1
|
Dossabhoy SS, Fisher AT, Chang TI, Owens DK, Arya S, Stern JR, Lee JT. Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair. J Vasc Surg 2024; 79:1360-1368.e3. [PMID: 38219966 PMCID: PMC11111352 DOI: 10.1016/j.jvs.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR. METHODS A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling. RESULTS Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05). CONCLUSIONS In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.
Collapse
Affiliation(s)
- Shernaz S. Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T. Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Douglas K. Owens
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA
| | - Shipra Arya
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R. Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T. Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Baszucki Vascular Surgery Biobank, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
2
|
Pitcher GS, Biggs JH, Dayama A, Newton DH, Tran K, Stoner MC, Smeds MR, Schermerhorn ML, Mix D. A national census for the off-label treatment of complex aortic aneurysms. J Vasc Surg 2024:S0741-5214(24)01080-2. [PMID: 38904580 DOI: 10.1016/j.jvs.2024.04.054] [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: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.
Collapse
Affiliation(s)
- Grayson S Pitcher
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Joedd H Biggs
- Division of Vascular Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Anand Dayama
- Sanford Vascular Associates, Sanford Health, Sioux Falls, SD
| | - Daniel H Newton
- Division of Vascular Surgery, Virginia Commonwealth University Health System, Richmond, VA
| | - Kenneth Tran
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, St Louis University School of Medicine, St Louis, MO
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Boston, MA
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
3
|
Fouad F, Saleem BR, Tielliu IFJ, Pegorer MA, Bellosta R, Esposito D, Fargion AT, Zeebregts CJ, de Vries JPPM, Schuurmann RCL. Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated Endovascular Aortic Repair: A Multicenter, Retrospective Cohort Study. J Endovasc Ther 2024:15266028241248600. [PMID: 38708986 DOI: 10.1177/15266028241248600] [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: 05/07/2024]
Abstract
PURPOSE The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic repair (FEVAR) and to determine and visualize BECS-associated complications. METHODS This multicenter retrospective study included patients who underwent FEVAR between 2018 and 2022 in 3 vascular centers participating in the VBX Expand Registry. Patients with at least one visceral artery treated with the VBX and with availability of 2 post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU] 1: 0-6 months; FU2: 9-24 months) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software. RESULTS In total, 90 VBX BECS were analyzed in 43 FEVAR patients. The median CTA FU for FU1 and FU2 was 35 days (interquartile range [IQR], 29-51 days) and 14 months (IQR, 13-15 months), respectively. The mean flare-to-fenestration distance was 5.6±2.0 mm on FU1 and remained unchanged at 5.7±2.0 mm on FU2 (p=.417). The flare-to-fenestration diameter ratio was 1.19±0.17 on FU1 and remained unchanged at 1.21±0.19 (p=.206). The mean apposition length was 18.6±5.3 mm on FU1 and remained 18.6±5.3 mm (p=.550). The flare angle was 31°±15° on FU1 and changed to 33°±16° (p=.009). On FU1, the BECS-associated complication rate was 1%, and the BECS-associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3%, and the BECS-associated reintervention rate was 1%. CONCLUSIONS The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up in this study. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions, but this should be confirmed in a larger study including enough patients and BECS to compare complicated and uncomplicated cases. CLINICAL IMPACT The three-dimensional flare geometry of the Gore Viabahn VBX BECS was assessed on the first and second postoperative CTA scans, and geometrical changes during this period were identified. For BECS that were diagnosed with a type 3c endoleak or occlusion, the BECS geometry was analyzed to detect geometrical components that were related to the complication. Geometric analysis of the flare may help to better detect and identify the cause of such complications.
Collapse
Affiliation(s)
- Fatima Fouad
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ben R Saleem
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ignace F J Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Matteo A Pegorer
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Richte C L Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
4
|
Vallabhaneni SR, Patel SR, Campbell B, Boyle JR, Cook A, Crosher A, Holder SM, Jenkins MP, Ormesher DC, Rosala-Hallas A, Jackson RJ. Editor's Choice - Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) - Peri-operative and Midterm Outcomes. Eur J Vasc Endovasc Surg 2024; 67:540-553. [PMID: 38428672 DOI: 10.1016/j.ejvs.2024.02.037] [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: 02/10/2024] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments vs. OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR). METHODS All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 - 4 mm, 5 - 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts). RESULTS Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; p = .001) and FEVAR (2.2%; p = .001) than OSR (4.5%). In standard risk patients with a 0 - 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR vs. 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 - 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR. CONCLUSION FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 - 4 mm neck length), with comparable midterm survival. For patients with short neck (5 - 9 mm) and complex neck (≥ 10 mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.
Collapse
Affiliation(s)
- Srinivasa R Vallabhaneni
- Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.
| | - Shaneel R Patel
- Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - Bruce Campbell
- Royal Devon University Healthcare Trust, Exeter, UK; University of Exeter Medical School, Exeter, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust, Cambridge, UK; Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | | | - Alastair Crosher
- Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Sophie M Holder
- Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Michael P Jenkins
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - David C Ormesher
- East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Anna Rosala-Hallas
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard J Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| |
Collapse
|
5
|
Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
Collapse
|
6
|
Elahwal M, Richards T, Imsirovic A, Bagga R, Almond G, Yusuf SW. Systematic review of the results of fenestrated endovascular aortic repair in octogenarians. Ann R Coll Surg Engl 2024; 106:106-117. [PMID: 37642117 PMCID: PMC10830342 DOI: 10.1308/rcsann.2023.0032] [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] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION With the increasing life expectancy of Western populations, more octogenarians are presenting with large abdominal aortic aneurysm (AAA). Endovascular repair offers a less invasive alternative and older patients who may not have been offered open repair in the past are now being considered for elective repair with this approach. Age in isolation may not be the only consideration in recommending elective aneurysm repair. We aimed to review the literature on complex endovascular AAA repairs (mainly fenestrated endovascular aortic repair [FEVAR]) in octogenarians. METHODS A literature search was conducted using the Ovid Medline®, Embase® and Cochrane Library databases for articles published up to January 2022. All English language publications from 1995 onwards were eligible for inclusion. Search terms included: "FEVAR", "F-EVAR", "fenestrated EVAR", "fenestrated endovascular aortic repair", "fenestrated endovascular aneurysm repair", "fenestrated AAA repair", "fenestrated endograft", "fenestrated stent graft", "fenestrated", "endograft", "EVAR", "octogenarian", "elderly", "above 80" and "over 80". METHODS The literature search identified 134 potential articles. Following qualitative assessment by two independent appraisers, this was refined to 11 studies, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. RESULTS The primary outcome measure was 30-day mortality, which was highly variable, ranging from 0% to 9% in octogenarians and from 0% to 5% in non-octogenarians. However, these differences were only found to be statistically significant in two studies. The secondary outcome measures included technical success rates, major adverse events, reintervention rates, freedom from reintervention, target vessel patency, freedom from target branch instability, and length of hospital and intensive care unit stay. No statistically significant differences were found between octogenarians and non-octogenarians. Long-term survival was significantly lower for octogenarians in two studies. CONCLUSIONS The perioperative outcomes of FEVAR in octogenarians are comparable with those of younger patients. FEVAR therefore appears to be an acceptable option for complex endovascular aneurysm repairs in carefully selected octogenarians. Nevertheless, this review highlights the paucity of published data on the outcomes of endovascular repair of complex aneurysms in octogenarians.
Collapse
Affiliation(s)
- M Elahwal
- University Hospitals Sussex NHS Foundation Trust, UK
| | - T Richards
- University Hospitals Sussex NHS Foundation Trust, UK
| | - A Imsirovic
- University Hospitals Sussex NHS Foundation Trust, UK
| | - R Bagga
- University Hospitals Sussex NHS Foundation Trust, UK
| | - G Almond
- University Hospitals Sussex NHS Foundation Trust, UK
| | - SW Yusuf
- University Hospitals Sussex NHS Foundation Trust, UK
| |
Collapse
|
7
|
Guéroult AM, Bashir A, Azhar B, Budge J, Roy I, Loftus I, Holt P. Long Term Outcomes and Durability of Fenestrated Endovascular Aneurysm Repair: A Meta-analysis of Time to Event Data. Eur J Vasc Endovasc Surg 2024; 67:119-129. [PMID: 37572869 DOI: 10.1016/j.ejvs.2023.08.012] [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: 03/29/2023] [Revised: 07/13/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE Despite widespread use, long term outcomes for fenestrated endovascular aneurysm repair (FEVAR) are uncertain. This meta-analysis reports long term survival, freedom from re-intervention, target vessel patency, and one year sac regression after FEVAR. DATA SOURCES Systematic review and meta-analysis to pool time to event data according to PRISMA guidelines. The study was registered with the international prospective register of systematic reviews (PROSPERO) (ID: CRD42023401468). REVIEW METHODS Medline, Embase, and Cochrane databases were searched from 1992 - 2023; articles were independently screened by two authors. Publication of complete time to event data for any outcome of interest was an inclusion criterion. Raw Kaplan-Meier probabilities were directly extracted from published curves and pooled by random effects. Risk of bias was assessed using ROBINS I and certainty with GRADE. RESULTS A total of 3 569 records were retrieved, 2 869 screened after duplicate removal, yielding 37 included studies (n = 4 371). The pooled mean age was 73.2 years (interquartile range [IQR] 72.2, 73.7) and 87.4% were male (95% confidence interval [CI] 85.8 - 88.9). Pooled Kaplan-Meier estimated probabilities of survival (n = 34 studies, n = 4 192 patients) at one, three, and five years were 91.6% (95% CI 90.2 - 92.9), 80.8% (95% CI 78.0 - 83.2), and 65.1% (95% CI 60.9 - 69.1). For freedom from re-intervention (n = 24, n = 3 211 patients) at one, three, and five years these were 90.2% (95% CI 87.3 - 92.7), 80.9% (95% CI 76.5 - 84.9), and 73.8% (95% CI 67.1 - 79.6). For target vessel patency (n = 13, n = 5805 target vessels) at one, three, and five years, these were 96.6% (95% CI 94.9 - 98.0), 94.5% (95% CI 91.7 - 96.7), and 93.1% (95% CI 89.3 - 96.0). Pooled estimate of sac regression (n = 8, n = 560) at one year was 40.2% (95% CI 28.9 - 52.7). Risk of bias was judged as moderate in 11 studies and low for the remaining 26. CONCLUSION There are moderate to low certainty data supporting reasonable long term outcome estimates following fenestrated endovascular aneurysm repair. Beyond five years there is a lack of data in the literature.
