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Jónsson GG, Shehab M, Wanhainen A, Mani K, Kuzniar M, Lindström D. Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm. J Endovasc Ther 2023:15266028231215976. [PMID: 38049945 DOI: 10.1177/15266028231215976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. METHODS Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. RESULTS (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. CONCLUSIONS Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. CLINICAL IMPACT Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Maysam Shehab
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
- Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Marek Kuzniar
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - David Lindström
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
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Ferreira M, Mannarino M, Cunha R, Ferreira D, Capotorto LF. Urgent Juxtarenal Aortic Aneurysm Repair With Modified Off-the-shelf Endograft to Preserve Intercostal Arteries and Branch Incorporation by Transfemoral Access. J Endovasc Ther 2023:15266028231199042. [PMID: 37731319 DOI: 10.1177/15266028231199042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE To demonstrate the feasibility of the modification to preserve intercostal arteries of the t-Branch Endograft (Cook Medical, Bloomington, IN) in an urgent setting, associated with a less invasive approach for branch incorporation from percutaneous femoral access with steerable sheaths. TECHNIQUE A 73-year-old female patient presented at our institution with intense abdominal pain. Angiotomography showed a 50-mm juxtarenal aortic aneurysm, with no signs of rupture. Urgent endovascular repair was indicated due to abdominal symptom with an off-the-shelf multi-branched endograft. To limit descending thoracic aortic coverage, we performed t-Branch modification to preserve intercostal arteries and minimize the risk of spinal cord injury, associated with a percutaneous transfemoral approach and branch incorporation with steerable sheaths to avoid the risks associated with a superior axillary or brachial access. Control angiotomography showed adequate aneurysm sac exclusion with patency of all four visceral vessels. CONCLUSION t-Branch-modified endograft to limit aortic coverage is an alternative option in urgent cases to diminish the risk of spinal cord injury, and association of steerable sheaths with branch incorporation is leading complex aortic repairs to an even less invasive procedure. CLINICAL IMPACT This paper highlights the possibility of performing complex endovascular aortic repair in an urgent setting with modification of an off-the-shelf multi branched endograft limiting intercostal arteries coverage, thereby diminishing the risk of spinal cord ischemia. This technical innovation provides an alternative for clinicians when treating large, rapidly expanding, or symptomatic juxtarenal, pararenal, paravisceral or type 4 thoracoabdominal aortic aneurysms that could not wait for a custom-made device and do not need extensive thoracic aortic coverage that an off-the-shelf device provides. In summary, expand the possibilities of an endovascular repair of complex aortic aneurysms.
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Affiliation(s)
- Marcelo Ferreira
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Matheus Mannarino
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Rodrigo Cunha
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Diego Ferreira
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Luis Fernando Capotorto
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
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Gallitto E, Faggioli G, Spath P, Feroldi FM, Pini R, Logiacco A, Sufali G, Caputo S, Gargiulo M. New Preloaded System for Renal and Visceral Arteries in Fenestrated Endografting. J Endovasc Ther 2023:15266028231179868. [PMID: 37309170 DOI: 10.1177/15266028231179868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM/BACKGROUND The New Preloaded System (NPS) for renal/visceral arteries (TVVs) is an emerging technology in fenestrated endografting (FEVAR) that allows TVVs cannulation and stenting through the same access of the endograft main body. However, only few preliminary experiences are currently available in the literature. The aim of this study is to report the outcomes of NPS-FEVAR in juxta/para-renal (J/P-AAAs) and thoracoabdominal (TAAAs) aneurysms repair. METHODS This is a prospective (NCT05224219), single-center/observational study of patients submitted to NPS-FEVAR for J/PAAAs and TAAAs between 2019 and 2022 (July). Definitions and outcomes were evaluated according to the current SVS-reporting standard. Technical success (TS) and TS preloaded related, spinal cord ischemia (SCI), and 30-day mortality were assessed as early endpoints. Survival, freedom from reinterventions (FFRs), and freedom from TTVs-instability (FFTVVs-instability) were analyzed during follow-up. RESULTS Among 157 F/B-EVAR cases, 74 (47%) NPS-FEVAR were planned and enrolled in the study [48 (65%) J/P-AAAs; 26 (35%) TAAAs]. The main indication for NPS-FEVAR was the presence of a hostile iliac axis (54%-73%) or the necessity of expeditious pelvic/lower-limb reperfusion for SCI prevention in TAAAs (20%-27%). Overall, 292 TVVs were accommodated by 289 fenestrations and 3 branches; 188 of 289 (65%) fenestrations were preloaded. NPS-FEVAR configuration was from "below" and "from below to above" in 28 (38%) and 46 (62%) cases, respectively. TS and TS preloaded system-related was 96% (71/74) and 99% (73/74), respectively. Target visceral vessels patency at the completion angiography was 99% (290/292). Failures were 2 renal arteries loss and 1 massive bleeding from a percutaneous closure system breakage. The latter patient developed postoperative multiorgans failure and died on the fifth postoperative day, causing only 30-day/in-hospital mortality (1.3%). One (1.3%) patient with a JAAA and preoperative bilateral occlusion of the hypogastric arteries suffered SCI. The median follow-up was 14 (IQR: 8) months. The estimated 3-year survival was 91% with no aneurysm-related mortality during follow-up. The estimated 3-year FFR and FFTVVs-instability were 85 and 92%, respectively. CONCLUSION New preloaded system FEVAR is a safe and effective option in the treatment of J/PAAAs and TAAAs in the presence of hostile iliac access or to guarantee an expeditious pelvic/lower limb reperfusion, leading to satisfactory results in terms of TS, early and mid-term clinical outcomes. CLINICAL IMPACT New preloaded system for fenestrated and branched endografting allows to increase the feasibility of the advanced endovascular aortic repair in challenging iliac access, thoracoabdominal aneurysm repair and reduce difficulties in target visceral vessels cannulation.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesca M Feroldi
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gemmi Sufali
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefania Caputo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Mancuso E, Bootun R, Stather PW, Crawford M, Delbridge M, Tariq Ali M, Al-Jundi W. Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair. J Endovasc Ther 2023:15266028231173309. [PMID: 37199296 DOI: 10.1177/15266028231173309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
PURPOSE Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. MATERIALS A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. METHODS Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. RESULTS Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. CONCLUSIONS The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. CLINICAL IMPACT With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.
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Affiliation(s)
- Enrico Mancuso
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Roshan Bootun
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Philip W Stather
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Michael Crawford
- Norfolk Centre for Interventional Radiology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Michael Delbridge
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mohammad Tariq Ali
- Norfolk Centre for Interventional Radiology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Wissam Al-Jundi
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
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Taneva GT, Mirgolbabaee H, Groot Jebbink E, Reijnen MMPJ, Donas KP. Systematic Review of the Current In Vitro Experience of the Endovascular Treatment of Juxtarenal Abdominal Aortic Aneurysms by Fenestrated and Parallel Endografting. J Endovasc Ther 2023; 30:8-17. [PMID: 35114834 DOI: 10.1177/15266028221075242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To identify and analyze the published in vitro benchtop experiments for the assessment of endovascular techniques used for the treatment of juxtarenal abdominal aortic aneurysms (jAAAs). DATA SOURCES Scopus, PubMed, and Web of Science. REVIEW METHODS A systematic literature search was carried out throughout March 2021 following PRISMA guidelines. Two investigators independently performed title and abstract screening to reveal all benchtop testing evaluating the endovascular treatment of jAAA. RESULTS A total of 19 studies were included, 8 evaluating fenestrated (FEVAR) and 11 parallel grafts (PGs). FEVAR studies used different custom testing apparatus (n=7) or 3D-printed models (n=1) to analyze dislodgement and migration resistance, misalignment consequences and causation, and bridging stents' radial force, flareability, fatigue, and fracture resistance. All PG studies used silicone-based models to analyze optimal oversizing, sealing length, gutter behavior, and possible reduction. Test evaluation in FEVAR in vitro testing was based on pullout force analysis (N=5), photo evaluation (n=1), fluoroscopy (n=1), X-rays (n=4), CT analysis (n=3), macro- and microscopic evaluation (n=4), water permeability (n=1), and fatigue simulator testing (n=1), while it was based on CT analysis in all PG studies adding ECG-gate in one study. The most frequently tested devices were Zenit (Cook) (n=7), Endurant (Medtronic) (n=5), and Excluder (Gore) (n=5) as main grafts, and Advanta V12 (n=14) as the bridging device. CONCLUSIONS This systematic review presents a broad analysis of the current in vitro methods evaluating the endovascular treatment of jAAA. Fundamental issues have been benchtop tested in both FEVAR and PGs. The analysis of the included studies allowed to recommend an optimal testing design. In vitro testing is a potential tool to further elucidate points of attention hard to investigate in vivo to finally enhance the endovascular treatment outcomes. Future in vitro studies are needed to evaluate the in vitro performance of all indistinctively used devices in the clinical practice.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Hadi Mirgolbabaee
