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Raulli SJ, Gomes VC, Parodi FE, Vasan P, Sun D, Marston WA, Pascarella L, McGinigle KL, Wood JC, Farber MA. Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent. J Vasc Surg 2024; 80:302-310. [PMID: 38608964 DOI: 10.1016/j.jvs.2024.04.017] [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: 01/29/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.
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Affiliation(s)
- Stephen J Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Vivian Carla Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Priya Vasan
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dichen Sun
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob C Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
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Mendes BC, Rodrigues DVS, Chait J. Appropriateness of care in complex fenestrated-branched aortic endografting. Semin Vasc Surg 2024; 37:210-217. [PMID: 39151999 DOI: 10.1053/j.semvascsurg.2024.05.002] [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: 03/18/2024] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 08/19/2024]
Abstract
Fenestrated and branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms is increasingly replacing open repair as the primary modality of treatment. Mid- and long-term results are encouraging and support its use in the correct settings. Nevertheless, appropriateness of indication for treatment, patient selection, and surgeon and hospital performance has not been clearly evaluated and reviewed. The objective of this review article was to identify areas in which appropriateness of care is relevant and can be optimized when considering treatment of patients with fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Gonda Vascular Center, 200 First Street SW, Rochester, MN, 55902.
| | - Diego V S Rodrigues
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Gonda Vascular Center, 200 First Street SW, Rochester, MN, 55902
| | - Jesse Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Gonda Vascular Center, 200 First Street SW, Rochester, MN, 55902
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Vigezzi GP, Barbati C, Blandi L, Guddemi A, Melloni A, Salvati S, Bertoglio L, Odone A. Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression. Ann Surg 2024; 279:961-972. [PMID: 38214159 DOI: 10.1097/sla.0000000000006190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair. BACKGROUND Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited. METHODS We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics. RESULTS Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias. CONCLUSIONS Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.
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Affiliation(s)
- Giacomo Pietro Vigezzi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- Collegio Ca' della Paglia, Fondazione Ghislieri, Pavia, Italy
| | - Chiara Barbati
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Lorenzo Blandi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Annalisa Guddemi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Andrea Melloni
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Simone Salvati
- Division of Vascular Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Bertoglio
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- HTA Committee, IRCCS San Raffaele Hospital, Milan, Italy
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Takazawa A, Asakura T, Nakajima H, Yoshitake A. Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report. J Cardiothorac Surg 2024; 19:212. [PMID: 38616278 PMCID: PMC11017646 DOI: 10.1186/s13019-024-02703-0] [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: 09/07/2023] [Accepted: 03/27/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND A ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required. CASE PRESENTATION A 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography. CONCLUSIONS We provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.
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Affiliation(s)
- Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan.
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
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Steadman JA, Tenorio ER, Chait J, Vierkant RA, DeMartino RR, Oderich GS, Mendes BC. Preoperative predictors of nonhome discharge after fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg 2024; 79:469-477.e3. [PMID: 37956958 DOI: 10.1016/j.jvs.2023.11.015] [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: 07/22/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Nonhome discharge (NHD) has significant implications for patient counseling and discharge planning and is frequently required following fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA). We aimed to identify preoperative predictors of NHD after elective FB-EVAR for CAAA and TAAA and develop a risk calculator able to predict NHD. METHODS A retrospective review of prospectively collected data on all patients undergoing FB-EVAR between January 2007 and December 2021 at a single institution was performed. Exclusion criteria were admission from a nonhome setting, emergency and repeat FB-EVAR, and discharge to an unknown destination. The cohort was randomly split into separate development (70% of patients) and validation (30%) cohorts to develop a predictive calculator for NHD. Independent variables associated with NHD were assessed in a series of logistic regression analyses from 100 bootstrapped samples of the development set, and a model was developed using the most predictive variables. Resulting parameter estimates were applied to data in the validation set to assess model discrimination and calibration. RESULTS From the initial cohort of 712 FB-EVAR patients, 644 were included in the study (74% male; mean age, 75.4 ± 7.6 years), including 452 with CAAA (70%) and 192 with TAAA (30%). Early mortality occurred in eight patients (1.2%; 5 in CAAA and 3 in TAAA) and the median hospital stay was 5 days (4 for CAAA and 7 for TAAA). Ninety-seven patients (15%) had a NHD. On multivariable analysis, older age (per year, odds ratio [OR], 1.08; P < .001), female gender (OR, 3.03; P < .001), smoking (OR, 2.86; P = .01), congestive heart failure (OR, 3.05; P = .004), peripheral artery disease (OR, 1.81; P = .07), and extent I (OR, 3.17), II (OR, 2.84), and III (OR, 2.52; all P = .08) TAAAs were associated with an increased likelihood of NHD in the development set. Based on these factors, the risk calculator was developed which accurately predicts NHD in the validation set with an area under the curve of 0.7. CONCLUSIONS Older, female smokers with congestive heart failure and peripheral artery disease and more extensive aneurysms are at highest risk of NHD after FB-EVAR. Using only preoperative factors, our risk calculator can predict accurately who will have a NHD, allowing enhanced preoperative patient counselling and accelerated hospital discharge.
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Affiliation(s)
- Jessica A Steadman
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Department of Cardiovascular and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | - Jesse Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Robert A Vierkant
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | | | - Gustavo S Oderich
- Department of Cardiovascular and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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Mahmood DN, Rocha R, Ouzounian M, Teng Tan K, Forbes SM, Chung JCY, Lindsay TF. Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe. J Endovasc Ther 2024:15266028241229005. [PMID: 38339966 DOI: 10.1177/15266028241229005] [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: 02/12/2024]
Abstract
PURPOSE The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. MATERIALS AND METHODS A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. RESULTS Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. CONCLUSION Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. CLINICAL IMPACT This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, ON, Canada
| | - Samantha M Forbes
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Sulzer TAL, Vacirca A, Mesnard T, Baghbani-Oskouei A, Savadi S, Kanamori LR, van Lier F, de Bruin JL, Verhagen HJM, Oderich GS. How We Would Treat Our Own Thoracoabdominal Aortic Aneurysm. J Cardiothorac Vasc Anesth 2024; 38:379-387. [PMID: 38042741 DOI: 10.1053/j.jvca.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 12/04/2023]
Abstract
This manuscript is intended to provide a comprehensive review of the current state of knowledge on endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The management of these complex aneurysms requires an interdisciplinary and patient-specific approach in high-volume centers. An index case is used to discuss the diagnosis and treatment of a patient undergoing fenestrated-branched endovascular aneurysm repair for a TAAA.
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Affiliation(s)
- Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - 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
| | - 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, TX.
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Katsarou M, Auyang PL, Chinnadurai P, Bismuth J. "Octafen": A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2024; 31:19-25. [PMID: 35869618 DOI: 10.1177/15266028221113752] [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] [Indexed: 01/07/2024]
Abstract
PURPOSE To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA). TECHNIQUE Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages. CONCLUSION The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices. CLINICAL IMPACT In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The 'Octafen' technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.
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Affiliation(s)
- Maria Katsarou
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Section of Vascular Surgery, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Philip L Auyang
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ponraj Chinnadurai
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Advanced Therapies, Siemens Medical Solutions, Malvern, PA, USA
| | - Jean Bismuth
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
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Liu T, Zhao J, Sun J, Wu K, Wang W. Comparison of efficiency and safety of open surgery, hybrid surgery and endovascular repair for the treatment of thoracoabdominal aneurysms: a systemic review and network meta-analysis. Front Cardiovasc Med 2023; 10:1257628. [PMID: 38162130 PMCID: PMC10757346 DOI: 10.3389/fcvm.2023.1257628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024] Open
Abstract
Objective The objective of this study was to perform a network meta-analysis (NMA) to assess the efficacy and safety of three different surgical interventions- open surgical repair (OSR), hybrid surgical repair (HSR), and endovascular repair (EVAR)- for the treatment of thoracoabdominal aortic aneurysms (TAAAs). Methods Electronic repositories like PubMed, Embase, Web of Science, Scopus, ScienceDirect, the Cochrane library, Clinical trial, and China National Knowledge Infrastructure (CNKI) were systematically searched to identify studies that compared the efficacy of OSR, HSR, and EVAR with endografts for the treatment of TAAAs until December 24th, 2022. Random-effects and fixed-effects models were employed to analyze the data gathered in a network meta-analysis. The study's primary outcomes of interest encompassed in-hospital mortality, long-term survival rate, and postoperative complications. Results Eleven comparative studies meet inclusion criterias. There were 2,222 patients in OSR, 1,574 patients in EVAR and 537 patients in HSR. EVAR has lower one-month mortality than OSR (RR: 0.31; 95% CI: 0.17-0.70) and HSR (RR: 0.37; 95% CI: 0.22-0.71), and lower incident rate of renal complications than HSR (RR: 0.20; 95% CI: 0.08-0.43) and OSR (RR: 0.34; 95% CI: 0.16-0.65). Nonetheless, there was no noteworthy discrepancy identified in the long-term survival rates of these procedures. Conclusions As compared with OSR, HSR, and EVAR, EVER has lower one-month mortality, and lower incident rates of complications. Systematic review registration PROSPERO (CRD42022313829).