Collapse
Affiliation(s)
| | - Aisha Bashir
- St George's Vascular Institute; St George's, University of London, UK
| | - Bilal Azhar
- St George's Vascular Institute; St George's, University of London, UK
| | - James Budge
- St George's Vascular Institute; St George's, University of London, UK
| | - Iain Roy
- St George's Vascular Institute; St George's, University of London, UK
| | - Ian Loftus
- St George's Vascular Institute; St George's, University of London, UK
| | - Peter Holt
- St George's Vascular Institute; St George's, University of London, UK
| |
Collapse
|
8
|
Mulatti GC, Joviliano EE, Pereira AH, Fioranelli A, Pereira AA, Brito-Queiroz A, Von Ristow A, Freire LMD, Ferreira MMDV, Lourenço M, De Luccia N, Silveira PG, Yoshida RDA, Fidelis RJR, Boustany SM, de Araujo WJB, de Oliveira JCP. Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm. J Vasc Bras 2023; 22:e20230040. [PMID: 38021279 PMCID: PMC10648059 DOI: 10.1590/1677-5449.202300402] [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: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.
Collapse
Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Ribeirão Preto, SP, Brasil.
| | - Adamastor Humberto Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | - Alexandre Araújo Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | - André Brito-Queiroz
- Universidade Federal da Bahia - UFBA, Hospital Ana Nery, Salvador, BA, Brasil.
| | - Arno Von Ristow
- Pontifícia Universidade Católica do Rio de Janeiro - PUC-Rio, Rio de Janeiro, RJ, Brasil.
| | | | | | | | - Nelson De Luccia
- Universidade de São Paulo - USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | | | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil.
| | | | - Sharbel Mahfuz Boustany
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | | |
Collapse
|
9
|
Zerwes S, Kiessling J, Schaefer A, Liebetrau D, Gosslau Y, Bruijnen HK, Hyhlik-Duerr A. Combining Endovascular Aneurysm Sealing with Chimney Grafts - 5 Year Follow-Up after 47 Procedures. Ann Vasc Surg 2023; 96:195-206. [PMID: 37075835 DOI: 10.1016/j.avsg.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/31/2023] [Accepted: 03/31/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND To evaluate longer-term results of a cohort treated with primary chimney endovascular aneurysm sealing (ChEVAS) for complex abdominal aortic aneurysms or secondary ChEVAS after failed endovascular aneurysm repair/endovascular aneurysm sealing. METHODS A single-center study was conducted of 47 consecutive patients (mean age 72 ± 8 years, range 50-91; 38 men) treated with ChEVAS from February 2014 to November 2016 and followed through December 2021. The main outcome measures were all-cause mortality (ACM), aneurysm-related mortality, occurrence of secondary complications and conversion to open surgery. Data are presented as the median (interquartile range [IQR]) and absolute range. RESULTS 35 patients received a primary ChEVAS (=group I) and 12 patients a secondary ChEVAS (=group II). Technical success was 97% (group I) and 92% (group II); 30-day mortality was 3% and 8%, respectively. The median proximal sealing zone length was 20.5 mm (IQR 16, 24; range 10-48) in group I and 26 mm (IQR 17.5, 30; range 8-45) in group II, respectively. During a median time of follow-up of 62 months (range 0-88), ACM amounted to 60% (group I) and 58% (group II); aneurysm mortality was 29% and 8%, respectively. An endoleak was seen in 57% (group I: 15 type Ia endoleaks, four isolated type Ib, and 1 endoleak type V) and 25% (group II: 1 endoleak type Ia, one type II, and 2 type V), aneurysm growth in 40% and 17%, migration in 40% and 17%, resulting in 20% and 25% conversions in group I and II, respectively. Overall a secondary intervention was performed in 51% (group I) and 25% (group II), respectively. The occurrence of complications did not significantly differ between the 2 groups. Neither the number of chimney grafts, nor the thrombus ratio significantly affected the occurrence of abovementioned complications. CONCLUSIONS While initially delivering a high technical success rate, ChEVAS fails to provide acceptable longer-term results both in primary and secondary ChEVAS, resulting in high rates of complications, secondary interventions and open conversions.
Collapse
Affiliation(s)
- Sebastian Zerwes
- Clinic for vascular and endovascular surgery, Medizinische Fakultät, Universität of Augsburg, Augsburg.
| | - Johanna Kiessling
- Clinic for vascular and endovascular surgery, Sankt Gertrauden Krankenhaus, Berlin
| | - Alexander Schaefer
- Clinic for vascular and endovascular surgery, Medizinische Fakultät, Universität of Augsburg, Augsburg
| | - Dominik Liebetrau
- Clinic for vascular and endovascular surgery, Medizinische Fakultät, Universität of Augsburg, Augsburg
| | - Yvonne Gosslau
- Clinic for vascular and endovascular surgery, Medizinische Fakultät, Universität of Augsburg, Augsburg
| | - Hans-Kees Bruijnen
- formerly Clinic for vascular and endovascular surgery, retired vascular surgeon, Medizinische Fakultät, Universität of Augsburg, Augsburg
| | - Alexander Hyhlik-Duerr
- Clinic for vascular and endovascular surgery, Medizinische Fakultät, Universität of Augsburg, Augsburg
| |
Collapse
|
10
|
Bizos A, Hostalrich A, Chaufour X, Desgranges P, Layese R, Cochennec F, Canoui-Poitrine F. Comparison of Fenestrated Stentgrafts and Open Repair for Juxtarenal Aortic Aneurysms Using a Propensity Score Matching. Ann Vasc Surg 2023; 95:50-61. [PMID: 37270093 DOI: 10.1016/j.avsg.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The purpose of this study was to compare postoperative morbi-mortality and medium-term follow-up of fenestrated stent grafting and open repair (OR) for patients with juxtarenal aortic aneurysms (JRAAs). METHODS All consecutive patients who underwent custom-made fenestrated endovascular aortic repair (FEVAR) or OR for complex abdominal aortic aneurysm between 2005 and 2017 in 2 tertiary centers were scrutinized. Patients with JRAA constituted the study group. Suprarenal and thoracoabdominal aortic aneurysms were excluded. The groups were made comparable through the use of a propensity score matching. RESULTS 277 patients with JRAAs were included, 102 (36.8%) in the FEVAR group and 175 (63.2%) in the OR group, respectively. After propensity score matching, 54 FEVAR patients (52.9%) and 103 OR patients (58.9%) were included for analysis. In-hospital mortality rates were 1.9% (n = 1) in the FEVAR group versus 6.9% (n = 7) in the OR group (P = 0.483). Postoperative complications were less common in the FEVAR group (14.8% vs. 30.7%; P = 0.033). Mean follow-up was 42.1 months in the FEVAR group and 40 months in the OR group. Overall mortality rates at 12 and 36 months were 11.5% and 24.5% in the FEVAR group versus 9.1 % (P = 0.691) and 11.6% (P = 0.067) in the OR group. Late reinterventions were more frequent in the FEVAR group (11.3% vs. 2.9%; P = 0.047). However, freedom from reintervention rates were not significantly different at 12 months (FEVAR: 86% vs. OR: 90%; P = 0.560) and 36 months (FEVAR: 86% vs. OR: 88.4%, P = 0.690). In the FEVAR group, persistent endoleak during follow-up was identified in 11.3% of cases. CONCLUSIONS In the present study, there was no statistical difference in terms of mortality in-hospital at 12 or 36 months between FEVAR and OR groups for JRAA. FEVAR for JRAA was associated with a significant reduction of overall postoperative major complications compared with OR. There were significantly more late reinterventions in the FEVAR group.
Collapse
Affiliation(s)
- Alia Bizos
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France.
| | - Aurélien Hostalrich
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Xavier Chaufour
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Richard Layese
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Florence Canoui-Poitrine
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| |
Collapse
|
11
|
Yazar O, Pilz da Cunha G, de Haan MW, Mees BM, Schurink GW. Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:268-278. [PMID: 36106397 DOI: 10.23736/s0021-9509.22.12311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The impact of stent-graft complexity on clinical outcome after fenestrated endovascular aortic aneurysm repair (FEVAR) has been conflicting in the literature. The objective of this study was to compare mid-term results of stent-grafts with renal fenestrations alone with more complex stent-grafts including mesenteric fenestrations. METHODS A single center retrospective study was conducted on 154 patients, who underwent FEVAR from 2006 to 2020 at our institution. RESULTS There were 54 (35.1%) patients in the renal FEVAR group and 100 (64.9%) patients in the complex FEVAR group. Median follow-up of the total group was 25 months (IQR 7-45). There were no significant differences in technical success and perioperative mortality. Intraoperative complications (4% vs. 18%, P=0.001), operative time (145 min vs. 191 min, P=0.001), radiation dose (119372 mGy*cm2 vs. 159573 mGy*cm2, P=0.004) and fluoroscopy time (39 min vs. 54 min, P=0.007) were significantly lower in the renal FEVAR group. During follow-up target vessel instability, endoleaks and reinterventions were not significantly different between the two groups. CONCLUSIONS In this single center retrospective study, renal FEVAR was a safe and effective treatment for patients with juxtarenal AAA demonstrating fewer intraoperative complications and similar mid-term outcomes as complex FEVAR. If the anatomy is compatible for renal FEVAR, it might be unnecessary to expose patients to potentially more complications by choosing a complex FEVAR strategy.