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Erik Groot Jebbink
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel M P J Reijnen
- Multi-Modality Medical Imaging (M3I) Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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Ferreira M, Mannarino M, Cunha R, Ferreira D, Capotorto LF, Oderich GS. Stent Graft Modification to Preserve Intercostal Arteries Using Thoracoabdominal Off-the-Shelf Multibranched (t-Branch) Endograft. J Endovasc Ther 2021; 28:382-387. [PMID: 33759610 DOI: 10.1177/1526602821996718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To demonstrate an off-the-shelf multibranched (t-Branch) modification to allow intercostal arteries preservation during juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aortic aneurysm repair. Technique: The t-Branch is an off-the-shelf device not customized for specific patient anatomy and may be offered for urgent endovascular repair for patients with complex aortic aneurysms. However, a concern when treating patients who do not aneurysms extending above the celiac axis is that the more proximal extension which is required with this device may render patients at high risk for spinal cord injury. We report a novel technique with t-Branch modification performing a 180° fabric back windows at the first 2 sealing stents that allow perfusion to the intercostal arteries. Conclusion: T-Branch-PIA (preserving intercostal arteries) modification limits intercostal arteries coverage while optimizing proximal seal zone in juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aneurysms, thereby may decrease the risk of spinal cord injury.
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Affiliation(s)
- Marcelo Ferreira
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Matheus Mannarino
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil.,Department of Vascular and Endovascular Surgery, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil
| | - Rodrigo Cunha
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Diego Ferreira
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Luis Fernando Capotorto
- Department of Vascular and Endovascular Surgery, SITE Endovascular, Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Program, UTHealth, McGovern Medical School, Cardiothoracic & Vascular Surgery, Memorial Hermann Texas Medical Center, Houston, TX, USA
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van Schaik TG, Meekel JP, Jongkind V, Lely RJ, Truijers M, Hoksbergen AWJ, Wisselink W, Blankensteijn JD, Yeung KK. Secondary Fill Minimizes Gutter Size in Chimney EVAS Configurations In Vitro. J Endovasc Ther 2018; 26:62-71. [PMID: 30572773 PMCID: PMC6330694 DOI: 10.1177/1526602818819494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Purpose: To investigate in an in vitro model if secondary endobag filling can reduce gutter size during chimney endovascular aneurysm sealing (chEVAS). Materials and Methods: Nellix EVAS systems were deployed in 2 silicone juxtarenal aneurysm models with suprarenal aortic diameters of 19 and 24 mm. Four configurations were tested: EVAS with 6-mm balloon-expandable (BE) or self-expanding (SE) chimney grafts (CGs) in the renal branches of both models. Balloons were inflated simultaneously in the CGs and main endografts during primary and secondary endobag filling and polymer curing. Computed tomography (CT) was performed immediately after the primary and secondary fills. Cross-sectional lumen areas were measured on the CT images to calculate gutter volumes and percent change. CG compression was calculated as the reduction in lumen surface area measured perpendicular to the central lumen line. The largest gutter volume and highest compression were presented per CG configuration per model. Results: Secondary endobag filling reduced the largest gutter volumes from 99.4 to 73.1 mm3 (13.2% change) and 84.2 to 72.0 mm3 (27.6% change) in the BECG configurations and from 67.2 to 44.0 mm3 (34.5% change) and 92.7 to 82.3 mm3 (11.2% change) in the SECG configurations in the 19- and 24-mm models, respectively. Secondary endobag filling increased CG compression in 6 of 8 configurations. BECG compression changed by −0.2% and 5.4% and by −1.0% and 0.4% in the 19- and 24-mm models, respectively. SECG compression changed by 10.2% and 16.0% and by 7.2% and 7.3% in the 19- and 24-mm models, respectively. Conclusion: Secondary endobag filling reduced paragraft gutters; however, this technique did not obliterate them. Increased CG compression and prolonged renal ischemia time should be considered if secondary endobag filling is used.
