Five-year outcomes of physician-modified endografts for repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveThere is paucity of data on the durability of physician modified endografts (PMEGs) for complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) despite widespread use. The aim of this study was to evaluate and compare the early and long-term outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for CAAAs and TAAAs using PMEGs.MethodsWe reviewed clinical data and outcomes of patients treated by FB-EVAR using PMEGs for CAAAs (defined as short-neck infrarenal, juxtarenal, and pararenal AAAs) and TAAAs between 2007 and 2019. All patients were treated by a dedicated team with extensive manufactured device experience. Endpoints included 30-day mortality and major adverse events, patient survival and freedom from aortic-related mortality (ARM), freedom from secondary intervention, target artery (TA) patency, and freedom from TA endoleak and TA instability.ResultsOf 645 patients undergoing FB-EVAR, 156 patients (24%) treated with PMEG (121 males; mean age, 75 ± 8 years) were included. There were 89 CAAAs, 33 extent IV TAAAs and 34 extent I to III TAAAs. A total of 452 renal-mesenteric targets (3.1 ± 1.0 vessels/patient) were incorporated. Patients with TAAAs had significantly (P < .05) larger aneurysms (73 ± 11 vs 68 ± 14 mm), more TAs incorporated (3.4 ± 0.9 vs 2.8 ± 1.0), and more often had previous aortic repair (54% vs 27%). Technical success was higher in patients treated for CAAAs (99% vs 91%; P = .04). Thirty-day and/or in-hospital mortality was 5.7% and was significantly lower for CAAAs compared with TAAAs (2% vs 10%; P = .04), with three of nine early mortalities (33%) among patients treated emergently. After a mean follow-up of 49 ± 38 months, there were 12 aortic-related deaths (7.6%), including nine early deaths (5.7%) from perioperative complications and three late deaths (1.9%) from rupture. At 5 years, patient survival was 41%. Patients treated for CAAAs had higher 5-year freedom from ARM (P = .016), TA instability (P = .05), TA endoleak (P = .01), and TA secondary interventions (P = .05) with a higher, but non-significant, freedom from sac enlargement ≥5 mm (P = .11). Primary and secondary TA patency was 91% ± 2% and 99% ± 1%, respectively. Sac regression ≥5 mm occurred in 67 patients (43%) and was associated with increased survival (hazard ratio, 0.54; 95% confidence interval, 0.37-0.80) compared with those without sac regression.ConclusionsFB-EVAR using PMEGs was performed with acceptable long-term outcomes. Overall patient survival was low due to significant underlying comorbidities. Patients treated for CAAAs had higher freedom from ARM, TA instability, TA endoleak, TA secondary interventions, and a trend towards higher freedom from sac enlargement compared with patients treated for TAAAs. Sac regression was associated with improved patient survival.     

Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal,suprarenal, and thoracoabdominal aneurysms at a single institution

ObjectiveDespite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs.MethodsThis retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests.ResultsSeventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months).ConclusionsParallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.     

主动脉腔内修复术治疗腹主动脉瘤或夹层合并腹部恶性肿瘤

目的 观察主动脉腔内修复术（EVAR）治疗腹主动脉瘤（AAA）或腹主动脉夹层（AAD）合并腹部恶性肿瘤的价值。方法 回顾性分析17例接受EVAR治疗的AAA（n=14）/AAD（n=3）合并腹部恶性肿瘤患者,其中12例于EVAR后接受腹腔镜肿瘤切除术、1例接受开腹肿瘤切除术,4例因心肺功能欠佳仅接受药物治疗;观察EVAR治疗效果。结果 EVAR成功率为100%,术中无严重不良反应及并发症;术后1个月CTA显示支架位置良好、通畅。术后随访1~28个月,期间均未见明显并发症,亦未见AAA/AAD相关死亡病例。结论 EVAR治疗AAA/AAD合并腹部恶性肿瘤效果较佳。     

Risk factors for early and late mortality after fenestrated and branched endovascular repair of complex aneurysms

