CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms

Latest evidence on chimney endovascular repair of abdominal aortic aneurysms and the renal artery angulation pitfall

This article summarizes the key findings in literature up to date on the endovascular treatment of complex abdominal aortic aneurysms (AAAs) employing the chimney technique. Additionally, an unexplored pitfall is described regarding the target vessel angulation. Although balloon-expandable covered stents present more favorable configuration in downward-oriented target vessels, transverse and upward-oriented target vessels may benefit from other endovascular techniques imploring careful case planning and further investigation on the topic.

Predictors of inadequate EndoAnchors aortic wall penetration for the Endosutured therapy in hostile neck patients

BACKGROUND

The use of EndoAnchors is increasing; however, not much about appropriate use in terms of aortic wall penetration (AWP) is described. We aim to evaluate the procedural and anatomical conditions related with borderline (b) or absence (ab) of AWP when checked on first CT-scan after the Endosutured aortic repair (ESAR) for hostile neck anatomies (HNA).

METHODS

This study with NCT04100499 is a single center prospective evaluation of patients receiving EndoAnchors for prevention or treatment of a proximal EVAR failure. AWP was evaluated on first CT-scan and findings correlated with neck anatomical features and procedural data. The sum of borderline and absence of AWP was considered as Inadequate - In-AWP (failure). Adjunctive procedures, reinterventions, all-cause mortality, absence of type Ia EL and aneurysm related mortality are also described.

RESULTS

Forty-eight patients were treated during the study period and 43 high-surgical risk patients were finally included in the study for analysis with at least one HNA criteria (58%) and associating two in 21% or even three in 21%. A total of 250 EndoAnchors were deployed at a median 6 (range, 4-10) per case. From those, 31 (12.5%) achieved b-AWP and 11 (4.4%) ab-AWP, meaning 42 (16.8%) EndoAnchors with In-AWP. Univariate-analysis showed being an occasional user and a therapeutic case as predictor for at least one and more failures. The only predictor on multivariate analysis for two or more EndoAnchors with In-AWP was being an occasional user. Cumulative-survival and freedom from type-Ia EL at 2-years was 84% and 95%; respectively.

CONCLUSIONS

Outcomes of the ESAR therapy should be validated according to their aortic wall penetration checked on first CT-scan. EndoAnchors use in HNA should not be considered an easy approach for the endovascular technique, especially for therapeutic cases. An individual and specific case analysis counterbalancing inadequate use of the device in unexperienced users should be evaluated against the increased risk of proximal failure as in standard EVAR alone during HNA treatment.

The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review

INTRODUCTION

Open repair (OR), fenestrated endovascular aneurysm repair (fEVAR) and endovascular exclusion using parallel graft (chEVAR) are complementary procedures used for treatment of juxtarenal abdominal aortic aneurysm (jrAAA). The aim of our study was to assess available literature and analyze dispersion of OR, fEVAR and chEVAR procedures among reported papers related to treatment of jrAAA.

EVIDENCE ACQUISITION

The PubMed database was systematically searched using predefined strategy and key words related to treatment of jrAAA on September 28th, 2019. Studies were assessed for eligibility using the inclusion and exclusion criteria with at least five patients treated with at least one of the procedures while systematic reviews, meta-analysis, reviews, comments, editorials and letters were excluded as well as studies without clear classification of the location of the aneurysm, studies not specifying the number of patients treated with each of the techniques or not discriminated between aortic pathologies (juxtarenal, paravisceral and thoracoabdominal), hybrid procedures, endoanchors or with branched stent-graft.

EVIDENCE SYNTHESIS

Overall, 1533 papers were identified while papers that met inclusion criteria were either representing experience of single institution (87 papers) or from multicenter studies (6 papers), national or international registries (18 papers). In the period between January 1977 and December 2017, treatment of 5664 patients with jrAAA was reported in 87 papers as a single institution report. Out of them 2531 (45%) were treated with OR, 2592 (46%) with fEVAR and 541 (9%) with chEVAR. Out of 29 institutions reporting OR, there were 11 (37.9%) with more than 100 treated patients while 21 (41.1%) out of 51 institutions that reported more than 50 jrAAA treated with fEVAR. Only four institutions reported results of all three treatment modalities.

CONCLUSIONS

Based on the results reported in the literature, regardless of its complexity and costs, fEVAR for jrAAA has been accepted in substantial number of hospitals worldwide, while number of reported procedures is reaching OR.

The role of computerized tomographic angiography in the diagnosis of pathologically modified renal arteries

Introduction: The most common causes of renal artery disease are stenosis, as a consequence of atherosclerosis and fibromuscular dysplasia. Computed tomographic (CT) angiography is a non-invasive method, which enables visualization of vascular structures and walls of blood vessels, as well as morphology of the renal parenchyma. Objective: To determine the importance of CT angiography in detecting the cause and degree of renal arterial disease. Methods: A total of 45 patients were included in the cross-sectional study conducted from March 2017 to March 2019 in the KBC DR Dragiša Mišović-Dedinje, Belgrade, Serbia. Criteria for inclusion were suspicion of secondary arterial hypertension, patients in preparation for kidney transplantation and in the follow-up period after transplantation, as well as patients with suspected traumatic lesions. We analyzed the causes of the disease, the morphology of the blood vessel wall, the percentage of stenosis, and the renal parenchyma. Results: The most common causes of renal arterial disease are atherosclerosis, which was found in 33 (73%) patients, renal artery aneurysm was found in 5 (11%) subjects, fibromuscular dysplasia in 4 (8.9%) and trauma in 1 (2) , 3%) of the patient. There were 10 (22.2%) patients with a significant (average 80 ± 14.5%) degree of stenosis. The sensitivity of CT angiography in the detection of atherosclerotic changes in the renal arteries was 87.9%, while the sensitivity of CT angiography in the detection of fibromuscular dysplasia was 75%. A statistically significant correlation was found between atherosclerotic stenosis of the renal arteries and a positive CTA finding (p = 0.0002). Conclusion: CT angiography is an important method of visualization and quantification of pathological changes in the renal arteries.

FEVAR/BEVAR have limitations and do not always represent the preferred option for juxtarenal reconstruction

Following the definition given by the recent ESVS guidelines, juxtarenal abdominal aortic aneurysm (JAAA) is defined as an aneurysm extending up to but not involving the renal arteries, necessitating suprarenal aortic clamping for open surgery, i.e. a short neck (<10 mm). JAAA repair always represents a challenge intervention, either by open or endovascular means, mostly related to the renal arteries involvement. Concerning endovascular repair, different options can be considered. Among them, fenestrated endografts (FEVAR) should be considered as a first option1, due to their reported safety and efficacy. However, when the anatomy is not favorable or when FEVAR devices are not available in an emergency setting for instance, other alternatives can be considered like parallel graft or chimney technique (ChEVAR). Do nothing is the last alternative when medical and anatomical circumstances are absolutely poor. In the following pages, we will review the limitations of FEVAR and branched endografts, the better indications and anatomical conditions for a successful repair with ChEVAR technique and its current clinical results reported in the literature.