Chimney vs. Fenestrated Endovascular vs. Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta-Analysis of the Medium-Term Results

Long-Term Outcomes of Endovascular Aortic Repair with Parallel Chimney or Periscope Stent Grafts for Ruptured Complex Abdominal Aortic Aneurysms

Background: The parallel stent graft endovascular aortic repair (PGEVAR) technique is an off-the-shelf option used for elective complex abdominal aortic aneurysm repair with acceptable outcome results, as reported so far. The PGEVAR technique, using chimney or periscope parallel grafts, can also be used for patients with ruptured complex abdominal aortic aneurysms. However, only few data about the mid- to long-term outcomes are available. Methods: Data from patients treated between August 2009 and July 2023 with the PGEVAR technique for ruptured complex abdominal aortic aneurysms were analyzed. The endpoints of this study were primary and secondary technical success, perioperative mortality, rate of proximal type 1a (gutter) endoleaks (T1aEL), and overall and aneurysm-related survival. Secondary endpoints were major adverse events, durability of parallel grafts, and factors associated with overall survival. Results: Twenty patients (mean age: 77 ± 9 y; 18 male) with ruptured complex abdominal aortic aneurysm were treated, receiving PGEVAR for ruptured juxtarenal (n = 11), suprarenal (n = 7), or distal thoracoabdominal Crawford IV aortic aneurysms (n = 2) with a mean diameter of 82 ± 18 mm (range 59-120). The patients had PGEVAR with implantation of 39 parallel grafts (1.95 PGs per patient; 23 chimney and 16 periscope) for revascularization of the celiac artery (n = 3), superior mesenteric artery (n = 9), and renal arteries (n = 27). Three patients had delayed PG implantation within 10 days. Primary technical success was 15/20 (75%) with five patients having an early proximal T1aEL, three of them having successful reintervention (secondary success rate: 18/20; 90%), with no persistent bleeding. Two patients had late T1aELs. The presence of an early T1aEL was related to the number of PGs (≥2) implanted (p = 0.038) or insufficient aortic SG oversizing (p = 0.038). In-hospital mortality was 1/20 (5%). Perioperative mortality up to 32 days was 3/20 (15%), with two further late aneurysm-related deaths and eight late aneurysm-unrelated deaths (overall mortality 13/20; 65%) during follow-up (median 34 months; range 1-115). Major adverse events were observed in 11 (55%) patients. Secondary parallel stent graft patency at 1 and 3 years was 97.4 and 94.1%. During follow-up, aneurysm sac behavior was determined in 19 patients, which showed diameter progression (n = 3), stable aneurysm disease (n = 3), and aneurysm diameter regression in 13 (68.4%) patients. Overall survival was 75% after 1 year, and 53% and 22% after 3 and 5 years. Factors associated with overall long-term survival were age < 80 years (p = 0.037), juxtarenal aneurysms (p = 0.023), the absence of major adverse events (p = 0.025), and aneurysm sac regression (p = 0.003). Conclusions: Treatment of ruptured complex abdominal aortic aneurysm with the PGEVAR technique is associated with acceptable perioperative and long-term outcomes with high PG patency rates. Early proximal T1aELs are observed with a relevant frequency, requiring early reintervention with successful sealing of most relevant endoleaks. To note, limitation of the number of parallel stent grafts implanted at the proximal aortic sealing sites, sufficient PG sealing length, and adequate main aortic SG oversizing are most relevant to avoid T1a (gutter) ELs. The selection of juxtarenal aortic aneurysms and evidence for aneurysm sac diameter regression after PGEVAR had a prognostic impact.

Outcomes and Imaging Surveillance Adherence in Juxta-Renal Aortic Aneurysms Repairs: A VASQIP Retrospective Study

OBJECTIVE

Fenestrated endovascular aortic repair (FEVAR) has demonstrated its value in the management of juxtarenal abdominal aortic aneurysms (JAAA), but data were largely derived from clinical trials and high-volume centers. Although routine imaging surveillance is recommended following endovascular interventions, little is known regarding follow-up compliance post-FEVAR. We examined the real-world treatment outcomes and adherence to the postoperative follow-up protocol after elective interventions for JAAA at Veteran Affairs (VA) health care facilities, the largest integrated health care system in the United State.