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Affiliation(s)
- Tinghua Liu
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jiani Zhao
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jinjian Sun
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Kemin Wu
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Wang
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Bilman V, Rinaldi E, Loschi D, Sheick-Yousif B, Melissano G. Suitability of current off-the-shelf devices for endovascular TAAA repair: a systematic review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:459-469. [PMID: 37199677 DOI: 10.23736/s0021-9509.23.12704-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
INTRODUCTION The aim of the present study is to perform a systematic review of published papers regarding the suitability of the current off-the-shelf (OTS) devices for endovascular thoracoabdominal aortic aneurysm (TAAA) repair. EVIDENCE ACQUISITION A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed. EVIDENCE SYNTHESIS A total of 19 studies were published between 2014 and 2023. Thirteen clinical studies and six theoretical feasibility studies were included. Eleven studies reported the clinical outcomes of the t-Branch stent-graft, one detailed the observational results of the use of the E-nside endoprosthesis, and one described the TAMBE stent-graft results. The following data primarily involve the t-Branch device outcomes. A total of 1131 patients that underwent aneurysm repair using an OTS stent-graft were identified. Among those, 1002, 116 and 13 patients received a t-Branch, E-nside, and TAMBE stent-grafts, respectively. A total of 767 (67.8%) were men, with a mean age of 71.6±7.4 years old, and a mean Body Mass Index (BMI) of 26.3±3.8 kg/m2. Technical success ranged from 64% to 100%. A total of 4172 target visceral vessels (TVV) were planned for bridging, with a success rate ranging from 92 to 100%. The total of early and late reinterventions reported were 64 and 48, respectively, mainly due to endoleaks and visceral branch occlusions. Among the theoretical feasibility studies, six described the feasibility of the t-Branch device in a total of 661 patients, two described the E-nside and the TAMBE devices feasibility comprising 351 patients for each stent-graft. The overall feasibility of the t-Branch device varied from 39% to 88%, the E-nside from 43% to 75%, and the TAMBE stent-graft ranged from 33% to 94%. CONCLUSIONS This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA.
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Affiliation(s)
- Victor Bilman
- Department of Vascular Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Enrico Rinaldi
- Department of Vascular Surgery, Vita-Salute San Raffaele University School of Medicine, IRCCS San Raffaele Hospital, Milan, Italy
| | - Diletta Loschi
- Department of Vascular Surgery, Vita-Salute San Raffaele University School of Medicine, IRCCS San Raffaele Hospital, Milan, Italy
| | - Basheer Sheick-Yousif
- Department of Vascular Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Germano Melissano
- Department of Vascular Surgery, Vita-Salute San Raffaele University School of Medicine, IRCCS San Raffaele Hospital, Milan, Italy -
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Chait J, Gilkey GD, Mendes BC, Ramakrishna H. Complex Endovascular Aortic Reconstruction: An Update. J Cardiothorac Vasc Anesth 2023; 37:2125-2132. [PMID: 37344248 DOI: 10.1053/j.jvca.2023.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Jesse Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - George D Gilkey
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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12
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Sun Y, Zhang Y, Sun X, Yin H, Wang S, Li X, Wang Z, Luo SX, Cheng Z. Clinical effect of endovascular repair of complex aortic lesions using optimized Octopus surgery. Front Bioeng Biotechnol 2023; 11:1240651. [PMID: 37545894 PMCID: PMC10399452 DOI: 10.3389/fbioe.2023.1240651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Objective: Complex aortic lesions, especially those involving branches of the visceral artery, remain a challenge to treat. A single-center study using the Octopus technique to evaluate the safety and short-term effects of endovascular repair of complex aortic lesions was reported and documented. Methods: The data of six cases who underwent optimized Octopus surgery in our center from August 2020 to February 2022 were analyzed retrospectively. The choice of operation scheme, operation time, operation complications, and follow-up data were analyzed among them. Results: The average age of the six patients undergoing optimized Octopus surgery was 55.1 ± 17.2 years. Two cases were diagnosed as pararenal aortic aneurysms; four cases were aortic dissection involving the visceral artery. All cases achieved technical success; all visceral arteries were reconstructed as planned. A total of 17 visceral arteries were planned to be reconstructed; five celiac arteries were embolized. Three cases of gutter endoleak were found during the operation without embolization but with follow-up observation. There were two cases of slight damage to renal function and two cases of perioperative death. Other complications, such as intestinal ischemia and spinal cord ischemia, did not occur. Follow-up ranged from 6 months to 30 months. One patient died of gastrointestinal bleeding 6 months after the operation. At the 6 months follow-up, computed tomographic angiography showed that all internal leaks had disappeared. The patency rate of the visceral artery was 100%, and no complications, such as stent displacement and occlusion, occurred during the follow-up period. Conclusion: With fenestrated and branched stent grafts technology not widely available, and off label use not a viable option, Octopus technology for treating complex aortic lesions should be considered. The Octopus technique is an up-and-coming surgical method, but we should recognize its operation difficulty, operation-related complications, and long-term prognosis. We should pay attention to and continue to optimize Octopus technology.
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13
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Ma X, Feng Y, Tardzenyuy MA, Qin B, Zhu Q, Akilu W, Li S, Wei X, Feng X, Cheng C. Debranching abdominal aortic hybrid surgery for aortic diseases involving the visceral arteries. Front Cardiovasc Med 2023; 10:1219788. [PMID: 37522078 PMCID: PMC10374220 DOI: 10.3389/fcvm.2023.1219788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/15/2023] [Indexed: 08/01/2023] Open
Abstract
Objective Aortic diseases involving branches of the visceral arteries mainly include thoracoabdominal aortic aneurysm (TAAA), aortic dissection (AD) and abdominal aortic aneurysm (AAA). The focus of treatment is to reconstruct the splanchnic arteries and restore blood supply to the organs. Commonly used methods include thoracoabdominal aortic replacement, thoracic endovascular aortic repair and hybrid approaches. Hybrid surgery for aortic disease involving the visceral arteries, consisting of visceral aortic debranching with retrograde revascularization of the celiac trunk and renal arteries and using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients. This study retrospectively analyzed recorded data of patients and contrasted the outcomes with those of a similar group of patients who underwent conventional open repair surgery. Methods Between 2019 and 2022, 72 patients (52 men) with an average age of 61.57 ± 8.66 years (range, 36-79 years) underwent one-stage debranching abdominal aortic hybrid surgery. These patients, the hybrid group, underwent preoperative Computed Tomographic Angiography (CTA) and had been diagnosed with aortic disease (aneurysm or dissection) involving the visceral arteries and were at high risk for open repair. The criteria used to define these patients as high-risk group who are in the need of hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4. In all cases, we accomplished total visceral aortic debranching through a previous visceral artery retrograde revascularization with synthetic grafts (customized Y or four-bifurcated grafts), and aortic endovascular repair with one of two different commercially produced stent grafts (Medtronic® and Lifetech®). In some cases, we chose to connect the renal artery to the artificial vessel with a stent graft (Viabahn) and partly or totally anastomosed. We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 46 patients (36 men) with an average age 54.15 ± 12.12 years (range, 32-76). These 46 patients, the conventional open group, were selected for having had thoracoabdominal aortic replacement between 2019 and 2022. Results In the hybrid group, 72 visceral bypasses were completed, and endovascular repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 2.78%, and perioperative morbidity was 9.72% (renal insufficiency in 1, unilateral renal infarction in 5, Intestinal ischemia in 1). At 1-month postoperative CTA showed 2 endoleaks, one of which was intervened. At follow-up, there were unplanned reoperation rate of 4.29% and 5 (7.14%) deaths. The remaining patients' grafts were patent at postoperative CTA and no endoleak or stent graft migration had occurred. In the conventional open group, 1 died intraoperatively, 4 died perioperatively, perioperative mortality was 10.87% and complications were respiratory failure in 5, intestinal paralysis/necrosis in 4, renal insufficiency in 17, and paraplegia in 2. At follow-up, 5 (12.20%) patients presented with synthetic grafts hematoma 4 (9.76%) patient died, and 6 (14.63%) patients required unplanned reoperation intervention. Conclusion Hybrid surgery is technically feasible in selected cases. For aortic diseases involving the visceral arteries, the application of hybrid abdominal aorta debranching can simplify the operation process, decrease the risks of mortality and morbidity in high-risk and high-age populations and decrease the incidence of various complications while achieving ideal early clinical efficacy. However, a larger series is required for valid statistical comparisons, and longer follow-ups are necessary to evaluate the long-term efficacy of hybrid surgery.
