A New Technique to Enhance Endovascular Thoracoabdominal Aortic Aneurysm Therapy—The Sandwich Procedure

Outcomes of Elective and Non-elective Fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms

OBJECTIVE

To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs).

BACKGROUND

FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described.

METHODS

Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair.

RESULTS

A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001).

CONCLUSIONS

Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Mid-term Outcomes of Physician-Modified Fenestrated or Branched Endovascular Repair for Post-dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

To report the early experience and mid-term outcomes of physician-modified fenestrated or branched endovascular repair (PM-F/BEVAR) for patients with post-dissection thoracoabdominal aortic aneurysm (PD-TAAA).

METHODS

PD-TAAA patients treated with PM-F/BEVAR between December 2014 and September 2020 in our institution were retrospectively analyzed.

RESULTS

Out of the 39 patients, technical success defined as successful deployment of all stent grafts with patent target vessels (TVs) and exclusion of the lesion without type I or III endoleak was achieved in 35 patients (89.7%). A total of 126 TVs were successfully reconstructed. Thirty-day mortality was 0%. Seven major adverse events occurred including one acute kidney injury, four renal infarctions, one retroperitoneal hematoma and one left renal artery occlusion. Seven type II endoleak and three type III endoleak were detected. During a mean 29.4 ± 15.5 months follow-up period, the mortality was zero. Three renal arteries and one external iliac artery occluded in four patients. No other new onset major adverse event occurred. No patient required reintervention. One type II endoleak spontaneously resolved, while the remaining six remained stable. One early type III endoleak diminished, and one new type III endoleak occurred at 2 months. The primary patency of TV was 96.8% (120/124). Shrinkage or stability of aneurysm diameter can be observed in 38 patients (97.4%). The false lumen thrombosis rate was 89.7% (35/39).

CONCLUSIONS

The present study showed encouraging results of PM-F/BEVAR for treatment of PD-TAAAs.

LEVEL OF EVIDENCE

Level 4, Case Series.

Off the Shelf Thoracic Endovascular Aortic Repair with Sandwich Technique for the Treatment of a Thoraco-abdominal Penetrating Aortic Ulcer

Introduction

Penetrating aortic ulcers (PAUs) are the rarest subset of acute aortic syndromes, and a thoraco-abdominal (TA) location is uncommon. Endovascular surgery is considered first line treatment. Custom made branched/fenestrated endografts have been successfully applied in this disease but are unavailable in the urgent setting. Off the shelf solutions may be required in high risk patients. The case of a symptomatic rapidly expanding TA-PAU without a distal seal zone that underwent urgent endovascular repair is described.

Report

An 81 year old male presented with acute intense thoracic pain. Workup revealed a large TA-PAU. As pain was refractory and computed tomography angiography confirmed rapid expansion, urgent repair was proposed. Due to multiple comorbidities and absence of adequate distal seal zone, an off label endovascular treatment was proposed. The patient underwent successful endovascular repair with two aortic stent grafts (GORE cTAG) with 30% oversize and 50–55 mm overlap between modules, combined with chimney self expanding stent grafts (GORE VIABAHN) to the coeliac trunk and superior mesenteric artery in a sandwich configuration. The post-operative course was uneventful. Follow up at 18 months revealed no endoleaks and patent bridging stent grafts without visceral compromise.

Discussion

Thoracic endovascular aortic repair (TEVAR) is considered the first treatment option for urgent PAU. However, anatomic requirements limit its use in the thoraco-abdominal aorta. Parallel graft techniques have been described to overcome these anatomic constraints in TA aneurysms. The use of a “sandwich technique” to successfully exclude a PAU without a distal sealing zone for standard TEVAR is described. The advantage was limited aortic coverage compared with a branched device or an “octopus” technique. This solution is particularly useful in urgent situations when patients cannot wait for a custom made device and the morbidity associated with open or hybrid repair is unacceptably high. An off the shelf sandwich technique is a potential safe and long lasting therapeutic option for the urgent treatment of TA-PAU.

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Endovascular therapy is the standard treatment of aortic PAU.

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Customized endografts are dependent on a long manufacturing time.

