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Ulsaker H, Halvorsen H, Braaten AO, Dorenberg E, Rikken Lindberg B, Nordhus KC, Jakobsen Ø, Brekken R, Seternes A, Manstad-Hulaas F. Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study. SCAND CARDIOVASC J 2024; 58:2335906. [PMID: 38613333 DOI: 10.1080/14017431.2024.2335906] [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: 11/16/2023] [Accepted: 03/24/2024] [Indexed: 04/14/2024]
Abstract
Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
| | | | | | - Eric Dorenberg
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | | | - Øyvind Jakobsen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North, Norway
| | - Reidar Brekken
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Health Research, SINTEF, Trondheim, Norway
| | - Arne Seternes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St. Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Radiology, St. Olavs University Hospital, Trondheim, Norway
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Piazza M, Squizzato F, Pratesi G, Parlani G, Simonte G, Giudice R, Mansour W, Veraldi GF, Gennai S, Antonello M. Editor's Choice - Outcomes of Off the Shelf Outer Branched Versus Inner Branched Endografts in the Treatment of Thoraco-Abdominal Aortic Aneurysm in the B.R.I.O. (BRanched Inner - Outer) Study Group. Eur J Vasc Endovasc Surg 2024; 68:50-59. [PMID: 38636923 DOI: 10.1016/j.ejvs.2024.04.005] [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: 09/20/2023] [Revised: 01/25/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE This study aimed to compare two commercially available off the shelf branched endografts for thoraco-abdominal aortic aneurysm (TAAA) repair, namely the E-nside (Artivion) and Zenith t-Branch (Cook Medical) devices. METHODS This multicentre retrospective study (2020 - 2023) included patients treated by branched endovascular aortic repair (BEVAR) for TAAA using the inner branched E-nside or the outer branched t-Branch. Endpoints were 30 day technical success and major adverse events (MAEs) as well as one year freedom from target vessel instability and main endograft instability. RESULTS The study included 163 patients: 79 (307 target vessels) treated with E-nside and 84 (325 target vessels) with t-branch. Aneurysm extent was I - III in 91 patients (55.8%; 47% of E-nside and 66% of t-Branch) and IV in 72 patients (44.2%; 53% of E-nside and 34% of t-Branch) (p = .011). An adjunctive proximal thoracic endograft was used in 43% of E-nside vs. 69% of t-Branch (p < .001), with less frequent thoracic endografting (14% vs. 76%; p < .001) and shorter length of coverage (p = .024) in extent IV TAAA treated by E-nside. E-nside cases had shorter renal artery bridging lengths (66 ± 17 mm vs. 76 ± 20 mm; p < .010) and less frequent use of a distal bifurcated endograft (53% vs. 80%; p < .001). Comparing 30 day results, the mortality rate was 1% vs. 2% (p = .62), any MAE occurred in 18% vs. 21% (p = .55), the stroke rate was 3% vs. 0% (p = .23), and the elective spinal cord ischaemia rate was 5% vs. 8% (p = .40) for E-nside and t-Branch, respectively. At one year, freedom from target vessel instability was 96 ± 3% for E-nside and 95 ± 3% for t-Branch (p = .58), and freedom from endograft instability was 98 ± 2% vs. 97 ± 3% (p = .46), respectively. CONCLUSION Both off the shelf devices provided excellent early and one year results. The E-nside may require shorter thoracic aortic coverage and bridging length for the renal arteries, and less frequent implantation of a concomitant proximal thoracic or distal abdominal bifurcated endograft. However, these aspects did not determine significant differences in clinical outcomes.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy. https://www.twitter.com/dr_fsquizzato
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianbattista Parlani
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Wassim Mansour
- Vascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I -"La Sapienza" University of Rome, Rome, Italy
| | | | - Stefano Gennai
- Division of Vascular Surgery, University Hospital of Modena and Reggio Emilia, Baggiovara (MO), Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Silverberg D, Bar Dayan A, Speter C, Fish M, Halak M. The Use of the Off-the-Shelf Inner Branch E-nside Endograft for the Treatment of Elective and Emergent Complex Aortic Aneurysms-A Single-Center Experience. Ann Vasc Surg 2024; 104:132-138. [PMID: 37495095 DOI: 10.1016/j.avsg.2023.07.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/28/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND The aim of this single-center study was to evaluate the early results of the off-the-shelf inner branch E-nside endograft in the treatment of complex aortic aneurysms and thoracoabdominal aortic aneurysms. METHODS We performed a retrospective analysis of a prospectively maintained database of all patients treated with the E-nside endograft at our institution during the years 2021-2023. Parameters evaluated were technical success, early major adverse events, target vessel patency, and the presence of endoleaks. RESULTS In total 16 patients underwent treatment with the E-nside endograft. Six additional patients were evaluated for the device but were excluded due to anatomical considerations. Mean age was 71 (range 59-84) and 14 (88%) were males. Mean aneurysm diameter was 66 mm (range 54-85). Aneurysms treated included thoracoabdominal in 9 (56%), juxtarenal aneurysms in 5 (31%), postdissection aneurysm in 1 (6%) and a type 1A endoleak after a failed endovascular aneurysm repair in 1 (6%). Five of the treated aneurysms were symptomatic. A total of 58 side branches were placed into target visceral arteries. Mean operative time was 190 min (range 150-360). Technical success was achieved in 15/16 of the patients (94%). At 30 days, 1 perioperative mortality and 3 major adverse events occurred, 2 of them branch related. CONCLUSIONS The E-nside endograft is a feasible option for the treatment of a broad spectrum of aortic pathologies. As it is an off-the-shelf device, it can be used selectively in elective and emergent settings with acceptable 30-day mortality and morbidity. Further follow-up is required to determine the durability of this treatment option and patency of side branches.
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MESH Headings
- Humans
- Male
- Aged
- Female
- Retrospective Studies
- Endovascular Procedures/instrumentation
- Endovascular Procedures/adverse effects
- Blood Vessel Prosthesis
- Middle Aged
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/adverse effects
- Treatment Outcome
- Aged, 80 and over
- Prosthesis Design
- Time Factors
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/physiopathology
- Elective Surgical Procedures
- Databases, Factual
- Stents
- Risk Factors
- Endoleak/etiology
- Endoleak/surgery
- Vascular Patency
- Emergencies
- Postoperative Complications/etiology
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/physiopathology
- Aortic Aneurysm, Abdominal/mortality
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Affiliation(s)
- Daniel Silverberg
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel.
| | - Avner Bar Dayan
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Chen Speter
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Michal Fish
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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Chen Y, Bashir M, Guo J, Piffaretti G, Jubouri M, D'Oria M. Expert-Based Narrative Review on Contemporary Use of an Off-The-Shelf Multibranched Endograft for Endovascular Treatment of Thoracoabdominal Aortic Aneurysms: Device Design, Anatomical Suitability, Technical Tips, Perioperative Care, Clinical Applications, and Real-World Experience. Ann Vasc Surg 2024; 108:98-111. [PMID: 38942377 DOI: 10.1016/j.avsg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 06/30/2024]
Abstract
Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm patients have anatomic limitations to fenestrated stent-grafts given a large lumen, that is, the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, IN), which has been commercially available in Europe to treat thoracoabdominal aortic aneurysm since June 2012, represents a feasible off-the-shelf alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior endovascular aneurysm repair), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been carried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Jiayin Guo
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Matti Jubouri
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Mario D'Oria
- Department of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
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Piazza M, Squizzato F, Ferri M, Pratesi G, Gatta E, Orrico M, Giudice R, Antonello M. Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft. J Vasc Surg 2024:S0741-5214(24)01235-7. [PMID: 38908806 DOI: 10.1016/j.jvs.2024.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). METHODS Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. RESULTS Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. CONCLUSIONS The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Matteo Orrico
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Matsagkas M, Spanos K, Haidoulis A, Kouvelos G, Dakis K, Arnaoutoglou E, Giannoukas A. Initial Experience of the Covered Endovascular Reconstruction of Iliac Bifurcation Technique. J Endovasc Ther 2024:15266028241256507. [PMID: 38813976 DOI: 10.1177/15266028241256507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
INTRODUCTION The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique. METHODS This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate. RESULTS Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB. CONCLUSION The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability. CLINICAL IMPACT The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.
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Affiliation(s)
- Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Haidoulis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Dakis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Elena Arnaoutoglou
- Anaesthesiology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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7
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Enzmann FK, Grandi A, Panuccio G, Torrealba JI, Kluckner M, Nana P, Rohlffs F, Kölbel T. Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair. J Endovasc Ther 2024:15266028241251985. [PMID: 38708984 DOI: 10.1177/15266028241251985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
PURPOSE The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.
