Fenestrated and Branched Stent Grafts for Repair of Complex Aortic Aneurysms

Antegrade endograft deployment with supra-aortic debranching to treat arch and descending thoracic aortic lesions. A single-center experience

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is a widely used procedure that has drastically changed the management of thoracic aortic diseases. We assess the effectiveness of supra-aortic debranching during antegrade TEVAR procedures with a retrospective analysis of our clinical experience METHODS: Between December 2005 and April 2017, 55 patients underwent 64 TEVAR procedures. Among them, there were 8 male patients, mean age 72, who underwent hybrid antegrade stent-graft deployment. Particularly, for degenerative aneurysms of the aortic arch 3 patients, for aneurysm of descending thoracic aorta 3, for post-traumatic pseudoaneurysm 1 and for penetrating aortic ulcer 1 which had resulted in an aortoesophageal fistula. Proximal landing zones were Z0:1, Z1:3 and Z2:4. Type I hybrid aortic arch repair was performed in 1 case, carotid-carotid bypass in 2, carotid-subclavian in 5 and aorto-carotid in 1.

RESULTS

The 30-day postoperative mortality was 12,5%. One patient suffered a temporary right hemiplegia which resolved after left aorto-carotid bypass. No endoleaks were observed postoperatively and in follow-up period. In the long term and a mean follow-up of 4.9 years, there were no deaths related to the stent-graft implantation or to revascularization procedures. Regarding the aortic arch rerouting procedure, there were no pseudoaneurysm or other anastomotic events.

CONCLUSION

Antegrade delivery of the endograft, combined with hybrid and revascularization procedures of the supra-aortic vessels is a safe treatment modality, in complex hostile anatomies. However, further improvements are recommended due to the presence of neurologic complications and reinterventions.

Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits

OBJECTIVES

The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access.

METHODS

A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention.

RESULTS

Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease.

CONCLUSIONS

Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.

Inaccurate Risk Assessment by the ACS NSQIP Risk Calculator in Aortic Surgery

OBJECTIVES

The aim of this retrospective study was to assess the predictive performance of the American College of Surgeons (ACS) risk calculator for aortic aneurysm repair for the patient population of a Dutch tertiary referral hospital.

METHODS

This retrospective study included all patients who underwent elective endovascular or open aortic aneurysm repair at our institution between the years 2013 and 2019. Preoperative patient demographics and postoperative complication data were collected, and individual risk assessments were generated using five different current procedural terminology (CPT) codes. Receiver operating characteristic (ROC) curves, calibration plots, Brier scores, and Index of Prediction Accuracy (IPA) values were generated to evaluate the predictive performance of the ACS risk calculator in terms of discrimination and calibration.

RESULTS

Two hundred thirty-four patients who underwent elective endovascular or open aortic aneurysm repair were identified. Only five out of thirteen risk predictions were found to be sufficiently discriminative. Furthermore, the ACS risk calculator showed a structurally insufficient calibration. Most Brier scores were close to 0; however, comparison to a null model though IPA-scores showed the predictions generated by the ACS risk calculator to be inaccurate. Overall, the ACS risk calculator showed a consistent underestimation of the risk of complications.

CONCLUSIONS

The ACS risk calculator proved to be inaccurate within the framework of endovascular and open aortic aneurysm repair in our medical center. To minimize the effects of patient selection and cultural differences, multicenter collaboration is necessary to assess the performance of the ACS risk calculator in aortic surgery.

Risk assessment in aortic aneurysm repair by medical specialists versus the American College of Surgeons National Surgical Quality Improvement Program risk calculator outcomes

Objective

The aim of this online clinical vignette-based survey study was to compare risk assessments by vascular surgeons, anaesthesiologists and interventional radiologists involved in treating patients with aortic aneurysms in the Netherlands with the NSQIP risk calculator outcomes.

Methods

Participants, recruited using purposive sampling, provided their estimation of the likelihood of postoperative complications and events following aortic surgery in five fictional cases. These cases were subsequently scored using the NSQIP calculator. The risk assessments were statistically analysed using the ANOVA and student t-test.

Results

All participating specialists i.e. twelve vascular surgeons, ten interventional radiologists and ten anaesthesiologists completed the survey. In the vast majority of outcomes and vignettes, no significant differences were found between various specialists, whereas significant differences were found between the NSQIP risk calculator outcomes and the combined risk assessments of the specialists. Overall, specialist risk assessments differ from the NSQIP, but neither particularly higher nor lower compared to the risk calculator.