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Off the shelf techniques can be used in urgent settings in high risk patients.

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TEVAR with sandwich technique can be used safely for urgent repair TA PAU.

Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels

Open thoracoabdominal aortic aneurysm (TAAA) repair remains a surgical challenge. Hybrid and total endovascular repair have emerged as alternatives in treating TAAA. Total endovascular TAAA repair may be best performed with branched/fenestrated stent grafts. However, these technologies are not yet widely available. Thus, currently total endovascular TAAA repair using the chimney/snorkel techniques is considered a viable option in many centers.

In this article, we briefly review 2 readily available techniques with off-the-shelf devices, hybrid procedure using total abdominal debranching, and total endovascular repair using chimney/snorkel procedures. The hybrid TAAA repair avoids thoracotomy but requires laparotomy and carries high morbidity and mortality (eg, operative mortality, 4%-26% and renal failure, 4%-26%), comparable to traditional open repair. The staged hybrid approach has been proposed to minimize the invasiveness of the procedure, whereas the associated risk of interval aortic deaths is not negligible. Total endovascular repair reduces the morbidity and mortality after TAAA repair (eg, operative mortality, 3%-20% and renal failure, 0%-20%). However, it is technically demanding and the risks of future reinterventions—and need for repetitive surveillance—is inevitable (eg, immediate type I endoleak, 7%-16% and 1-year branch patency, 93%-98%). Currently, there are not enough data to determine which less-invasive option for open repair in patients with TAAA is superior. These alternatives should complement each other and be applied to carefully selected populations as a part of the overall toolbox in treating TAAA.

Immediate outcome of endovascular treatment of ruptured juxtarenal aneurysm with parallel stents

Rupture of an abdominal aortic aneurysm is an event with a high mortality rate and treatment is a medical emergency. Endovascular treatment of these aneurysms has become established as a minimally invasive alternative to classical open surgery and is now the first-choice option. However, 20 to 50% of patients with abdominal aortic aneurysms do not have anatomy favorable for endovascular treatment because of a short aneurysm neck or because visceral branches are involved by the aneurysm. We report the case of a 70-year-old patient who underwent endovascular repair of a ruptured juxtarenal aneurysm with deployment of parallel stents in the renal arteries (in a chimney technique). Clinical data and details of the procedure are reported. Technical success was achieved and there were no postoperative complications.

Endovascular Repair of a Ruptured Thoracoabdominal Aortic Aneurysm With the Sandwich Technique: A Case Report

INTRODUCTION

aortic aneurysms involving the renal and visceral arteries are endovascular challenges, especially for emergencies. We report a case of ruptured thoracoabdominal aortic aneurysm (TAAA) in a morbidly obese 71-year-old man. The patient was admitted with a stable hemodynamic state. A computed tomography angiogram (CTA) revealed a contained ruptured TAAA with an occluded celiac trunk and left renal artery due to previous nephrectomy. Due to the emergency and his comorbidities, we performed an endovascular aortic repair with the sandwich technique and 2 chimneys. Two bridging stents (chimneys) were deployed between the aorta and the target vessels (superior mesenteric and right renal arteries) in a space created in-between 2 aortic straight endografts. Ten days postoperative, acute renal failure appeared and right renal stent occlusion was diagnosed on CTA. Unfortunately, no adequate kidney revascularization could be obtained, requiring permanent hemodialysis. At a 3-month follow-up visit, the patient did well with stable aneurysm dimensions.

CONCLUSIONS

encouraging outcomes of chimney-EVAR techniques, comparable to those in published reports of fenestrated-EVAR and branched-EVAR, support this procedure as a valid off-the-shelf available alternative in emergency situations. Nevertheless, only few midterm results achieved are actually available and long-term outcomes are actually unknown.

Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries

Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.