BackgroundThe objective of this study was to evaluate outcomes after fenestrated and branched endovascular aneurysm repair (F-BEVAR) performed in high-risk patients to treat pararenal (PR) aneurysms and thoracoabdominal aortic aneurysms (TAAAs) and to identify those patients likely to benefit from this treatment.MethodsA prospective single-center review of patients treated electively for PR aneurysm and TAAA using F-BEVAR between 2004 and 2016 was performed. Survival was estimated using the Kaplan-Meier method. Risk factors associated with 30-day morbidity and mortality during follow-up were determined using multivariate statistical techniques and a Cox regression model including all variables that were significant on univariate analysis (P < .05).ResultsThere were 468 patients (median age, 71.6 years) identified, with American Society of Anesthesiologists score ≥3 in 94.7%. There were 221 (47.2%) type I to type III TAAAs and 247 (52.8%) type IV and type V TAAAs and PR aneurysms, with a median diameter of 58 mm. Technical success for target vessel stenting was 99.1% (1493/1506). The 30-day mortality rate was 4.9% (23 patients). The spinal cord ischemia rate was 3.8% (18 patients). Twenty patients (4.3%) required postoperative dialysis and four patients (0.8%) long-term dialysis after discharge. Median follow-up was 29 months. Survival at 1 year, 3 years, and 5 years was 86.7% (95% confidence interval [CI], 83.1-89.6), 73.3% (95% CI, 68.3-77.6), and 59.6% (95% CI, 53.4-65.2), respectively. Freedom from any target vessel occlusion and freedom from secondary procedures were 96.2% (95% CI, 93.8-97.7) and 88.2% (95% CI, 84.8-90.9) at 1 year and 90.0% (95% CI, 84.5-91.9) and 70.2% (95% CI, 63.9-75.6) at 5 years, respectively. In multivariate analysis, early mortality was associated with procedure time (hazard ratio [HR], 1.007 per minute; 95% CI, 1.003-1.010; P < .001), TAAA preoperative diameter (HR, 1.053 per millimeter; 95% CI, 1.020-1.087; P = .001), and chronic kidney disease (HR, 3.139; 95% CI, 1.369-7.196; P = .007). Mortality during the first 24 months of follow-up was associated with Crawford types I to III (HR, 1.526; 95% CI, 1.061-2.196; P = .023) compared with infradiaphragmatic repairs, chronic kidney disease (HR, 1.874; 95% CI, 1.294-2.712; P < .001), and TAAA preoperative diameter (HR, 1.027 per millimeter; 95% CI, 1.010-1.044; P = .002). In addition to these risk factors, mortality after 24 months of follow-up was also associated with age at repair (HR, 1.055 per year; 95% CI, 1.021-1.090; P = .001).ConclusionsF-BEVAR performed in high-risk patients is associated with favorable outcomes. Judicious selection of patients should take into consideration the reported risk factors associated with early and late mortality.     

A systematic review on the quality of life and functional status after abdominal aortic aneurysm repair in elderly patients with an average age older than 75 years

Objective

Endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) are increasingly performed in elderly patients (>75 years of age) with satisfactory results. Quality of life (QOL) is increasingly considered a primary goal of intervention after AAA repair. However, there is currently no consensus on QOL after these procedures in elderly patients.

Mycotic aortic aneurysms treated by endovascular repair: initial experience in a single center

Introduction: Mycotic aortic aneurysm (MAA) is an uncommon cause of aneurysmal aortic disease. However, it may have an aggressive presentation and a complicated early outcome. Endovascular aneurysm repair (EVAR) of MAA is emerging as an alternative to open repair (OR) for the treatment of these aneurysms, particularly in high-risk surgical patients. We report a single-center experience with the endovascular management of mycotic aortic aneurysms.

Material and methods: Two mycotic abdominal aortic aneurysms were treated with an endovascular stent graft at Centre Hospitalier Régional du Val de Sambre, Belgium. The mean follow-up was 15 months. Technical success was achieved in all two patients. CT-scan follow up showed shrinkage of the aneurysm sac, with no evidence of infection along the stent graft and no signs of endoleakage in all patients. One patient died during the follow-up period from a cause unrelated to the aneurysm.

Conclusion: EVAR is an effective and safe option and might be a suitable alternative to OR in the absence of predictors of poor prognosis for the treatment of non-complicated forms of MAA.     