Collapse
Affiliation(s)
- Ozan Yazar
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Vascular Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Gabriela Pilz da Cunha
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michiel W de Haan
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Barend M Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands -
| |
Collapse
|
12
|
Zlatanovic P, Mascia D, Ancetti S, Yeung KK, Graumans MJ, Jongkind V, Viitala H, Venermo M. Short Term and Long Term Clinical Outcomes of Endovascular versus Open Repair for Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using Propensity Score Matching: Results from Juxta- and pararenal aortic Aneurysm Multicentre European Study (JAMES). Eur J Vasc Endovasc Surg 2023; 65:828-836. [PMID: 36858252 DOI: 10.1016/j.ejvs.2023.02.070] [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: 09/16/2021] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE The aim of this study was to compare the short and long term clinical outcomes of endovascular (EVAR) vs. open surgical repair (OSR) of juxtarenal (JAAAs) and pararenal abdominal aortic aneurysms (PAAAs) in five high volume European academic centres. METHODS This was a retrospective multicentre cohort study of five high volume European academic centres (> 50 open or 50 endovascular abdominal aortic aneurysm repairs annually) including 834 consecutive patients who were operated on and prospectively followed. Using propensity score matching (PSM) each patient who underwent OSR was matched with one patient who underwent EVAR in a 1:1 ratio (145 patients per group). The primary endpoint was long term all cause mortality, while the secondary endpoint was freedom from aortic related re-intervention. RESULTS After a follow up of 87 months, no difference in overall survival between the two groups was observed (38.6% for EVAR vs. 42.1% for OSR; p = .88). Patients undergoing EVAR underwent aortic related re-interventions more frequently (24.1% vs. 6.9%; p < .001). Acute kidney injury (AKI) occurred more frequently in patients in the OSR group (40.7% vs. 24.8%; p = .006). However, most patients who suffered from AKI recovered without further progression to renal failure. In hospital (3.4% for EVAR vs. 4.1% for OSR; p = 1.0) and 30 day (4.1% for EVAR vs. 5.5% for OSR; p = .80) mortality rates did not differ between groups. CONCLUSION Both open and endovascular treatment can be performed in high volume aortic centres with low short term mortality and morbidity rates, and good long term outcomes. These data provide useful information to help patients choose between the two procedures when both are feasible.
Collapse
Affiliation(s)
- Petar Zlatanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia.
| | - Daniele Mascia
- Vascular Surgery Unit at the San Raffaele Hospital, Milan, Italy
| | | | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Maarten Jaap Graumans
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Department of Vascular Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - Herman Viitala
- Vascular Surgery at the Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Vascular Surgery at the Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
13
|
Rastogi V, Marcaccio CL, Kim NH, Patel PB, Anjorin AC, Zettervall SL, Patel VI, de Bruin JL, Verhagen HJM, Schermerhorn ML. The effect of supraceliac versus infraceliac landing zone on outcomes following fenestrated endovascular repair of juxta-/pararenal aortic aneurysms. J Vasc Surg 2023; 77:9-19.e2. [PMID: 35981657 PMCID: PMC9789162 DOI: 10.1016/j.jvs.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE With increasing experience in fenestrated endovascular aneurysm repair (FEVAR) over time, devices designed to treat juxta-/pararenal aortic aneurysms have evolved in complexity to extend to more proximal landing zones and incorporate more target vessels. We assessed perioperative outcomes in patients who underwent juxta-/pararenal FEVAR with supraceliac vs infraceliac sealing in the Vascular Quality Initiative. METHODS We identified all patients who underwent elective FEVAR (commercially available FEVAR and physician-modified endografts) for juxta-/pararenal aortic aneurysms in the Vascular Quality Initiative between 2014 and 2021. Supraceliac sealing was defined as proximal sealing in aortic zone 5, or zone 6 with a celiac scallop/fenestration/branch or celiac occlusion. Primary outcomes were perioperative and 3-year mortality. Secondary outcomes included completion endoleaks, in-hospital complications, and factors associated with 3-year mortality. We calculated propensity scores and used inverse probability-weighted Cox regression and logistic regression modeling to assess outcomes. RESULTS Among 1486 patients identified, 1246 patients (84%) underwent infraceliac sealing, and 240 patients (16%) underwent supraceliac sealing. Of the supraceliac patients, 74 (31%) had a celiac scallop, 144 (60%) had a celiac fenestration/branch, and 22 (9.2%) had a celiac occlusion (intentional or unintentional). After risk-adjusted analyses, there were no differences in perioperative mortality following supraceliac sealing compared with infraceliac sealing (2.3% vs 2.5%; hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.26-1.8; P = .42), or 3-year mortality (12% vs 15%; HR, 0.89; 95% CI, 0.53-1.5; P = .67). Compared with infraceliac sealing, supraceliac sealing was associated with lower odds of type-IA completion endoleaks (odds ratio [OR], 0.24; 95% CI, 0.05-0.67), but higher odds of any complication (12% vs 6.9%; OR, 1.6; 95% CI, 1.01-2.5) including cardiac complications (5.5% vs 1.9%; OR, 2.6; 95% CI, 1.3-5.1), lower extremity ischemia (3.0% vs 0.9%; OR, 3.2; 95% CI, 1.02-9.5), and acute kidney injury (16% vs 11%; OR, 1.6; 95% CI, 1.05-2.3). Though non-significant, there was a trend towards higher risk of spinal cord ischemia following supraceliac sealing compared with infraceliac sealing (1.7% vs 0.8%; OR, 2.2; 95% CI, 0.70-6.4). There were no differences in bowel ischemia between groups (1.7% vs 1.5%; OR, 0.83; 95% CI, 0.24-1.23). A more proximal aneurysm disease extent was associated with higher 3-year mortality (HR zone 8 vs 9, 1.7; 95% CI, 1.1-2.5), whereas procedural characteristics had no influence. CONCLUSIONS Compared with sealing at an infraceliac level, supraceliac sealing was associated with lower risk of type IA endoleaks and similar mortality. However, clinicians should be aware that supraceliac sealing was associated with higher perioperative morbidity. Future studies with longer follow-up are needed to adequately assess durability differences to comprehensively weigh the risks and benefits of utilizing a higher sealing zone within the visceral aorta for juxta-/pararenal FEVAR.
Collapse
Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicole H Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aderike C Anjorin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
14
|
Hyun S, Kim H, Mok SK, Yun SS, Park SC, Kim JY. Anatomical feasibility of fenestrated stent graft to treat complex abdominal aortic aneurysms from a Korean single institute database. Ann Surg Treat Res 2023; 104:34-42. [PMID: 36685774 PMCID: PMC9830046 DOI: 10.4174/astr.2023.104.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose This study aims to investigate the feasibility of Zenith Fenestrated AAA Endovascular Graft (Z-FEN, Cook Medical) from a single Korean institution database by evaluating the vascular anatomy of Korean abdominal aortic aneurysm (AAA) patients with hostile aortic neck. Methods This is a retrospective study on patients with AAA who underwent endovascular aortic repair (EVAR) and open surgery repair between January 2012 and December 2021 (n = 211). The anatomic characteristics of the aortic neck were evaluated using 3-dimensional reconstructed computed tomographic scans. For the juxtarenal AAA patients (n = 39), feasibility of fenestrated stent graft was evaluated under the protocol of fenestrated EVAR. For those who were not suitable for the application of Z-FEN, the reasons for unsuitability were analyzed. Results Among 211 AAA patients, 108 patients (51.2%) had complex aortic neck, and 39 (18.5%) had insufficient aortic neck length (<15 mm) for conventional EVAR. Of the 39 patients with juxtarenal AAAs, 13 (33.3%) were determined feasible for Z-FEN. Twenty-six patients (66.7%) were noncandidate for Z-FEN due to severe neck angulation, short aortic neck length, inadequate iliac artery anatomy, large aortic neck diameter, and severe calcification and thrombosis. Proximal aortic neck length of the non-feasible group was significantly shorter than that of the feasible group (P = 0.002). Conclusion Z-FEN was applicable to 33.3% of the juxtarenal AAA patients. As recent studies confirm, the effectiveness and safety of fenestrated EVAR, Z-FEN can be an option for AAA patients with short aortic neck.