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Affiliation(s)
- Theodorus G van Schaik
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Jorn P Meekel
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Vincent Jongkind
- 3 Department of Surgery, Westfriesgasthuis, Hoorn, the Netherlands
| | - Rutger J Lely
- 2 Department of Interventional Radiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten Truijers
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Arjan W J Hoksbergen
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Willem Wisselink
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Jan D Blankensteijn
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Kak Khee Yeung
- 1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
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Tricarico R, He Y, Laquian L, Scali ST, Tran-Son-Tay R, Beck AW, Berceli SA. Hemodynamic and Anatomic Predictors of Renovisceral Stent-Graft Occlusion Following Chimney Endovascular Repair of Juxtarenal Aortic Aneurysms. J Endovasc Ther 2017; 24:880-888. [PMID: 28914135 DOI: 10.1177/1526602817731096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To identify anatomic and hemodynamic changes associated with impending visceral chimney stent-graft occlusion after endovascular aneurysm repair (EVAR) with the chimney technique (chEVAR). METHODS A retrospective evaluation was performed of computed tomography scans from 41 patients who underwent juxtarenal chEVAR from 2008 to 2012 to identify stent-grafts demonstrating conformational changes following initial placement. Six subjects (mean age 74 years; 3 men) were selected for detailed reconstruction and computational hemodynamic analysis; 4 had at least 1 occluded chimney stent-graft. This subset of repairs was systematically analyzed to define the anatomic and hemodynamic impact of these changes and identify signature patterns associated with impending renovisceral stent-graft occlusion. Spatial and temporal analyses of cross-sectional area, centerline angle, intraluminal pressure, and wall shear stress (WSS) were performed within the superior mesenteric and renal artery chimney grafts used for repair. RESULTS Conformational changes in the chimney stent-grafts and associated perturbations, in both local WSS and pressure, were responsible for the 5 occlusions in the 13 stented branches. Anatomic and hemodynamic signatures leading to occlusion were identified within 1 month postoperatively, with a lumen area <14 mm2 (p=0.04), systolic pressure gradient >25 Pa/mm (p=0.03), and systolic WSS >45 Pa (p=0.03) associated with future chimney stent-graft occlusion. CONCLUSION Chimney stent-grafts at increased risk for occlusion demonstrated anatomic and hemodynamic signatures within 1 month of juxtarenal chEVAR. Analysis of these parameters in the early postoperative period may be useful for identifying and remediating these high-risk stent-grafts.
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Affiliation(s)
- Rosamaria Tricarico
- 1 Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Yong He
- 2 North Florida/South Georgia Veterans Health System, University of Florida, Gainesville, FL, USA.,3 Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Liza Laquian
- 3 Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Salvatore T Scali
- 2 North Florida/South Georgia Veterans Health System, University of Florida, Gainesville, FL, USA.,3 Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Roger Tran-Son-Tay
- 1 Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA.,4 Department of Mechanical and Aerospace Engineering, University of Florida, Gainesville, FL, USA
| | - Adam W Beck
- 5 University of Alabama School of Medicine, Birmingham, AL, USA
| | - Scott A Berceli
- 1 Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA.,2 North Florida/South Georgia Veterans Health System, University of Florida, Gainesville, FL, USA.,3 Department of Surgery, University of Florida, Gainesville, FL, USA