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Affiliation(s)
- Xiantao Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Feng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mbenkum Achiri Tardzenyuy
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Qin
- Department of Cardiothoracic Surgery, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Qiangzhang Zhu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wajeehullahi Akilu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiliang Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Feng
- Division of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Cai Cheng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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14
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Wang M, Yao C, Yin HH, Wang JS, Liao BY, Li ZL, Wu RD, Peng GY, Chang GQ. Endovascular Treatment of Ruptured or Symptomatic Thoracoabdominal and Pararenal Aortic Aneurysms Using Octopus Endograft Technique: Mid-Term Clinical Outcomes. J Endovasc Ther 2023; 30:163-175. [PMID: 35179077 DOI: 10.1177/15266028221075236] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of using off-the-shelf "Octopus" technique to treat ruptured or symptomatic thoracoabdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PRAAA). METHODS AND RESULTS All cases who underwent "Octopus" technique from May 2016 to May 2019 at our center were retrospectively analyzed. A total of 10 cases (8 males) were included. The mean age was 54.5±14.2 years (range: 31-80 years). Eight cases presented as aneurysm rupture or impending rupture accepted emergency repair. Technical success, defined by placement of all endografts as planned, was achieved in all cases. A total of 30 target visceral branches were successfully cannulated, 9 celiac arteries were covered intentionally. Intraoperative endoleak was observed in 6 patients, all of them were gutter leak. During hospital stay, there was no death, no side branch occlusion or spinal cord ischemia. Median follow-up was 30 months (range: 12-50 months). One patient died of lung cancer at 14-month follow-up. There was no secondary endoleak. The primary endoleak were found spontaneously resolved in 3 cases at 7 days, 3-month, and 1-year imaging. One persistent endoleak totally resolved after sealing of gutter spaces at 4-month follow-up. The other 2 persistent endoleak decreased during follow-up, which are still under observation. The branch patency rate was 90.3% (28/31). All the 3 occluded branches were renal arteries. Branch occlusion occurred in 2 cases at 1-month follow-up and 1 case at 2-year follow-up, but renal insufficiency was not observed in these cases. Obvious aneurysm sac shrinkage (≥5 mm) was observed in all cases. The aneurysm size shrunk from 7.6±1.9 to 5.5±1.4 cm. No spinal cord ischemia occurred during follow-up. CONCLUSION Treatment of ruptured TAAA and PRAAA with "Octopus" technique is feasible and safe for high surgical risk patients in the absence of fenestrated and branched devices. The long-term clinical outcomes needed to be investigated.
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Affiliation(s)
- Mian Wang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hen-Hui Yin
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Song Wang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bing-Ye Liao
- Anesthesia Surgery Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zi-Lun Li
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ri-Dong Wu
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gui-Yan Peng
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guang-Qi Chang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis an Treatment of Vascular Diseases, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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15
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Cloud-based fusion imaging improves operative metrics during fenestrated endovascular aneurysm repair. J Vasc Surg 2023; 77:366-373. [PMID: 36181994 DOI: 10.1016/j.jvs.2022.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Endovascular treatment of complex aortic pathology has been associated with increases in procedural-related metrics, including the operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased the radiation dose and iodinated contrast use during endovascular aneurysm repair. The aim of the present study was to report our institutional experience with the use of a cloud-based fusion imaging platform during fenestrated endovascular aneurysm repair (FEVAR). METHODS A retrospective review of a prospectively maintained aortic database was performed to identify all patients who had undergone FEVAR with commercially available devices (Zenith Fenestrated; Cook Medical Inc, Bloomington, IN) between 2013 and 2020 and all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVARs performed with overlay map guidance. The patient demographic, clinical, and procedure metrics were analyzed, with a comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from comparative analysis if the data were incomplete in the dataset or they had a documented history of prior open or endovascular abdominal aortic aneurysm repair. RESULTS During the 7-year study period, 191 FEVARs had been performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVARs. A complete dataset was available for 137 FEVARs. With exclusion to select for de novo FEVAR, a comparative analysis was performed of 53 FEVAR without and 63 with Cydar EV imaging guidance. The cohorts were similar in patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between the two groups for major adverse postoperative events, length of stay, or length of intensive care unit stay. The use of Cydar EV resulted in nonsignificant decreases in the mean fluoroscopy time (69.3 ± 28 minutes vs 66.2 ± 33 minutes; P = .598) and operative time (204.4 ± 64 minutes vs 186 ± 105 minutes; P = .278). A statistically significant decrease was found in the iodinated contrast volume (105 ± 44 mL vs 83 ± 32 mL; P = .005), patient radiation exposure using the dose area product (1,049,841 mGy/cm2 vs 630,990 mGy/cm2; P < .001) and cumulative air kerma levels (4518 mGy vs 3084 mGy; P = .02) for patients undergoing FEVAR with Cydar EV guidance. CONCLUSIONS At our aortic center, we have observed a trend toward shorter operative times and significant reductions in both iodinated contrast use and radiation exposure during FEVAR using the Cydar EV intelligent maps. Intelligent map guidance improved the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.
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Forbes SM, Mahmood DN, Rocha R, Tan KT, Ouzounian M, Chung JCY, Lindsay TF. Females experience elevated early morbidity and mortality but similar mid-term survival compared to males after branched/fenestrated endovascular aortic aneurysm repair. J Vasc Surg 2022; 77:1349-1358.e5. [PMID: 36581014 DOI: 10.1016/j.jvs.2022.12.031] [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: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal (JRAA) aortic aneurysms. METHODS Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range [IQR], 1.6-5.3 years). RESULTS No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 [IQR, 425-625] vs 420 [IQR, 350-510] minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 [IQR, 150-270] vs 175 [IQR, 130-225] mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 [IQR, 1-5] vs 1 [IQR, 1-3] days; P = .002) and hospital stay (8 [IQR, 5-13] vs 5 [IQR, 3-9] days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but mid-term (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in mid-term follow-up reintervention, endoleak, and rupture rates were observed. CONCLUSIONS Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar mid-term outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.
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Affiliation(s)
- Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kongteng Tan Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Patel RJ, Mathlouthi A, Al-Nouri O, Lane JS, Malas MB, Barleben AR. A Single Center Review of a Total Transfemoral Approach to Upper Extremity Access in Branched and Fenestrated Physician Modified Endografts. Ann Vasc Surg 2022; 86:117-126. [PMID: 35809740 PMCID: PMC10339283 DOI: 10.1016/j.avsg.2022.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches. METHODS Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes. RESULTS Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke. CONCLUSIONS This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA.
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Argyriou C, Spiliopoulos S, Katsanos K, Papatheodorou N, Lazarides MK, Georgiadis GS. Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis. J Endovasc Ther 2022; 29:646-658. [PMID: 34836463 DOI: 10.1177/15266028211059451] [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] [Indexed: 02/05/2023]
Abstract
PURPOSE Thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive alternative option in the treatment of thoracoabdominal aortic aneurysm (TAAA) diseases, reporting lower morbidity and mortality rates compared with open or hybrid repair. A challenging situation arises when the aneurysm involves the celiac artery (CA), precluding a safe distal landing zone. We investigated the safety and efficacy of CA coverage in the treatment of complex TAAA diseases during endovascular management. MATERIALS AND METHODS A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The electronic bibliographic sources searched were MEDLINE and SCOPUS databases. Primary outcomes of interest were perioperative and 30-day mortality. Any type of endoleak, mesenteric ischemia, perioperative spinal cord ischemia, and reintervention rates were secondary end points. A random-effects meta-analysis was performed. Summary statistics of event risks were expressed as proportions and 95% confidence interval (CI). RESULTS Ten observational cohort studies published between 2009 and 2020, reporting a total of 175 patients, were eligible for quantitative synthesis. Indications for TEVAR were primary TAAAs in 82% of patients, aortic dissection in 14% of patients, type Ib endoleak after previous endograft deployment in 3% of patients, and penetrating aortic ulcer in 1 patient. Reintervention rate was 9% (95% CI, 4%-20%) and spinal cord ischemia was 7% (95% CI, 4%--12%). Type II endoleak was the predominant type of endoleak in 10% of patients (95% CI, 4%-22%), followed by type I endoleak in 5% of patients (95% CI, 2%-12%) and type III endoleak in 1% (95% CI, 0%-16%) of patients. Mesenteric ischemia occurred in 6% of patients (95% CI, 3%-10%). Thirty-day mortality was 5% (95% CI, 2%-13%) and the pooled estimate for overall mortality was 21% (95% CI, 14%-31%). CONCLUSIONS Celiac artery coverage during TEVAR is a challenging but feasible option for the treatment of TAAA diseases, providing acceptable morbidity and mortality rates. Demonstration of adequate visceral collateral pathways before definitive CA coverage is the sine quo non for the success of the technique.