Parallel graft techniques for urgent complex aortic diseases: Mid-term results of 12 cases

OBJECTIVES

Open repair is still the first choice for thoraco-abdominal and para-renal aortic aneurysms, but surgical treatment is burdened by significant morbidity and mortality, especially in urgent setting. Endovascular treatment by fenestrated or branched endografts is feasible and safe; but in urgent/emergent settings, custom-made endografts are hardly available in due time, and the repair with standard multibranched devices is still debated in cases with complex anatomy. Parallel grafting, on the other hand, which exploits covered stents to preserve patency of the visceral vessels, has been shown as a valuable option and can be performed in urgency, though some concerns still remain regarding its durability and complications. The purpose of this case series is to review the outcomes of all consecutive cases of complex aortic diseases treated with this technique in emergent/urgent setting.

MATERIALS AND METHODS

All cases of endovascular aortic repair of thoraco-abdominal and para-thoraco-abdominal performed in urgency or emergency from 2016 to June 2019 were retrospectively reviewed, recording clinical records, operative technique, primary technical success, and long-term outcomes. Each patient was followed-up by computed tomography angiography three months after the procedure and yearly thereafter.

RESULTS

Twenty consecutive patients (median age: 68, range: 47-89, male/female ratio: 16:4) affected by para-thoraco-abdominal (12) or thoraco-abdominal (8) were treated in urgent or emergent setting by chimney and/or periscope technique. A total number of 37 visceral vessels were stented (29 renal arteries, 1 polar artery of the kidney, 3 superior mesenteric arteries, and 4 coeliac trunks). Primary technical success was 100%, with one perioperative death. One patient died on post-operative month III for unrelated cause. Two type II endoleaks were detected at the first post-operative imaging studies and were managed conservatively. One type IB endoleak was treated by endovascular repair with a custom-made endograft (overall re-intervention rate: 5%). Over a median 22 months follow-up (range: 4-40, interquartile range: 12 months), all stentgrafts were patent.

CONCLUSION

Parallel graft is a feasible and safe option that should be considered in urgent and emergent treatment of para-thoraco-abdominal and thoraco-abdominal, when fenestrated and branched endografts cannot be used.

Intraoperative adverse events and early outcomes of custom-made fenestrated stent grafts and physician-modified stent grafts for complex aortic aneurysms

OBJECTIVE

Physician-modified fenestrated stent grafts (PMSGs) are a useful option for urgent or semiurgent treatment of complex abdominal aortic aneurysms (CAAAs). The aim of this study was to describe in-hospital outcomes of custom-made fenestrated stent grafts (CMSGs) and PMSGs for the treatment of CAAAs and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

In this single-center, retrospective study, all consecutives patients with CAAAs or TAAAs undergoing endovascular repair using Zenith CMSGs (Cook Medical, Bloomington, Ind) or PMSGs between January 2012 and November 2017 were included. End points were intraoperative adverse events, in-hospital mortality, postoperative complications, reinterventions, target vessel patency, and endoleaks.

RESULTS

Ninety-seven patients were included (CMSGs, n = 69; PMSGs, n = 28). The PMSG group included more patients assigned to American Society of Anesthesiologists class 4 (n = 14 [50%] vs n = 16 [23%]; P = .006) and more TAAAs (n = 17 [61%] vs n = 10 [15%]; P < .0001). Intraoperative adverse events were recorded in eight (11%) patients in the CMSG group vs six (21%) patients in the PMSG group. No intraoperative death or open conversion occurred. In-hospital mortality rates were of 4% (n = 3) in the CMSG group and 14% in the PMSG group (n = 4). Chronic renal failure was an independent preoperative risk factor of postoperative death or complications (odds ratio, 4.88; 95% confidence interval, 1.65-14.43; P = .004). Rates of postoperative complications were 22% (n = 15) and 25% (n = 7) in the CMSG and PMSG groups. Spinal cord ischemia rates were 4% (n = 3) and 7% (n = 2) in the CMSG and PMSG groups. Reintervention rates were 16% (n = 11) in the CMSG group and 32% (n = 9) in the PMSG group. At discharge, target vessel patency rate in CMSGs was 98% (n = 207/210). All target vessels (n = 98) were patent in the PMSG group. Endoleaks at discharge were observed in 24% of the CMSG group (n = 16) vs 8% of the PMSG group (n = 2).

