Complex Endovascular Aortic Reconstruction: An Update

Outcomes of Patients Treated with Double-Wide Scallop vs Fenestrations for Celiac Artery Incorporation During Repair of Complex Abdominal Aortic Aneurysms

OBJECTIVES

Celiac artery (CA) incorporation during FB-EVAR for complex abdominal aortic aneurysms (cAAA) is typically performed with fenestrations. Double-wide scallops (DWS) can be used when appropriate. We aimed to assess outcomes of patients treated with DWS for the CA during FB-EVAR for cAAA.

METHODS

This is a single-center retrospective review of patients enrolled in a prospective investigational device exemption trial undergoing FB-EVAR for cAAA from 2013-2020. Use of DWS or fenestrations for management of the CA was selected to optimize seal. Patients with longer lengths of normal caliber aorta between the renal and celiac arteries, and without thoracic aortic ectasia or multifocal thoracic aortic aneurysms were considered for DWS, whereas those with shorter visceral segment seal zones or thoracic aortic disease were preferentially treated with fenestrations for the CA. Endpoints were morbidity, mortality, technical success, freedom from type IA endoleak, and target vessel instability (TVI).

RESULTS

FB-EVAR with CA DWS or fenestration was performed in 131 patients, 97 male (74%). DWS were used in 68 patients (52%) and fenestrations in 63 (48%). Mean age was 75±7.4 years in both groups. Demographics, cardiovascular risk factors, and mean aortic diameter (p=0.382) were similar between groups. Median number of incorporated vessels was similar (4, p=0.373) between groups. Median endovascular operative time (DWS=118[98-154] min, Fenestration=141[122-170] min, p=0.006) and fluoroscopy time (DWS=64[51-78] min, Fenestration=70[61-83] min, p=0.032) were shorter with DWS, with no difference in contrast volume (p=0.204). Technical success was 96% with DWS and 100% with fenestrations (p=0.096). Three patients with DWS had partial or complete CA coverage. Median aortic coverage (above CA) was higher with fenestrations (Fenestration=5.5[4.5-6.4] cm, DWS=3.8[3.5-4.2] cm, p<0.001). There was no difference in 30-day mortality (DWS=0%, Fenestration=1.6%, p=0.297) or major adverse events (DWS=17.6% vs Fenestration=17.5%, p=0.978). Median follow-up was 42 months [25, 50]. There were no Type IA endoleaks, aortic ruptures, or open conversions. There was no difference in sac regression (DWS=60%, Fenestration=67%, p=0.449), survival (p=0.859) or CA TVI (p=0.320).

CONCLUSIONS

FB-EVAR with DWS and fenestrations show comparable perioperative and long-term outcomes without significant differences in technical success, TVI, and sac regression when used with precise device selection based on visceral segment seal zone lengths and risk for aortic degeneration. Device design should be determined by patient anatomy and seal-zone given comparable outcomes.

Up and over staged endoconduit technique for endovascular aortic aneurysm repair

Adverse iliofemoral anatomy can preclude complex endovascular aortic aneurysm repair. This study aims to describe the "up-and-over" staged endoconduit technique to improve access and avoid vascular injury before complex endovascular aneurysm repair. A staged procedure for complex endovascular aortic aneurysm repair is performed using an endoconduit (W.L. Gore & Associates). After obtaining contralateral femoral access, the extension of iliofemoral disease is assessed using angiography. The endoconduit is advanced "up and over" the aortic bifurcation and delivered percutaneously into the common femoral artery to treat a diseased access site and maintain intact the ipsilateral femoral access for future stent graft deployment. Internal iliac artery patency is maintained when feasible. During complex aneurysm repair, the endoconduit is accessed directly under ultrasound guidance using sequential dilation to avoid vascular injury. PerClose sutures (Abbott Vascular) are used to close the endoconduit femoral access site. This study found that staged "up and over" endoconduit creation is a useful technique before complex endovascular aneurysm repair in patients with adverse iliofemoral anatomy. Avoiding accessing the main femoral access site during the first stage prevents vascular or access site injuries and allows for both iliac and femoral disease to be addressed.