Collapse
Affiliation(s)
- Sangho Hyun
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Hojung Kim
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Sang Kyun Mok
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Sang Seob Yun
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Sun Cheol Park
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Jang Yong Kim
- Department of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| |
Collapse
|
15
|
Sénémaud J, Becquemin JP, Chakfé N, Touma J, Desgranges P, Cochennec F. Midterm Results of Physician-Modified Stent Grafts for Thoracoabdominal and Complex Abdominal Aortic Aneurysms Repair. Ann Vasc Surg 2022:S0890-5096(22)00762-2. [PMID: 36460175 DOI: 10.1016/j.avsg.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND To assess midterm results of physician-modified stent grafts (PMSG) for the treatment of emergent complex abdominal and thoracoabdominal aortic aneurysms (TAAA) in high-risk patients. METHODS All consecutive patients with emergent complex abdominal or TAAA undergoing PMSG technique between January 2012 and July 2019 were retrospectively included. Indications for PMSG were symptomatic aneurysms and rapidly growing aneurysms >70 mm. Ruptured aneurysms were excluded. RESULTS Thirty-three patients (mean age: 74 +/- 11 years) were included. The mean aneurysm diameter was 76 +- 20 mm. Patients presented with TAAA (n = 20, 61%), complex abdominal aortic aneurysms (CAAA, n = 9, 27%), type I endoleak after previous endovascular aneurysm repair (n = 3, 9%) and intramural aortic hematoma (n = 1, 3%). Chimney technique was performed in addition to PMSG in seven cases (21%). Intraoperative adverse events were recorded in seven cases (35%) in the TAAA group and one case (11%) in the CAAA group. In-hospital mortality rate was 15% (n = 3) in the TAAA group and 11% (n = 1) in the CAAA group. Moderate to severe complications were recorded in 45% of cases (n = 15). Spinal cord ischemia occurred in two cases (6%, one case without residual deficit and one with minor motor deficit). One (3%) patient required transient hemodialysis. One patient presented with early aortic rupture and required an open conversion. The mean follow-up duration was 31 months (1-79). Overall survival estimates were 81.4% (95% confidence interval [CI]: 63.1.-91.2) at 1 year and 71.6% (95% CI: 52.6-84.1) at 2 years. Freedom from reintervention rates at 1 and 2 years were 61.2% (95% CI: 41.7-75.9) and 57.4% (95% CI: 37.9-72.8). Target vessel primary patency rates at 1 and 2 years were 99.2% (95% CI: 94.2-99.9) and 97.7% (95% CI: 90.7-99.4). CONCLUSIONS PMSG for high-risk patients with complex aneurysms provided acceptable technical success and excellent target vessel patency rates but were associated with a 12% in-hospital mortality rate. Reinterventions were frequent. This technique should be limited to selected high-risk patients for whom the risk of rupture in the short-term is deemed too high to wait for graft manufacturing of custom-made device.
Collapse
Affiliation(s)
- Jean Sénémaud
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Jean-Pierre Becquemin
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France.
| |
Collapse
|
16
|
Hossack M, Simpson G, Shaw P, Fisher R, Torella F, Brennan J, Smout J. Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms. AORTA (STAMFORD, CONN.) 2022; 10:114-121. [PMID: 36318932 PMCID: PMC9626034 DOI: 10.1055/s-0042-1748959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background
Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach.
Methods
Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery.
Results
One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm,
p
= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%,
p
< 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair.
Conclusion
OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.
Collapse
Affiliation(s)
- Martin Hossack
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom,Address for correspondence Martin Hossack, MBChB, BSc Liverpool Vascular and Endovascular ServiceLink 8C, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom L7 8XP
| | - Gregory Simpson
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Penelope Shaw
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Robert Fisher
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom
| | - John Brennan
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Jonathan Smout
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| |
Collapse
|
17
|
Lima GBB, Dias-Neto M, Tenorio ER, Baghbani-Oskouei A, Oderich GS. Endovascular Repair of Complex Aortic Aneurysms. Adv Surg 2022; 56:305-319. [PMID: 36096574 DOI: 10.1016/j.yasu.2022.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fenestrated-branched endovascular aortic repair (FB-EVAR) has gained widespread acceptance in patients with complex aortic aneurysms. It has evolved from an alternative to treat elderly and higher risk patients to the first line of treatment in most patients with suitable anatomy, independent of the clinical risk. Currently, these devices are available off-the-shelf (ready to use) and tailored to the patient anatomy with the options of fenestrated, branched and mixed fenestrated, and branched designs. Reports from single and multicenter experiences and systematic reviews have shown lower mortality and morbidity for FB-EVAR compared with historical results of open surgical repair. The main advantages are noted on mortality, respiratory complications, acute kidney injury, and length of hospital stay. The purpose of this article is to review the advances in the endovascular repair of complex aortic aneurysms exploring the indications for treatment, preoperative evaluation, patient selection, device design, and implantation technique.
Collapse
Affiliation(s)
- Guilherme B B Lima
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Marina Dias-Neto
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Emanuel R Tenorio
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| | - Gustavo S Oderich
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, 6400 Fannin Street, Suite 2850, Houston, TX 77030, USA.
| |
Collapse
|
18
|
Uijtterhaegen G, VAN Langenhove K, Moreels N, VAN Herzeele I, Vermassen F. Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:317-327. [PMID: 35142459 DOI: 10.23736/s0021-9509.22.11964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility. METHODS This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR. RESULTS One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak. CONCLUSIONS This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.
Collapse
Affiliation(s)
- Gilles Uijtterhaegen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium -
| | - Karen VAN Langenhove
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
19
|
Kapahnke S, Bürger M, Torsello GF, Omran S, Hinterseher I, Greiner A, Frese JP. Cannulation of visceral vessels using a steerable sheathin fenestrated and branched aortic endografts. Ann Vasc Surg 2022; 85:305-313. [PMID: 35271960 DOI: 10.1016/j.avsg.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/18/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A critical step in the endovascular treatment of complex aortic aneurysm is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR). METHODS Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or non-challenging TV. RESULTS Fifty-three patients (median age 73 (Q1, Q3 (68 - 80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n = 26; 49%), juxtarenal aneurysms (n = 23; 43.5%) and penetrating aortic ulcers (PAU) (n = 4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of three TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus non-challenging TV (p = 0.457). One patient died within 30 days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36 months, the survival rate was 87%, 87%, and 81%, respectively Primary patency after 12 months was 98.6%, and 97.9% of vessels remained FFR during follow-up. CONCLUSION Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.
Collapse
Affiliation(s)
- Sebastian Kapahnke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Matthias Bürger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Giovanni Federico Torsello
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Irene Hinterseher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane - Campus Neuruppin, Vascular Surgery; Fehrbelliner Str. 38, 16816 Neuruppin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan Paul Frese
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| |
Collapse
|
20
|
Gregory M, Metcalfe M, Steiner K. Profile of the Ovation ALTO abdominal stent graft for the treatment of abdominal aortic aneurysms: overview of its safety and efficacy. Expert Rev Med Devices 2021; 18:1145-1153. [PMID: 34851807 DOI: 10.1080/17434440.2021.2013804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Ovation ALTO is the next generation aortic stent graft from Endologix for the treatment of infra-renal abdominal aortic aneurysms. The device uses polymer-injected rings to create a proximal seal at the aneurysm neck. AREAS COVERED Results from the first clinical study of the ALTO graft are analyzed and the potential benefits of the graft in minimizing post-treatment aneurysmal neck dilation discussed. The implications of the ALTO's Instructions-For-Use (IFU) and low-profile delivery system are also reviewed. EXPERT OPINION The re-positioning of the sealing rings higher on the graft and an integrated compliant balloon are the most significant improvements on the Ovation iX, facilitating accurate placement of the proximal sealing ring and prompt balloon dilation of the polymer rings. The expansion the IFU to include neck lengths of ≥7 mm will mean more patients are eligible for infra-renal EVAR within IFU with the ALTO device. The published data on the device to date is limited. With over 1000 implants worldwide we would hope for more published data to become available. If this demonstrates similar mid-term results to that seen with the Ovation iX in arguably more hostile neck anatomy, then the Ovation ALTO is likely to be more widely used.
Collapse
Affiliation(s)
- Mark Gregory
- East and North Hertfordshire Nhs Trust, Department of Radiology, Stevenage, UK
| | - Matt Metcalfe
- East and North Hertfordshire Nhs Trust, Department of Vascular Surgery, Stevenage, UK
| | - Kate Steiner
- East and North Hertfordshire Nhs Trust, Department of Radiology, Stevenage, UK
| |
Collapse
|
21
|
Patel SR, Ormesher DC, Smith SR, Wong KHF, Bevis P, Bicknell CD, Boyle JR, Brennan JA, Campbell B, Cook A, Crosher AP, Duarte RV, Flett MM, Gamble C, Jackson RJ, Juszczak MT, Loftus IM, Nordon IM, Patel JV, Platt K, Psarelli EE, Rowlands PC, Smyth JV, Spachos T, Taggart L, Taylor C, Vallabhaneni SR. A risk-adjusted and anatomically stratified cohort comparison study of open surgery, endovascular techniques and medical management for juxtarenal aortic aneurysms-the UK COMPlex AneurySm Study (UK-COMPASS): a study protocol. BMJ Open 2021; 11:e054493. [PMID: 34848524 PMCID: PMC8634354 DOI: 10.1136/bmjopen-2021-054493] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In one-third of all abdominal aortic aneurysms (AAAs), the aneurysm neck is short (juxtarenal) or shows other adverse anatomical features rendering operations more complex, hazardous and expensive. Surgical options include open surgical repair and endovascular aneurysm repair (EVAR) techniques including fenestrated EVAR, EVAR with adjuncts (chimneys/endoanchors) and off-label standard EVAR. The aim of the UK COMPlex AneurySm Study (UK-COMPASS) is to answer the research question identified by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme: 'What is the clinical and cost-effectiveness of strategies for the management of juxtarenal AAA, including fenestrated endovascular repair?' METHODS AND ANALYSIS UK-COMPASS is a cohort study comparing clinical and cost-effectiveness of different strategies used to manage complex AAAs with stratification of physiological fitness and anatomical complexity, with statistical correction for baseline risk and indication biases. There are two data streams. First, a stream of routinely collected data from Hospital Episode Statistics and National Vascular Registry (NVR). Preoperative CT scans of all patients who underwent elective AAA repair in England between 1 November 2017 and 31 October 2019 are subjected to Corelab analysis to accurately identify and include every complex aneurysm treated. Second, a site-reported data stream regarding quality of life and treatment costs from prospectively recruited patients across England. Site recruitment also includes patients with complex aneurysms larger than 55 mm diameter in whom an operation is deferred (medical management). The primary outcome measure is perioperative all-cause mortality. Follow-up will be to a median of 5 years. ETHICS AND DISSEMINATION The study has received full regulatory approvals from a Research Ethics Committee, the Confidentiality Advisory Group and the Health Research Authority. Data sharing agreements are in place with National Health Service Digital and the NVR. Dissemination will be via NIHR HTA reporting, peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER ISRCTN85731188.