CONCLUSIONS

Our study showed clinically relevant differences of several important in-hospital outcomes in the CMSG and PMSG groups. Larger cohorts and longer follow-up are needed to allow direct comparison. PMSGs may offer acceptable in-hospital results in patients requiring urgent interventions when CMSGs are not available or possible.

Chimney Stent Graft Technique for Endovascular Repair of Penetrating Atherosclerotic Ulcers of Abdominal Aorta with Bilateral Common Iliac Artery Aneurysms and Ectopic Right Renal Artery Stenosis

Ectopic renal artery (RA), a rare congenital anomaly, presents a challenge in open surgery and endovascular repair for abdominal aortic lesions. To preserve the abnormal main blood supply and renal function complicates the procedures requiring careful imaging measurement and well-designed therapeutic strategy. We report on a 68-year-old man with abdominal aortic atherosclerotic ulcers, bilateral common iliac artery aneurysms, and right ectopic RA stenosis that was successfully managed with antegrade chimney technique, resulting in well-excluded lesions and well-reconstructed renal blood supply without any complication. This endovascular procedure may be useful for repair of abdominal aortic lesions with ectopic RA in high-risk surgical patients.

Double-Barreled and Branched Endografting for Thoracoabdominal Aortic Aneurysm: The Hexapus Technique

OBJECTIVE

To treat thoracoabdominal aortic aneurysm (TAAA), we introduced an alternative "Hexapus" technique by double-barreled and branched endografting.

TECHNIQUE AND RESULT

We established 2 transfemoral and 2 transaxillary access routes first and then deployed two abdominal bifurcated stentgrafts landing at the descending thoracic aorta through transfemoral routes, respectively. Two pairs of parallel stentgrafts were deployed via bilateral transaxillary route from each of contralateral limbs of main body stentgrafts to visceral arteries. Finally, we extended the ipsilateral limbs of main body stentgrafts to bilateral common iliac arteries as distal landings. The creation of six branches (four viscerals and two iliacs) resembles a hexapus. We have executed this Hexapus technique in three patients, and the final angiography during operation and postoperative 12-month image follow-up showed patent visceral branches and no any endoleaks.

CONCLUSION

Our Hexapus technique is feasible in treating TAAA if patient is inoperable or no commercial fenestrated or branched stentgraft is available.

Endovascular Repair of Complex Aortoiliac Aneurysm with the Sandwich Technique in Sixteen Patients

BACKGROUND

This study aimed to evaluate the safety and efficiency of the sandwich technique in endovascular repair of complex aortoiliac aneurysm.

METHODS

Sixteen patients (mean age 69.6 years, ranging from 58 to 78 years) with complex aortoiliac aneurysm were studied retrospectively from October 2013 to September 2017 in two vascular centers of teaching hospitals. Computed tomography angiography (CTA) was performed to make individual therapy. They were all performed endovascular repair with sandwich technique, including one with the sandwich, chimney, and fenestrated techniques during the same procedure. All patients were followed up at 1 month, 3 months, 6 months, 12 months, and yearly thereafter with X-ray, ultrasound, and/or CTA.

RESULTS

The initial technical success was 81.25%, and the assisted technical success was 100%. At final angiography, little flow of a type I and a type III endoleak was found in two patients with observation. Two type II endoleaks were also detected. During the perioperative period, two patients suffered myocardial infarction. One pulmonary infection and one urinary infection happened. No death or cerebrovascular events occurred. During the follow-up (mean 18 months, ranging from 2 to 45 months), three stent occlusions were detected. One case got reintervened for his external iliac artery stent thrombosis in the first month postoperatively. The other two were under observation. A readmission happened to one man for his right brachial artery pseudoaneurysm in the third month postoperatively. One patient died of nonaneurysmal related reason in the eighth month. No aneurysmal related death, rupture, or new endoleak was found. No paralysis, claudication, or bowel ischemia was complained of. The primary patency of the preserved branches were 94.7%, 92.0%, 92.0%, 92.0%, 92.0% separately in first, sixth, 12th, 24th, and 36th month.

CONCLUSIONS

For patients who are not candidates for open surgery or conventional endovascular repair with complex aortoiliac aneurysm, the sandwich technique is a feasible alternative to management.

