Treatment of Hostile Proximal Necks During Endovascular Aneurysm Repair

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15 mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39 months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.

The use of EndoAnchors in endovascular repair of abdominal aortic aneurysms with challenging proximal neck: Single-centre experience

Objectives

The aim of this study was to present a single-centre experience with EndoAnchors in patients who underwent endovascular repair for abdominal aortic aneurysms with challenging proximal neck, both in the prevention and treatment of endograft migration and type Ia endoleaks.

Methods

We retrospectively analysed 17 consecutive patients treated with EndoAnchors between June 2015 and May 2018 at our institution. EndoAnchors were applied during the initial endovascular aneurysm repair procedure (primary implant) to prevent proximal neck complications in difficult anatomies (nine patients), and in the follow-up after aneurysm exclusion (secondary implant) to correct type Ia endoleak and/or stent-graft migration (eight patients).

Results

Mean time for anchors implant was 23 min (range 12–41), with a mean of 5 EndoAnchors deployed per patient. Six patients in the secondary implant group required a proximal cuff due to stent-graft migration ≥10 mm. Technical success was achieved in all cases, with no complications related to deployment of the anchors. At a median follow-up of 13 months (range 4–39, interquartile range 9–20), there were no aneurysm-related deaths or aneurysm ruptures, and all patients were free from reinterventions. CT-scan surveillance showed no evidence of type Ia endoleak, anchors dislodgement or stent-graft migration, with a mean reduction of aneurysm diameter of 0.4 mm (range 0–19); there was no sac growth or aortic neck enlargement in any case.

Conclusions

EndoAnchors can be safely used in the prevention and treatment of type Ia endoleaks in patients with challenging aortic necks, with good results in terms of sac exclusion and diameter reduction in the mid-term follow-up.

[Proximal fixation devices in endovascular repair of abdominal aortic aneyrysm with unfavourable proximal neck anatomy]

Abdominal aortic aneurysm is a common vascular disease requiring surgical treatment. Currently, endovascular aortic repair is a good alternative to open surgery. However, high incidence of unfavorable anatomical variants of the proximal landing zone limit the use of endovascular aortic repair in these patients. Additional techniques can increase applicability of endovascular procedure with optimal results. Two patients with unfavorable proximal neck anatomy undergoing endovascular aortic repair with anchor type of proximal fixation devices are reported in the article.

Complications and Reinterventions After Fenestrated and Branched EVAR in Patients with Paravisceral and Thoracoabdominal Aneurysms

The application of endovascular strategies to treat aneurysms involving the abdominal and thoracoabdominal aorta has evolved significantly since the inception of endovascular aneurysm repair. Advances in endograft technology and operator experience have enabled the management of a wider spectrum of challenging aortic anatomy. Fenestrated endovascular and branched endovascular aneurysm repair represent two technical innovations, which have expanded endovascular treatment options to include patients with paravisceral and thoracoabdominal aortic aneurysms. Although similar in many ways to standard aortic endografts, fenestrated and branched endografts have specific short- and long-term complications due to their unique modular endograft design and their sophisticated deployment mechanisms. This article aims to examine the commonly encountered complications with these devices and the endovascular reintervention strategies.

A Custom-Made Treovance® Abdominal Aortic Aneurysm Endograft to Correct Late Failure of Trombone Technique with a Tube Endograft

BACKGROUND

Unfavorable anatomy is one of the major limitations of endovascular aortic aneurysm repair (EVAR) with specifically adverse proximal neck morphology excluding many patients from receiving the standard endograft devices. Thoracic tube endografts have been used to overcome the issue of wide infrarenal necks, either as a sole device (single tubes or double tubes using the trombone technique) or as the proximal part of a bifurcated device fixed to the aortic bifurcation or infrarenally oriented. However, custom-made large proximal diameter bifurcated endograft designs have never been used.

METHODS

We present the case of a 56-year-old man with Marfan syndrome, suffering abdominal aortic aneurysm (AAA) enlargement from a type Ib endoleak after previous EVAR with 2 Endofit tube endografts (trombone technique). He was considered unfit for open surgery while possible alternatives such as fenestrated endovascular AAA repair and chimney technique were excluded.

RESULTS

The patient was treated with a custom-made 44-mm proximal diameter, bifurcated Bolton Medical Treovance device with technical and clinical success. No immediate or perioperative complications were noted. Follow-up after 6 months showed graft patency and no endoleak of any type.

CONCLUSIONS

This alternative technique for hostile proximal neck management is promising and needs long-term follow-up; an issue which is discussed within the broader context of custom-made device regulations.