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Affiliation(s)
- Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Evros, Alexandroupolis, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rio, Greece
| | | | - Miltos K Lazarides
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Evros, Alexandroupolis, Greece
- University of Nicosia, Nicosia, Cyprus
| | - George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Evros, Alexandroupolis, Greece
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Franklin RN, Timi JRR, Baumgardt G, Bortoluzzi C, Galego G, Oderich GS, Silveira PG. Laboratory "In-vitro" Evaluation of the Parallel Stent Graft Association for the Iliac Sandwich Technique. Cardiovasc Intervent Radiol 2022; 45:1377-1384. [PMID: 35778578 DOI: 10.1007/s00270-022-03182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/11/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES The Iliac Sandwich is an off-label technique that uses parallel stent grafts to treat aortoiliac aneurysms. The purpose of this experimental study is to evaluate the conformability and juxtaposition of stent grafts combinations used in this technique through in-vitro mechanical evaluation, computed tomography (CT) analyses, and a controlled pulsatile flow system. METHODS The combinations of two Viabahn® ("V-V") or Viabahn® and Excluder® iliac extension ("V-E") were analysed using CT imaging with measurement of the gutter area by two independent analysts before and after balloon angioplasty. In a second phase, the parallel stent combinations were also evaluated using CT imaging after being implanted in the aortic aneurysm model with a pulsatile flow system with controlled temperature, viscosity, and density. RESULTS The "V-E" group had a better conformability when compared to the "V-V" group, ensuring smaller gutter areas (0.0064 cm2 ± 0.01 vs. 0.0228 cm2 ± 0.03, p < 0.001). Post dilatation with two non-compliant balloons resulted in enlargement of the gutter area (Area A, p 0.065; Area B, p 0.071). Conversely, post dilatation with a non-compliant balloon for the internal iliac component and a compliant balloon for the external iliac device reduced the gutter area (Area A, p 0.008; Area B, p 0.010). CONCLUSION The combination of Viabahn® and Excluder® iliac extension device ("V-E") had a smaller gutter area compared to two Viabahn® parallel stents for the Iliac Sandwich Technique. Post dilatation using a non-compliant balloon for the internal iliac device and a compliant balloon for the external iliac provided superior conformability and juxtaposition.
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Affiliation(s)
- Rafael Narciso Franklin
- Coris Cirurgia Vascular e Endovascular, Rua Menino Deus, 63 sala 504, Baia Sul Medical Center, Centro, Florianópolis, SC, 88020-210, Brazil. .,Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
| | | | | | - Cristiano Bortoluzzi
- Coris Cirurgia Vascular e Endovascular, Rua Menino Deus, 63 sala 504, Baia Sul Medical Center, Centro, Florianópolis, SC, 88020-210, Brazil
| | - Gilberto Galego
- Coris Cirurgia Vascular e Endovascular, Rua Menino Deus, 63 sala 504, Baia Sul Medical Center, Centro, Florianópolis, SC, 88020-210, Brazil.,Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Gustavo S Oderich
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pierre Galvagni Silveira
- Coris Cirurgia Vascular e Endovascular, Rua Menino Deus, 63 sala 504, Baia Sul Medical Center, Centro, Florianópolis, SC, 88020-210, Brazil.,Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
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20
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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21
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Hu Z, Zhang Z, Liu H, Chen Z. Fenestrated and Branched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:901193. [PMID: 35711352 PMCID: PMC9197478 DOI: 10.3389/fcvm.2022.901193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose To investigate the safety and efficacy of total endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent-grafts. Methods The MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and December 2021 to identify literature relevant to the use of fenestrated and branched endografts for the treatment of TAAAs. Studies with <4 cases and those on juxtarenal or pararenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate spinal cord ischemia (SCI), irreversible SCI, renal insufficiency, dialysis, endoleak, reintervention, target vessel patency, 30-day mortality and overall mortality. Fourteen studies comprising 1,114 patients (mean age 72.42 years, 847 men) were selected. The mean TAAA diameter was 67 mm. The Crawford TAAA classification was type I-III in 759 cases, type IV in 344 cases, and type V in 10 cases. Outcomes of the meta-analysis are reported as proportions and 95% confidence intervals (CIs). Results The pooled rates for 30-day mortality and overall mortality were 6% and 18%, respectively. The pooled rate for technical success was 94% (95% CI, 93–96%), for SCI was 8% (95% CI, 7–10%), for irreversible SCI was 6% (95% CI, 4–7%), for reversible SCI was 5% (95% CI, 4–6%), for reversible SCI was 2% (95% CI, 2–3%), for renal insufficiency was 7% (95% CI, 5–10%), for dialysis was 3% (95% CI, 2–4%), for target vessel patency was 98% (95% CI, 97–99%), and for reintervention was 15% (95% CI, 9–24%). Conclusion Fenestrated and branched endografts for the treatment of TAAAs are safe and effective with acceptable early results. Lifelong regular follow-up and additional prospective studies are necessary to substantiate whether this technique is valid.
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22
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Tenorio ER, Dias-Neto MF, Lima GBB, Estrera AL, Oderich GS. Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges. Ann Cardiothorac Surg 2021; 10:744-767. [PMID: 34926178 PMCID: PMC8640886 DOI: 10.21037/acs-2021-taes-24] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 12/23/2022]
Abstract
Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Marina F Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Anthony L Estrera
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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23
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Busch A, Wolk S, Lutz B, Zimmermann C, Ankudinov M, Klenk D, Ehehalt F, Rössel T, Ludwig S, Reeps C. [Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR - complementary or competitive?]. Zentralbl Chir 2021; 146:470-478. [PMID: 34666359 DOI: 10.1055/a-1562-2770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.
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Affiliation(s)
- Albert Busch
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Steffen Wolk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Brigitta Lutz
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Carolin Zimmermann
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Miroslav Ankudinov
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - David Klenk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Florian Ehehalt
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Stefan Ludwig
- General, Thoracic and Vascular Surgery, University of Dresden, Dresden, Germany
| | - Christian Reeps
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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24
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Floros N, Kölbel T, Tsilimparis N, Oberhuber A, Kindl D, Kalder J, Kotelis D, Schmidt A, Branzan D, Adolf D, Schelzig H, Wagenhäuser MU. First-in-Human Clinical Application of the Medyria TrackCath System in Endovascular Repair of Complex Aortic Aneurysms (ACCESS Trial): A Prospective Multicenter Single-Arm Clinical Trial. J Endovasc Ther 2021; 28:914-926. [PMID: 34289739 DOI: 10.1177/15266028211030536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The Medyria TrackCath Catheter (MedTCC) is an innovative, thermal convection-based blood flow velocity (BFV) tracking catheter that may be used during complex aortic endovascular procedures for identification and catheterization of target orifices. The ACCESS Trial analyzes the safety and performance of the MedTCC for targeted vessel catheterization to generally evaluate the feasibility of thermal convection-based BFV. MATERIALS AND METHODS We performed a first-in-human, proof-of-concept, prospective single-arm multicenter clinical trial between March 2018 and February 2019 in patients who underwent endovascular aortic procedures at 4 high-volume centers. During these procedures, the MedTCC was advanced over a guidewire through the femoral access. The D-shape was enfolded in the reno-visceral part of the aorta and target orifices were identified and catheterized with a guidewire via the side port of the MedTCC through BFV tracking. BFV measurements were performed at baseline (Baseline-BFV), alignment to the orifice (Orifice-BFV), and following catheterization (Confirmation-BFV) to prove correct identification and catheterization of target orifices. The procedural success rate, the catheterization success rate, procedure-related parameters, and (serious) adverse events ((S)AE) during the follow-up were analyzed. RESULTS A total of 38 patients were included in the safety group (SG) and 26 in the performance group (PG). The procedural success rate was 89% (PG), the MedTCC catheterization success rate was 98% (PG). The MedTCC reliably measured BFV changes indicated by significant differences in BFV between Baseline-BFV and Orifice-BFV (p<0.05). Median (interquartile range; IQR) fluoroscopy time per orifice was 5.0 (1.5-8.5) minutes [total surgery 49 (26-74) minutes], median (IQR) contrast agent used per orifice was 1.0 (0-5.0) mL [total surgery 80 (40-100) mL], and median (IQR) MedTCC-based procedural time was 3.0 (2.0-6.0) minutes. There was no device-related SAE. CONCLUSIONS The ACCESS Trial suggests that BFV measurement allows for reliable target orifice identification and catheterization. The use of MedTCC is safe and generates short fluoroscopy time and low contrast agent use, which in turn might facilitate complex endovascular procedures.