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Roy IN, Gharib M, Zerwes S, Jakob R, Torella F, McWilliams RG, Fisher RK. Anatomical Applicability of Endovascular Aneurysm Sealing Techniques in a Consecutive Cohort of Fenestrated Endovascular Aneurysm Repairs. J Endovasc Ther 2017; 24:773-778. [PMID: 28895448 DOI: 10.1177/1526602817728069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine how many endovascular aneurysm sealing (EVAS) procedures with/without off-label use of chimneys (ChEVAS) could have been performed in a cohort of patients who had undergone fenestrated endovascular aneurysm repair (FEVAR). METHODS Sixty patients (median age 76.3 years; 54 men) who underwent FEVAR in our institution between 2013 and 2015 were selected for the study. The median aneurysm diameter was 62.0 mm (interquartile range 59.3, 69.0). Preoperative computed tomography angiograms (CTA) were anonymized and sent to 2 physicians with experience of more than 40 ChEVAS interventions. These ChEVAS planners were blinded to the study purpose and asked to agree upon an EVAS/ChEVAS plan. The primary outcome was the percentage of the FEVAR patients in whom an EVAS/ChEVAS was technically possible. The secondary outcomes were a comparison of seal zones, number of target vessels, and device cost. RESULTS An EVAS-based intervention would have been technically possible in 56 (93.3%) of the FEVAR patients. The median proximal aortic seal zone was significantly more distal in the EVAS/ChEVAS procedures vs the FEVAR cases (zone 8 vs zone 7, p<0.001) and fewer target vessels were involved (median 2 vs 3, p<0.001). The cost of the EVAS/ChEVAS device was 66% of the FEVAR device. Planners would not currently advocate an EVAS-based intervention in 43 (76.8%) of these 56 patients due to concerns regarding the risk of migration associated with the lumen thrombus ratios observed. CONCLUSION EVAS is technically feasible in the majority of patients undergoing FEVAR in our institution but currently advocated in only 23.2%. The seal zone was more distal, fewer target vessels were involved, and the device cost was lower in the planned EVAS/ChEVAS interventions.
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Affiliation(s)
- Iain N Roy
- 1 Institute of Ageing & Chronic Disease, University of Liverpool, UK.,2 Liverpool Vascular & Endovascular Service, Royal Liverpool Hospital, Liverpool, UK
| | - Menatalla Gharib
- 1 Institute of Ageing & Chronic Disease, University of Liverpool, UK
| | - Sebastian Zerwes
- 3 Department of Vascular & Endovascular Surgery, Klinikum Augsburg, Germany
| | - Rudolf Jakob
- 3 Department of Vascular & Endovascular Surgery, Klinikum Augsburg, Germany
| | - Francesco Torella
- 2 Liverpool Vascular & Endovascular Service, Royal Liverpool Hospital, Liverpool, UK.,4 School of Physical Sciences, University of Liverpool, UK
| | | | - Robert K Fisher
- 2 Liverpool Vascular & Endovascular Service, Royal Liverpool Hospital, Liverpool, UK.,4 School of Physical Sciences, University of Liverpool, UK
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10
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Abstract
Objectives To evaluate the impact of renal artery morphology on fluoroscopy time in chimney endovascular aneurysm repair. Methods Morphology of renal artery was retrospectively quantified in the preoperative CT angiography. Renal artery angulation, ostial diameter, severity of ostial stenosis, main renal artery length, and tortuosity were analyzed with a 3D workstation. The main measure outcome was fluoroscopic time as an indicator of complexity. Uni- and multivariate logistic regression analyses were performed to determine predictors of longer fluoroscopy. Secondary endpoints were amount of contrast medium, patency of renal artery, and type Ia endoleak. Results The enrolled 38 patients (mean age 75.0 years; 34 males) were stratified at the median of fluoroscopic time of 35.2 min (interquartile range, 21.5) and classified in group A ( n = 19) and group B ( n = 19) having a fluoroscopic time of 24.5 (interquartile range, 5.9) and 46.4 (interquartile range, 16.0) min, respectively. The severity of ostial stenosis (OsSte) was significantly different between group A and B of 26.3 ± 13.4% and 41.6 ± 18.0%, respectively; P < .01. ROC curve analysis revealed that 35.5% was an optimal cut-off for OsSte. The difference of renal angulation (RAng) (-22.5° and -2.0°; interquartile ranges 49 and 35; P = .13), and main renal artery length (33.4 ± 11.8 mm and 33.7 ± 14.3 mm; P = .94) were not significantly different. In multivariate analysis after dichotomizing OsSte and RAng, OsSte > 35.5% was identified as the only significant predictor for the longer fluoroscopy (HR: 4.33; 95% CI: 1.02-18.4, P = .04). As for the secondary endpoints, no significant differences were observed between the groups. No correlation between longer fluoroscopy and renal patency or type Ia endoleak was observed. Conclusion Severity of ostial stenosis seems to be a significant predictor for longer fluoroscopic time.
