Endovascular repair of a dissecting pararenal abdominal aortic aneurysm in a patient with type III Loeys-Dietz syndrome

Iliac branch endoprosthesis for repair of a common iliac artery aneurysm in Loeys-Dietz syndrome type 3

The commercial availability of the iliac branch endoprosthesis (IBE) has permitted endovascular repair of iliac artery aneurysms with the preservation of pelvic circulation. However, the device instructions for use require certain anatomic criteria that can limit deployment in ≤30% of patients. Moreover, branched endovascular treatment of common iliac artery aneurysms with IBE in patients with connective tissue disorders such as Loeys-Dietz syndrome has not been described. In the present report, we have described our technique of alternative endograft aortoiliac reconstruction to overcome anatomic barriers to IBE placement in a patient with a giant common iliac artery aneurysm in the setting of a rare pathogenic variant in the SMAD3 gene.

Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease

OBJECTIVE

In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD.

METHODS

A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected.

RESULTS

Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent thirty-seven endovascular procedures between 2006 and 2020 with mean follow up of 54 ± 41 months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and 8 chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, twenty-five (68%) proximal landing zones were in the native aorta or branch vessel, eleven (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20 ± 15 days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30 days, two endografts (of 37, 5%) required reintervention. After 30 days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention.

CONCLUSIONS

This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

Elucidating the role of the AFX2 endograft in endovascular treatment of aortic pathology

OBJECTIVE

The purpose of this study is to elucidate the role of the AFX2 platform in the endovascular treatment of aortic pathology.

METHODS

All procedures by a single surgeon resulting in implantation of a bifurcated unibody stent graft were retrospectively reviewed. Indications for selection of the AFX2 endograft in each case were evaluated. Aortic anatomy was determined via review of pre-operative computed tomography (CT) scans. Cumulative event probabilities for endoleak, reintervention, and mortality were estimated. Patient and procedural details were described using mean, standard deviation, medians, and interquartile range (IQR). Kaplan-Meier survival analysis estimated freedom from mortality and reintervention. Cumulative incidence probabilities were calculated as one minus the Kaplan-Meier estimator.

RESULTS

Between March 2018 and December 2020, the author (NN) used 142 aortic endografts in 142 patients. Of these, 46 (32.4%) were AFX2 endografts and the remaining were modular bifurcated devices, predominantly Medtronic Endurant II and Terumo Treo. No AFX-Strata or AFX-Duraply devices were placed. Amongst the patients who received an AFX2, mean age was 71.3 +/- 9.8 years with 84.8% male. Median operative time was 116 (86-166) minutes, with contrast dose of 79 (41-120) milliliters and fluoroscopy time of 12 (8.6-18) minutes. Overall, 78.3% (n=36) of AFX2 devices were placed in aortas with maximum true lumen diameter <5.0cm. Median postoperative follow-up was 1.7 years (IQR 1.0-2.4 years), with a maximum follow-up of 3.6 years. There was 1 patient lost to follow-up at 5 months. The 2-year incidence of type II endoleak, reintervention, and all-cause mortality was 12.7% (95% CI, 0-29.6%), 2.2% (95% CI, 0-6.3%), and 11.3% (95% CI, 0.1-2.1.2%), respectively. There were no type I or III endoleaks.

CONCLUSION

The AFX2 endograft plays a safe and effective role in treatment of infrarenal aortic pathologies that may be otherwise more technically challenging for traditional modular, bifurcated devices.