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Affiliation(s)
- Nikolaos Floros
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Daniel Kindl
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Johannes Kalder
- Department of Vascular Surgery, University Hospital RWTH Aachen, European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen, European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Andrej Schmidt
- Clinic and Policlinic V, Angiology, University Hospital Leipzig, Germany
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | | | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
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25
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Lommen MJ, Vogel JJ, VandenHull A, Reed V, Pohlson K, Answini GA, Maldonado TS, Naslund TC, Shames ML, Kelly PW. Incidence of Acute and Chronic Renal Failure Following Branched Endovascular Repair of Complex Aortic Aneurysms. Ann Vasc Surg 2021; 76:232-243. [PMID: 34182119 PMCID: PMC8595526 DOI: 10.1016/j.avsg.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/02/2021] [Accepted: 04/23/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to examine the incidence of acute kidney injury and chronic renal impairment following branched endovascular aneurysm repair (BEVAR) of complex thoracoabdominal aortic aneurysms (TAAA) using the Medtronic Valiant Thoracoabdominal Aortic Aneurysm stent graft system (MVM), the physician-modified Visceral Manifold, and Unitary Manifold stent graft systems. The objective was to report the acute and chronic renal function changes in patients following complex TAAA aneurysm repair. METHODS This is an analysis of 139 patients undergoing branched endovascular repair for complex TAAAs between 2012 and 2020. Patient renal function was evaluated using serum creatinine and estimated glomerular filtration rate at baseline, 48 hr, discharge, 1 month, 6 months, and annually to 2 years. Patients on dialysis prior to the procedure were excluded from data analysis. RESULTS A total of 139 patients (mean age 71.13; 64.7% male) treated for TAAA with BEVAR met inclusion criteria and were evaluated. A total of 530 visceral vessels were stented. A majority of patients (n = 131, 94.2%) underwent a single procedure while 8 required staged procedures. Thirty-day, 1-year and 2-year all-cause mortality rates were 5.8%, 25.2%, and 32.4%, respectively. Primary and secondary patency rates at a median follow-up of 26.9 months (95% CI; 21.1 - 32.7) were 96.2% and 97.5% for all vessels and 95.4% and 96.9% for renal arteries, respectively. Postoperative acute kidney injury (AKI) was identified in 22 (15.8%) patients. At discharge, 16 patients (11.6%) had an increase in CKD stage with 3 requiring permanent dialysis. Five additional patients required permanent dialysis over the 2-year follow-up period for a total of 8 (5.8%). Increasing age (HR = 1.0327, P= 0.0477), hemoglobin < 7 prior to procedure (HR = 2.4812, P= 0.0093), increasing maximum aortic diameter (HR = 1.0189, P= 0.0084), presence of AKI (HR = 2.0757, P= 0.0182), and increase in CKD stage (HR = 1.3520, P= 0.002) at discharge were significantly associated with decreased patient survival. CONCLUSIONS Postoperative AKI and a chronic decline in renal function continue to be problematic in endovascular repair of complex aortic aneurysms. This study found that BEVAR using the manifold configuration resulted in immediate and mid-term renal function that is comparable to similar analyses of branched and/or fenestrated grafts.
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Affiliation(s)
- Matthew J Lommen
- University of South Dakota, Sanford School of Medicine, Vermillion, SD
| | - Jack J Vogel
- University of South Dakota, Sanford School of Medicine, Vermillion, SD
| | | | - Valerie Reed
- Sanford Research, Research Design and Biostatistics Core, Sioux Falls, SD
| | | | | | - Thomas S Maldonado
- Division of Vascular Surgery, New York University Langone Health, New York, NY
| | - Thomas C Naslund
- Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Murray L Shames
- Division of Vascular Surgery, University of South Florida Morsani School of Medicine, Tampa, FL
| | - Patrick W Kelly
- Sanford Health, Vascular Surgery Associates, Sioux Falls, SD.
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Kölbel T, Spanos K, Jama K, Behrendt CA, Panuccio G, Eleshra A, Rohlffs F, Jakimowicz T. Early outcomes of the t-Branch off-the-shelf multi-branched stent graft in 542 patients for elective and urgent aortic pathologies - a retrospective observational study. J Vasc Surg 2021; 74:1817-1824. [PMID: 34171424 DOI: 10.1016/j.jvs.2021.05.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in >500 patients being treated with the t-Branch device. METHODS A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia. RESULTS A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P < .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P < .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P < .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P < .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P < .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P < .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively. CONCLUSIONS Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable.
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Affiliation(s)
- Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany; Departments of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
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Abisi S, Gkoutzios P, Carmichael M, Patel S, Sallam M, Donati T, Zayed H. The Early Outcomes of BeGraft Peripheral Plus in Branched Endovascular Repair of Thoracoabdominal Aneurysms. J Endovasc Ther 2021; 28:707-715. [PMID: 34160322 DOI: 10.1177/15266028211025019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE No bridging stent-graft (BSG) has been specifically designed for branched endovascular aortic repair (BEVAR) and therefore different "off-label" stent-grafts have been used. Recently, a third generation of balloon-expandable stent-graft has become available. Here we evaluate the outcomes of the BeGraft Peripheral Plus (B+) used as a BSG for internal/externalor inner branches during BEVAR. MATERIALS AND METHODS Consecutive patients undergoing BEVAR using B+ as a BSG since its release in 2017 were included into the study. The primary endpoints were technical success and target vessel patency during follow-up. Secondary endpoints included the need for adjunct extension and relining of the BSG, branch instability rate, including occlusion, reinterventions for restonosis, kink, fracture, or endoleak (types 1 and 3). RESULTS A total of 163 visceral branches in 46 patients were included with a median follow-up 15 months (4-36 months). Primary technical success was achieved in all visceral branches (69 inner branches and 94 internal/external branches) with the exception of 1 BSG that required serial dilatation until full expansion was achieved with overall branch patency was 98% at 2 years. An additional stent-graft was necessary in 35 branches (21%) following deployment of a B+ BSG to cover a longer bridging distance and optimize the distal and proximal sealing. Relining of B+ BSG was not routinely carried out during the index procedure and a self-expanding uncovered nitinol stent was necessary in only 3% of branches to smooth the distal transition zone between the BSG and target vessel. There were 4 events (2.4%) of branch related instability, including 2 occlusions and 2 late reinterventions for a partial in-stent-graft thrombosis. CONCLUSION Our study findings show satisfactory early outcomes of B+ as a BSG in BEVAR with low occlusion and reintervention rates. Extensions of BSG might be required to achieve adequate seal in the target vessels but routine relining BSG in branches was not required.