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Affiliation(s)
- Masayuki Sugimoto
- 1 Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Giovanni Torsello
- 1 Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany.,2 Clinic for Vascular and Endovascular Surgery, University Clinic of Münster, Münster, Germany
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11
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Abstract
PURPOSE To report the successful treatment of a type IIIb endoleak with an Amplatzer Septal Occluder. CASE REPORT A 76-year-old man was found to have a type IIIb endoleak in the proximal body component of a fenestrated graft at 4-year surveillance imaging; the leak was associated with rapid aneurysm growth. The anatomy of the graft and position of the fabric defect precluded treatment by relining with a secondary endograft. The defect was demonstrated with catheter angiography, sized with an angioplasty balloon, and repaired using an Amplatzer Septal Occluder. Follow-up imaging at 6 months showed no endoleak and marked reduction in the aneurysm size. CONCLUSION The Amplatzer Septal Occluder may be considered as an option for managing type IIIb endoleaks.
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Affiliation(s)
| | - Tze Yuan Chan
- 1 Radiology Department, Royal Liverpool University Hospital, Liverpool, UK
| | - Jonathan Smout
- 2 Liverpool Vascular and Endovascular Service, Liverpool, UK
| | | | - Robert K Fisher
- 2 Liverpool Vascular and Endovascular Service, Liverpool, UK
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12
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Khanafer A, Khashram M, Ruiz CM, Mann D, Laing A. Use of the Off-the-Shelf t-Branch Device to Treat an Acute Type Ia Endoleak in a Symptomatic Juxtarenal Abdominal Aortic Aneurysm. J Endovasc Ther 2015; 23:212-5. [PMID: 26637838 DOI: 10.1177/1526602815618493] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report the use of the off-the-shelf Zenith t-Branch Thoracoabdominal Endovascular Graft for the treatment of a symptomatic acute type Ia endoleak subsequent to previous infrarenal bifurcated endovascular aneurysm repair. CASE REPORT A 72-year-old man presented 4 years after implantation of an Anaconda stent-graft with sac expansion and type II endoleak, which was treated over the next 18 months with repeated coil and glue embolization of the leak and sac. Six months after the last attempt, imaging disclosed a new type Ia endoleak. Sac enlargement became symptomatic, and emergent treatment was performed using the off-the-shelf Zenith b-Branch device. The 4 visceral arteries were bridged with Fluency stent-grafts. The Anaconda stent-graft precluded the use of a standard Zenith universal distal body bifurcated device below the t-Branch graft, so a reversed tapered 16×20×82-mm iliac limb was placed to bridge the t-Branch to the larger Anaconda limb; the smaller 12-mm contralateral Anaconda limb was occluded. The procedure was concluded with a femorofemoral bypass. At 10 months after the procedure, the patient is well; the sac diameter has decreased, and there is no endoleak on imaging. CONCLUSION The multibranched Zenith t-branch device may be useful in treating proximal endoleaks in bifurcated stent-grafts.
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Affiliation(s)
- Adib Khanafer
- Vascular, Endovascular, & Renal Transplant Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Manar Khashram
- Department of Vascular Surgery, University of Otago, Christchurch, New Zealand
| | - Carmen-Maria Ruiz
- Vascular, Endovascular, & Renal Transplant Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Dana Mann
- Interventional Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew Laing
- Interventional Radiology, Christchurch Hospital, Christchurch, New Zealand
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Malkawi AH, de Bruin JL, Loftus IM, Thompson MM. Treatment of a juxtarenal aneurysm with the Nellix endovascular aneurysm sealing system and chimney stent. J Endovasc Ther 2015; 21:538-40. [PMID: 25101582 DOI: 10.1583/14-4698r.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To present treatment of a juxtarenal aneurysm using the Nellix endovascular aneurysm sealing system (EVAS) and a chimney stent. CASE REPORT A 79-year-old woman was diagnosed with a 6-cm juxtarenal aneurysm. Standard endovascular aneurysm repair was not possible due to lack of an adequate infrarenal landing zone, and poor iliac access and angulated visceral aortic branches precluded a custom-made fenestrated solution. The patient was not a suitable candidate for open surgery due to significant comorbidity, so she underwent successful endovascular aneurysm repair with the Nellix EVAS system and a renal chimney stent. Follow-up imaging at 6 months showed a sealed aneurysm sac and patent renal chimney stent. CONCLUSION The Nellix EVAS system obliterates the aneurysm sac using polymer-filled endobags. The ability of the endobags to conform to adjacent structures may offer advantages over conventional endografts when combined with parallel grafts designed to treat juxtarenal aneurysms.
