Technical Solutions for Common Problems in TEVAR:

Vascular Access Challenges in Thoracic Endovascular Aortic Repair: A Literature Review

BACKGROUND

This review aims to comprehensively summarize access challenges in thoracic endovascular aortic repair (TEVAR) by describing vascular access routes, associated risks, outcomes, and complications.

METHODS

A literature search was conducted utilizing the PubMed (Medline), Scopus, and Web of Science databases. Qualitative and quantitative data from selected studies are extracted and discussed according to available standards for narrative reviews.

RESULTS

In total, there were 109 eligible studies based on predefined inclusion- and exclusion criteria. There were 39 original articles or reviews and 57 case series or case reports. This article summarizes the evidence from these studies and discusses traditional retrograde access routes and techniques for TEVAR via a femoral or iliac route, with or without the use of conduits. Next, alternative antegrade access routes and techniques via a brachial, axillary, carotid, ascending aorta, transapical, transcaval, or another route are discussed. Vascular access complications are presented with specific attention to the importance of gender and alternative antegrade access routes.

CONCLUSIONS

Multiple access routes and techniques are currently available to overcome access challenges associated with TEVAR, based on low grade evidence from heterogeneous studies. Future research that compares different access routes and techniques might help in the development of a tailored access protocol for specific patients with challenging TEVAR access.

Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis

PURPOSE

The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies.

MATERIALS AND METHODS

A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality.

RESULTS

Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004).

CONCLUSION

Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.

Iliac Stent Migration during Thoracic Endovascular Aortic Aneurysm Repair Resulting in Functional Coarctation

Iliac arterial disease, unfavorable anatomy, and prior stenting all pose challenges to access in endovascular abdominal aortic repair (EVAR) and thoracic aortic repair (TEVAR). Iliac access injury during T/EVAR may lead to rupture, dissection, thrombosis, or distal ischemia. Some have advocated iliac stent prior to T/EVAR in patients with suboptimal iliac access. The rate of complication and iliac stent migration during subsequent T/EVAR is undocumented. This case report describes a unique instance of self-expanding iliac stent migration during TEVAR which pinched the thoracic aortic endograft causing functional aortic coarctation.

Thoracic Aorta Aneurysm Repair in a Patient with a Solitary Kidney: Hybrid Surgery as a Bailout Procedure

Thoracic endovascular aortic repair (TEVAR) is an emerging treatment option for thoracic aorta aneurysms (TAA). Endovascular access is a challenge. We present a novel TEVAR technique in a patient with single kidney and a 6.4 cm TAA. Attempting to place a sheath through iliac arteries was unsuccessful. The decision to proceed to hybrid TEVAR was made. The protection of the solitary kidney was achieved through axillo-femoral bypass, followed by an end-to-side anastomosis between the aorta and a bifurcated graft. Through the graft, a stent was introduced in the thoracic aorta. With the use of contrast material, the right position of the graft was confirmed.

Unfavorable iliac artery anatomy causing access limitations during endovascular abdominal aortic aneurysm repair: application of the endoconduit technique

Endovascular aneurysm repair (EVAR) is already considered the first choice treatment for abdominal aortic aneurysms (AAA). Several different strategies have been used to address limitations to arterial access caused by unfavorable iliac artery anatomy. The aim of this report is to illustrate the advantages and limitations of each option and present the results of using the internal endoconduit technique and the difficulties involved.

Hybrid Antegrade Thoracic Aortic Stenting via a Temporary Ascending Aortic Graft Conduit for a Patient with Poor Peripheral Vascular Access

In patients with poor peripheral vascular access, thoracic aortic stenting procedures can be technically very challenging. Antegrade aortic stent deployments during concomitant open ascending and arch procedures are well described, but the issue of long endovascular catheters and wires may make such an approach difficult and awkward. We describe a novel hybrid method involving a temporary graft conduit to the ascending aorta which is brought caudal toward the foot of the table to facilitate antegrade deployment of the thoracic stent graft.