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Affiliation(s)
- Florian K Enzmann
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - José Ignacio Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Kluckner
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Xodo A, Taglialavoro J, Lepidi S, Pilon F, Calvagna C, Griselli F, Milite D, Badalamenti G, Ruaro B, D'Oria M. Novel Technique for Intentional Occlusion of Directional Branches During Complex Endovascular Aortic Repair Using Microvascular Plugs. Vasc Endovascular Surg 2024; 58:110-114. [PMID: 37466345 DOI: 10.1177/15385744231191234] [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: 07/20/2023]
Abstract
PURPOSE To demonstrate the feasibility and outcomes of using the microvascular plug (MVP) for intentional occlusion of directional branches (DB) during complex endovascular aortic procedures. CASE REPORT Two patients were treated with the off-the-shelf four-branched Zenith t-Branch thoracoabdominal stent-graft (Cook Medical, Bloomington, Ind). In both cases, the renal arteries (on one side in patient #1 and on both sides in patient #2, respectively) were occluded at time of index intervention. Preoperative planning included the intentional occlusion of each DB with one 7Q-MVP. Technical success was achieved in all cases and maintained at mid-term follow-up (12 months and 36 months, respectively). CONCLUSIONS Use of the MVP appears to be feasible and effective for intentional occlusion of DB during complex endovascular aortic repair. This novel and simple technique may present some unique technical advantages, allowing precise placement of the device while avoiding extension using a bridging stent and DB cannulation with larger sheaths.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Division, San Bortolo Hospital, Vicenza, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
| | - Fabio Pilon
- Vascular and Endovascular Surgery Division, San Bortolo Hospital, Vicenza, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
| | - Filippo Griselli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
| | - Domenico Milite
- Vascular and Endovascular Surgery Division, San Bortolo Hospital, Vicenza, Italy
| | - Giovanni Badalamenti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital, Trieste, Italy
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Chen Y, Liu Z, Wang S, D'Oria M, Zhang X, Bi J, Cui D, Dai X. Systematic Review and Meta-analysis of Short-term and Mid-term Outcomes After Use of t-Branch Off-the-shelf Multibranched Endograft for Elective and Urgent Treatment of Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2023:15266028231220322. [PMID: 38158706 DOI: 10.1177/15266028231220322] [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: 01/03/2024]
Abstract
OBJECTIVE To conduct a meta-analysis to assess the safety and efficacy of t-Branch off-the-shelf multibranched endograft for the treatment of thoracoabdominal aortic aneurysm (TAAA). DATA SOURCES PubMed, Embase, and Web of Science. REVIEW METHODS Online databases were searched from June 2012 to March 2023. The data were pooled together using a random-effects model of proportions. The outcomes overall included technical success, spinal cord ischemia, target vessel occlusion, type I or III endoleak, reintervention, early mortality (30-day), and mid-term outcomes. Subgroup meta-analyses and meta-regression were performed to explore variation among studies. RESULTS A total of 15 studies containing 1238 patients were included in the meta-analysis. The overall study quality assessment was found to be moderate to good. The pooled technical success was 97.0% (95% confidence interval [CI]=95.5-98.6, I2=53.01%, 1185/1238 cases, 15 studies). Overall, early mortality was 7.3% (95% CI=4.4-10.1, I2=74.48%, 124/1238 cases, 15 studies). Early spinal cord ischemia was 13.4% (95% CI=9.6-17.2, I2=67.24%, 160/1238 cases, 15 studies), and early type I or III endoleak was 6.0% (95% CI=3.4-8.5, I2=53.71%, 68/1032 cases, 9 studies). Mid-term outcomes showed target vessel occlusion was 4% (95% CI=1.4-6.5, I2=65.18%, 28/528 cases, 10 studies, 5-21.2 months), type I or III endoleak was 4.7% (95% CI=2-7.5, I2=49.74%, 38/512 cases, 10 studies, 5-21.2 months), reintervention was 11.2% (95% CI=8.1-14.3, I2=31.06%, 85/650 cases, 10 studies, 5-21.2 months), and pooled mortality was 13.9% (95% CI=7.2-20.7, I2=76.32%, 84/550 cases, 11 studies, 5-21.2 months). Meta-regression found a significant linear association between higher technical success and earlier publication year (p=0.014) and studies with anatomic inclusion criteria (p=0.037). Urgent patients (p=0.021) and later publication year (p=0.048) were significantly associated with higher early mortality. CONCLUSION The use of the off-the-shelf t-Branch multibranched endograft for elective or urgent endovascular TAAA repair is associated with high technical success rates and proved to be safe and effective at early and mid-term follow-up. However, the heterogeneity between the included studies is high, and prospective, randomized studies along with future larger studies with long-term follow-up are needed. CLINICAL IMPACT The Zenith t-Branch (Cook Medical, Bloomington, Ind) was approved as a commercially available device in Europe in June 2012. Although a decade has past, the outcomes of t-Branch have rarely been synthesized at the global level. This meta-analysis included 15 studies containing 1238 patients. The meta-analyses included technical success, major adverse events, reintervention, early mortality, and mid-term outcomes. The outcome was very meaningful and representative for the use of t-Branch. It is helpful for endovascular surgeons to make decisions on the treatment of TAAA patients.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuaishuai Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardio-thoraco-vascular Department, University Hospital of Trieste Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Dongsheng Cui
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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10
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Nana P, Spanos K, Jakimowicz T, Torrealba JI, Jama K, Panuccio G, Rohlffs F, Kölbel T. Urgent and emergent repair of complex aortic aneurysms using an off-the-shelf branched device. Front Cardiovasc Med 2023; 10:1277459. [PMID: 37808886 PMCID: PMC10556233 DOI: 10.3389/fcvm.2023.1277459] [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: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Endovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft. Methods Prospectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed. Results 225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I-III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p < .001) were more common in emergent cases. Technical success was 97.8%. Thirty-day mortality and MAE rates were 17.8% and 30.6%, respectively. SCI rate was 14.7%, (4.8% paraplegia rate) with 22.2% of patients receiving prophylactic cerebrospinal drainage. Thirty-day mortality (13.3% vs. 26.7%, p = .04) and MAE (26.0% vs. 43.0%, p = .02) were more common among emergent cases while technical success (97.6% vs. 98.3%, p = .9), and SCI (13.3% vs. 18.3%, p = .4) were similar. Survival at 12-months was 83.5% (SE 5.9%) for the urgent and 77.1% (SE 8.2%) for the emergent group (log rank, p = 0.96). Conclusion T-Branch represents an effective and safe solution for the management of urgent and emergent cases with complex aortic aneurysms, with high technical success, promising early mortality and SCI rates.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jose I. Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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11
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Piazza M, Squizzato F, Pratesi G, Tshomba Y, Gaggiano A, Gatta E, Simonte G, Piffaretti G, Frigatti P, Veraldi GF, Silingardi R, Antonello M. Editor's Choice - Early Outcomes of a Novel Off the Shelf Preloaded Inner Branch Endograft for the Treatment of Complex Aortic Pathologies in the ItaliaN Branched Registry of E-nside EnDograft (INBREED). Eur J Vasc Endovasc Surg 2023; 65:811-817. [PMID: 36871927 DOI: 10.1016/j.ejvs.2023.02.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/02/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the early outcomes of a novel off the shelf pre-loaded inner branched thoraco-abdominal endograft (E-nside) in the treatment of aortic pathologies. METHODS Data from a physician initiated national multicentre registry on patients treated with the E-nside endograft, were prospectively collected and analysed. Pre-operative clinical and anatomical characteristics, procedural data, and early outcomes (90 days) were recorded in a dedicated electronic data capture system. The primary endpoint was technical success. Secondary endpoints were early mortality (90 days), procedural metrics, target vessel patency, endoleak rate, and major adverse events (MAEs) at 90 days. RESULTS In total, 116 patients from 31 Italian centres were included. Mean ± standard deviation (SD) patient age was 73 ± 8 years and 76 (65.5%) were male. Aortic pathologies included degenerative aneurysm in 98 (84.5%), post-dissection aneurysm in five (4.3%), pseudoaneurysm in six (5.2%), penetrating aortic ulcer or intramural haematoma in four (3.4%), and subacute dissection in three (2.6%). Mean ± SD aneurysm diameter was 66 ± 17 mm; aneurysm extent was Crawford I - III in 55 (50.4%), IV in 21 (19.2%), pararenal in 29 (26.7%), and juxtarenal in four (3.7%). The procedure setting was urgent in 25 (21.5%) patients. Median procedural time was 240 minutes (interquartile range [IQR] 195, 303), with a median contrast volume of 175 mL (IQR 120, 235). The endograft's technical success rate was 98.2% and the 90 day mortality rate was 5.2% (n = 6; 2.1% for elective repair and 16% for urgent repair). The 90-days cumulative MAE rate was 24.1% (n = 28). At 90 days, there were 10 (2.3%) target vessel related events (nine occlusions and one type IC endoleak) and one type 1A endoleak requiring re-intervention. CONCLUSION In this real life, non-sponsored registry, the E-nside endograft was used for the treatment of a broad spectrum of aortic pathologies, including urgent cases and different anatomies. The results showed excellent technical implantation safety and efficacy, as well as early outcomes. Longer term follow up is needed to better define the clinical role of this novel endograft.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Paolo Frigatti
- Division of Vascular Surgery, Azienda Sanitaria Universitaria Friuli Centrale, S. Maria della Misericordia University Hospital of Udine, Udine, Italy
| | | | - Roberto Silingardi
- Division of Vascular Surgery, University Hospital of Modena and Reggio Emilia, Baggiovara (MO), Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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12
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Grandi A, Melloni A, D'Oria M, Lepidi S, Bonardelli S, Kölbel T, Bertoglio L. Emergent endovascular treatment options for thoracoabdominal aortic aneurysm. Semin Vasc Surg 2023; 36:174-188. [PMID: 37330232 DOI: 10.1053/j.semvascsurg.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy.