Risk factors for target vessel endoleaks after physician-modified fenestrated or branched endovascular aortic repair for postdissection thoracoabdominal aortic aneurysms

ObjectivePatients with postdissection thoracoabdominal aortic aneurysms (TAAAs) have been more likely to develop endoleaks than those with degenerative TAAAs after fenestrated or branched endovascular aortic repair (F/BEVAR). In the present study, we aimed to determine the risk factors for target vessel (TV)-related endoleaks after visceral segment F/BEVAR for postdissection TAAAs.MethodsWe performed a retrospective analysis of all patients with degenerative and postdissection TAAAs treated with F/BEVAR between 2017 and 2021. All the patients had undergone computed tomography angiography before and 3 months, 6 months, and annually after discharge. Two experienced vascular surgeons had used data from computed tomography angiography and vascular angiography to judge the presence of endoleaks. The study end points were mortality, aneurysm rupture, and the emergence of and reintervention for TV-related endoleaks.ResultsA total of 195 patients (mean age, 66 ± 10 years; 69% men) had undergone F/BEVAR for 99 postdissection TAAAs and 96 degenerative TAAAs. During a mean follow-up of 16 ± 12 months, we found that the patients with postdissection TAAAs were younger (age, 64 ± 10 years vs 69 ± 9 years; P = .001), had required more prior aortic repairs (58% vs 40%; P = .012), and had had a higher body mass index (26.1 ± 3.4 kg/m² vs 24.8 ± 3 kg/m²; P = .008), a larger visceral segment aortic diameter (47.1 ± 7.5 mm vs 44.5 ± 7.5 mm; P = .016), and more TV-related endoleaks (18% vs 7%; P = .023) compared with those with degenerative TAAAs. Of the 99 patients with postdissection TAAAs, 327 renal–mesenteric arteries were revascularized using 12 scallops, 141 fenestrations, and 174 inner or outer branch stents. A total of 25 TV-related endoleaks were identified among 18 patients during follow-up, including 6 type Ic (retrograde from the distal end of the branch), 3 type IIIb (bridging stent fabric tear), and 16 type IIIc endoleaks (detachment or loose connection of the bridging stent). The patients with an endoleak had had a larger visceral aortic diameter (52.7 ± 6.4 mm vs 45.8 ± 7.2 mm; P < .001) and had undergone revascularization of more TVs (3.7 ± 0.7 vs 3.2 ± 0.9; P = .032). In contrast, true lumen compression did not seem to affect the occurrence of TV endoleaks (39% vs 27%; P = .323). The use of presewn branch stents in the fenestration position was associated with a lower risk of TV-related endoleaks (5% vs 11%; P = .025). In addition, TVs derived entirely or partially from the false lumen were more prone to the development of endoleaks after reconstruction (19% vs 4% [P < .001]; and 15% vs 4% [P = .047], respectively).ConclusionsWe found that patients with postdissection TAAAs were more likely to have TV-related endoleaks after F/BEVAR in the visceral region than those with degenerative TAAAs. Additionally, patients with a larger aortic diameter and a greater number of fenestrations in the visceral region were more likely to have experienced TV-related endoleaks. Branch vessels deriving from the false lumen were also more likely to develop endoleaks after reconstruction, and prefabricated branch stents were related to a lower possibility of TV-related endoleaks.     

Clinical presentation,operative management,and long-term outcomes of rupture after previous abdominal aortic aneurysm repair

ObjectiveThe aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR).MethodsWe reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II).ResultsOf 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta.ConclusionsLAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.     

Outcomes of iliofemoral conduits during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveTo describe the technical pitfalls and outcomes of iliofemoral conduits during fenestrated-branched endovascular repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).MethodsWe retrospectively reviewed the clinical data of 466 consecutive patients enrolled in a previous prospective nonrandomized study to investigate FB-EVAR for CAAAs/TAAAs (2013-2021). Iliofemoral conduits were performed through open surgical technique (temporary or permanent) in patients with patent internal iliac arteries or endovascular technique among those with occluded internal iliac arteries. End points were assessed in patients who had any iliac conduit or no conduits, and in patients who had conduits performed prior or during the index FB-EVAR, including procedural metrics, technical success, and major adverse events (MAE).ResultsThere were 138 CAAAs, 141 extent IV, and 187 extent I-III TAAAs treated by FB-EVAR with an average of 3.89 ± 0.52 vessels incorporated per patient. Any iliac conduit was required in 35 patients (7.5%), including 24 patients (10.4%) treated between 2013 and 2017 and 11 (4.7%) who had procedures between 2018 and 2021 (P = .019). Nineteen patients had permanent conduits using iliofemoral bypass, 11 had temporary iliac conduits, and 5 had endoconduits. Iliofemoral conduits were necessary in 12% of patients with extent I to III TAAA, in 6% with extent IV TAAA, and in 3% with CAAA (P = .009). The use of iliofemoral conduit was more frequent among women (74% vs 27%; P < .001) and in patients with chronic obstructive pulmonary disease (49% vs 28%; P = .013), peripheral artery disease (31% vs 15%; P = .009), and American Society of Anesthesiologists classification of III or higher (74% vs 51%; P = .009). There were no inadvertent iliac artery disruptions in the entire study. The 30-day mortality and MAE were 1% and 19%, respectively, for all patients. An iliofemoral conduit using retroperitoneal exposure during the index FB-EVAR was associated with longer operative time (322 ± 97 minutes vs 323 ± 110 minutes vs 215 ± 90 minutes; P < .001), higher estimated blood loss (425 ± 620 mL vs 580 ± 1050 mL vs 250 ± 400 mL; P < .001), and rate of red blood transfusion (92% vs 78% vs 32%; P < .001) and lower technical success (83% vs 87% vs 98%; P < .001), but no difference in intraoperative access complications and MAEs, compared with iliofemoral conduits without retroperitoneal exposure during the index FB-EVAR and control patients who had FB-EVAR without iliofemoral conduits, respectively. There were no differences in mortality or in other specific MAE among the three groups.ConclusionsFB-EVAR with selective use of iliofemoral conduits was safe with low mortality and no occurrence of inadvertent iliac artery disruption or conversion. A staged approach is associated with shorter operating time, less blood loss, and lower transfusion requirements in the index procedure.     

Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair

ObjectiveThe use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access.MethodsProspectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality.ResultsAmong 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43).ConclusionsIn the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach.     

A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without “shaggy aorta”

ObjectiveIn the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of “shaggy aorta” (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes.MethodsAll consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores.ResultsA total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic “shagginess” and no significant difference was identified (P = .546).ConclusionsDespite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of “shagginess” seems not to impact on postoperative outcomes.     

The “bare branch” for safe spinal cord ischemia prevention after total endovascular repair of thoracoabdominal aneurysms

ObjectiveStaged endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with temporary perfusion of the sac through a branch left unstented or a dedicated branch is a strategy intended to reduce the risk of postoperative spinal cord ischemia (SCI). However, potential complications of this approach are aneurysm sac progression between stages, visceral embolism, and occlusion or displacement of components. We here present the “bare branch” technique, a safe adjunct to TAAA repair in terms of interstage complications.MethodsIn the first step, one branch, preferentially the one for the celiac trunk, is stented by a bare stent; in the second step, the bare branch is relined with a covered stent. There were 32 TAAAs (5 type I, 6 type II, 16 type III, 5 type IV) treated by this approach at our center from January 2015 to December 2017 (median follow-up, 13 months [range, 2-24 months]). Data were prospectively collected and retrospectively analyzed. Primary end points were aneurysm sac exclusion and freedom from major adverse events, which included SCI. Secondary end points were freedom from aneurysm growth between the stages and freedom from minor adverse events.ResultsPreoperative mean maximum diameter was 68.4 mm; 32 endografts (8 off-the-shelf and 24 custom-made devices) were used. The mean aortic coverage was 364 mm. The mean interval time between the two stages was 10.5 weeks (range, 7-20 weeks). In-hospital mortality was 0%. Type I or type III endoleak rate was 3.2%, whereas one type II endoleak was registered (3.2%). Two patients showed paraparesis, one after the first stage and one after the second stage, both noted at 4/5 on the Tarlov scale, and fully recovered so that the SCI rate was 6.4% with 0% permanent neurologic deficit. Interstage mean maximum diameter was 68.6 mm (P > .05). After the second step, there was an average of 4.7 spinal arteries (standard deviation, 1.4; P < .05) per patient with an increase in visibility and of diameter by 0.7 mm (standard deviation, 0.4 mm).ConclusionsThis is a reproducible adjunct to staged TAAA endovascular repair. The use of a bare branch instead of a branch left completely open has the clear advantage of an easy catheterization in the second step. Furthermore, by having the target vessel stented with a bare stent, the risk of embolism is avoided. In this experience, there was no significant aneurysm sac growth in between the steps. Further comparative studies may determine whether there are different hemodynamic forces with this technique with respect to those already described in the literature.     

Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent graft

Fenestrated-branched endovascular repair has been applied to treat chronic postdissection thoracoabdominal aortic aneurysms (TAAAs). We report a patient with diffuse postdissection aortic aneurysm involving the arch and thoracoabdominal aorta treated in a staged fashion with redo aortic arch repair using the frozen elephant trunk technique, followed by completion endovascular TAAA using preloaded guidewire system and a five-vessel fenestrated and branched stent graft. A technical video illustrates the use of onlay fusion and sequential catheterization with the preloaded guidewire system to facilitate TAAA repair.     