Combination of Octopus and Periscope Techniques for the Management of Visceral Branches From Type V Thoracoabdominal Aortic Aneurysm: A Case Report

PURPOSE:

To describe an endovascular technique combining the octopus and periscope techniques for the treatment of a patient with type V thoracoabdominal aortic aneurysm in order to protect the patient's visceral circulation.

CASE REPORT:

An 84-year-old male patient was hospitalized for type V thoracoabdominal aortic aneurysm involving celiac axis, superior mesenteric artery, and both renal arteries. The patient's aneurysm was successfully treated by combining the octopus technique and periscope techniques. The 1-year follow-up computed tomography angiography showed that the endograft and the branches were patent. The gutters had thrombosed with no signs of endoleak. No spinal cord ischemia or impairment of the renal function was observed during the follow-up.

CONCLUSIONS:

This case is an example of the successful usage of the combined octopus and periscope techniques in protecting the renovisceral arteries arising from a type V thoracoabdominal aortic aneurysm; this combined technique might be applicable in carefully selected patients.

Use of Double-Barrel Gore Excluder Bifurcated Endografts for Renal Artery Incorporation in an Urgent Endovascular Repair of a Thoracoabdominal Aortic Aneurysm

Total endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) in an urgent setting requires an advanced endovascular skill set and an innovative approach. We describe a novel technique of treating a symptomatic Crawford extent 4 TAAA with a combination of multilayered parallel endografting and double-barrel Gore Excluder bifurcated endografts to achieve complete aneurysm exclusion with visceral and bilateral renal artery incorporation. A 75-year-old male presented with a symptomatic 10 cm Crawford extent 4 TAAA. Severe medical comorbidities, including chronic obstructive lung disease and cardiac arrhythmia, as well as prior open infrarenal aortic aneurysm repair made him high risk for an urgent re-do open repair. His previous open infrarenal aortic replacement created a short distance between the lowest renal artery and the flow divider of the aortic graft, which posed a challenge in using a bifurcated aortic endograft as a distal component of the previously described multilayered parallel endografting. Therefore, celiac and superior mesenteric arteries were treated with a multilayered parallel grafting configuration, whereas bilateral renal arteries were incorporated using side-by-side bifurcated modular stent grafts in double-barrel fashion. Contralateral gates served as cuffs for renal artery branch stent grafts, and ipsilateral limbs were deployed within the common iliac arteries. The patient recovered well and was discharged 3 days after repair. Follow-up imaging at 1 month demonstrated patent celiac, superior mesenteric, and bilateral renal artery flow, with no endoleak and stable aneurysm sac. The patient is doing well clinically 1 year after the operation.

A Novel Off-the-Shelf Technique for Endovascular Repair of Type III and IV Thoracoabdominal Aortic Aneurysms Using the Gore Excluder and Viabahn Branches

BACKGROUND

The aim of this study is to describe the use of a novel off-the-shelf technique to repair type III and type IV thoracoabdominal aortic aneurysms (TAAAs) in the absence of available prefabricated branched devices.

METHODS

All patients undergoing endovascular repair of type III and IV TAAAs using this technique were included from a prospectively maintained registry at a regional aortic referral center. The proximal bifurcated Gore C3 Excluder device is positioned in the descending thoracic aorta with the contralateral gate 2-3 cm above the celiac artery. From an axillary approach, the contralateral gate renovisceral branches are sequentially cannulated and simultaneously stented using Viabahn covered stents. In cases were the celiac artery could not be excluded, a parallel stent (snorkel) was added adjacent to the proximal endograft. All branches are simultaneously balloon dilated to ensure proximal gutter seal in the contralateral gate. Via the ipsilateral limb, the device can then be extended with a flared iliac extension and/or additional bifurcated device to obtain seal in the distal aorta (previous open repair) or common iliac arteries.