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13
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Spath P, Tsilimparis N, Furlan F, Hamwi T, Prendes CF, Stana J. Additional Aortic Coverage With an Off The Shelf, Multibranched Endograft Compared With Custom Made Devices For Endovascular Repair of Pararenal Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2023; 65:710-718. [PMID: 36707021 DOI: 10.1016/j.ejvs.2023.01.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/07/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Pararenal abdominal aortic aneurysms (p-AAA) require complex endovascular aortic repair or open surgical repair with suprarenal clamping. Custom made devices (CMD), including fenestrated and branched endovascular aortic repair (F/B-EVAR) or off the shelf (OTS) multibranched devices, are available treatment options. The aim of this study was to determine the additional healthy aortic coverage using an OTS multibranched endograft vs. a CMD for the treatment of p-AAAs. METHODS This was a retrospective single centre analysis of prospectively collected data. Consecutive patients with p-AAAs requiring a proximal landing zone above the coeliac artery (CA), planned and treated with CMDs (Zenith Fenestrated) between January 2017 and December 2021 were included in this study. Treatment with supracoeliac coverage using available OTS multibranched devices was simulated using available pre-operative images: T-Branch; E-nside; and TAMBE. Study endpoints included the need for additional proximal aortic coverage, and the number of the segmental arteries additionally covered proximally from the CA for OTS devices compared with CMDs. RESULTS Eighty three patients with p-AAAs were treated with CMDs (all FEVAR), including juxtarenal AAAs (n = 46; 56%), suprarenal AAAs (n = 20; 24%), and short neck AAAs (n = 17; 20%). In this study, treatment with 249 (3 × 83) OTS endografts was simulated. When compared with CMDs, OTS devices required a mean of 74 ± 19 mm of additional proximal healthy aortic coverage from the CA (CMD: 33 ± 19 mm vs. OTS: 108 ± 6 mm; p ≤ .001), as well as an average sacrifice of 2.5 additional segmental arteries (CMD: 1.3 ± 0.8 vs. OTS: 3.8 ± 0.9; p ≤ .001). In 94% of patients, at least one of the available multibranched endografts could have been implanted in accordance with instructions for use. CONCLUSION Despite not requiring customisation time, OTS endografts for the treatment of p-AAA lead to more extensive healthy aortic coverage, as well as an average sacrifice of 2.5 additional segmental arteries, compared with CMDs. When compared with OTS devices, CMDs appear to limit the extent of unnecessary aortic coverage and the theoretical subsequent risk of spinal cord ischaemia.
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Affiliation(s)
- Paolo Spath
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany.
| | - Federico Furlan
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
| | - Tarek Hamwi
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
| | - Carlota F Prendes
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
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14
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Spanos K, Jakimowicz T, Nana P, Behrendt CA, Panuccio G, Kouvelos G, Jama K, Eleshra A, Rohlffs F, Kölbel T. Outcomes of Directional Branches of the T-Branch Off-the-Shelf Multi-Branched Stent-Graft. J Clin Med 2022; 11:jcm11216513. [PMID: 36362739 PMCID: PMC9659142 DOI: 10.3390/jcm11216513] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Background: A controversy on bridging covered stent (BCS) choice, between self-expanding (SECS) and balloon-expandable (BECS) stents, still exists in branched endovascular repair. This study aimed to determine the primary target vessel (TV) patency in patients treated with the t-Branch device and identify factors impairing the outcomes. Methods: A retrospective study was undertaken, including patients treated with the t-Branch (Cook Medical, Bloomington, IN, USA) between 2014 and 2019 (early 2014–2016; late 2017–2019). The endpoint was the primary patency (CT: celiac trunk, SMA, superior mesenteric artery, RRA: right renal artery, LRA: left renal artery) during the follow-up. Any branch instability event was assessed. The factors affecting the patency were determined using multivariable regression models and Kaplan–Meier analyses. Results: In total, 2018 TVs were analyzed; 1542 SECSs and 476 BECSs. The CT patency was 99.8% (SE 0.2%) at the 1st month, with no other event. The SMA patency was 97.8% (SE 1) at the 12th month. The RRA patency was 96.7% (SE 2) at the 24th month. The LRA patency was 99% (SE 0.4) at the 6th month. Relining was the only factor independently associated with the SMA patency (OR 8.27; 95% CI 1.4–4.9; p = 0.02). The freedom from instability was 62% (SE 4.3%) and 45% (SE 5.4%) at the 24th month and 36th month. No significant difference was identified between the BECSs and SECSs in the early or late experience. Conclusion: BCS for the t-Branch branches performed with a good primary patency during the short-term follow-up. The type of BCS did not influence the patency. Relining might be protective for SMA patency.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
- Correspondence: ; Tel.: +30-241350-1739
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, 20251 Hamburg, Germany
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Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3. J Am Coll Cardiol 2022; 80:845-856. [PMID: 35981828 DOI: 10.1016/j.jacc.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022]
Abstract
Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.
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16
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Nana P, Spanos K, Behrendt CA, Dakis K, Brotis A, Kouvelos G, Giannoukas A, Kölbel T. Editor's Choice - Sex Specific Outcomes After Complex Fenestrated and Branched Endovascular Aortic Repair: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2022; 64:200-208. [PMID: 35598720 DOI: 10.1016/j.ejvs.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/17/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As females are at higher mortality risk after endovascular aortic repair, this study aimed to compare the 30-day and 12-month mortality, morbidity, and re-intervention rates between the sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR). DATA SOURCES A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL, up to 30 July 2021, was performed. REVIEW METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, and its protocol was registered in PROSPERO (CRD42021273418). Observational studies (2010-21), with ≥ 20 patients, reporting on sex specific outcomes (mortality, acute kidney injury [AKI], spinal cord ischaemia [SCI], and re-intervention, after F/BEVAR), were considered eligible. Risk of bias in the studies was assessed using ROBINS-I, and evidence quality was assessed using GRADE. The primary outcome was the sex specific 30-day mortality rate, AKI, SCI, and re-intervention rates; secondary outcomes were survival and freedom from re-intervention at 12 months after F/BEVAR. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Four retrospective and one prospective study (2 421 patients; 26% females) were included. The 30-day mortality rate was 12% in females vs. 3% in males (OR 2.65, 95% CI 1.79 - 3.92; Ι2 = 0%). The 30-day AKI, SCI, and re-intervention rates were similar (OR 1.45, 95% CI 1.03 - 2.03; Ι2 = 0%; OR 1.86, 95% CI 1.27 - 2.74; Ι2 = 38%; and OR 1.06, 95% CI 0.66 - 1.77; Ι2 = 0%, respectively). The 12-month survival rate was lower in females (OR 0.95, 95% CI 0.91 - 0.99; Ι2 = 38%). When excluding 30-day deaths, there was no difference in 12-month survival between sexes (OR 0.99, 95% CI 0.95 - 1.02; Ι2 = 32%). The 12-month freedom from re-intervention was similar between sexes (OR 0.87, 95% CI 0.75 - 1.01; Ι2 = 0%). CONCLUSION Female patients treated by F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality rate remains an issue. When excluding 30-day deaths, the 12-month survival rate was similar between the sexes. Early morbidity and re-intervention rates were comparable.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
| | | | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
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17
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Ulsaker H, Seternes A, Brekken R, Manstad-Hulaas F. Midterm Outcomes for Endovascular Repair of Thoracoabdominal Aortic Aneurysms. EJVES Vasc Forum 2022; 56:6-10. [PMID: 35572162 PMCID: PMC9092505 DOI: 10.1016/j.ejvsvf.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/08/2022] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To investigate technical and clinical outcomes in patients with thoraco-abdominal aortic aneurysms treated with the multibranched off the shelf Zenith t-Branch stent graft or a custom made device (CMD). Methods A retrospective study was conducted of patients operated on at a single tertiary vascular centre in Norway. Twenty eight t-Branch and 17 CMD patients were identified. Demographic, aneurysm, and peri-operative data were summarised and compared. Results Thirty day mortality was 4% (2/45), with mortality rates of 7% (2/28) and 0 in t-Branch and CMD patients, respectively (p = .52). Technical success was 87% (39/45), with a non-significant difference between t-Branch and CMD procedures of 89% (25/28) and 82% (14/17), respectively (p = .63). Stent graft coverage was significantly longer in t-Branch patients (p = .020). Paraparesis or paraplegia developed in 18% (5/28) of t-Branch patients and 12% (2/17) of CMD patients (p = .69), and spinal cord ischaemia was associated with Crawford type II aneurysms (p = .010) and aortic coverage >400 mm (p = .050). The estimated survival at one and two years for t-Branch patients was 93% and 88%, and 100% and 92% for CMD patients. Freedom from re-intervention was estimated at 70% and 43% at one and two years for t-Branch patients, and 58% and 50% for CMD patients. Conclusion The study showed low 30 day mortality rates, acceptable technical success rates, high medium term survival, and no statistically significant differences in clinically relevant outcomes between t-Branch and CMD patients. Clinical outcomes do not vary significantly between t-Branch and CMD patients. 30 day mortality was low among both t-Branch and CMD patients. Midterm survival was high in both groups.