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Affiliation(s)
- Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Panos Gkoutzios
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michelle Carmichael
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sanjay Patel
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Morad Sallam
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tommaso Donati
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Resch T, de Vries JP, Haulon S. Optimising Target Vessel Patency after Complex Aortic Repair: Things We Know that We Know. Eur J Vasc Endovasc Surg 2021; 62:4-6. [PMID: 34024705 DOI: 10.1016/j.ejvs.2021.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Jean-Paul de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Stéphan Haulon
- Aortic Centre Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
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Torsello GB, Pitoulias A, Litterscheid S, Berekoven B, Torsello GF, Austermann M, Bosiers MJ. Performance of the Gore VBX Balloon Expandable Endoprosthesis as Bridging Stent-Graft in Branched Endovascular Aortic Repair for Thoracoabdominal Aneurysms. J Endovasc Ther 2021; 28:549-554. [PMID: 33908821 DOI: 10.1177/15266028211010455] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Bridging stent stability is crucial for efficacy and safety of branched aortic endovascular repair (bEVAR) of thoracoabdominal aortic aneurysms (TAAAs). In this study, we assess the performance of the new Viabahn Balloon-Expandable endoprosthesis (VBX) in bEVAR. Based on our learning curve we give recommendations for a safe and effective use of the device. MATERIALS AND METHODS We prospectively collected the data of patients with TAAAs undergoing bEVAR between December 2017 and December 2019. All patients with implantation of at least 1 VBX stent-graft as bridging stent were included in our single-center analysis. Demographic, comorbidity, and computed tomography angiography (CTA) data of 112 patients were retrospectively evaluated. Primary endpoint was a composite of branch-related technical success and freedom from target vessel instability. Secondary endpoints were clinical and ongoing clinical success. RESULTS Primary endpoint: technical success was achieved in all patients (100%) with a freedom from target vessel instability of 96.3% after a median follow-up of 18 months. Overall mortality was 13.4% (n=15) and 13 patients underwent secondary interventions, 12 of them are still alive and 1 suffered from aneurysm sac expansion, consequently an ongoing clinical success of 75.9% was reached. After modification of the implantation technique during the course of the study by selecting longer stent lengths after accurate estimation of vessel curvature and expected adaptation of the flexible endoskeleton to the specific anatomical conditions, no type Ic endoleaks were observed in the last 70 cases. CONCLUSIONS The VBX stent-graft can be safely used as bridging stent for branched thoracoabdominal repair. However, learning curve should be considered to avoid type Ic endoleak and edge stenosis. Based on this experience longer landing zones and 2-step deployment of VBX are useful for successful bridging also of challenging target vessels.
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Affiliation(s)
| | - Apostolos Pitoulias
- Second Department of Surgery, Division of Vascular Surgery, School of Medicine Aristotle University of Thessaloniki, "G. Gennimatas" Hospital, Thessaloniki, Greece
| | - Sarah Litterscheid
- Institute for Vascular Research, St Franziskus Hospital, Münster, Germany
| | - Bärbel Berekoven
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Giovanni-Federico Torsello
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Charité Campus Virchow-Klinikum, Charité University Medicine, Berlin, Germany
| | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Michel J Bosiers
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
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Abisi S, Zymvragoudakis V, Gkoutzios P, Sallam M, Donati T, Saha P, Zayed H. Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair. J Vasc Surg 2021; 74:871-879. [PMID: 33647435 DOI: 10.1016/j.jvs.2021.01.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Complex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR). METHODS All patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined. RESULTS A total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm2 (range, 8260-55,070 dGycm2). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non-aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months). CONCLUSIONS The use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.
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Affiliation(s)
- Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Panos Gkoutzios
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Morad Sallam
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Tommaso Donati
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Prakash Saha
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Rocha RV, De Mestral C, Tam DY, Lee DS, Al-Omran M, Austin PC, Forbes TL, Ouzounian M, Lindsay TF. Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2020; 73:1934-1941.e1. [PMID: 33098943 DOI: 10.1016/j.jvs.2020.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). METHODS Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. RESULTS Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). CONCLUSIONS TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles De Mestral
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Cardiovascular Program, ICES, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, ICES, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Malekpour F, Scott CK, Kirkwood ML, Timaran CH. Sequential Catheterization and Progressive Deployment of the Zenith® t-Branch™ Device for Branched Endovascular Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2020; 44:156-160. [PMID: 33033887 DOI: 10.1007/s00270-020-02654-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a sequential deployment technique of the Zenith® t-Branch™ device for branched endovascular aortic aneurysm repair that might reduce potential rotation and increases optimal positioning of the device. TECHNIQUE After obtaining bilateral groin and right brachial access, the device is advanced over a through-and-through brachio-femoral guidewire and positioned based on prior measurements and landmarks. The t-Branch device is deployed one branch at a time and each visceral branch is sequentially catheterized from brachial access using live CT-fusion and intravascular ultrasound guidance. Full deployment prior to branch catheterization is avoided to maintain device stability, reduced spontaneous rotation, wider working room and freedom in positioning of the device while target artery catheterization is secured. CONCLUSION Sequential catheterization amid progressive deployment of the Zenith® t-Branch™ device is an effective method of deployment of the device that ensures optimal positioning and secured catheterization of the target vessels.
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Affiliation(s)
- Fatemeh Malekpour
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd., POB#1, Suite 620, Dallas, TX, 75390-9157, USA.
| | - Carla K Scott
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd., POB#1, Suite 620, Dallas, TX, 75390-9157, USA
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd., POB#1, Suite 620, Dallas, TX, 75390-9157, USA
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd., POB#1, Suite 620, Dallas, TX, 75390-9157, USA
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Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms. J Vasc Surg 2020; 72:866-872. [DOI: 10.1016/j.jvs.2019.10.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/01/2019] [Indexed: 11/22/2022]
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Çekmecelioglu D, Orozco-Sevilla V, Coselli JS. Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape. Asian Cardiovasc Thorac Ann 2020; 29:643-653. [PMID: 32772547 DOI: 10.1177/0218492320949073] [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: 11/16/2022]
Abstract
Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.
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Affiliation(s)
- Davut Çekmecelioglu
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA.,Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
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Early Renal Function Alterations in Renal Branches vs. Renal Fenestrations - A Dynamic Scintigraphy Based Prospective Study. Eur J Vasc Endovasc Surg 2020; 60:395-401. [PMID: 32665199 DOI: 10.1016/j.ejvs.2020.05.023] [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: 10/05/2019] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of this prospective single centre study was to assess whether branches and fenestrations have different outcomes on renal function in the early phase. METHODS From March 2018 to June 2019, 67 patients who underwent elective fenestrated and branched endovascular aneurysm repair (F/BEVAR) procedures were enrolled in this study. The patients were divided into two groups according to the renal bridging component configuration (fenestration vs. branch). All of them underwent dynamic renal scintigraphy with 99mTc diethylenetriaminepentaacetic acid (DTPA), two weeks pre-operatively, and three months and one year post-operatively. The primary end points were peri-procedural technical success, 30 day major adverse events, differences in glomerular filtration rate (GFR) between the branch and fenestration configurations, and variations between the pre-operative and the post-operative dynamic renal scintigraphy. RESULTS Overall, 135 kidneys were analysed: 63 in the 32 patients treated with fenestrations, and 72 in the 35 patients treated with branches; the mean GFR on baseline scintigraphy was 58.4 ± 30.9 mL/min in the fenestration group, and 65.1 ± 29.2 mL/min in the branch group. Only kidneys associated with a patent fenestration/branch were included in the split GFR final analysis. The mean total GFR at three month scintigraphy decreased by 6.0 ± 2.9 mL/min in the fenestration group and by 23.4 ± 6.4 mL/min in the branch group. The split GFR decreased by 3.5 ± 0.6 mL/min in the fenestration group, and by 15.4 ± 5.4 mL/min in the branch group. The GFR decrease remained stable at one year. CONCLUSION In this study, the use of branches for renal arteries during F/BEVAR resulted in a greater decrease in the GFR than in those patients who were treated with fenestrations alone. The scintigraphic alterations were evident at an early phase.
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Dossabhoy SS, Simons JP, Crawford AS, Aiello FA, Judelson DR, Arous EJ, Messina LM, Schanzer A. Impact of acute kidney injury on long-term outcomes after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2020; 72:55-65.e1. [DOI: 10.1016/j.jvs.2019.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
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Verhoeven ELG, Marques de Marino P, Katsargyris A. Increasing Role of Fenestrated and Branched Endoluminal Techniques in the Thoracoabdominal Segment Including Supra- and Pararenal AAA. Cardiovasc Intervent Radiol 2020; 43:1779-1787. [PMID: 32556605 DOI: 10.1007/s00270-020-02525-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/09/2020] [Indexed: 01/06/2023]
Abstract
Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.
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Affiliation(s)
- Eric L G Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany
| | - Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Breslauer Strasse 201, 90471, Nuremberg, Germany.