METHODS

This is a retrospective cohort study. We queried the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database for elective FEVARs and juxtarenal open surgical repairs (j-OSR), then merged follow-up imaging and mortality information. Our primary endpoints were mortality following FEVAR and j-OSR, and adherence to surveillance guidelines. Secondary endpoints included short-term postoperative complications.

RESULTS

A total of 1110 veterans who underwent first-time JAAA repair between 2002 and 2019 (FEVAR, 26% [n=290]; j-OSR, 74% [n=820]) were included in the analysis. The number of j-OSR captured in the database gradually declined by 50%, from 62 interventions in 2002 to 28 in 2019, while FEVAR procedures quadrupled from 20 procedures in 2014 to 94 in 2019. The median follow-up was 3.99 years (95% confidence interval [CI]: 3.73-4.87) for FEVAR patients, and 12.80 (12.31-13.70) for those that underwent jOSR. A significantly lower risk of 30-day mortality was observed following FEVAR compared to j-OSR (1% vs 5%, odds ratio [OR]: 5.03 [1.54-16.38]; p=0.003). At 5 years, FEVAR was linked with significantly higher mortality (41.5% vs 21%, p<0.001) after adjusting for confounders (aHR=2.10 [1.56-2.82], p<0.001). Of surviving patients, the follow-up imaging rate was 66.3% by 1-year post-FEVAR. Follow-up rate at 5 years was 7% post-FEVAR compared to 32% post j-OSR.

CONCLUSION

Elective FEVAR is associated with lower perioperative mortality and morbidities compared to elective j-OSR for juxtarenal aortic aneurysms. However, the perioperative survival benefits of FEVAR diminish over time, with its mortality surpassing that of j-OSR at longer follow-up periods. The compliance with post-FEVAR imaging surveillance is also low. Further research is warranted to develop strategies to improve adherence to imaging surveillance protocols.

CLINICAL IMPACT

This study provides real-world evidence on the outcomes and follow-up adherence following fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms (JAAA) in the Veterans Affairs health care system. With FEVAR's increasing use, the findings highlight the need for improved surveillance protocols, as adherence to postoperative imaging declines significantly after the first year. Clinicians should be aware of the risk of long-term mortality despite FEVAR's short-term benefits, urging better follow-up strategies that relay a survival benefit for patients.

Abdominal Stent Grafting With Coil Embolization for an Abdominal Aortic Aneurysm Sac With a Short Neck

A 68-year-old man underwent endovascular abdominal aortic aneurysm repair for a two-humped abdominal aortic aneurysm (AAA) with a short neck. The abdominal aorta had severe calcification, suggesting a high risk for type Ia endoleak. Initially, a catheter was placed in the aneurysm sac, followed by stent graft deployment. Then, coils were inserted into the aneurysm neck. Subsequently, the type Ia endoleak was resolved. One year after the surgery, no evidence of endoleak was observed, and the aneurysm size had decreased by 10 mm. Therefore, this procedure may be effective for short-neck AAAs.

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.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Complex abdominal aortic aneurysms: a review of radiological and clinical assessment, endovascular interventions, and current evidence of management outcomes

Endovascular aortic aneurysm repair (EVAR) is an established approach to treating abdominal aortic aneurysms, however, challenges arise when the aneurysm involves visceral branches with insufficient normal segment of the aorta to provide aneurysm seal without excluding those vessels. To overcome this, a range of technological developments and solutions have been proposed including fenestrated, branched, physician-modified stents, and chimney techniques. Understanding the currently available evidence for each option is essential to select the most suitable procedure for each patient. Overall, the evidence for fenestrated endovascular repair is the most comprehensive of these techniques and shows an early post-operative advantage over open surgical repair (OSR) but with a catch-up mortality in the mid-term period. In this review, we will describe these endovascular options, pre- and post-procedure radiological assessment and current evidence of outcomes.