Collapse
Affiliation(s)
- Shaneel R Patel
- Vascular Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - David C Ormesher
- Vascular Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Samuel R Smith
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Paul Bevis
- Vascular Surgery, North Bristol NHS Trust, Bristol, UK
| | - Colin D Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jonathan R Boyle
- Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John A Brennan
- Vascular Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Bruce Campbell
- Vascular Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
| | - Alastair P Crosher
- Radiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Rui V Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard J Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Maciej T Juszczak
- Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian M Loftus
- Vascular Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ian M Nordon
- Vascular Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jai V Patel
- Interventional Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kellie Platt
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | | | - Peter C Rowlands
- Radiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - John V Smyth
- Vascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Theodoros Spachos
- Vascular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Leigh Taggart
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Srinivasa Rao Vallabhaneni
- Vascular Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| |
Collapse
|
22
|
Blakeslee-Carter J, Beck AW, Spangler EL. Type 3 Endoleaks in Complex Endovascular Abdominal Aortic Aneurysm Repair within the Vascular Quality Initiative. J Vasc Surg 2021; 75:1172-1180. [PMID: 34740805 DOI: 10.1016/j.jvs.2021.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Type 3 Endoleaks (T3EL) following complex EVAR (c-EVAR) for abdominal aortic aneurysm have been historically difficult to study due to their relative rarity. Previous studies within standard infrarenal EVAR have found an association between T3EL and decreased survival. This study aims to evaluate the occurrence of T3EL in a national multicenter cohort, identify potential procedural characteristics associated with T3EL development, and determine their impact on clinical outcomes in c-EVAR. METHODS A retrospective cohort review was conducted of elective c-EVAR for non-ruptured aneurysms within the Vascular Quality Initiative (VQI) between January 2010 and March 2020. The VQI standards define c-EVAR as suprarenal or pararenal AAA repaired with any thoracoabdominal repairs, fenestrated/branched repairs, parallel stent repairs, custom manufactured devices, and physician modified endografts. End-points assessed were rates of T3EL within c-EVAR, and impact of T3EL on reintervention and survival. Index endoleaks were defined as endoleaks discovered during index hospitalization. Incident endoleaks were defined as new endoleaks, that were not present at index hospitalization, discovered at follow-up. RESULTS 4,070 c-EVAR cases were identified between January 2010 and March 2020, of which, 2,656 (65.2%) had appropriate follow-up data. Half the cohort had a modified or custom graft (n=2,055/4,070, 50.5%). Branches were employed in 3,687 patients (90.5%), while fenestrations and chimney techniques were documented in 13% (n=533) and 15.1% (n=613) respectively . The rate of index T3EL was 4.1% (n=167), and the rate of incident T3EL at follow-up was 0.04% (n=1). Devices categorized as either custom or physician modified were utilized more frequently in patients with index T3EL (78.4%, n=131/167) compared to patients without index T3EL (49.2%, n=1,924/3,903) (p<0.001). Compared to those without T3EL, the presence of index T3EL was not statistically associated with increased aortic reinterventions or increased mortality. CONCLUSIONS T3EL in c-EVAR remain relatively uncommon and are identified predominately at index hospitalization. Development of T3EL was associated with higher device modularity and modification, which suggests that as device technologies continue to advance and become more intricate the occurrence of T3EL may persist and continue to require evaluation. In this study, the presence of T3EL did not appear to have a statistically significant relationship with aortic reinterventions or survival, however these findings are not definitive due to low event rate numbers and high potential for Type 2 errors. Amid the theoretical risk of device fatigue and degeneration, continued evaluations of large cohorts at extended follow-up intervals and diligent reporting remain paramount.
Collapse
Affiliation(s)
- Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
| |
Collapse
|
23
|
Li S, Chen M, Zheng Y, Liu Z, Zeng R. Custom-made fenestrated stent for mycotic aortic aneurysms: a report of two cases. BMC Cardiovasc Disord 2021; 21:428. [PMID: 34507541 PMCID: PMC8434722 DOI: 10.1186/s12872-021-02234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Mycotic aortic aneurysm is a rare and potentially life-threatening lesion, and endovascular repair has become increasingly accepted for intervention. Fenestrated endografts are available options to treat aneurysms involving visceral arteries. Here, we first report two patients with mycotic aortic aneurysm involving paraviscereal aorta who were successfully treated with custom-made fenestrated endograft. Case presentation Two patients were presented with mycotic aortic aneurysm. Due to their comorbidities and the involvement of the renal arteries, company-manufactured fenestrated stents were designed. Meanwhile, antibiotic therapy was administrated for 2 months before endovascular repair. Patients improved well without complications. Conclusions Custom-made fenestrated endovascular stent is an effective and feasible alternative solution to mycotic paravisceral aorta aneurysm.
Collapse
Affiliation(s)
- Siting Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Mengyin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China.
| | - Zhili Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China
| |
Collapse
|
24
|
Patel SR, Roy IN, McWilliams RG, Brennan JA, Vallabhaneni SR, Neequaye SK, Smout JD, Fisher RK. Characterising the incidence and mode of visceral stent failure after fenestrated endovascular aneurysm repair (FEVAR). JRSM Cardiovasc Dis 2021; 10:20480040211012503. [PMID: 34211706 PMCID: PMC8217896 DOI: 10.1177/20480040211012503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/20/2021] [Accepted: 04/01/2021] [Indexed: 12/05/2022] Open
Abstract
Background In FEVAR, visceral stents provide continuity and maintain perfusion between
the main body of the stent and the respective visceral artery. The aim of
this study was to characterise the incidence and mode of visceral stent
failure (type Ic endoleak, type IIIa endoleak, stenosis/kink, fracture,
crush and occlusion) after FEVAR in a large cohort of patients at a
high-volume centre. Methods A retrospective review of visceral stents placed during FEVAR over 15 years
(February 2003-December 2018) was performed. Kaplan-Meier analyses of
freedom from visceral stent-related complications were performed. The
outcomes between graft configurations of varying complexity were compared,
as were the outcomes of different stent types and different visceral
vessels. Results Visceral stent complications occurred in 47/236 patients (19.9%) and 54/653
stents (8.3%). Median follow up was 3.7 years (IQR 1.7–5.3 years). There was
no difference in visceral stent complication rate between renal, SMA and
coeliac arteries. Visceral stent complications were more frequent in more
complex grafts compared to less complex grafts. Visceral stent complications
were more frequent in uncovered stents compared to covered stents. Visceral
stent-related endoleaks (type Ic and type IIIa) occurred exclusively around
renal artery stents. The most common modes of failure with SMA stents were
kinking and fracture, whereas with coeliac artery stents it was external
crush. Conclusion Visceral stent complications after FEVAR are common and merit continued and
close long-term surveillance. The mode of visceral stent failure varies
across the vessels in which the stents are located.
Collapse
Affiliation(s)
- Shaneel R Patel
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Iain N Roy
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard G McWilliams
- Department of Interventional Radiology, Royal Liverpool University Hospital, Liverpool, UK
| | - John A Brennan
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Simon K Neequaye
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Jonathan D Smout
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert K Fisher
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| |
Collapse
|
25
|
Pomy BJ, Rosenfeld ES, Lala S, Lee KB, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Macsata RA, Nguyen BN. Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency. Ann Vasc Surg 2021; 75:349-357. [PMID: 33831525 DOI: 10.1016/j.avsg.2021.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/12/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). CONCLUSION For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.
Collapse
Affiliation(s)
- Benjamin J Pomy
- The George Washington University Department of Surgery, Washington, District of Columbia.
| | - Ethan S Rosenfeld
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Salim Lala
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - K Benjamin Lee
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Andrew D Sparks
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Richard L Amdur
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - John J Ricotta
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Anton N Sidawy
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Robyn A Macsata
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Bao-Ngoc Nguyen
- The George Washington University Department of Surgery, Washington, District of Columbia
| |
Collapse
|
26
|
Portugal MFC, Teivelis MP, da Silva MFA, Stabellini N, Fioranelli A, Szlejf C, Amaro E, Wolosker N. Endovascular correction of isolated descending thoracic aortic disease: a descriptive analysis of 1,344 procedures over 10 years in the public health system of São Paulo. Clinics (Sao Paulo) 2021; 76:e2332. [PMID: 33567046 PMCID: PMC7847257 DOI: 10.6061/clinics/2021/e2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.
