 5 (3%) cases, respectively. SMA was incorporated with fenestrations and branches in 131 (66%) and 69 (34%) cases, respectively. Directional branch (P < .001), aortic diameter ≥35 mm at the SMA level (P < .001), and ≥2 SMA bridging stent-grafts (P = .001) were more frequent in TAAAs. Relining of the SMA stent-graft with a bare metal stent was necessary in 41 (21%) cases to correct an acute angle between the stent-graft and native artery (39), stent-graft stenosis (1), or SMA dissection (1). Relining was associated with type A or C SMA configuration (OR: 17; 95% CI: 1.8-157.3; P = .01). SMA-TS was achieved in all cases. Overall, 15 (7.5%) patients had SMA-AEs [early: 9 (60%), follow-up: 6 (40%)] due to stenosis (2), endoleak (8), and bowel ischemia (5). Aortic diameter ≥35 mm at the SMA level was an independent risk factor for SMA-AEs (OR: 4; 95% CI: 1.4-13.8; P = .01). Fourteen (7%) patients died during hospitalization with 10 (5%) events within the 30-postoperative day. Emergency cases (OR: 33; 95% CI: 5.7-191.3; P = .001), peripheral arterial occlusive disease (OR: 14; 95% CI: 2.3-88.8; P = .004), and bowel ischemia (OR: 41; 95% CI: 1.9-87.9; P = .01) were risk factors for 30-day/in-hospital mortality. The mean follow-up was 32 ± 24 months; estimated 3-year survival was 81%, with no case of late SMA-related mortality or occlusion. The estimated 3-year freedom from overall and SMA-related reinterventions was 74% and 95%, respectively. Conclusion SMA orientation determines the necessity of stent-graft relining. Aortic diameter ≥35 mm at the SMA level is a predictor of SMA-AEs. Nevertheless, SMA-related outcomes of FB-EVAR are satisfactory, with excellent technical success and promising clinical outcomes during the follow-up.
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Affiliation(s)
- E. Gallitto
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - G. Faggioli
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - A. Vacirca
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - M. Lodato
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
| | - A. Cappiello
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
| | - A. Logiacco
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
| | - F. Feroldi
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
| | - R. Pini
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - M. Gargiulo
- Vascular Surgery, University of Bologna—DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
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Fargion AT, Esposito D, Speziali S, Pulli R, Gallitto E, Faggioli G, Gargiulo M, Bertoglio L, Melissano G, Chiesa R, Simonte G, Isernia G, Lenti M, Pratesi C. Fate of target visceral vessels in fenestrated and branched complex endovascular aortic repair. J Vasc Surg 2023; 78:584-592.e2. [PMID: 37187414 DOI: 10.1016/j.jvs.2023.05.003] [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: 03/25/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To assess branch vessel outcomes after endovascular repair of complex aortic aneurysms analyzing possible factors influencing early and long-term results. METHODS The Italian Multicentre Fenestrated and Branched registry enrolled 596 consecutive patients treated with fenestrated and branched endografts for complex aortic disease from January 2008 to December 2019 by four Italian academic centers. The primary end points of the study were technical success (defined as target visceral vessel [TVV] patency and absence of bridging device-related endoleak at final intraoperative control), and freedom from TVV instability (defined as the combined results of type IC/IIIC endoleaks and patency loss) during follow-up. Secondary end points were overall survival and TVV-related reinterventions. RESULTS We excluded 591 patients (3 patients with a surgical debranching and 2 patients who died before completion from the study cohort) were treated for a total of 1991 visceral vessels targeted by either a directional branch or a fenestration. The overall technical success rate was 98.4%. Failure was related to the use of an off-the-shelf (OTS) device (custom-made device vs OTS, HR, 0.220; P = .007) and a preoperative TVV stenosis of >50% (HR, 12.460; P < .001). The mean follow-up time was 25.1 months (interquartile range, 3-39 months). The overall estimated survival rates were 87%, 77.4%, and 67.8% at 1, 3, and 5 years, respectively (standard error [SE], 0.015, 0.022, and 0.032). During follow-up, TVV branch instability was observed in 91 vessels (5%): 48 type IC/IIIC endoleaks (2.6%) and 43 stenoses-thromboses (2.4%). The extent of aneurysm disease (thoracoabdominal aortic aneurysm [TAAA] types I-III vs TAAA type IV/juxtarenal aortic aneurysm/pararenal aortic aneurysm) was the only independent predictor for developing a TVV-related type IC/IIIC endoleak (HR, 3.899; 95% confidence interval [CI]:, 1.924-7.900; P < .001). Risk of patency loss was independently associated with branch configuration (HR, 8.883; P < .001; 95% CI, 3.750-21.043) and renal arteries (HR, 2.848; P = .030; 95% CI, 1.108-7.319). Estimated rates at 1, 3, and 5 years of freedom from TVV instability and freedom from TVV-related reintervention were 96.6%, 93.8%, and 90% (SE, 0.005, 0.007, and 0.014) and 97.4%, 95.0%, and 91.6% (SE, 0.004, 0.007, and 0.013), respectively. CONCLUSIONS Intraoperative failure to bridge a TVV was associated with a preoperative TVV stenosis of >50% and the use of OTS devices. Midterm outcomes were satisfying, with an estimated 5-year freedom from TVV instability and reintervention of 90.0% and 91.6%, respectively. During follow-up, the larger extent of aneurysm disease was associated with an increased risk of TVV-related endoleaks, whereas a branch configuration and renal arteries were more prone to patency loss.