RESULTS

Eight patients (male = 6, mean 78 years of age) were treated in this manner since January 2015. All patients underwent repair using Gore C3 device with 3 (n = 5) or 4 (n = 3) renovisceral branches. The celiac artery was sacrificed in 4 patients and 1 renal artery in 1 patient. Mean fluoroscopy time was 88.7 min with a mean of 92.3 cc contrast utilized. Median length of stay was 7 days with 3 days spent in the intensive care unit. No major cardiac, respiratory, renal, neurologic, or wound complications occurred. Three patients had early endoleaks treated with additional endovascular techniques (n = 2) or open surgical ligation (n = 1) during the index hospitalization. Two late endoleaks were identified; 1 type II with stable sac size and 1 type III requiring iliac limb relining. All limbs and branches remain patent at the time of the last imaging study (mean 6.8 months).

CONCLUSIONS

We present an endovascular technique for repair of type III and IV TAAAs which appears to be both feasible and safe with good short-term outcomes.

Aortic aneurysm endovascular treatment with the parallel graft technique from the aortic arch to the iliac axis

BACKGROUND

The chimney technique has been developed for the treatment of complex aortic aneurysms. We analyzed the midterm to long-term outcomes of this approach from a single-center experience.

METHODS

From October 2008 to July 2016, 58 patients underwent endovascular aortic aneurysm repair using the chimney technique. Indications for treatment were thoracic aortic aneurysm (TAA) (N.=11), thoracoabdominal aortic aneurysm (TAAA) (N.=2), pararenal aortic aneurysm (PAAA) (N.=15), aortoiliac/isolated hypogastric artery aneurysm (N.=25), type I endoleak after previous TEVAR/EVAR (N.=4), proximal pseudoaneurysm after AAA open repair (N.=1). Elective (82.8%) and emergent (17.2%) procedures were included.

RESULTS

The immediate technical success was 100%. Single, double and triple chimneys were performed in 46, 10, and two patients, respectively. Overall, 61 target vessels (three left common carotid arteries, eight left subclavian arteries, three celiac trunks, three superior mesenteric arteries, 19 renal arteries and 25 hypogastric arteries) were involved. Postoperative mortality was 0. No neurologic complications were registered. Primary patency rate of the chimney stent/stent graft was 98.3%. Low-flow type I endoleak was observed in four patients (6.9%). Postoperative chimney graft re-intervention rate was 1.7%. The median follow-up was 32±20 months (range 3-96 months). Overall estimated survival at 12, 50, and 80 months was 100%, 89% and 44%, respectively. Estimated freedom from endoleak at 1, 12, 24, and 36 months was 96.5%, 95%, 95%, and 93%, respectively. One hypogastric artery stent-graft occluded at the 3rd month of follow-up. No reintervention was performed.

CONCLUSIONS

Our experience with the chimney technique for aortic aneurysms from the aortic arch to the iliac axis shows promising and durable mid- and long-term results. Endograft oversizing, associated with the chimney graft diameter and length choice remain fundamental to reduce the risk of the most frequent procedure complications: type I endoleak and CG occlusion. The wider use of this technique should be justified in patients considered at high risk for open repair and/or not suitable for the custom-made branched/fenestrated endografts.

Multilayered Parallel Endografting for Urgent Endovascular Repair of a Severely Angulated Thoracoabdominal Aortic Aneurysm

Total endovascular repair of TAAA using branched, fenestrated stent grafts have been performed with promising midterm results. However, severe angulation of the aorta as well as close proximity of the visceral and renal artery ostia pose a significant technical challenge in designing and implanting branched, fenestrated stent grafts. Parallel grafting offers an alternative technique, allowing an urgent, or emergent total endovascular repair of symptomatic, or ruptured TAAA. We describe a technique of 4-vessel incorporation in a total endovascular repair of TAAA, using multilayered parallel endografting via bilateral femoral and unilateral brachial access. A 76-year-old male with severe chronic obstructive pulmonary disease and coronary artery disease presented with a symptomatic 9 cm extent IV thoracoabdominal aortic aneurysm. The thoracic, and paravisceral segments of his aorta, as well as the iliac arteries were severely angulated, whereas the superior mesenteric and the celiac arteries had a common origin. An urgent total endovascular aortic repair was performed. The aorta and the iliac arteries were straightened by placing stiff wires from bilateral femoral arteries in a "buddy" fashion. In addition, a brachiofemoral "body-floss" wire was established. Over this body-floss wire, thoracic stent grafts were deployed in multiple layers, alternating with parallel branch stents into visceral and renal arteries. Distally, a bifurcated modular stent graft was deployed down to the common iliacs, achieving complete aneurysm exclusion. Patient recovered well without complications and was discharged home in 5 days. Postoperative computed tomography scan showed patent visceral and renal stents and complete exclusion of the aneurysm without evidence of endoleak.