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18
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Outcomes of multibranched off-the-shelf stent graft in elective and urgent/emergent repair of complex aortic aneurysms with narrow internal aortic lumen. J Vasc Surg 2022; 76:326-334. [PMID: 35314297 DOI: 10.1016/j.jvs.2022.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/06/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft (Cook Medical, Bloomington, IN, USA) in the treatment of complex aortic aneurysms with narrow internal aortic lumen. METHODS Between 2016 and 2020, 48 patients (mean age 73 years) underwent elective or urgent/emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in 2 Italian vascular centers. Among these, 20 patients presented a paravisceral/pararenal luminal diameter < 25 mm. Major clinical and radiological outcomes of patients with narrow aortic lumen were compared with patients with larger lumen in a multicenter, non-randomized, retrospective fashion. RESULTS The in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range 1 - 63), late t-Branch procedure-related mortality and the need for re-intervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (Group 1) with patients with small lumen (Group 2), no significant difference was found regarding fluoroscopy time (p = 0.3), technical success (p = 1), early (p = 0.4) and late (p = 1) mortality, spinal cord ischemia (p = 0.2), bowel ischemia (p = 0.5), renal (p = 0.7), cardiac (p = 1), and respiratory complications (p = 1), re-intervention rate (p = 1), and primary patency rate of stented target vessels (p = 1). CONCLUSION The use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible also when maneuverability is reduced, with low mortality and morbidity, and acceptable re-intervention need. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.
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19
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Nana P, Spanos K, Brodis A, Panuccio G, Kouvelos G, Behrendt CA, Giannoukas A, Kölbel T. Meta-analysis of Comparative Studies Between Self- and Balloon-Expandable Bridging Stent Grafts in Branched Endovascular Aneurysm Repair. J Endovasc Ther 2022; 30:336-346. [PMID: 35293261 DOI: 10.1177/15266028221083458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Currently there is no robust evidence which type of bridging stent graft provides better outcomes after branched endovascular aortic repair (BEVAR). Self-expanding (SESG) and balloon-expandable (BESG) stent grafts are both commonly used to connect branches to their respective target vessels (TV). The aim of the current review was to evaluate the impact of the type of bridging stent grafts on TV outcomes during the mid-term follow-up after BEVAR. MATERIALS AND METHODS The study protocol was registered to the PROSPERO (CRD42021274766). A search of the English literature was conducted, using PubMed and EMBASE databases via Ovid and Cochrane database via CENTRAL, from inception to June 30, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Only comparative studies on BEVAR reporting TV outcomes related to BESG vs SESG were considered eligible. Individual studies were assessed for risk of bias using the Newcastle Ottawa Scale. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcomes were primary patency, freedom from endoleak, TV instability, and re-intervention between BESG and SESG, used as bridging stents in branches. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis. RESULTS Five out of 609 articles published from 2016 to 2020 were included in the analysis. In total, 1406 TV were revascularized, 547 (38.9 %) with BESGs and 859 with SESGs. The overall pooled primary patency (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.29-1.09; p=.256, I2=4.24%) and freedom from branch-related endoleak (OR, 0.65; 95% CI, 0.17-1.48; p<.122, I2=0.18%) did not differ between the stent types during the available follow-up (17 months, range = 12-35 months). In 4 studies (619 TV), SESG required fewer secondary interventions (OR, 1.04; 95% CI, 0.23-1.83; p=.009, I2=0%) and TV instability rate was lower (OR, 0.99; 95% CI, 0.33-1.65; p=.003, I2=0%) compared with BESG during the available follow-up. CONCLUSION BESG and SESG seem to perform similarly in terms of primary patency and branch-related endoleak during the mid-term follow-up. Current data from retrospective studies suggest that overall TV instability and re-intervention rates are favorable for SESG as bridging stent grafts in BEVAR.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, General University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.,German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- Vascular Surgery Department, General University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.,German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Alexandros Brodis
- Neurosurgery Department, General University Hospital of Larissa, Larissa, Greece
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - George Kouvelos
- Vascular Surgery Department, General University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Athanasios Giannoukas
- Vascular Surgery Department, General University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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20
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Spinella G, Finotello A, Pisa FR, Conti M, Pratesi G, Pane B, Lanzarone E. Temporary Reperfusion of the Aneurysm Sac as a Prevention of Spinal Cord Ischemia After Endovascular Treatment of Thoracoabdominal Aortic Aneurysm: Systematic Review and Meta-analysis. J Endovasc Ther 2022; 30:323-335. [PMID: 35287499 DOI: 10.1177/15266028221082008] [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: 11/16/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is still a feared complication for patients suffering from thoracoabdominal aortic aneurysm (TAAA) who undergo endovascular treatment. The aims of this work are to review the available literature on different reperfusion methods of the aneurysm sac, and to analyze whether the different reperfusion methods, also in combination with other factors, are effective in reducing SCI risk and if the impact varies with the patient's age. METHODS PubMed/MEDLINE library was searched for studies published until November 2020 concerning TAAA, endovascular repair, and SCI preventive measures. Systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. Primary outcome consisted of correlation between endovascular repair techniques (type A: single step; type B: staged approach with reperfusion branches; type C: staged sequential approach with positioning of the thoracic component). A logistic-weighted regression for each event (SCI, transient, and permanent) was then performed with type of treatment, age, and interaction between them as input factors. Finally, another logistic-weighted regression was performed to analyze the other relevant factors for which observations are available together with the endovascular technique. RESULTS Data from 53 studies with a total of 3095 patients were analyzed. Type A, type B, and type C endovascular strategies were adopted in 75%, 13%, and 12% of studied patients, respectively. Data showed that both type B and type C treatments are associated with lower risk of SCI, with a higher reduction of type C with respect to type B, although this positive trend is limited for elder patients. Moreover, a greater aortic diameter, a reduced aneurysm extent, and the absence of cerebrospinal fluid drainage positioning contribute to lower the risk of SCI. Concerning permanent SCI, both type B and type C are effective in reducing percentages for all ages, with type C treatment more beneficial for younger patients and type B for elder ones. CONCLUSION According to the anatomy and the endovascular repair feasibility criteria, staged endovascular treatment appears to offer relevant advantages over single-step treatment in reducing the risk of SCI, regardless of the reperfusion method adopted.