Conclusions

Risk assessment by vascular surgeons, anaesthesiologists and interventional radiologists differs significantly with NSQIP risk calculator outcomes, within the framework of both endovascular and open aortic aneurysm repair. Based on these results, implementing the NSQIP risk calculator in preoperative workup could be of added value in both patient planning as well as adequately informing patients for obtaining consent.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

BACKGROUND

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

RESULTS

Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

CONCLUSIONS

The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

The removal of all proximal aneurysmal aortic tissue does not affect anastomotic degeneration after open juxtarenal aortic aneurysm repair

OBJECTIVE

For the open treatment of juxtarenal aortic aneurysms (JRAAs), some argue for the removal of all proximal aneurysmal aortic tissue to prevent future degeneration, whereas others deem it unnecessary. This study sought to compare perioperative and long-term outcomes of two different approaches to treatment of JRAAs.

METHODS

Patients who underwent open JRAA repair from 2007 to 2015 at our institution were reviewed and stratified by operative technique: plication of the aneurysm cuff with graft sewn up to the renal arteries (PLI) vs a beveled anastomosis with left renal artery bypass (LRB). Patients who underwent additional mesenteric bypasses were excluded. Primary outcomes included death, anastomotic degeneration, and decline in renal function. Univariate and Kaplan-Meier analyses were performed.

RESULTS

There were 199 patients identified, 56% PLI (n = 112) and 44% LRB (n = 87). The majority were male (68%), white (89%), and smokers (58%). Mean age was 71.5 ± 8.5 years. LRB patients were more likely to have chronic kidney disease (29% vs 13%; P = .01) and larger juxtarenal diameters (median, 25 mm vs 28 mm; P = .001). LRB patients had longer postoperative length of stay (median, 8 days vs 7 days; P = .003) and longer operative times (median, 4.7 hours vs 3.7 hours; P < .001). Overall 30-day mortality was 2% (n = 4), with no difference between cohorts. There were no differences in perioperative complications except for the development of acute kidney injury, which was more common in LRB patients (47% vs 23%; P < .001). During 3-year follow-up, there was no difference in anastomotic aneurysmal degeneration or sac growth. In the long term, LRB patients were more likely to develop an occluded left renal artery (20% vs 0%; P = .004) and right renal artery stenosis (29% vs 3%; P = .002). However, neither group was more likely to have a decline in renal function (PLI, 23%; LRB, 25%; P = .84). There was no difference in 5-year mortality (P = .72).

CONCLUSIONS

The more complex technique involving LRB was not protective against long-term anastomotic degeneration, decline in renal function, or mortality. In addition, LRB led to longer length of stay and operative times, with increased risk of perioperative acute kidney injury. In an era when fewer open aortic repairs are being performed, it is reasonable to consider the PLI technique in the treatment of JRAAs, particularly in patients with baseline chronic kidney disease.

Hemodynamic Performance of Multilayer Stents in the Treatment of Aneurysms with a Branch Attached

Although multilayer stents (MSs) can be used to treat aneurysm effectively, for some aneurysms with branches attached, the hemodynamic mechanisms are still unclear. In this work, we modeled five cases that involve 1-4-layer stents implanted in aneurysms with side branches, and the numerical approach was used. Case 1 corresponds to an aneurysm without a stent, and cases 2-5 represent 1-4-layer stents being employed within aneurysms, respectively. The results showed that the velocity within the sac declined dramatically and the eddies' intensity weakened with increased number of stent layers, time-averaged wall shear stress (TAWSS), and nitric oxide production rate (TARNO) dropped linearly with increase in stent porosity, and oscillatory shear index (OSI) and relative residence time (RRT) increased evidently with MS intervention. Moreover, the MSs had a slight effect on the patency of the side branch; its flow rate was still above the normal case than without aneurysm. It can be concluded that MSs are helpful in promoting the growth of thrombus within the aneurysm through an isolated hemodynamic environment and keeping the branch unobstructed, but more clinical evidences are required.

Single Centre Experience with Anaconda Custom-made Fenestrated Stent Graft in the Endovascular Repair of the Juxtarenal Aneurysms

Aim:

The fenestrated Anaconda custom-made stent graft is one of the recently widely accepted fenestrated devices for managing complex juxta- and pararenal aortic pathology. This study showed its feasibility for treatment of challenging juxtarenal anatomy of the abdominal aorta.

Methods:

Over the period of 12 months, 9 patients with juxtarenal aortic aneurysm underwent fenestrated stent graft implantation in our institution. The graft fenestrations were customized on the basis of computerized tomography (CT-Angiography; CTA). Selected visceral ostia were protected with covered balloon-expandable stents after partial stent graft deployment. The perioperative and short term data were collected prospectively.