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Affiliation(s)
- Aaron Thomas Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy.
| | - Davide Esposito
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Sara Speziali
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Raffaele Pulli
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Sant'Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Sant'Orsola, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Sant'Orsola, Bologna, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, S. Maria Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, S. Maria Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, S. Maria Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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Ma X, Feng Y, Tardzenyuy MA, Qin B, Zhu Q, Akilu W, Li S, Wei X, Feng X, Cheng C. Debranching abdominal aortic hybrid surgery for aortic diseases involving the visceral arteries. Front Cardiovasc Med 2023; 10:1219788. [PMID: 37522078 PMCID: PMC10374220 DOI: 10.3389/fcvm.2023.1219788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/15/2023] [Indexed: 08/01/2023] Open
Abstract
Objective Aortic diseases involving branches of the visceral arteries mainly include thoracoabdominal aortic aneurysm (TAAA), aortic dissection (AD) and abdominal aortic aneurysm (AAA). The focus of treatment is to reconstruct the splanchnic arteries and restore blood supply to the organs. Commonly used methods include thoracoabdominal aortic replacement, thoracic endovascular aortic repair and hybrid approaches. Hybrid surgery for aortic disease involving the visceral arteries, consisting of visceral aortic debranching with retrograde revascularization of the celiac trunk and renal arteries and using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients. This study retrospectively analyzed recorded data of patients and contrasted the outcomes with those of a similar group of patients who underwent conventional open repair surgery. Methods Between 2019 and 2022, 72 patients (52 men) with an average age of 61.57 ± 8.66 years (range, 36-79 years) underwent one-stage debranching abdominal aortic hybrid surgery. These patients, the hybrid group, underwent preoperative Computed Tomographic Angiography (CTA) and had been diagnosed with aortic disease (aneurysm or dissection) involving the visceral arteries and were at high risk for open repair. The criteria used to define these patients as high-risk group who are in the need of hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4. In all cases, we accomplished total visceral aortic debranching through a previous visceral artery retrograde revascularization with synthetic grafts (customized Y or four-bifurcated grafts), and aortic endovascular repair with one of two different commercially produced stent grafts (Medtronic® and Lifetech®). In some cases, we chose to connect the renal artery to the artificial vessel with a stent graft (Viabahn) and partly or totally anastomosed. We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 46 patients (36 men) with an average age 54.15 ± 12.12 years (range, 32-76). These 46 patients, the conventional open group, were selected for having had thoracoabdominal aortic replacement between 2019 and 2022. Results In the hybrid group, 72 visceral bypasses were completed, and endovascular repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 2.78%, and perioperative morbidity was 9.72% (renal insufficiency in 1, unilateral renal infarction in 5, Intestinal ischemia in 1). At 1-month postoperative CTA showed 2 endoleaks, one of which was intervened. At follow-up, there were unplanned reoperation rate of 4.29% and 5 (7.14%) deaths. The remaining patients' grafts were patent at postoperative CTA and no endoleak or stent graft migration had occurred. In the conventional open group, 1 died intraoperatively, 4 died perioperatively, perioperative mortality was 10.87% and complications were respiratory failure in 5, intestinal paralysis/necrosis in 4, renal insufficiency in 17, and paraplegia in 2. At follow-up, 5 (12.20%) patients presented with synthetic grafts hematoma 4 (9.76%) patient died, and 6 (14.63%) patients required unplanned reoperation intervention. Conclusion Hybrid surgery is technically feasible in selected cases. For aortic diseases involving the visceral arteries, the application of hybrid abdominal aorta debranching can simplify the operation process, decrease the risks of mortality and morbidity in high-risk and high-age populations and decrease the incidence of various complications while achieving ideal early clinical efficacy. However, a larger series is required for valid statistical comparisons, and longer follow-ups are necessary to evaluate the long-term efficacy of hybrid surgery.