Collapse
Affiliation(s)
| | - Marcelo Passos Teivelis
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Sao Paulo, SP, BR
| | | | | | - Alexandre Fioranelli
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
- Faculdade de Ciencias Medicas, Santa Casa de Sao Paulo, Sao Paulo, SP, BR
| | | | - Edson Amaro
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
| | - Nelson Wolosker
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Sao Paulo, SP, BR
- Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
27
|
Deslarzes-Dubuis C, Tran K, Colvard BD, Lee JT. Renal Stent Complications and Impact on Renal Function after Standard Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2020; 72:106-113. [PMID: 33249133 DOI: 10.1016/j.avsg.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND To report renal outcomes including long-term patency, secondary interventions, and related renal function after fenestrated endovascular aortic repair (fEVAR). METHODS Single-center retrospective review of patients undergoing fEVAR between 2012 and 2018 using the Cook ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent-related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease formula. RESULTS During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4%, and the mean follow-up was 23.3 months. Seventeen renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations, and 1 type III endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1 day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5 days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48 months, respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23 (0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs. 55.58 mL/min/1.73 m2, P = 0.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by chronic kidney disease staging compared with baseline (P = 0.51). CONCLUSIONS fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent-graft complications.
Collapse
Affiliation(s)
- Celine Deslarzes-Dubuis
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Benjamin D Colvard
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA.
| |
Collapse
|
28
|
Oderich GS, Farber MA, Schneider D, Makaroun M, Sanchez LA, Schanzer A, Beck AW, Starnes BW, Fillinger M, Tenorio ER, Chen M, Zhou Q. Final 5-year results of the United States Zenith Fenestrated prospective multicenter study for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2020; 73:1128-1138.e2. [PMID: 32891806 DOI: 10.1016/j.jvs.2020.08.128] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To report 5-year results of the prospective, multicenter study designed to evaluate the Zenith Fenestrated AAA Endovascular Graft (William A. Cook Australia, Brisbane, Australia) for juxtarenal abdominal aortic aneurysms (AAAs). METHODS Sixty-seven patients (54 male, mean age 74 ± 8 years) were prospectively enrolled at 14 U.S. centers from 2005 to 2012. Fenestrated stent grafts were used in patients with infrarenal aortic neck lengths of 4 to 14 mm to target 178 renal-mesenteric arteries with a mean of 2.7 vessels per patient. At 5 years, 42 of the 67 patients completed the final study follow-up, with clinical examination obtained in 41 and computed tomography imaging in 39. Outcomes adjudicated by a clinical events committee included all-cause and aneurysm-related mortality, major adverse events, renal stent occlusion/stenosis, renal function changes and renal infarcts, aneurysm sac enlargement (>5 mm), device migration (≥10 mm), type I/III endoleak, and secondary interventions. RESULTS Median follow-up was 59.8 months (range, 0.1-67.5 months). There were seven deaths, including one (1.5%) within 30 days (procedure-related) and six beyond 30 days (not procedure-related in five, indeterminate in one). At 5 years, freedom from all-cause mortality was 88.8 ± 4.2% and freedom from aneurysm-related mortality was 96.8 ± 2.3%. There were no aneurysm ruptures or conversions to open surgery. Of the 129 renal arteries targeted by fenestrations, five (4%) occluded and 14 (11%) developed in-stent stenosis. Treatment included redo stenting/angioplasty in 13 vessels, renal artery bypass in 2 vessels, and failed thrombectomy in 1 vessel. Primary and secondary renal target patency was 82.7 ± 4.1% and 95.7 ± 2.1% at 5 years, respectively. Dialysis was required in one patient who had pre-existing chronic kidney disease. During the 5 years, there was 1 type IA endoleak (1.5%), 1 type IB endoleak (1.5%), 2 device migrations (3%), and 4 aneurysm sac enlargements (6%). Overall, 81% of patients had sac shrinkage at 5 years. Of 20 patients who underwent secondary interventions, 12 were for renal in-stent stenosis or occlusion, 7 were for endoleak, and 1 was for both indications. Freedom from secondary intervention was 63.5 ± 7.2% at 5 years. CONCLUSIONS These 5-year results confirm the safety and effectiveness of the Zenith Fenestrated AAA stent graft with no late graft- or aneurysm-related deaths. In-stent stenosis of bare metal renal stents was the most frequent indication for secondary intervention. The low rate of type IA endoleak, sac enlargement, and device migration support its use in patients with juxtarenal AAAs.
Collapse
Affiliation(s)
- Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex.
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren Schneider
- Division of Vascular and Endovascular Surgery, Department of Surgery, Cornell-Weil Medical Center, New York, NY
| | - Michel Makaroun
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Luis A Sanchez
- Center for Advanced Medicine Heart & Vascular Center, Washington University, St Louis, Mo
| | - Andres Schanzer
- Division of Vascular Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Mark Fillinger
- Division of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Min Chen
- Cook Research Incorporated, West Lafayette, Ind
| | - Qing Zhou
- Cook Research Incorporated, West Lafayette, Ind
| | | |
Collapse
|
29
|
Pini R, Giordano J, Ferri M, Palmieri B, Solcia M, Michelagnoli S, Chisci E, Fadda Gian F, Cappiello P, Talarico F, Licata S, Frigatti P, Ronchey S, Mangialardi N, Pratesi C, Salvini M, Milite D, Pilon F, Perkmann R, Stringari C, Pulli R, Faggioli G, Gargiulo M. The Italian Multicentre Registry of Fenestrated Anaconda™ Endografts for Complex Abdominal Aortic Aneurysms Repair. Eur J Vasc Endovasc Surg 2020; 60:181-191. [PMID: 32709467 DOI: 10.1016/j.ejvs.2020.04.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/17/2020] [Accepted: 04/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR). METHODS Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up. RESULTS One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively. CONCLUSION The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies.
Collapse
Affiliation(s)
- Rodolfo Pini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Policlinico Sant'Orsola-Malpighi, Bologna, Italy.
| | - Jacopo Giordano
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | - Bruno Palmieri
- Dipartimento Cardiotoracovascolare, Ospedale Niguarda, Milan, Italy
| | - Marco Solcia
- Dipartimento Cardiotoracovascolare, Ospedale Niguarda, Milan, Italy
| | | | - Emiliano Chisci
- Dipartimento Chirurgico, Ospedale San Giovanni di Dio, Florence, Italy
| | | | | | | | - Silvio Licata
- Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Paolo Frigatti
- Dipartimento di Chirurgia Generale, Ospedale Santa Maria della Misericordia, Udine, Italy
| | - Sonia Ronchey
- Dipartimento delle Specialità Chirurgiche, Azienda Ospedaliera San Filippo Neri, Rome, Italy
| | - Nicola Mangialardi
- Dipartimento delle Specialità Chirurgiche, Azienda Ospedaliera San Filippo Neri, Rome, Italy
| | - Carlo Pratesi
- Dipartimento di Medicina Sperimentale e Clinica, Ospedale Careggi, Florence, Italy
| | - Mauro Salvini
- Dipartimento Chirurgico, Ospedale Civile, Alessandria, Italy
| | - Domenico Milite
- Dipartimento Strutturale Area Chirurgia Maggiore, Ospedale San Bortolo, Vicenza, Italy
| | - Fabio Pilon
- Dipartimento Strutturale Area Chirurgia Maggiore, Ospedale San Bortolo, Vicenza, Italy
| | | | | | - Raffaele Pulli
- Dipartimento dell'Emergenza e dei Trapianti di Organi, Policlinico di Bari, Bari, Italy
| | - Gianluca Faggioli
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| |
Collapse
|
30
|
Lindström D, Kettunen H, Engström J, Lundberg G. Outcome After Fenestrated and Branched Repair of Aortic Aneurysms—Device Failures Predict Reintervention Rates. Ann Vasc Surg 2020; 66:142-151. [DOI: 10.1016/j.avsg.2019.10.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
|
31
|
Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 2020; 73:4S-52S. [PMID: 32615285 DOI: 10.1016/j.jvs.2020.06.011] [Citation(s) in RCA: 237] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022]
Abstract
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.
Collapse
|
32
|
Davis FM, Albright J, Battaglia M, Eliason J, Coleman D, Mouawad N, Knepper J, Mansour MA, Corriere M, Osborne NH, Henke PK. Fenestrated repair improves perioperative outcomes but lacks a hospital volume association for complex abdominal aortic aneurysms. J Vasc Surg 2020; 73:417-425.e1. [PMID: 32473343 DOI: 10.1016/j.jvs.2020.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Complex abdominal aortic aneurysms (AAAs) have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of complex AAAs has been well established, but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigated the outcomes of OSR and FEVAR for the treatment of complex AAAs and examined the hospital volume-outcome relationship for these procedures. METHODS A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2018 who underwent elective repair of a juxtarenal/pararenal AAA with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, and new dialysis. Secondary end points included postoperative pneumonia, renal dysfunction (creatine concentration increase of >2 mg/dL from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low- and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting in comparing outcomes between treatment groups. RESULTS A total of 589 patients underwent FEVAR (n = 186) or OSR (n = 403) for a complex AAA. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs 2.9%; P < .001) and need for dialysis (11.3% vs 1.8; P < .001). Postoperative pneumonia (6.8% vs 0.3%; P < .001) and need for transfusion (39.4% vs 10.4%; P < .001) were also significantly higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days, respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1 year, with the majority being type II. With a median follow-up period of 331 days (229-378 days), 1% of FEVAR patients required a secondary procedure, and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low- and high-volume aortic centers based on their annual FEVAR volume of complex AAAs. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction. CONCLUSIONS FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity, although long-term durability warrants further research.