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Zierler RE. Duplex ultrasound follow-up after fenestrated and branched endovascular aneurysm repair (FEVAR and BEVAR). Semin Vasc Surg 2020; 33:60-64. [PMID: 33308597 DOI: 10.1053/j.semvascsurg.2020.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular aneurysm repair (EVAR) is now the predominant method for treatment of infrarenal abdominal aortic aneurysms. Although EVAR has numerous advantages over standard open surgical repair, it also exposes patients to risks such as aneurysm sac enlargement, endoleaks, and graft migration, which make surveillance or follow-up mandatory. Fenestrated (FEVAR) and branched (BEVAR) endografts have extended the application of EVAR to juxtarenal, pararenal/paravisceral, and thoracoabdominal aneurysms, with some complex aneurysms requiring combined approaches (F-BEVAR). Duplex ultrasound has been recommended as an alternative to frequent computed tomography imaging for EVAR follow-up when it can provide the clinically necessary information. The major components of a post-EVAR duplex examination include measurement of aortic aneurysm sac size, assessment for endoleak, and evaluation of the endograft for patency and integrity. The duplex protocol for EVAR follow-up can be extended for follow-up after FEVAR, BEVAR, and F-BEVAR, with additional attention to the device components associated with fenestrations and branches. At the University of Washington, the physician-modified endovascular graft approach has been used for FEVAR. During these procedures, covered stents are placed in the renal arteries through fenestrations and the superior mesenteric artery is perfused through a fenestration, but typically remains unstented. Duplex scanning of the renal and mesenteric arteries has been performed preoperatively and at 30 days, 6 months, 1 year, and annually. In a review of patients having covered stents placed in non-stenotic renal arteries during FEVAR, both peak systolic velocity and the renal to aortic velocity ratio remained below the standard significant stenosis threshold in most patients. The duplex velocity criteria for stenosis in native renal arteries appeared to overestimate the severity of stenosis in renal artery covered stents. The unstented superior mesenteric artery remained widely patent in the presence of fenestrations or crossing struts and was not associated with endoleaks. Duplex ultrasound protocols for follow-up after FEVAR, BEVAR, and F-BEVAR can be based on those that have been established for standard EVAR, along with assessment of fenestrations and branches, as well as patency of the renal and mesenteric arteries.
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Affiliation(s)
- R Eugene Zierler
- Department of Surgery, University of Washington School of Medicine, Box 356410, Seattle, WA 98195-6410; D. E. Strandness, Jr. Vascular Laboratory, University of Washington Medical Center, Seattle, WA; Harborview Medical Center, Seattle, WA.
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He Y, Jia S, Sun G, Cao L, Wang X, Zhang H, Jia X, Ma X, Xiong J, Liu X, Guo W. Fenestrated/Branched Endovascular Repair for Postdissection Thoracoabdominal Aneurysms: A Systematic Review with Pooled Data Analysis. Vasc Endovascular Surg 2020; 54:510-518. [PMID: 32436464 DOI: 10.1177/1538574420927131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Patients who have survived an acute aortic dissection remain at risk for postdissection thoracoabdominal aortic aneurysms (PD-TAAAs). Fenestrated/branched endovascular repair for PD-TAAA is increasingly used in some high-volume centers, but outcomes are still limited because of the additional challenges compared to atherosclerotic thoracoabdominal aneurysms. This study was performed to evaluate the literature on fenestrated/branched endovascular repair for PD-TAAAs. METHODS PubMed, Embase, and the Cochrane Database were searched for relevant studies published until September 2019. Outcome data were extracted to evaluate the technical success, 30-day mortality, later survival, major complications, endoleaks, target vessel patency, and reintervention. Studies were analyzed in a pooled proportion meta-analysis. RESULTS In total, 143 patients from 4 studies were identified for the pooled data analysis. The pooled technical success rate was 98% (95% CI: 86%-100%). After the treatment, the overall estimated 30-day mortality rate was 3% (95% CI: 1%-8%), early spinal cord ischemia rate was 10% (95% CI: 4%-21%), early renal injury rate was 5% (95% CI: 1%-19%), endoleak rate was 33% (95% CI: 22%-47%), reintervention rate at a median follow-up of 22.5 months was 34% (95% CI: 27%-42%), and all-cause mortality rate was 12% (95% CI: 6%-24%). CONCLUSIONS The use of fenestrated/branched stent grafts for the treatment of PD-TAAA appears generally feasible based on the limited literature, but endoleaks and reinterventions are frequent.
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Affiliation(s)
- Yuan He
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Senhao Jia
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Guoyi Sun
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Long Cao
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China.,Department of General Surgery, Chinese PLA No. 983 Hospital, Hebei District, Tianjin, People's Republic of China
| | - Xinhao Wang
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Hongpeng Zhang
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xin Jia
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xiaohui Ma
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Jiang Xiong
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xiaoping Liu
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Wei Guo
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
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Tenorio ER, Squizzato F, Balachandran P, Oderich GS. Endovascular TAAA repair: current status and future challenges. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01436-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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41
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Fidalgo-Domingos L, San Norberto EM, Fidalgo-Domingos D, Martín-Pedrosa M, Cenizo N, Estévez I, Revilla Á, Vaquero C. Geometric and hemodynamic analysis of fenestrated and multibranched aortic endografts. J Vasc Surg 2020; 72:1567-1575. [PMID: 32173193 DOI: 10.1016/j.jvs.2020.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/06/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair. METHODS Patients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations. RESULTS Twenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10-3 N ± 18.7 × 10-3 N vs 12.31 × 10-3 N ± 6.8 × 10-3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively. CONCLUSIONS Longer stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.
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Affiliation(s)
- Liliana Fidalgo-Domingos
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Enrique M San Norberto
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | | | - Miguel Martín-Pedrosa
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Noelia Cenizo
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Isabel Estévez
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Revilla
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Carlos Vaquero
- Department of Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Rocha RV, Lindsay TF, Austin PC, Al-Omran M, Forbes TL, Lee DS, Ouzounian M. Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: A population-based study. J Thorac Cardiovasc Surg 2019; 161:516-527.e6. [PMID: 31780062 DOI: 10.1016/j.jtcvs.2019.09.148] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 09/08/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We sought to determine the early and late outcomes of endovascular versus open thoracoabdominal aortic aneurysm repair. METHODS We performed a multicenter population-based study across the province of Ontario, Canada, from 2006 to 2017. The primary end point was mortality. Secondary end points were time to first event of a composite of mortality, permanent spinal cord injury, permanent dialysis, and stroke, the individual end points of the composite, patient disposition at discharge, hospital length of stay, myocardial infarction, and secondary procedures at follow-up. RESULTS A total of 664 adults undergoing surgical repair of a thoracoabdominal aortic aneurysm (endovascular: n = 303 [45.5%] vs open: n = 361 [54.5%]) were identified using an algorithm of administrative codes validated against the operative records. Propensity score matching resulted in 241 patient pairs. Endovascular repairs increased during the study and currently comprise more than 50% of total repairs. In the matched sample, open repair was associated with a higher incidence of in-hospital death (17.4% vs 10.8%, P = .04), complications (26.1% vs 17.4%, P = .02), discharge to rehabilitation facilities (18.7% vs 10.0%, P = .02), and longer length of stay (12 [7-21] vs 6 [3-13] days, P < .01). Long-term mortality was not significantly different (hazard ratio, 1.09; 95% confidence interval, 0.78-1.50), nor were the other secondary end points, with the exception of secondary procedures, which were higher in the endovascular group (hazard ratio, 2.64; 95% confidence interval, 1.54-4.55). At 8 years, overall survival was 41.3% versus 44.6% after endovascular and open repair (P = .62). CONCLUSIONS Endovascular repair was associated with improved early outcomes but higher rates of secondary procedures after discharge. Long-term survival after thoracoabdominal aortic aneurysm repair is poor and independent of repair technique.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Ogawa Y, Watkins AC, Lingala B, Nathan I, Chiu P, Iwakoshi S, He H, Lee JT, Fischbein M, Woo YJ, Dake MD. Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery. J Thorac Cardiovasc Surg 2019; 161:2004-2012. [PMID: 31926735 DOI: 10.1016/j.jtcvs.2019.10.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become first-line treatment for descending thoracic aortic rupture (DTAR), but its midterm and long-term outcomes remain undescribed. This study evaluated whether TEVAR would improve midterm outcomes of nontraumatic DTAR relative to open surgical repair (OSR). METHODS Between December 1999 and October 2018, 118 patients with DTAR were treated with either OSR (n = 39) or TEVAR (n = 79) at a single center. Primary end points were 30-day and long-term all-cause mortalities. Secondary end points included stroke, permanent spinal cord ischemia (SCI), prolonged ventilation support or tracheostomy, permanent hemodialysis, and aortic reintervention. RESULTS Thirty-day mortality was significantly lower with TEVAR (OSR, 38.5%; TEVAR, 16.5%; P = .01). Stroke (15.6% vs 3.8%; P = .03), permanent SCI (15.6% vs 2.5%; P = .02), prolonged ventilation (30.8% vs 8.9%; P = .002), and tracheostomy (12.8% vs 2.5%; P = .04) were significantly lower after TEVAR than OSR. Need for hemodialysis trended higher after OSR (12.8% vs 5.1%; P = .2). Mean follow ups were 1048 ± 1591 days for OSR group and 828 ± 1258 days for TEVAR. All-cause mortality at last follow-up was significantly lower after TEVAR than OSR (35.4% vs 66.7%; P = .001). Aortic reintervention was required more frequently within 30 days after TEVAR (15.2% vs 2.6%; P = .06). By multivariate analysis, TAAA was an independent predictor for mortality. CONCLUSIONS TEVAR improves both early and midterm outcomes of DTAR relative to OSR. TAAA was a predictor of mortality. Endovascular approach to DTAR may provide the greatest chance at survival.