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Affiliation(s)
- Xiantao Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Feng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mbenkum Achiri Tardzenyuy
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Qin
- Department of Cardiothoracic Surgery, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Qiangzhang Zhu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wajeehullahi Akilu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiliang Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Feng
- Division of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Cai Cheng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Kapalla M, Busch A, Lutz B, Nebelung H, Wolk S, Reeps C. Single-center initial experience with inner-branch complex EVAR in 44 patients. Front Cardiovasc Med 2023; 10:1188501. [PMID: 37396572 PMCID: PMC10309562 DOI: 10.3389/fcvm.2023.1188501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023] Open
Abstract
Purpose The use of inner-branch aortic stent grafts in the treatment of complex aortic pathologies aims at broad applicability and stable bridging stent sealing compared to other endovascular technologies. The objective of this study was to evaluate the early outcomes with a single manufacturer custom-made and off-the-shelf inner-branched endograft in a mixed patient cohort. Methods This retrospective, monocentric study between 2019 and 2022 included 44 patients treated with inner-branched aortic stent grafts (iBEVAR) as custom-made device (CMD) or off-the-shelf device (E-nside) with at least four inner branches. The primary endpoints were technical and clinical success. Results Overall, 77% (n = 34) and 23% (n = 10) of the patients (mean age 77 ± 6.5 years, n = 36 male) were treated with a custom-made iBEVAR with at least four inner branches and an off-the-shelf graft, respectively. Treatment indications were thoracoabdominal pathologies in 52.2% (n = 23), complex abdominal aneurysms in 25% (n = 11), and type Ia endoleaks in 22.7% (n = 10). Preoperative spinal catheter placement was performed in 27% (n = 12) of patients. Implantation was entirely percutaneous in 75% (n = 33). Technical success was 100%. Target vessel success manifested at 99% (178/180). There was no in-hospital mortality. Permanent paraplegia developed in 6.8% (n = 3) of patients. The mean follow-up was 12 months (range 0-52 months). Three late deaths (6.8%) occurred, one related to an aortic graft infection. Kaplan-Meier estimated 1-year survival manifested at 95% and branch patency at 98% (177/180). Re-intervention was necessary for a total of six patients (13.6%). Conclusions Inner-branch aortic stent grafts provide a feasible option for the treatment of complex aortic pathologies, both elective (custom-made) and urgent (off-the-shelf). The technical success rate is high with acceptable short-term outcomes and moderate re-intervention rates comparable to existing platforms. Further follow-up will evaluate long-term outcomes.
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Affiliation(s)
- Marvin Kapalla
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Albert Busch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Brigitta Lutz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Heiner Nebelung
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
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Bertoglio L, Melloni A, Bugna C, Grignani C, Bucci D, Foglia E, Chiesa R, Odone A. In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms. J Vasc Surg 2023:S0741-5214(23)01034-0. [PMID: 37076108 DOI: 10.1016/j.jvs.2023.03.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center. METHODS This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness. RESULTS Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved. CONCLUSIONS ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Bugna
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Camilla Grignani
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daria Bucci
- School of Public Health, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Foglia
- School of Industrial Engineering, Carlo Cattaneo - LIUC University and LIUC Business School, Castellanza, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
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Simonte G, Isernia G, Gatta E, Neri E, Parlani G, Candeloro L, Schiavon S, Pagliariccio G, Cini M, Lenti M, Carbonari L, Ricci C. Inner branched complex aortic repair outcomes from a national multicenter registry using the E-xtra design platform. J Vasc Surg 2023; 77:338-346. [PMID: 36070846 DOI: 10.1016/j.jvs.2022.08.034] [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: 04/23/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience. METHODS All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up. RESULTS From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively. CONCLUSIONS Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed.