Collapse
Affiliation(s)
- Frank M Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jeremy Albright
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Mich
| | - Michael Battaglia
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Mich
| | - Jonathan Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Dawn Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Jordan Knepper
- Department of Surgery, Henry Ford Health System, Jackson, Mich
| | - M Ashraf Mansour
- Department of Surgery, Spectrum Health System, Grand Rapids, Mich
| | - Matthew Corriere
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| |
Collapse
|
33
|
Overeem S, Schuurmann R, Schumacher M, Jolink F, Ketel M, Nijendijk B, Slump K, Versluis M, de Vries JP. Validation of a Novel Methodology to Evaluate Changes in the Flare Geometry of Renovisceral Bridging Stent-Grafts After Fenestrated Endovascular Aneurysm Repair. J Endovasc Ther 2020; 27:436-444. [DOI: 10.1177/1526602820915932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To validate a novel method to evaluate changes in the geometry of renovisceral bridging stent-grafts (BSGs) in patients undergoing fenestrated endovascular aneurysm repair (fEVAR). Materials and Methods: Retrospective analysis was conducted of serial computed tomography angiograms (CTAs) of 10 fEVAR patients (31 BSGs) with at least 2 years of CTA follow-up. Centerline reconstructions were made through the fenestrated stent-graft (FSG) and each BSG. Flare geometry was reconstructed based on marker coordinates and a mesh of the aortic lumen. The shortest distance was calculated from the top of the flare circumference to the FSG fabric. The amount of flaring was assessed with the flare to fenestration diameter ratio and BSG compression to diameter ratio (D-ratio). All measurements were performed by 2 observers. Interobserver variability was assessed; results are presented as the intraclass correlation coefficient (ICC) and repeatability coefficient (RC). Results: Excellent interobserver agreement was achieved for BSG diameter and flare to fenestration distance calculations (ICC 0.865 and 0.944; RC 2.2% and 4.5%, respectively). Six patients had BSG-related complications during follow-up: 2 type IIIc endoleaks and 4 BSG occlusions. Five of the 6 BSGs with complications showed a considerable change in the D-ratio compared with the first postoperative CTA. Conclusion: Precise assessment of the geometry of visceral BSGs in fEVAR is feasible with the presented method. Geometrical changes that may precede later complications can be detected, which could aid in localization of the origin, but a larger series of patients is necessary to define its true clinical merit.
Collapse
Affiliation(s)
- Simon Overeem
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Multimodality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Richte Schuurmann
- Multimodality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, the Netherlands
| | - Michiel Schumacher
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Floortje Jolink
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirte Ketel
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Bob Nijendijk
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Kees Slump
- Robotics and Mechatronics, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Michel Versluis
- Physics of Fluids Group, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Jean-Paul de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, the Netherlands
| |
Collapse
|
34
|
|
35
|
Liang NL, Mohapatra A, Avgerinos ED, Katsargyris A. Acute Kidney Injury after Complex Endovascular Aneurysm Repair. Curr Pharm Des 2020; 25:4686-4694. [DOI: 10.2174/1381612825666191129095829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022]
Abstract
Background:
Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative
morbidity than standard infrarenal endovascular repair.
Objective:
This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular
repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.
Methods:
A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal,
and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further
analyzed by the level of anatomic complexity and method of repair.
Results:
52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017.
The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19%
(temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute
kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency
did not demonstrate any associations with the outcome.
Conclusion:
Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively
associated factors other than increasing anatomic complexity and operative time. Further study is
needed for the identification of predictors related to postoperative acute kidney injury.
Collapse
Affiliation(s)
- Nathan L. Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Abhisekh Mohapatra
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Efthymios D. Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
| |
Collapse
|
36
|
Chaufour X, Segal J, Soler R, Daniel G, Rosset E, Favre JP, Magnan PE, Ricco JB. Editor's Choice – Durability of Open Repair of Juxtarenal Abdominal Aortic Aneurysms: A Multicentre Retrospective Study in Five French Academic Centres. Eur J Vasc Endovasc Surg 2020; 59:40-49. [DOI: 10.1016/j.ejvs.2019.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
|
37
|
Derycke L, Sénémaud J, Perrin D, Avril S, Desgranges P, Albertini JN, Cochennec F, Haulon S. Patient Specific Computer Modelling for Automated Sizing of Fenestrated Stent Grafts. Eur J Vasc Endovasc Surg 2019; 59:237-246. [PMID: 31865026 DOI: 10.1016/j.ejvs.2019.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim was to validate a computational patient specific model of Zenith® fenestrated device deployment in abdominal aortic aneurysms to predict fenestration positions. METHODS This was a retrospective analysis of the accuracy of numerical simulation for fenestrated stent graft sizing. Finite element computational simulation was performed in 51 consecutive patients that underwent successful endovascular repair with Zenith® fenestrated stent grafts in two vascular surgery units with a high volume of aortic procedures. Longitudinal and rotational clock positions of fenestrations were measured on the simulated models. These measurements were compared with those obtained by (i) an independent observer on the post-operative computed tomography (CT) scan and (ii) by the stent graft manufacturer planning team on the pre-operative CT scan. (iii) Pre- and post-operative positions were also compared. Longitudinal distance and clock face discrepancies >3 mm and 15°, respectively, were considered significant. Reproducibility was assessed using Bland-Altman and linear regression analysis. RESULTS A total of 195 target arteries were analysed. Both Bland-Altman and linear regression showed good reproducibility between the three measurement techniques performed. The median absolute difference between the simulation and post-operative CT scan was 1.0 ± 1.1 mm for longitudinal distance measurements and 6.9 ± 6.1° for clock positions. The median absolute difference between the planning centre and post-operative CT scan was 0.8 ± 0.8 mm for longitudinal distance measurements and 5.1 ± 5.0° for clock positions. Finally, the median absolute difference between the simulation and the planning centre was 0.96 ± 0.97 mm for longitudinal distance measurements and 4.8 ± 3.6° for clock positions. CONCLUSION The numerical model of deployed fenestrated stent grafts is accurate for planning position of fenestrations. It has been validated in 51 patients, for whom fenestration locations were similar to the sizing performed by physicians and the planning centre.
Collapse
Affiliation(s)
- Lucie Derycke
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Centre CIS, F - 42023 Saint-Etienne, France; Department of Vascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France.
| | - Jean Sénémaud
- Department of Vascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France
| | | | - Stephane Avril
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Centre CIS, F - 42023 Saint-Etienne, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France
| | - Jean-Noel Albertini
- Department of Cardio-Vascular Surgery, Centre Hospitalier Régional Universitaire de Saint-Etienne, Saint-Priez-en-Jarez, France
| | - Frederic Cochennec
- Department of Vascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France
| | - Stephan Haulon
- Department of Aortic and Vascular Surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, INSERM UMR_S 999, Université Paris Sud, France
| |
Collapse
|
38
|
Conway AM, Qato K, Nguyen Tran NT, Stoffels GJ, Giangola G, Carroccio A. Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair. J Vasc Surg 2019; 72:144-153. [PMID: 31831312 DOI: 10.1016/j.jvs.2019.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/11/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series. METHODS A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality. RESULTS There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 ± 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P < .0001), hypertension (85.5% vs 82.0%; P < .0001), preoperative creatinine (1.11 vs 1.08; P = .001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P < .0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P < .0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P < .0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P = .007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P = .01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P = .06). CONCLUSIONS A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.
Collapse
Affiliation(s)
- Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Nhan T Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| |
Collapse
|
39
|
Overeem SP, Goudeketting SR, Schuurmann RC, Heyligers JM, Verhagen HJ, Versluis M, de Vries JPP. Assessment of changes in stent graft geometry after chimney endovascular aneurysm sealing. J Vasc Surg 2019; 70:1754-1764. [DOI: 10.1016/j.jvs.2019.02.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
|
40
|
Intraoperative adverse events and early outcomes of custom-made fenestrated stent grafts and physician-modified stent grafts for complex aortic aneurysms. J Vasc Surg 2019; 71:1834-1842.e1. [PMID: 31708298 PMCID: PMC7126501 DOI: 10.1016/j.jvs.2019.07.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/20/2019] [Indexed: 11/23/2022]
Abstract
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.
Collapse
|
41
|
Jones AD, Waduud MA, Walker P, Stocken D, Bailey MA, Scott DJA. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open 2019; 3:572-584. [PMID: 31592091 PMCID: PMC6773647 DOI: 10.1002/bjs5.50178] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 04/01/2019] [Indexed: 11/12/2022] Open
Abstract
Background Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short- and long-term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms. Methods A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms 'juxta/para/suprarenal' were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30-day/in-hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak. Results Twenty-seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case-control study and a single prospective non-randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively. Conclusion No significant difference was noted in 30-day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long-term durability is a concern, with far higher reintervention rates after FEVAR.