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Affiliation(s)
- Yukihisa Ogawa
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Itoga Nathan
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Shinichi Iwakoshi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Hao He
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif; University of Arizona Heath Sciences, Tucson, Ariz.
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Rocha RV, Lindsay TF, Friedrich JO, Shan S, Sinha S, Yanagawa B, Al-Omran M, Forbes TL, Ouzounian M. Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2019; 71:1396-1412.e12. [PMID: 31690525 DOI: 10.1016/j.jvs.2019.06.216] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/04/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of thoracoabdominal aortic aneurysms (TAAAs). METHODS MEDLINE and Embase were searched for studies from January 2006 to March 2018 that reported either endovascular (using branched or fenestrated endografts) or open repair of TAAA in at least 10 patients. Outcomes of interest included perioperative mortality, spinal cord injury (SCI), renal failure requiring dialysis, and stroke. Pooled proportions were determined using a random-effects model. RESULTS The analysis included 71 studies, of which 24 and 47 reported outcomes after endovascular and open TAAA repair, respectively. Endovascular cohort patients were older and had higher rates of coronary artery disease, chronic obstructive pulmonary disease, and diabetes. Endovascular repair was associated with higher rates of SCI (13.5%; 95% confidence interval [CI], 10.5%-16.7%) compared with open repair (7.4%; 95% CI, 6.2%-8.7%; P < .01) but similar rates of permanent paralysis (5.2% [95% CI, 3.8%-6.7%] vs 4.4% [95% CI, 3.3%-5.6%]; P = .39), lower rates of postoperative dialysis (6.4% [95% CI, 3.2%-9.5%] vs 12.0% [95% CI, 8.2%-16.3%]; P = .03) but similar rates of being discharged on permanent dialysis (3.7% [95% CI, 2.0%-5.9%] vs 3.8% [95% CI, 2.9%-5.3%]; P = .93), a trend to lower stroke (2.7% [95% CI, 1.9%-3.6%] vs 3.9% [95% CI, 3.0%-4.9%]; P = .06), and similar perioperative mortality (7.4% [95% CI, 5.9%-9.1%] vs 8.9% [95% CI, 7.2%-10.9%]; P = .21). CONCLUSIONS This systematic review summarizes the contemporary literature results of endovascular and open TAAA repair. Endovascular repair studies included patients with more comorbidities and were associated with higher rates of SCI but similar rates of permanent paraplegia, whereas open repair studies had higher rates of postoperative dialysis but similar rates of being discharged on permanent dialysis. Perioperative mortality rates were similar. Universally adopted reporting standards for patient characteristics, outcomes, and the conduct of contemporary comparative studies will allow better assessment and comparisons of the risks associated with the two surgical treatment options for TAAA.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Critical Care and Medicine Departments and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shubham Shan
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sidhartha Sinha
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Dua A, Lavingia KS, Deslarzes-Dubuis C, Dake MD, Lee JT. Early Experience with the Octopus Endovascular Strategy in the Management of Thoracoabdominal Aneurysms. Ann Vasc Surg 2019; 61:350-355. [DOI: 10.1016/j.avsg.2019.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/18/2019] [Accepted: 05/24/2019] [Indexed: 12/20/2022]
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Geometric changes over time in bridging stents after branched and fenestrated endovascular repair for thoracoabdominal aneurysm. J Vasc Surg 2019; 70:702-709. [DOI: 10.1016/j.jvs.2018.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 12/12/2018] [Indexed: 11/21/2022]
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47
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Nguyen TT, Simons JP, Podder S, Crawford AS, Judelson DR, Arous EJ, Aiello FA, Schanzer A. Imaging Obtained Up To 12 Months Preoperatively Is Adequate for Planning Fenestrated/Branched Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2019; 53:563-571. [PMID: 31362600 DOI: 10.1177/1538574419864769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Patients referred for fenestrated/branched endovascular aortic repair (F/BEVAR) often present with a previous computed tomography angiogram (CTA), but it is unknown how recent the CTA must be to ensure accurate F/BEVAR planning. We sought to determine whether anatomic planning parameters change significantly between a CTA used for F/BEVAR planning and a CTA obtained 6 to 12 months prior. METHODS Two blinded observers reviewed preoperative CTAs from 21 patients who underwent F/BEVAR. Each patient had a "recent" scan obtained 0 to 6 months before F/BEVAR planning and a "prior" scan obtained 6 to 12 months before the "recent" CTA. Standard measurements included (1) target vessel separation distances, (2) target vessel origin clock position, and (3) proximal F/BEVAR device diameter. Clinically significant differences for target vessel separation distance, target vessel origin clock position, and proximal F/BEVAR device diameter were predefined as >5 mm, >30 minutes, and >4 mm, respectively. Differences between "recent"/"prior" CTA scans were examined by paired t test. RESULTS Mean time interval between paired "recent"/"prior" CTAs was 8.0 months (standard deviation: ±1.7). Mean difference in paired "recent"/"prior" target vessel distance (relative to celiac artery [CA]) was 2.6 mm for the superior mesenteric artery (SMA), 2.5 mm for the right renal artery (RRA), and 3.3 mm for the left renal artery (LRA). Of the 21 paired "recent"/"prior" CTAs, clinically significant differences were observed in 2, 4, and 2 patients for SMA, RRA, and LRA target vessel distance, respectively. Target vessel clock position (SMA reference at 12:00) varied by 12 minutes for the CA, 13 minutes for the RRA, and 15 minutes for the LRA. One paired "recent"/"prior" CTA was found to have a clinically significant difference for the LRA. No clinically significant differences were observed for proximal device diameter. CONCLUSIONS In patients who underwent successful F/BEVAR, measurement comparisons between CTAs obtained up to 1 year prior were minor and unlikely to yield clinically significant changes to F/BEVAR design.
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Affiliation(s)
- Tammy T Nguyen
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jessica P Simons
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sourav Podder
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Allison S Crawford
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dejah R Judelson
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Edward J Arous
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Francesco A Aiello
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
| | - Andres Schanzer
- 1 Division of Vascular and Endovascular Surgery, UMass Memorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA, USA
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Gallitto E, Faggioli G, Pini R, Mascoli C, Freyrie A, Vento V, Ancetti S, Stella A, Gargiulo M. Total Endovascular Repair of Contained Ruptured Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2019; 58:211-221. [DOI: 10.1016/j.avsg.2018.12.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/04/2018] [Indexed: 11/16/2022]
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Tong YH, Yu T, Zhou M, Liu C, Li XQ, Liu CJ, Liu Z. Three-year follow-up of composite stent grafts used in the repair of Crawford Type III thoracoabdominal aortic aneurysms; A case report. J Int Med Res 2019; 48:300060519848627. [PMID: 31130032 PMCID: PMC7287198 DOI: 10.1177/0300060519848627] [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] [Indexed: 11/21/2022] Open
Abstract
Complex aortic aneurysms are difficult to treat endovascularly and so techniques have been developed to broaden the management options. We report a case of 51-year-old man with several thoracoabdominal aortic aneurysms (TAAAs) who underwent endovascular repair with “off-label” stent grafts. Three aortic stent grafts and four branched stent grafts were used in the procedure using chimney and periscope techniques. The patient was followed for three years with regular computed tomography angiography (CTA). Scans at 3 and 12 months showed that the TAAAs were repaired and all visceral arteries were patent. Although, scans at the two- and three-year follow-ups showed that the stent graft in the superior mesenteric artery was occluded, the patient did not have any complications probably as a result of coeliac artery compensation.
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Affiliation(s)
- Yuan-Hao Tong
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Tong Yu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Chen Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Xiao-Qiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Chang-Jian Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
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Walker J, Kaushik S, Hoffman M, Gasper W, Hiramoto J, Reilly L, Chuter T. Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms. J Vasc Surg 2019; 69:341-347. [PMID: 30683193 DOI: 10.1016/j.jvs.2018.04.074] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/09/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. METHODS There were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. RESULTS Mean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. CONCLUSIONS Total endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.
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Affiliation(s)
- Joy Walker
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Smita Kaushik
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Megan Hoffman
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Warren Gasper
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Jade Hiramoto
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Linda Reilly
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Timothy Chuter
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
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