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Affiliation(s)
- Giovanni Spinella
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Alice Finotello
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy.,Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Fabio Riccardo Pisa
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Bianca Pane
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
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21
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Rinaldi E, Melloni A, Gallitto E, Fargion A, Isernia G, Kahlberg A, Bertoglio L, Faggioli G, Lenti M, Pratesi C, Gargiulo M, Melissano G, Chiesa R, Luigi B, Luca B, Roberto C, Gianluca F, Aaron F, Cecilia F, Enrico G, Mauro G, Giacomo I, Massimo L, Antonino L, Andrea K, Chiara M, Germano M, Andrea M, Rodolfo P, Carlo P, Enrico R, Gioele S, Sara S. Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry. J Endovasc Ther 2022; 30:281-288. [PMID: 35236159 DOI: 10.1177/15266028221081074] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). MATERIALS AND METHODS All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. RESULTS A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18). CONCLUSION The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.
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Affiliation(s)
- Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Baccani Luigi
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Faggioli Gianluca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fargion Aaron
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Fenelli Cecilia
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gallitto Enrico
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gargiulo Mauro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Isernia Giacomo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti Massimo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Logiacco Antonino
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Kahlberg Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mascoli Chiara
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melissano Germano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Melloni Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pini Rodolfo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pratesi Carlo
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Simonte Gioele
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Speziali Sara
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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22
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Shu C, He H, Li Q, Ye Z. Application of a custom-manufactured directional multibranched stent graft to treat thoracoabdominal aneurysms: A case report. VASCULAR INVESTIGATION AND THERAPY 2022. [DOI: 10.4103/2589-9686.348225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Gallitto E, Faggioli G, Spath P, Pini R, Mascoli C, Logiacco A, Gargiulo M. Urgent endovascular repair of thoracoabdominal aneurysms using an off-the-shelf multibranched endograft. Eur J Cardiothorac Surg 2021; 61:1087-1096. [PMID: 34964451 DOI: 10.1093/ejcts/ezab553] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/17/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our goal was to report outcomes of the endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) using the Cook Zenith t-Branch off-the-shelf multibranched endograft. METHODS Between 2010 and 2020, we collected patients with TAAAs who received an urgent endovascular repair using the Cook Zenith t-Branch (had a rupture, symptoms or diameter >80 mm). Thirty-day mortality, spinal cord ischaemia (SCI) and clinical success were assessed as early outcomes. Freedom from reintervention, target visceral vessel patency and survival were considered during follow-up. RESULTS Sixty-five cases were managed using the Cook Zenith t-Branch for 27 (42%) TAAA ruptures, 8 (12%) symptomatic TAAAs and 30 (46%) asymptomatic TAAAs with a diameter >80 mm. Crawford's extent I-II-III and IV were noted in 54 (83%) and 11 (17%), respectively. Eleven (17%) patients had SCI with 3 (5%) cases of permanent paraplegia. Postoperative dialysis (P = 0.04) and ruptured TAAAs (P = 0.05) were associated with SCI. Sixteen (25%) patients had reinterventions within the first 30 days postoperatively. The 30-day mortality was 14% (9). Ruptured TAAAs (P = 0.05) and technical failures (P = 0.01) were correlated with in-hospital mortality. Clinical success was 78% (51 patients). The mean follow-up was 18 ± 14 months. Survival at 24 months was 47% with no late TAAA-related deaths. Patients with ruptured TAAAs had lower survival than those who did not have ruptured TAAAs (52% vs 60% at 1 year; P = 0.05). Target visceral vessel patency and freedom from reintervention at 24 months were 89% and 60%, respectively. CONCLUSIONS An off-the-shelf multibranched endograft is safe and effective for treating urgent TAAAs. Postoperative SCI and 30-day mortality are satisfactory for this challenging clinical scenario. The early reintervention rate is not negligible. Midterm survival is low, especially in patients with a ruptured TAAA; therefore, accurate patient selection is mandatory.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi, 9th Massarenti Street, 40100, Bologna, Italy
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24
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Spanos K, Kölbel T, Heidemann F, Debus ES, Rohlffs F, Tsilimparis N. Early and mid-term durability of surgeon-modified and custom-made fenestrated devices for the treatment of complex aortic pathology. Ann Vasc Surg 2021; 83:212-221. [PMID: 34954035 DOI: 10.1016/j.avsg.2021.12.006] [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] [Received: 10/25/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (F-EVAR) has allowed successful treatment of patients with complex aortic aneurysms. Custom-made devices (CMDs) are manufactured by companies and tailored to the patient's anatomy to incorporate target vessels, while there is also the "off label" alternative with the devices modified by a surgeon in the operating room: surgeon-modified FEVAR (sm-FEVAR). This study aims to present and compare technical durability of CMDs- and sm-FEVAR for complex abdominal and thoracoabdominal aortic pathologies. METHODS A retrospective cohort study was undertaken including all consecutive patients treated with sm- or CMD-FEVAR during a 3-year period in a single centre. Only cases with at least three reno-visceral target vessels were included. Primary outcomes were technical success, and freedom from endoleak (EL) (Ia or III; all branch related) and re-intervention during follow-up period. Mortality and morbidity were also recorded. RESULTS 32 sm-FEVAR patients (81,3% male) and 79 CMD-FEVAR patients (77,2% male) were included. Indication for sm-FEVAR was exclusively urgent, while all CMD- FEVAR were elective. Technical success was similar in sm-FEVAR (100%) and CMD-FEVAR (98,7%) (p=0.523). Mean follow-up was 16.3±13 and 20±17.3 months for sm-FEVAR and CMD- FEVAR, respectively (p=0.28). The freedom from EL Ia rate was 91.7% [standard error (SE) 5.7%] at 12 months in sm-FEVAR, while it was 97.7% (SE 2.2%) and 92.3% (SE 4.3%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.69). The freedom from EL III rate was 95.5% (SE 4.4%) and 88% (SE 8.2%) at 12 and 24 months, respectively in sm-FEVAR, while it was 92.1% (SE 3.8%) and 89.2% (SE 4.7%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.68). The freedom from re-intervention rate was 91.6% (SE 5.7%) and 84.6% (SE 8.6%) at 12 and 24 months, respectively in sm-FEVAR, while it was 91.7% (SE 4%) and 83.4% (SE 5.9%) at 12 and 24 months, respectively in CMD-FEVAR (p=0.90). The survival rate was 87.5% (5.8%) and 76.3% (7.9%) at 1 and 12 months, respectively in sm-FEVAR, while it was 93.7% (2.7%) at 1 month in CMD-FEVAR without any other death during FU period. No bridging stent occlusions were noted during follow up period in any patient. CONCLUSION Sm-FEVAR offers good technical success and mid-term clinical outcomes in urgent cases of complex aortic pathologies. Its durability is acceptable and comparable to CMD-FEVAR with a relatively low re-intervention rate.
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Affiliation(s)
- Kostantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - E Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany; Department of Vascular Surgery, Hospital, LMU Munich, Munich, Germany
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Torrealba J, Panuccio G, Kölbel T, Gandet T, Heidemann F, Rohlffs F. Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies. J Endovasc Ther 2021; 29:697-704. [PMID: 34852653 DOI: 10.1177/15266028211061275] [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: 11/16/2022]
Abstract
PURPOSE To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. TECHNIQUE We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. CONCLUSION Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.
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Affiliation(s)
- Jose Torrealba
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Gandet
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Tsilimparis N, Stana J, Konstantinou N, Chen M, Zhou Q, Kölbel T. Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database. Eur J Cardiothorac Surg 2021; 62:6420381. [PMID: 34734253 DOI: 10.1093/ejcts/ezab476] [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: 03/27/2021] [Revised: 09/27/2021] [Accepted: 10/03/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset. METHODS The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors. RESULTS The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72). CONCLUSIONS Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Nikolaos Konstantinou
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Min Chen
- Cook Research Incorporated, West Lafayette, IN, USA
| | - Qing Zhou
- Cook Research Incorporated, West Lafayette, IN, USA
| | - Tilo Kölbel
- German Aortic Center, University Heart & Vascular Center, Hamburg, Germany
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Kapetanios D, Stana J, Prendes CF, Stavroulakis K, Koelbel T, Rantner B, Tsilimparis N. [Acute Complex Endovascular Aortic Repair - Off-the-shelf vs. Surgeon-modified Stent Grafts]. Zentralbl Chir 2021; 146:521-527. [PMID: 34666365 DOI: 10.1055/a-1647-3549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Treatment of complex abdominal and thoracoabdominal aortic aneurysms is challenging. Open surgical repair is a high-risk operation, especially in emergency cases. Endovascular aneurysm repair with a patient-specific custom-made stent graft in patients with symptomatic or ruptured complex aortic aneurysms is not possible, due to the manufacturing time required. In such cases, alternative endovascular techniques can be used. RESULTS The "off-the-shelf" and "surgeon-modified" stent grafts are valid options for the endovascular treatment of complex aneurysms in urgent and emergent patients. The former are standardised commercially manufactured fenestrated or branched stent grafts, which are available off-the-shelf with an anatomical feasibility in 50 - 80% of the patients. The "surgeon-modified" stent grafts refer to a technique, in which a commercially available stent graft is modified by the surgeon under sterile conditions directly before the implantation, in order to add the required fenestrations, scallops and/or branches. The modification takes approximately 60 - 120 min and haemodynamic stability of the patient is mandatory. Because of the off-label use of the commercial stent graft, detailed patient consent about the modification complications and risks should be performed whenever possible. A comparison of results on mortality and morbidity between "off-the-shelf" and "surgeon-modified" stent grafts has been published, although a direct comparison would be unfair for several reasons (different design, lack of extensive outcomes reports, long learning curve and different modification techniques). CONCLUSION The "surgeon-modified" and "off-the-shelf" fenestrated/branched stent grafts are used in the treatment of high-risk patients with symptomatic or contained ruptured complex aneurysms. The outcomes of the two techniques are good, although the long-term durability of the former should be further investigated.