Results:

The mean aneurysm diameter was 58.4 mm (range 46-73 mm). The mean infrarenal neck length was 3.5 mm (range 0-7 mm), no patient had a severe (>60°) angulation of proximal neck. 18 fenestration for renal arteries, 1 for SMA and 3 for coeliac´s were treated with Advanta V12 covered stent. All the target vessels were cannulated successfully through fenestrations and all the stent grafts were successfully deployed in patients with no technical issue in the release mechanism. All the patients have undergone 6 month follow-up, no aneurysm related or aneurysm-unrelated deaths were reported. On the CTA scan, 3 of the patients had a weak type IIb endoleak; no type I or Type III endoleak was demonstrated. All target vessels were open without an instance of branch-stent stenosis/occlusion. No reintervention was needed.

Conclusion:

The usage of custom-made Anaconda fenestrated stent graft for endovascular treatment of juxtarenal aortic aneurysms is feasible with acceptable intermediate-term results.

Antegrade thoracic endovascular aneurysm repair via the ascending aorta

PURPOSE

We performed antegrade thoracic endovascular aneurysm repair via the ascending aorta in selected high-risk patients scheduled for open surgery, in whom an iliofemoral or abdominal aortic approach was not feasible. We present our initial experience with this approach.

METHODS

Of 16 consecutive patients who underwent antegrade endovascular aneurysm repair via the ascending aorta at our institution, 3 had an emergency intervention for rupture and 3 had an urgent intervention for impending rupture or complicated aortic dissection. The procedure was scheduled in 10 patients. The median patient age was 77 years. In 13 patients, one or more concomitant procedures were performed. In 6 patients, vascular access for endovascular aneurysm repair was obtained via a branch of the replacement graft. In 10 patients, direct cannulation of the ascending aorta was carried out using 2 pursestring sutures.

RESULTS

The initial success rate was 100%. Early mortality occurred in 2 (12.5%) patients because of multiple organ failure in one and heart failure in the other. No patient required a second intervention during follow-up. The mean duration of follow-up was 19 months.

CONCLUSION

The antegrade approach is a useful alternative in patients with no access suitable for endovascular aneurysm repair and who are not appropriate candidates for open conventional thoracic aortic surgery. This approach is applicable to selected patients.

An in Vitro Twist Fatigue Test of Fabric Stent-Grafts Supported by Z-Stents vs. Ringed Stents

Whereas buckling can cause type III endoleaks, long-term twisting of a stent-graft was investigated here as a mechanism leading to type V endoleak or endotension. Two experimental device designs supported with Z-stents having strut angles of 35° or 45° were compared to a ringed control under accelerated twisting. Damage to each device was assessed and compared after different durations of twisting, with focus on damage that may allow leakage. Stent-grafts with 35° Z-stents had the most severe distortion and damage to the graft fabric. The 45° Z-stents caused less fabric damage. However, consistent stretching was still seen around the holes for sutures, which attach the stents to the graft fabric. Larger holes may become channels for fluid percolation through the wall. The ringed stent-graft had the least damage observed. Stent apexes with sharp angles appear to be responsible for major damage to the fabrics. Device manufacturers should consider stent apex angle when designing stent-grafts, and ensure their devices are resistant to twisting.

Introduction of laparoscopic abdominal aortic aneurysm repair

BACKGROUND

The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair.

METHODS

Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing laparoscopic or open AAA repair.

RESULTS

A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and 2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 66-75) years, and 92·3 per cent were men. There was no significant difference in sex distribution, age or V-POSSUM physiology score between laparoscopic and open repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic repair had significantly fewer postoperative cardiorespiratory and renal complications (P = 0·017), and were discharged from hospital sooner (median 5 (i.q.r. 3-7) versus 8 (6-11) days; P = 0 ·001).

CONCLUSION

Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable for EVAR.

Chimney technique for aortic arch pathologies: an 11-year single-center experience

PURPOSE

To report our single-center experience with the chimney technique for aortic arch pathologies and the mid- to long-term results in these patients.