Early Experience with Snorkels and Chimneys for Expanding the Indications for Use of Endovascular Aneurysm Repair

BACKGROUND

Although fenestrated and branched devices for juxtarenal and paravisceral aneurysms are available worldwide, limited ultrasound availability has perpetuated widespread utilization of adjunctive techniques for the endovascular treatment of these aneurysms. The objective of the study is to report on the technical feasibility and short-term durability of parallel grafts for juxtarenal and paravisceral aneurysms.

METHODS

We performed a retrospective review of a prospectively collected endovascular aneurysm repair database, including all patients who underwent a parallel stent procedure. End points included were the following: (1) number of vessels snorkeled; (2) endoleaks; (3) morbidity and mortality; and (4) snorkel graft patency.

RESULTS

Forty patients (85% male, mean 77.8 years) were treated for primary aneurysms (26), para-anastomotic aneurysms (6) following prior open repair, and endoleaks (8) following prior endovascular repair. Sixty-nine visceral vessels were preserved. Bilateral femoral arteries were accessed, as well as the left upper extremity via percutaneous (n = 5) brachial, open brachial (n = 15), or open axillary (n = 20) artery exposure with conduit. The mean length of surgery was 253 min with median intensive care unit stay of 2 days. There were 6 endoleaks noted, 8 access site complications, 1 perioperative death, and 3 branch vessel stent occlusions. We have a mean follow-up time of 17.6 months (range 3-44).

CONCLUSIONS

Parallel stent-graft repair for paravisceral aneurysms is feasible and has acceptable technical/clinical success and complication rates. Although long-term follow-up is still needed, this technique fills the gap in endovascular options for poor open surgical candidates in whom fenestrated devices are not available.

Review of Treatment for Thoracoabdominal Aortic Aneurysm, and the Modern Experience of Multi-Branched Endograft in Taiwan

Thoracoabdominal aortic aneurysm (TAAA) is a complicated aortic disease. Most treatments for other aortic aneurysms have already shifted from conventional open surgery to endovascular operation; but for TAAA, open surgery remains the gold standard treatment. Several alternative treatments such as hybrid operation as well as endovascular techniques are utilized for the treatment of TAAA. Some of the procedures combine off-the-shelf devices such as the chimney procedure. Some other procedures required custom-made specialized stent grafts. A new off-the-shelf multi-branched endograft, T-branch graft, was released in late 2012, though it was not introduced into Taiwan until 2015. Ultimately, also we plan to report the experience of multi-branched endograft in Taiwan.

Multibranched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms

Purpose: To evaluate the available literature on endovascular repair of thoracoabdominal (TAAA) and pararenal aortic aneurysms (PRAA) using multibranched stent-grafts. Methods: MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and June 2015 to identify articles related to the use of multibranched stent-grafts for the treatment of TAAA and PRAA. Articles with <4 cases and those on juxtarenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate 30-day mortality, all-cause mortality, spinal cord ischemia, renal insufficiency, endoleak, target vessel patency, and reintervention. Of 370 articles screened, only 4 articles encompassing 185 patients (mean age 71.1 years; 137 men) were aligned with the inclusion criteria. There were 23 PRAAs; the mean aneurysm diameter was 64.5 mm. The Crawford TAAA classification was 10 type I, 47 type II, 37 type III, 58 type IV, and 9 type V; there was 1 Stanford type B dissection in association with a large TAAA. Results of the meta-analyses are reported as proportions and 95% confidence interval (CI). Results: Pooled analysis indicated a technical success rate of 98.9%. As study heterogeneity was significant, random effects models were used for meta-analysis. The rate for 30-day mortality was 9% (95% CI 3% to 19%), for all-cause mortality 27% (95% CI 17% to 38%), endoleaks 10% (95% CI 1% to 25%), target vessel patency 98% (95% CI 95% to 99%), SCI 17% (95% CI 1% to 26%), irreversible SCI 6% (95% CI 3% to 10%), renal insufficiency 15% (95% CI 0.8% to 41%), and reinterventions 21% (95% CI 4% to 47%). Conclusion: Use of multibranched stent-grafts in the treatment of TAAAs and PRAAs appears to be feasible and safe based on satisfactory early outcomes in the limited literature available to date. Long-term surveillance and further studies are essential to determine the durability of this technique.