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Affiliation(s)
- Dimitrios Kapetanios
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Tilo Koelbel
- Gefäßchirurgie, Universitäres Herzzentrum, Hamburg, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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Zymvragoudakis V, Saha P, Gkoutzios P, Zayed H, Abisi S. Use of the Off-The-Shelf Pre-Cannulated E-Nside Endograft to Overcome Anatomical Challenges in Urgent Complex Endovascular Aortic Repair. Ann Vasc Surg 2021; 79:441.e1-441.e7. [PMID: 34653640 DOI: 10.1016/j.avsg.2021.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/15/2021] [Accepted: 07/30/2021] [Indexed: 11/01/2022]
Abstract
Treatment options for large or symptomatic complex aortic aneurysms that require urgent intervention remain limited. Patient factors and comorbidities often make open surgery unappealing, leading to increasing interest in endovascular solutions that can be employed in the urgent setting, such as off-the-shelf endografts. The E-nsideTM (Jotec GmbH, Hechingen, Germany) is a new off-the-shelf endograft with 4 pre-cannulated inner branches that has recently become available in Europe. We report the urgent treatment of 2 large complex aortic aneurysms using this device and discuss the benefits of this new technology. The E-nside off-the-shelf endograft with inner branches is a useful addition to our treatment options for complex aortic aneurysms, particularly those with a narrow aortic lumen. Pre-cannulation of branches provides consistent access to the branches and a readily available option for establishment of a through and through wire for added stability during cannulation and bridging stent-grafts placement. The design of inner branches provides flexibility during deployment of the endograft and cannulation of the target vessels in varied, challenging anatomies.
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Affiliation(s)
- Vassilios Zymvragoudakis
- 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
| | - Panos Gkoutzios
- Department of Interventional Radiology, 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
| | - Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Zimmermann A, Menges AL, Rancic Z, Meuli L, Dueppers P, Reutersberg B. E-nside Off-the-Shelf Inner Branch Stent Graft: Technical Aspects of Planning and Implantation. J Endovasc Ther 2021; 29:167-174. [PMID: 34569343 PMCID: PMC8928429 DOI: 10.1177/15266028211047967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose This article aims to present all aspects regarding patient selection, planning, and implantation technique for a new off-the-shelf pre-cannulated multi-inner branch stent graft. The stent graft comes in 4 different versions with proximal diameters of 33 and 38 mm and distal diameters of 26 and 30 mm. The 4 inner branches are located in the middle segment, which has a diameter of 24 mm. Technique With inner branch technology, the field of application for the treatment of thoracoabdominal aortic aneurysms (TAAA) has been further extended. In addition to routine use in elective cases the pre-cannulation of the inner branches predisposes especially for emergencies. Pre-cannulation is intended to reduce the time to cannulation and the radiation dose. All steps of planning, stent-graft deployment, and cannulation of the inner branches are described in detail. Conclusion The E-nside stent graft represents a promising new endovascular therapy in the treatment of acute and elective TAAA. By using inner branch technology, this endograft combines the advantages of fenestrated and branched stent grafts. Indication, planning, and implantation require experience in branched and fenestrated stent graft technology.
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Affiliation(s)
| | - Anna-Leonie Menges
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Zoran Rancic
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
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Eleshra A, Hatm M, Spanos K, Panuccio G, Rohlffs F, Debus ES, Behrendt CA, Tsilimparis N, Kölbel T. Early outcomes of t-Branch off-the-shelf multibranched stent-graft in urgent and emergent repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:416-424.e2. [PMID: 34480993 DOI: 10.1016/j.jvs.2021.07.237] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent-graft (Cook Medical, Bloomington, Ind). METHODS All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests. RESULTS The t-Branch stent-graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively. CONCLUSIONS The technical success of TAAA repair using t-Branch stent-graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation.
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Affiliation(s)
- Ahmed Eleshra
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.
| | - Mohamed Hatm
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - E Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Christian-A Behrendt
- 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
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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E G, G F, G M, A F, G I, M L, C P, R C, M G. Pre and postoperative predictors of clinical outcome of fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms in an Italian multicenter registry. J Vasc Surg 2021; 74:1795-1806.e6. [PMID: 34098004 DOI: 10.1016/j.jvs.2021.04.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Complex aortic aneurysms (juxtarenal j-AAA, pararenal p-AAAs, thoracoabdominal TAAAs) are treated with increasing frequency through fenestrated and branched endovascular repair (F/B-EVAR), however the outcome of these procedures is usually reported separately by single experiences and wider overviews are not frequent. The aim of this study was therefore to report an Italian experience analyzing the results obtained in 4 academic centers in order to evaluate predictors of outcome. METHODS Between 2008 and 2019, all consecutive patients undergoing F/B-EVAR in 4 Italian university centers were prospectively recorded and retrospectively analyzed. Preoperative comorbidities and postoperative complications were classified according with the SVS-reporting standard. Postoperative complications and 30-day / in-hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions (FFRs) and target visceral vessels (TVVs) patency were assessed as follow-up outcomes by Kaplan-Meier analysis. Risk factors for 30-day / in-hospital mortality and spinal cord ischemia (SCI) were determined by multivariate analysis. Risk factors for follow-up mortality and reinterventions were evaluated by Cox-regression model. RESULTS Five hundred and ninety-six patients underwent F/B-EVAR for 124(21%) j-AAAs, 121(20%) p-AAAs and 351(59%) TAAAs. Elective and urgent procedures were performed in 520(87%) and 76(13%) cases, respectively. Postoperative cardiac, pulmonary and renal complications were reported in 41(7%), 50(8%) and 80(13%) patients, respectively. Seven (1%) bowel ischemia and 23(4%) cerebrovascular complications occurred. Forty-seven (8%) patients suffered SCI with 17(3%) cases of permanent paraplegia. Crawford's extent I-II-III TAAAs (OR:13.41; 95%CI:1.77-101.65; P=.012) and postoperative renal complications (OR:3.84; 95%CI:1.70-8.69; P=.001) independently predicted SCI. Thirty-two (5%) patients died in the perioperative period. Preoperative chronic renal failure (OR:7.81; 95%CI:7.81-26.31; P=.001), postoperative bowel ischemia (OR:26.97; 95%CI:3.37-215.5; P=.002), cardiac (OR:5.77; 95%CI:1.41-23.64; P=<.001),cerebrovascular (OR:28.63; 95%CI:5.20-157.5; P:<.001) complications and SCI (OR:5.99; 95%CI:1.12-32.5; P=.036) were independently correlated with 30-day/hospital mortality. The mean follow-up was 25+7months. Freedom from TVVs occlusion and FFR were 96% and 92% at 1 year and 93% and 85% at 3 years, respectively. TAAAs (HR:3.16; 95%CI:1.68-5.92; P=<.001), post dissection TAAAs (HR:2.20; 95%CI:1.30-4.90; P=.05) and postoperative bowel ischemia (HR:11.98; 95%CI:1.53-93.31; P=.018) were independent predictors of reinterventions. Survival was 88% and 78% at 1 and 3 years, respectively. Preoperative chronic renal failure (HR:2.39; 95%CI:1.59-3.59; P=<.001), urgent repair (HR:1.80; 95%CI:1.03-3.20; P=.039), TAAAs (HR:2.01; 95%CI:1.13-3.56; P=.017),postoperative bowel ischemia (HR:5.55; 95%CI:2.11-14.59; P=.001), cardiac (HR:3.89; 95%CI:2.25-6.71; P=<.001) and pulmonary (HR:1.97; 95%CI:1.56-3.35; P=.013) complications were independent predictors of mortality during follow up. CONCLUSION F/B-EVAR is associated with satisfactory mid-term outcomes in a nationwide experience. A variety of risk factors should be considered in FB-EVAR indication and post-operative patients management in order to reduce the risk of postoperative complications and improve mid-term outcome.