METHODS

From June 2002 to May 2013, 26 patients (18 men; mean age 71.2 years, 53-86) underwent thoracic endovascular aortic repair (TEVAR) combined with chimney technique. Indications for treatment were: a proximal landing zone <15 mm long distal to the left subclavian artery (LSA), thoracic aortic aneurysm (n=13), complicated type B aortic dissection (n=10), type I endoleak after previous TEVAR (n=2), and penetrating aortic ulcer (n=1). Treatment was performed in the emergency setting in 7 cases. The 28 chimney stent-grafts (double chimneys in 2 patients) were deployed in the innominate artery (n=7), left common carotid artery (n=10), and LSA (n=11). All patients underwent computed tomography before discharge, at 1, 6, and 12 months, and yearly thereafter.

RESULTS

Technical success was 100%. One (3.8%) perioperative death was due to a cerebral hemorrhage. No major stroke was registered, but 3 (11.5%) minor strokes occurred (all resolved). Paraparesis developed in 2 (7.7%) patients. Median follow-up was 36.8 months (range 1-131), during which an additional 4 (15.4%) patients died, but only 1 death was aneurysm-related. Chimney graft patency was 89.3% (25/28); an asymptomatic fracture was found in a patent chimney stent-graft at the 18-month follow-up. The type I endoleak rate was 23% (n=6); 3 endoleaks associated with aneurysm sac enlargement were treated.

CONCLUSION

The chimney technique for aortic arch pathologies is safe and feasible and may be an option in patients considered at high risk for surgery or who are ineligible for conventional TEVAR, especially in the emergency setting. Concern persists regarding type I endoleak, and long-term follow-up remains mandatory.

Severe visceral ischemia and death after multilayer stent deployment for the treatment of a thoracoabdominal aortic aneurysm

The treatment of thoracoabdominal aortic aneurysms, both surgical and endovascular, has always been challenging. In the last years, the multilayer stent has emerged as an alternative device for the treatment of this condition. In this paper, we describe a catastrophic complication of the multilayer stent in a patient with thoracoabdominal aortic aneurysm, a case of massive visceral ischemia and death 3 months after stent deployment.

Scallop technique of urgent endovascular repair for symptomatic throacoabdominal aortic aneurysm with a ready-made device

A 72-year-old woman had a large thoracoabdominal aortic aneurysm (TAAA) with abdominal pain. This aneurysm involved the celiac artery and the superior mesenteric artery (SMA). The risk of open surgery was very high due to severe comorbidity, and there was no appropriate distal attachment for thoracic endovascular repair (TEVAR) with ready-made devices. Therefore, TEVAR with the scallop technique was performed in this urgent setting. A scallop was created in a Talent thoracic stent graft. The aneurysm was successfully excluded, and perfusion in the SMA was preserved using this scalloped endograft. The scallop technique with a ready-made device may be one of the treatment options for urgent TAAA.

Predictive factors for mortality after open repair of paravisceral abdominal aortic aneurysm

OBJECTIVE

The use of fenestrated and branched stent graft technology for paravisceral abdominal aortic aneurysms (PAAA) is on the rise; however, its application is limited in the United States to only a few selected centers. Most PAAAs are currently repaired using an open approach. The objective of this study was to determine which patients are at highest risk with open PAAA repair and might benefit most from endovascular repair using fenestrated or branched stent grafts.

METHODS

This was a retrospective cohort study using data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hospitals. We identified 598 patients (27.5% women) who underwent elective open PAAA repair from the 2007 to 2009 NSQIP, a prospective database maintained at >250 centers. The main outcome measure was 30-day postoperative mortality.

RESULTS

The median patient age was 73 years. The 30-day major morbidity rate was 30.1%, and the mortality rate was 4.5%. Major complications included reintubation (10.0%), sepsis (10.7%), return to operating room (9.2%), new dialysis requirement (5.9%), cardiac arrest or myocardial infarction (4.5%), and stroke (1.2%). Multivariate analyses identified four predictors of postoperative mortality after open PAAA repair: peripheral arterial disease (PAD) requiring revascularization or amputation, chronic obstructive pulmonary disease (COPD), anesthesia time, and female sex. PAD and COPD were present in only 5.2% and 20.4% of patients but were associated with a 16.1% and 9.0% mortality rate, respectively. The mortality rate in women was 7.3% vs 3.5% for men (P = .045).

CONCLUSIONS

PAD, COPD, and female sex are major risk factors for postoperative mortality after open PAAA repair. Fenestrated or branched stent graft repair may be a more valuable alternative to open repair for patients with one or more of these characteristics who have suitable access vessels.

National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice

OBJECTIVES

Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use.

METHODS

All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval.

RESULTS

Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P < .001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P = NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8-16.7/100,000) than in TEVAR (range, 4.5-6.9/100,000).

CONCLUSIONS

Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.