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Affiliation(s)
- Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Giacomo Isernia
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Eugenio Neri
- Cardiac and Great Vessels Surgery Unit, University of Siena, Siena, Italy
| | - Gianbattista Parlani
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Laura Candeloro
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Sara Schiavon
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Marco Cini
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Massimo Lenti
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Luciano Carbonari
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carmelo Ricci
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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Rinaldi E, Loschi D, Favia N, Santoro A, Chiesa R, Melissano G. Spinal Cord Ischemia in Open and Endovascular Aortic Repair. AORTA (STAMFORD, CONN.) 2022; 10:194-200. [PMID: 36521813 PMCID: PMC9754877 DOI: 10.1055/s-0042-1756669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Despite the improvements, spinal cord ischemia is still one of the major and most dramatic potential complications after thoracic and thoracoabdominal aortic treatments, for both open and endovascular procedures. A multimodal approach, which includes several intraoperative and postoperative maneuvers, may contribute to optimizing the spinal cord tolerance to ischemia. The aim of this article is to report the different techniques employed to improve spinal cord perfusion, directly and indirectly through collateral circulation.
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Affiliation(s)
- Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy,Address for correspondence Enrico Rinaldi, MD Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele UniversityVia Olgettina, 60, 20132 MilanItaly
| | - Diletta Loschi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Nicola Favia
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Annarita Santoro
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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24
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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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25
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Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
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Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
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26
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de Marino PM, Ibraheem A, Tesinsky P, Jiries MA, Katsargyris A, Verhoeven EL. Fenestrated and branched stent grafts for the treatment of post-dissection thoracoabdominal aortic aneurysms. Semin Vasc Surg 2022; 35:312-319. [DOI: 10.1053/j.semvascsurg.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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27
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Tenorio ER, Dias-Neto MF, Lima GBB, Baghbani-Oskouei A, Oderich GS. Lessons learned over two decades of fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:236-244. [DOI: 10.1053/j.semvascsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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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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Sultan S, Concannon J, Veerasingam D, Tawfick W, McHugh P, Jordan F, Hynes N. Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms. Cochrane Database Syst Rev 2022; 4:CD012926. [PMID: 35363887 PMCID: PMC9370075 DOI: 10.1002/14651858.cd012926.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracoabdominal aortic aneurysms (TAAAs) are a life-threatening condition which remain difficult to treat. Endovascular and open surgical repair (OSR) provide treatment options for patients, however, due to the lack of clinical trials comparing these, the optimum treatment option is unknown. OBJECTIVES To assess the effectiveness and safety of endovascular repair versus conventional OSR for the treatment of TAAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 April 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing endovascular repair to OSR for TAAAs for inclusion in the review. The main outcomes of interest were prevention of aneurysm rupture (participants without aneurysm rupture up to 5 years from intervention), aneurysm-related mortality (30 days and 12 months), all-cause mortality, spinal cord ischaemia (paraplegia, paraparesis), visceral arterial branch compromise causing mesenteric ischaemia or renal failure, and rate of reintervention. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts identified from the searches to identify those that met the inclusion criteria. We planned to undertake data collection, risk of bias assessment, and analysis in accordance with Cochrane recommendations. We planned to assess the certainty of the evidence using GRADE. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of endovascular compared to OSR in patients with TAAAs and are unable to provide any evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs addressing this objective are necessary, however conducting such studies will be logistically and ethically challenging for this life-threatening disease.
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Affiliation(s)
- Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Jamie Concannon
- Biomedical Engineering, Vascular and Endovascular Surgery, National University of Ireland Galway, Galway, Ireland
| | - Dave Veerasingam
- Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland
| | - Peter McHugh
- Mechanical and Biomedical Engineering, National University of Ireland Galway, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Niamh Hynes
- CURAM, SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
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30
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Rinaldi E, Melloni A, Gallitto E, Fargion A, Isernia G, Kahlberg A, Bertoglio L, Faggioli G, Lenti M, Pratesi C, Gargiulo M, Melissano G, Chiesa R, Luigi B, Luca B, Roberto C, Gianluca F, Aaron F, Cecilia F, Enrico G, Mauro G, Giacomo I, Massimo L, Antonino L, Andrea K, Chiara M, Germano M, Andrea M, Rodolfo P, Carlo P, Enrico R, Gioele S, Sara S. Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry. J Endovasc Ther 2022; 30:281-288. [PMID: 35236159 DOI: 10.1177/15266028221081074] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). MATERIALS AND METHODS All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. RESULTS A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18). CONCLUSION The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.