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions

OBJECTIVE

Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions.

METHODS

Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive.

RESULTS

Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases.

CONCLUSIONS

The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.

Hybrid Repair of an Aortic Arch Aneurysm Using Double Parallel Grafts Perfused by Retrograde Flow in Endovascular Repair Combined With Left Subclavian Artery Surgical Bypass

Despite its invasive nature, open surgical repair is still the first choice to treat aortic arch aneurysms. With the advancement of endovascular technology, thoracic endovascular aortic repair (TEVAR) has gained popularity in treating aortic aneurysms; however, blood flow preservation of the supra-arch branches remains a complicated challenge. This case report describes a hybrid procedure that successfully treated a patient with aortic arch aneurysm by combining the parallel grafts perfused by retrograde flow in the TEVAR procedure and a carotid-subclavian artery bypass.

Transarterial Endoleak Closure After Endovascular Thoracoabdominal Aneurysm Repair: When the "Sandwich" Goes Wrong

PURPOSE

To describe the use of vascular plugs to close a complex type Ib endoleak following the sandwich procedure used in conjunction with endovascular thoracoabdominal aortic aneurysm (TAAA) repair.

CASE REPORT

A 59-year-old man with a 6.5-mm TAAA was treated with initial deployment proximally of 2 Zenith TX2 stent-grafts. In preparation for the sandwich technique to preserve flow to the celiac trunk, a 10×100-mm Viabahn covered stent was delivered from a brachial access into the celiac trunk unprotected by the sheath of the introducer. The trigger wire system became snagged on the struts of the distal aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft, which migrated upward. The main body extension intended for the aortic component of the sandwich technique was deployed close to the distal end of the aneurysm sac, but a large type Ib endoleak formed in the gutter between the Viabahn, aortic extension, and sac wall. The leak perfused the celiac trunk, and the procedure was terminated. Increasing sac size on 3-month imaging prompted closure of the leak with 2 type II Amplatzer vascular plugs aiming to occlude the endoleak outflow into the Viabahn and the endoleak outflow at the site of the gutter. Imaging follow-up at 6 months demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk.

CONCLUSION

Transarterial treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning.

A novel endovascular debranching technique using physician-assembled endografts for repair of thoracoabdominal aneurysms

OBJECTIVE

The objective of this study was to demonstrate a technique that uses physician-assembled endografts to make use of the benefits of parallel grafts while also providing for circumferential seal and fixation in repair of thoracoabdominal aneurysms in inoperable patients.

METHODS

A single-center all-comers retrospective analysis of 14 patients was performed that looked at the early outcomes of patients treated for thoracoabdominal aneurysms. Three Crawford type II, four type III, four type IV, and three type V thoracoabdominal aneurysms were treated. Contrast material, fluoroscopy time, length of stay, clinical success, and technical success were measured.

RESULTS

There was no in-hospital, 30-day, or 6-month mortality. We found two type III endoleaks in the early design. One required coil embolization. Average volume of contrast material and average fluoroscopy time were 76.9 mL and 119.1 minutes, respectively. Average length of stay was 10.5 days, and average procedure time was 251.2 minutes. Clinical success was observed in 78.6% of patients to date, and technical success was observed in 85.7% of patients.

CONCLUSIONS

Short-term results show that this approach is safe. The device can be safely implanted, is off-the-shelf, and can treat each of the Crawford thoracoabdominal aneurysm types. Finally, the assembly of off-the-shelf components may shorten the regulatory path for this physician-assembled endograft.