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Affiliation(s)
- Gallitto E
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Faggioli G
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Melissano G
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fargion A
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Isernia G
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti M
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Pratesi C
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Chiesa R
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gargiulo M
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Youssef M, Gunaseelan M. A Branch-to-Branch Through-and-Through Wire Technique to Redirect a Branch Malposition in Multibranched Endovascular Aortic Aneurysm Repair. J Endovasc Ther 2021; 28:682-686. [PMID: 33998351 DOI: 10.1177/15266028211016434] [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: 11/15/2022]
Abstract
OBJECTIVE To describe a novel technique to redirect a malrotated branch when treating a symptomatic juxtarenal aortic aneurysm using an off-the-shelf multibranched endograft. TECHNIQUE A 75-year-old patient was admitted because of a symptomatic juxtarenal aortic aneurysm with a maximum diameter of 9.2 cm. The aneurysm showed no infrarenal neck. Because of his comorbidities, an endovascular repair using off-the-shelf multibranched endograft was considered as urgent procedure. During the deployment, the devise malrotated clockwise. The incorporation of the renal branches was performed successfully; however, the superior mesenteric artery (SMA) branch was malpositioned, so that the SMA could not be cannulated. Both celiac and SMA branches were simultaneously cannulated and snared outside of the endograft redirecting the malrotated SMA branch (a branch-to-branch through-and-through wire technique). Leaving the through-and-through wire in situ, the SMA could be intubated using parallel wire through the SMA branch. The final angiogram showed a good perfusion of the renovisceral vessels. The aneurysm was completely excluded. The patient was discharged into a rehabilitation facility 8 days later without complications. The 12-month follow-up period was uneventful. CONCLUSION A branch-to-branch through-and-through wire technique for branch repositioning is feasible and may present a bailout tool.
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Affiliation(s)
- Marwan Youssef
- Department of Vascular and Endovascular Surgery, Academic Asklepios Hospital Nord-Heidberg, Hamburg, Germany
| | - Meera Gunaseelan
- Department of Vascular and Endovascular Surgery, Academic Asklepios Hospital Nord-Heidberg, Hamburg, Germany
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Edman NI, Schanzer A, Crawford A, Oderich GS, Farber MA, Schneider DB, Timaran CH, Beck AW, Eagleton M, Sweet MP. Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium. J Vasc Surg 2021; 74:861-870. [PMID: 33775747 DOI: 10.1016/j.jvs.2021.02.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Fenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs. METHODS The data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia). RESULTS Of the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P < .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P < .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P < .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46). CONCLUSIONS Women undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash; Medical Scientist Training Program, University of Washington, Seattle, Wash
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Allison Crawford
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Program, Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Carlos H Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, Tex
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash.
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Bosiers M, Kölbel T, Resch T, Tsilimparis N, Torsello G, Austermann M. Early and mid-term results from a postmarket observational study of Zenith t-Branch thoracoabdominal endovascular graft. J Vasc Surg 2021; 74:1081-1089.e3. [PMID: 33684474 DOI: 10.1016/j.jvs.2021.01.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We have reported the short-term outcomes regarding the safety of the off-the-shelf Zenith t-Branch multibranched thoracoabdominal stent-graft (William Cook Europe ApS, Bjaeverskov, Denmark) in a postmarket, multicenter study. METHODS Patients who had been treated with the t-Branch device from September 2012 to November 2017 at three European centers were either prospectively or retrospectively enrolled in the present study. Device implantation and postprocedural follow-up were performed according to the standard of care at each center. The primary objectives of the present study were to assess the procedure-related mortality and morbidity at 30 days and 1 year and to assess the presence of endoleaks, device integrity, and stent-graft and branch vessel patency. RESULTS A total of 80 patients were included in the present study (mean age, 71.0 ± 7.4 years; 70.0% male). Most (n = 77) had been treated for thoracoabdominal aortic aneurysms (TAAAs) and the rest for dissection (n = 3). Most TAAAs were stable (72.7%; 56 of 77). The remaining TAAAs were symptomatic (7.8%; 6 of 77) or had a contained rupture (19.5%; 15 of 77). The t-Branch device was successfully deployed in 79 patients. In one patient, the delivery system of the device could not be advanced through the iliac artery. Within 30 days, one patient had died (1.3%). At 1 year, seven patients had died (8.8%), and no aortic rupture or conversion to open surgery had been reported. The 30-day neurologic events included stroke in three patients (3.8%), paraplegia in one (1.3%), and paraparesis in six patients (7.5%). Secondary interventions were required in nine patients (11.3%) during follow-up. Postoperative endoleaks were observed in 37 of 72 patients (51.4%), including type II endoleak in 30, type Ia in 4, and type III endoleak in 6 patients. At 1 year, endoleaks had been reported in 20 patients (16 with type II and 4 with type III). The t-Branch main body graft patency was 100% throughout the 1-year follow-up period. At 30 days after the procedure, all celiac and superior mesenteric artery branches were patent and one left renal and one right renal branch were occluded. At 1 year, occlusion had developed in three bridging stent-grafts for the celiac artery, one for the left renal artery, and two for the right renal artery. CONCLUSION The t-Branch device appears safe, with good 30-day and 1-year mortality and morbidity in the present study, including both stable and symptomatic cases.
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Affiliation(s)
- Michel Bosiers
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany.
| | - Tilo Kölbel
- University Heart and Vascular Center, Hamburg, Germany
| | | | - Nikolaos Tsilimparis
- University Heart and Vascular Center, Hamburg, Germany; Department of Vascular Surgery, Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Martin Austermann
- Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
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Makaloski V, Tsilimparis N, Panuccio G, Spanos K, Wyss TR, Rohlffs F, Debus ES, Kölbel T. Perioperative Outcome of Fenestrated and Branched Stent Grafting after Previous Open or Endovascular Abdominal Aortic Repair. Ann Vasc Surg 2021; 74:229-236. [PMID: 33549779 DOI: 10.1016/j.avsg.2020.12.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoracoabdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair. METHODS Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality. RESULTS We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and 8 with a tube graft. Of these, 2 patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, 3 of them with additional type Ia endoleak, 2 with stent-graft migration and 2 with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P = 0.746). Eighteen patients (86%) had branched stent grafting in the post-open versus 11 (52%) in the post-endo group (P < 0.01). In 2 patients in the post-open group, 3 renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, 2 due to cerebral hemorrhage and 2 due to pneumonia, and none in the post-endo fbEVAR group (P = 0.101). There were 5 nonstent-graft-related reinterventions, 2 (10%) in the post-open fbEVAR group and 3 (14%) in the post-endo fbEVAR group (P = 0.844). After 12 months there were 4 events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and 2 type II endoleaks were embolized with coils. There were no reinterventions in the post-open fbEVAR group during 12 months. CONCLUSIONS Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair.
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Affiliation(s)
- Vladimir Makaloski
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany; Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Thomas Rudolf Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Eike Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Duvnjak S, Bach-Frommer S, Resch TA. T Branch Repair of Ruptured a Type IV Thoracoabdominal Aortic Aneurysm Complicated by Renal Branch Occlusion. Vasc Endovascular Surg 2021; 55:495-500. [PMID: 33511919 DOI: 10.1177/1538574421989852] [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: 11/16/2022]
Abstract
A 60-year male patient presented with a thoracoabdominal aortic aneurysm rupture, which was treated emergently with a modified off-the-shelf t-Branch stent-graft (COOK Medical Inc). The sole renal branch occluded 1 month after TEVAR due to branch compression, and the patient became anuric and temporarily dialysis-dependent. Despite the prolonged renal ischemia time, the occluded renal branch was successfully opened with thrombolysis and reinforced with a bare-metal stent. The patient recovered his renal function and came off dialysis.