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Affiliation(s)
- Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, 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
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, 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
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Baccani Luigi
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Faggioli Gianluca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fargion Aaron
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Fenelli Cecilia
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gallitto Enrico
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gargiulo Mauro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Isernia Giacomo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti Massimo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Logiacco Antonino
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Kahlberg Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mascoli Chiara
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melissano Germano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Melloni Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pini Rodolfo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pratesi Carlo
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Simonte Gioele
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Speziali Sara
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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31
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Journal of Vascular Surgery – December 2021 Audiovisual Summary. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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32
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Huber TS. FEVAR and BEVAR: The new standard for comparison - Defining what is possible. J Vasc Surg 2021; 74:1807. [PMID: 34809810 DOI: 10.1016/j.jvs.2021.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/26/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine.
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Tenorio ER, Dias-Neto MF, Lima GBB, Estrera AL, Oderich GS. Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges. Ann Cardiothorac Surg 2021; 10:744-767. [PMID: 34926178 PMCID: PMC8640886 DOI: 10.21037/acs-2021-taes-24] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 12/23/2022]
Abstract
Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Marina F Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Anthony L Estrera
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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D'Oria M, Wanhainen A, Lindström D, Tegler G, Mani K. Pre-Operative Moderate to Severe Chronic Kidney Disease is Associated with Worse Short-Term and Mid-Term Outcomes in Patients Undergoing Fenestrated-Branched Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2021; 62:859-868. [PMID: 34716095 DOI: 10.1016/j.ejvs.2021.08.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/10/2021] [Accepted: 08/26/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review experience of fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal/thoraco-abdominal aortic aneurysms (PRAA/TAAA) and to assess the association between pre-operative moderate to severe chronic kidney disease (CKD) and post-operative outcomes. METHODS All consecutive patients undergoing (elective and non-elective) F-BEVAR at a single centre (1 January 2011 - 1 July 2019) were identified. Renal function was calculated as the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. Accordingly, presence of moderate to severe CKD was defined as eGFR < 60 mL/min/1.73m2. RESULTS Overall, 202 consecutive patients (mean age 72 ± 8 years; 25% women) underwent F-BEVAR for the treatment of PRAA/TAAA during the study period. Of these, 51 had a history of moderate to severe CKD (none on chronic haemodialysis). No statistically significant differences were found in demographics and major comorbidities between patients with or without a history of CKD. The overall peri-operative mortality rate was 2%, without statistically significant differences between study groups (p = .26). Patients with prior CKD had statistically significantly higher rates of acute kidney injury (AKI) (37% vs. 12%, p < .001). At three years, overall survival was statistically significantly lower in patients with history of CKD compared with those without pre-operative CKD (57% vs. 82%, p = .010). Similarly, freedom from renal function decline at three years was statistically significantly poorer in patients with prior history of CKD compared with those without pre-operative CKD (43% vs. 80%, p = .020). In a multivariable analysis CKD was independently associated with higher odds of peri-operative AKI (OR 2.8, 95% CI 1.9 - 5.8, p = .030), renal function decline (OR 4.9, 95% CI 1.7 - 9.2, p = .003), and all cause mortality (HR 3.2, 95% CI 1.2 - 8.6, p = .020). CONCLUSION Despite low peri-operative mortality rates that are comparable to patients with unimpaired renal function, occurrence of AKI was statistically significantly higher in subjects with pre-existing moderate to severe CKD. History of CKD was independently associated to renal function decline and poorer midterm survival.
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MESH Headings
- Aged
- Aged, 80 and over
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/surgery
- Blood Vessel Prosthesis
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/mortality
- Disease Progression
- Endovascular Procedures/adverse effects
- Endovascular Procedures/instrumentation
- Endovascular Procedures/mortality
- Female
- Glomerular Filtration Rate
- Humans
- Kidney/physiopathology
- Male
- Middle Aged
- Prosthesis Design
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/mortality
- Renal Insufficiency, Chronic/physiopathology
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Severity of Illness Index
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Mario D'Oria
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Lindström
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gustaf Tegler
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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