Collapse
Affiliation(s)
- A. D. Jones
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - M. A. Waduud
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - P. Walker
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - D. Stocken
- The Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - M. A. Bailey
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - D. J. A. Scott
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| |
Collapse
|
42
|
Yoon WJ. Fenestrated Endovascular Aneurysm Repair versus Snorkel Endovascular Aneurysm Repair: Competing yet Complementary Strategies. Vasc Specialist Int 2019; 35:121-128. [PMID: 31620398 PMCID: PMC6774433 DOI: 10.5758/vsi.2019.35.3.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 11/20/2022] Open
Abstract
Juxtarenal/pararenal aortic aneurysms and type IV thoracoabdominal aneurysms pose particular technical challenges for endovascular repair as they involve the visceral segment in addition to insufficient infrarenal neck for the use of standard endovascular aneurysm repair (EVAR) devices. To overcome these challenges, complex EVAR techniques have been developed to extend the proximal landing zone cephalad with maintaining perfusion to vital aortic branches, thereby broadening the applicability of endografting from the infrarenal to the suprarenal aorta. Complex EVAR can be divided into two broad categories: fenestrated endovascular aneurysm repair (FEVAR) and snorkel EVAR. FEVAR is a valid procedure with the standardized procedure, although it remains as a relatively complex procedure with a learning curve. Given time constraints for the custom fenestrated graft, snorkel EVAR may be an alternative for complex repairs in symptomatic or ruptured patients for whom custom-made endografts may not be immediately available. This article discusses these two most commonly used complex EVAR strategies.
Collapse
Affiliation(s)
- William J Yoon
- Division of Vascular Surgery, Department of Surgery, University of California-Davis Medical Center, Sacramento, CA, USA
| |
Collapse
|
43
|
Endovascular Treatment of Complex Aneurysms with the Use of Covera Stent Grafts. J Vasc Interv Radiol 2019; 30:1942-1948.e1. [PMID: 31530494 DOI: 10.1016/j.jvir.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To characterize the short-term results of a newly available self-expanding covered stent (Covera; CR Bard Peripheral Vascular Inc., Murray Hill, New Jersey) for the reconstruction of target vessels in complex aneurysms. MATERIALS AND METHODS From August 2017 to November 2018, this self-expanding covered stent was used in 17 patients (mean 72.6 ± 7.6 years of age) during endovascular aneurysm repair (EVAR) with hypogastric preservation (11.8%), branched EVAR (29.4%), fenestrated (F)-EVAR (17.6%), chimney + F-EVAR (11.8%), or chimney EVAR (29.4%). In more than 48 stented arteries (2.8 ± 1.1/patient), 25 were preserved using this self-expanding covered stent. RESULTS All target vessels were successfully preserved. There was no 30-day mortality and 1 in-hospital death. Intraoperative aneurysm exclusion was successful in 14 patients (82.4%) with a perioperative technical success rate of 82.4%. The actuarial survival rate was 93.8% at 6 months and 85.9% at 12 months. Aneurysm sac regression of >5 mm was observed in 4 cases (23.5%), and the sac remained stable in the remaining patients (13 cases [76.5%]). At 12 months, the primary clinical success rate was 76.5%, and assisted primary clinical success rate was 82.4%. No type 3 endoleak was related to a disruption of the reconstruction with the self-expanding covered stent. CONCLUSIONS This new self-expanding covered stent provides good short-term patency in chimneys, branches, or fenestrations. Larger series with long-term follow-up are required to determine if the stent can sustain the mechanical stress to which it will be submitted in these repairs.
Collapse
|
44
|
Zacharias N, Wang GJ, Sedrakyan A, Columbo JA, Boyle JR, Goodney PP. Using the Idea, Development, Exploration, Assessment, Long-Term Study Framework for Devices (IDEAL-D) to Better Understand the Evolution of Evidence Surrounding Fenestrated Abdominal Aortic Endovascular Grafts. Ann Vasc Surg 2019; 59:293-299. [PMID: 31009709 PMCID: PMC10767621 DOI: 10.1016/j.avsg.2019.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/06/2019] [Accepted: 02/10/2019] [Indexed: 12/20/2022]
Abstract
The use of fenestrated endovascular devices for repair of complex aortic aneurysms has increased to nearly 5,000 implantations annually among Medicare patients in the United States in recent years. Given that nearly all aspects of treatment for minimally invasive aortic intervention rely on medical devices to better care for patients with vascular disease, clearly understanding how new and innovative technology evolves over the life cycle of a medical device is an essential skill set for cardiovascular physicians. Despite the need for this understanding, there is no standard framework upon which cardiovascular physicians, regulators, and patients can rely on to better understand the evolution of evidence from product inception through adoption and long-term effectiveness evaluation. As the aforementioned devices are increasingly and broadly used, the need for a formal framework for regulation and device approval has emerged. The goal of this review is to describe the Idea, Development, Exploration, Assessment, Long-term Study Framework for Devices (IDEAL-D). This framework is a model developed recently by an international panel of experts dedicated to better understanding the data steps necessary to bring a device from idea to routine practice and further to marketing, approval, and monitoring. In this review, we use the example of fenestrated endovascular aortic devices to illustrate the IDEAL-D framework, how it can help cardiovascular physicians improve their understanding of new technology, and the evidence which surrounds it from inception to long-term use.
Collapse
Affiliation(s)
- Nikolaos Zacharias
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Grace J Wang
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Art Sedrakyan
- Department of Surgery, Weill Cornell Medical College, New York, NY
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Cambridge, UK
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
| |
Collapse
|
45
|
Durability of open surgical repair of type I-III thoracoabdominal aortic aneurysm. J Vasc Surg 2019; 70:413-423. [DOI: 10.1016/j.jvs.2018.10.110] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022]
|
46
|
Bortman J, Mahmood F, Schermerhorn M, Lo R, Swerdlow N, Mahmood F, Matyal R. Use of 3-Dimensional Printing to Create Patient-Specific Abdominal Aortic Aneurysm Models for Preoperative Planning. J Cardiothorac Vasc Anesth 2019; 33:1442-1446. [DOI: 10.1053/j.jvca.2018.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Indexed: 11/11/2022]
|
47
|
Lindström D, Mani K, Lundberg G, Wanhainen A. Bridging stent grafts in fenestrated and branched endovascular aortic repair: current practice and possible complications. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:476-484. [PMID: 30916523 DOI: 10.23736/s0021-9509.19.10942-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fenestrated and branched endovascular aortic repair (F/B-EVAR) is associated with a high degree of technical and clinical success. Despite this, studies have also reported high reintervention rates, and these are often related to the bridging stent grafts. Often new devices appear on the market before they have been tested in the bridging stent graft position. This review aims to assess the current literature on bridging stent grafts and discuss complications, illustrated by case reports. Complications reported with bridging stent grafts include; endoleak, kink, fracture, migration, occlusion, stenosis and perforation. Some known risk factors for bridging stent occlusions are renal artery stent grafts vs. SMA and celiac artery stent grafts. Some device specific complications have also been reported such as type IIIc endoleak with the Lifestream stent graft (Bard Peripheral Vascular, Tempe, AZ, USA) fractures and type IIId endoleaks with the 1st generation of Begraft (BentleyInnoMed, Hechingen, Germany). In addition, this review also discusses some newer devices with possible relation to complications such as stenosis and target vessel perforation. In conclusion, bridging stent grafts in fenestrated and branched aortic repair have a good midterm patency. Despite this, remaining issues are often related to the bridging stent grafts. Thorough follow-up and attention are needed, especially when new devices are introduced. The endovascular community should work towards a common global feedback system.
Collapse
Affiliation(s)
- David Lindström
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden -
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Göran Lundberg
- Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
48
|
Morikage N, Mizoguchi T, Takeuchi Y, Nagase T, Samura M, Ueda K, Suehiro K, Hamano K. Chimney Endovascular Aneurysm Repair Using Endurant Stent-Grafts With Bare Balloon-Expandable Stents for Patients With Juxtarenal Aortic Aneurysms. J Endovasc Ther 2019; 26:350-358. [PMID: 30900510 DOI: 10.1177/1526602819837311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms. MATERIALS AND METHODS Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES. RESULTS The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p<0.001 vs preoperative), with an individual mean sac regression of 6.2±5.9 mm. Overall primary chimney stent patency was 100%. One of the 2 cases of intraoperative type Ia endoleak resolved at the 6-month imaging, and no new type Ia endoleaks developed in any cases at follow-up. No additional treatment- or aneurysm-related events were observed. CONCLUSION Short-term outcomes of chEVAR using Endurant with uncovered BES have been favorable when covered stents were unavailable, and it can be useful for high-risk patients with juxtarenal aortic aneurysms.
Collapse
Affiliation(s)
- Noriyasu Morikage
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takahiro Mizoguchi
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yuriko Takeuchi
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takashi Nagase
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Makoto Samura
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Koshiro Ueda
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kotaro Suehiro
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kimikazu Hamano
- 1 Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| |
Collapse
|
49
|
Durability of open surgical repair of type IV thoracoabdominal aortic aneurysm. J Vasc Surg 2019; 69:661-670. [DOI: 10.1016/j.jvs.2018.05.249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
|
50
|
O'Donnell TFX, Patel VI, Deery SE, Li C, Swerdlow NJ, Liang P, Beck AW, Schermerhorn ML. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative. J Vasc Surg 2019; 70:369-380. [PMID: 30718110 DOI: 10.1016/j.jvs.2018.11.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices. METHODS We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality. RESULTS During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 ± 0.8, with PMEGs involving the most arteries (3.3 ± 0.8 for PMEG vs 2.5 ± 0.6 for FEVAR and 1.9 ± 0.9 for chimney/snorkel; P < .001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P = .13) and AKI (17% vs 18% vs 19%; P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P = .03) and MACEs (6.1% vs 5.4% vs 11.7%; P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P = .015), myocardial infarction (OR, 18.7 [2.6-136.8]; P = .004), and MACEs (OR, 11.1 [2.1-58.9]; P = .005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis. CONCLUSIONS The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies.
Collapse
Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, NewYork-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sarah E Deery
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
| |
Collapse
|