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Affiliation(s)
- Stevo Duvnjak
- Department of Vascular Surgery, 53146Rigshospitalet, Copenhagen, Denmark
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Grandi A, Carta N, Cambiaghi T, Bilman V, Melissano G, Chiesa R, Bertoglio L. Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft. J Endovasc Ther 2020; 28:283-294. [DOI: 10.1177/1526602820964916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To evaluate the potential anatomical feasibility of using the off-the-shelf multibranched Zenith t-Branch for the treatment of thoracoabdominal aortic aneurysms (TAAAs) in female patients. Materials and Methods: A total of 268 patients (median age 68 years; 69 women) with degenerative TAAA treated at a single institution by means of open or endovascular repair between 2007 and 2019 were retrospectively analyzed to determine the feasibility of using the Zenith t-Branch based on the manufacturer’s instructions for use. The factors determining overall anatomical feasibility were divided into vascular access, aortic anatomy, and visceral vessels. The results were stratified by sex and compared. A logistic regression model was constructed to determine any association between feasibility and clinical factors or potential confounding variables; results are expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: The overall anatomical feasibility was 39% (22% women vs 45% men, p=0.001). The feasibility was negatively influenced by female sex (p<0.001) in multivariable analysis (OR 2.9, 95% CI 1.5 to 5.4, p=0.001). Vascular access feasibility was 82% (61% women vs 89% men, p<0.001). Aorta feasibility was 65% (52% women vs 69% men, p<0.001), and visceral vessel feasibility was 74% (78% women vs 73% men, p=0.260). An access diameter ≤8.5 mm excluded 17% of the patients (39% women vs 9% men, p<0.001). The aortic feasibility was limited by the infrarenal aortic diameter in 16% of patients (45% women vs 6% men, p<0.001) and the aortic lumen at the visceral vessels in 17% patients (19% women vs 17% men, p=0.741). The visceral vessel feasibility was mainly limited by inadequate numbers or diameters of target vessels. Location and orientation of the target vessels were adequate in 96% of patients. Conclusion: A little more than a third of an all-comers cohort of patients with degenerative TAAA could have been treated with on-label use of the Zenith t-Branch. However, only 22% of women could have been treated because of sex-related anatomical limitations. New generations of multibranched devices should address these differences.
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Affiliation(s)
- Alessandro Grandi
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX, USA
| | - Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro, Brazil
| | - Germano Melissano
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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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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Leong BDK, Joseph FS. Total Percutaneous Femoral Approach for Branched Custom-Made Device Endovascular Repair of Thoracoabdominal Aneurysm. Ann Vasc Dis 2020; 13:347-350. [PMID: 33384745 PMCID: PMC7751077 DOI: 10.3400/avd.cr.20-00080] [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: 11/18/2022] Open
Abstract
Thoracoabdominal aortic aneurysm (TAAA) is a challenging vascular condition to manage. Traditionally, open surgical repair has been the standard of treatment. Endovascular repair for TAAA has gained much popularity because it is a minimally invasive approach that results in better mortality and morbidity profiles. We report a case of TAAA successfully treated with a custom-made multi-branch device through a total femoral approach with the use of a steerable sheath for branch cannulation and deployment of bridging stents to targeted visceral vessels. This approach avoided complications related to upper extremity access, such as stroke, and allowed shorter operative time with better workstation ergonomics.
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Affiliation(s)
- Benjamin Dak Keung Leong
- CardioVascular & Lung Centre, Gleneagles Hospital.,Unit of Vascular Surgery, Queen Elizabeth Hospital
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40
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Konstantinou N, Antonopoulos CN, Jerkku T, Banafsche R, Kölbel T, Fiorucci B, Tsilimparis N. Systematic review and meta-analysis of published studies on endovascular repair of thoracoabdominal aortic aneurysms with the t-Branch off-the-shelf multibranched endograft. J Vasc Surg 2020; 72:716-725.e1. [DOI: 10.1016/j.jvs.2020.01.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 01/17/2020] [Indexed: 12/01/2022]
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41
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Juszczak MT, Vezzosi M, Khan M, Mascaro J, Claridge M, Adam D. Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts. J Vasc Surg 2020; 72:435-444. [DOI: 10.1016/j.jvs.2019.10.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 10/05/2019] [Indexed: 11/28/2022]
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Mehmedovic A, Konstantinou N, Jerkku T, Pichlmaier M, Kölbel T, Rantner B, Banafsche R, Tsilimparis N. [Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?]. Zentralbl Chir 2020; 145:432-437. [PMID: 32659798 DOI: 10.1055/a-1186-2554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.
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Affiliation(s)
- Aldin Mehmedovic
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Konstantinou
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Thomas Jerkku
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Tilo Kölbel
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg-Eppendorf, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Ramin Banafsche
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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Edman NI, Bartek MA, Kang PC, Sweet MP. Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2020; 70:481-490. [PMID: 32603844 DOI: 10.1016/j.avsg.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. METHODS A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. RESULTS Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. CONCLUSIONS Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew A Bartek
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - P Chulhi Kang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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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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45
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Yang G, Zhang M, Muzepper M, Du X, Wang W, Liu C, Qiao T, Zhou M, Li X. Comparison of Physician-Modified Fenestrated/Branched Stent-Grafts and Hybrid Visceral Debranching Plus Stent-Graft Placement for Complex Thoracoabdominal Aortic Aneurysm Repair. J Endovasc Ther 2020; 27:749-756. [PMID: 32580618 DOI: 10.1177/1526602820934466] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate the immediate postoperative and midterm outcomes of complex thoracoabdominal aortic aneurysm (TAAA) treatment with fenestrated/branched physician-modified endovascular grafts (PMEGs) or open debranching of the visceral aorta with bypass graft revascularization plus endovascular aneurysm exclusion (hybrid repair). Materials and Methods: A retrospective analysis was conducted of 88 patients (mean age 70.0±10.6 years; 73 men) with complex TAAAs who underwent treatment with PMEGs (60, 68%) or a hybrid technique (28, 32%) between 2016 and 2019. The mean aneurysm diameter was 64.5±11.7 mm, and 37 patients (42%) were symptomatic. The Zenith TX2 and Ankura were the main stent-grafts used in the PMEG group. The hybrid technique involved visceral debranching with extra-anatomical bypass graft revascularization and subsequent stent-graft deployment (1- or 2-stage procedure). Results: In the PMEG group, 35 patients received modified stent-grafts with 4 fenestrations, 8 patients had 4 branches per device, and 17 patients had combinations (50 fenestrations and 18 branches) that successfully revascularized 228 of the 240 targets (95%). In the 28 hybrid cases, all 110 target vessels were successfully revascularized with bypass grafts. The overall 30-day mortality was 3.4% (2 PMEG and 1 hybrid), and the early rate of target vessel stenosis/occlusion was 3.3% (5 in PMEG group and 6 in the hybrid repair group). The 30-day morbidity was mainly attributed to pulmonary complications (15%), lower limb ischemia (8%), or spinal cord ischemia with paraplegia (6%). Eleven patients (13%) had deteriorated renal function with a >30% decrease in the glomerular filtration rate. The mean follow-up was 22.3±4.9 months, and mortality was 4.5% (3.3% in the PMEG group vs 7.1% in the hybrid repair group). Conclusion: PMEGs and hybrid techniques seem to be feasible treatment options for aortic aneurysms necessitating visceral vessel revascularization. PMEGs may have a lower morbidity than the hybrid technique, which nonetheless remains an important option available for complex aortic aneurysms.
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Affiliation(s)
- Guangmin Yang
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Ming Zhang
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Mehmutjan Muzepper
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xiaolong Du
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Wei Wang
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Cheng Liu
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Tong Qiao
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Min Zhou
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
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Tsilimparis N, Haulon S, Spanos K, Rohlffs F, Heidemann F, Resch T, Dias N, Kölbel T. Combined fenestrated-branched endovascular repair of the aortic arch and the thoracoabdominal aorta. J Vasc Surg 2020; 71:1825-1833. [DOI: 10.1016/j.jvs.2019.08.261] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/16/2019] [Indexed: 11/17/2022]
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Eleshra A, Oderich GS, Spanos K, Panuccio G, Kärkkäinen JM, Tenorio ER, Kölbel T. Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair. J Vasc Surg 2020; 72:1558-1566. [PMID: 32423775 DOI: 10.1016/j.jvs.2020.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair. METHODS A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded. RESULTS There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively. CONCLUSIONS The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.
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Affiliation(s)
- Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
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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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Acute Insulin Resistance and Rapid Alterations in Neuronal Derived Blood Exosome Concentration After Branched Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2020; 59:457-463. [DOI: 10.1016/j.ejvs.2019.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 09/26/2019] [Accepted: 10/11/2019] [Indexed: 12/23/2022]
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Tsilimparis N, Banafsche R, Stana J. Commentary: Physician-Modified Endografts: Surmounting Anatomical Challenges With Innovative Techniques to Optimize Treatment. J Endovasc Ther 2020; 27:130-131. [PMID: 31948379 DOI: 10.1177/1526602819897007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Ramin Banafsche
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
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