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Affiliation(s)
- Amir H Malkawi
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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Abstract
AIM To assess the early and short-term outcome of fenestrated and chimney grafting for juxtarenal aortic aneurysms. MATERIAL AND METHODS A prospective vascular registry of 28 patients who had undergone elective primary endovascular repair for abdominal aortic aneurysm between December 2007 and August 2011 with infrarenal neck anatomy unacceptable for conventional endovascular repair. Fenestrated endografts were designed based on reconstructed computed tomography (CT) data by the authors. Off-the-shelf grafts and stents were used for chimney cases. Patients were followed up until 31 May 2012. RESULTS A total of 21 (75%) patients were treated with fenestrated endografts, while 7 (25%) received chimney grafts. The mean aneurysm diameter was 65 mm (standard deviation = 7 mm) and the median neck length 2.5 mm (range: 0-10 mm). Altogether, 63 (mean = 2.3/patient) visceral arteries were incorporated (42 renal, 21 superior mesenteric arteries). The overall primary technical success rate was 93% (one type I and one type III endoleak). The mean follow-up was 22 months (standard deviation: 14 months). The primary type III endoleak resolved spontaneously with thrombosis of the target vessel, while the patient with primary type I endoleak died of acute myocardial infarction 3 weeks after the procedure. Two late endoleaks developed: one type II endoleak without aneurysm sac growth remains under surveillance, while in another patient, multiple attempts to treat type I endoleak proved unsuccessful and the patient later died of gastrointestinal bleeding. A total of 4 (14%) patients so far required additional procedures. Two patients died within 30 days of the device implantation and another six during the follow-up. No rupture occurred. The cumulative survival for patients with fenestrated endografts was 85% at 1 year and for those treated with chimney technique 57%. CONCLUSIONS The treatment of juxtarenal aortic aneurysms seems to be feasible by exploiting various endovascular techniques. Even with a low volume of cases, good immediate and short-term results can be achieved, especially with fenestrated endografts.
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Affiliation(s)
- V Suominen
- Division of Vascular Surgery, Tampere University Hospital, Tampere, Finland
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Belczak SQ, Lanziotti L, Botelho Y, Aun R, Silva ESD, Puech-Leão P, Luccia ND. Open and endovascular repair of juxtarenal abdominal aortic aneurysms: a systematic review. Clinics (Sao Paulo) 2014; 69:641-6. [PMID: 25318097 PMCID: PMC4192422 DOI: 10.6061/clinics/2014(09)11] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/10/2014] [Indexed: 11/18/2022] Open
Abstract
This systematic review focuses on the 30-day mortality associated with open surgery and fenestrated endografts for short-necked (<15 mm) juxtarenal abdominal aortic aneurysms. A search for studies published in English and indexed in the PubMed and Medline electronic databases from 2002 to 2012 was performed, using "juxtarenal abdominal aortic aneurysm" and "treatment" as the main keywords. Among the 110 potentially relevant studies that were initially identified, eight were in accordance with the inclusion criteria in the analysis. Similar outcomes for open and endovascular repair were observed for 30-day mortality. No differences were observed regarding the secondary outcomes (duration of surgery, hospital stay, postoperative renal dysfunction and late mortality), except that the late mortality rate was significantly higher for the patients treated with open repair after a median follow-up of 24 months. Fenestrated endografting is a viable alternative to conventional surgery in juxtarenal abdominal aortic aneurysms with a proximal neck <15 mm.
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Affiliation(s)
- Sergio Quilici Belczak
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Lanziotti
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Yuri Botelho
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Aun
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Erasmo Simão da Silva
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nelson de Luccia
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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