复杂瘤颈的近肾腹主动脉瘤腔内修复中烟囱技术的应用

目的探讨瘤颈解剖复杂的近肾腹主动脉瘤(juxtarenal aortic aneurysms,JAA)腔内修复(endovascular aneurysmrepair,EVAR)中应用烟囱技术的价值。方法 2007年1月～2011年10月,对7例瘤颈复杂的JAA采用EVAR治疗。由于瘤颈解剖结构不适于标准的腔内修复方案,术中自肱动脉穿刺预先于可能被覆膜支架主体覆盖的肾动脉置入导丝,置入修复腹主动脉瘤的覆膜支架主体后造影明确肾动脉覆盖情况,于相应肾动脉置入自膨支架或球囊扩张支架,以延长瘤颈长度使之符合EVAR要求,并有效保护肾动脉(即烟囱技术),然后再完成标准EVAR操作。结果 7例手术全部获成功。7例使用9枚肾动脉支架,其中5枚球扩支架,4枚自膨支架。腔内治疗最后的造影显示:腹主动脉瘤(abdominal aortic aneurysm,AAA)瘤腔隔绝良好,肾动脉血流良好。术中1例近端Ⅰ型内漏,近端增加Cuff后内漏消失;1例造影显示少量的Ⅱ型内漏,无须处理。7例随访1～52个月,平均11.6月:1例术后2个月因心功能衰竭死亡;1例Ⅱ型内漏术后3个月随访内漏消失;肾动脉烟囱支架均保持通畅。结论对于不适宜行开腹手术治疗的瘤颈解剖不佳的JAA,烟囱技术是传统EVAR技术的有效补充,远期效果及肾动脉支架长期通畅性尚需要进一步观察。     

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians

ObjectivePatients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up.MethodsRetrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics.ResultsThe study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group.ConclusionsEVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.     

The different effect of branches and fenestrations on early and long-term visceral vessel patency in complex aortic endovascular repair

BackgroundAortic endovascular treatment with fenestrated or branched devices (f/bEVAR) requires a connection between the aortic graft and the visceral vessel (VV). However, data on the perioperative and long-term fate of the VVs remain scarce. The aim of our study was to evaluate the VV loss (VVL) according to the type of revascularization performed (fenestrations vs branched) and the necessity for adjunctive visceral procedures (AVPs).MethodsFrom 2012 to 2017, all f/bEVAR procedures for juxtarenal abdominal aortic aneurysms (JAAAs), pararenal abdominal aortic aneurysms (PAAAs), and thoracoabdominal aortic aneurysms (TAAAs) were considered. The perioperative VVL, AVPs, and graft configuration were considered and evaluated during the follow-up period.ResultsIn 158 patients, 523 VVs were considered, 140 (26%) in JAAAs, 165 (32%) in PAAAs, and 218 (42%) in TAAAs. Branches were used for 114 vessels (52%) in TAAAs, 8 (5%) in PAAAs, and 0 (0%) in JAAAs. The overall perioperative VVL was 20 (3.8%) and was significantly greater in TAAAs than in PAAAs or JAAAs (6.4% vs 2.4% vs 1.4%; P = .03). The branches resulted in greater perioperative VVL compared with fenestration (9% [11 of 122] vs 2% [9 of 401]; P = .0001). A significant VVL difference between the branches and fenestrations was identified selectively only for the renal arteries: 11 of 52 (21%) vs 6 of 224 (2.5%; P = .001). The results of the multivariate analysis confirmed the independent greater risk of VVL for branches and renal arteries (odds ratio, 4.7; 95% confidence interval, 12.5-1.7; P = .04; odds ratio, 7.1; 95% confidence interval, 52.6-1.05; P = .05, respectively). AVPs were performed in 43 VVs (8.2%) because of dissection (n = 2; 0.4%), stenosis (m = 3; 0.6%), bleeding (n = 3; 0.6%), or kinking between the bridging stent graft and the VV (n = 35; 7%). A significant difference between the branches and fenestrations was seen only for kinking between the bridging stent graft and VV (12% [15 of 112] vs 5% [20 of 401]; P = .005). At 5 years, the incidence of VVL was 2% ± 1%. The fenestrations had significantly greater freedom from VVL compared with the branches (100% vs 87% ± 6%; P = .04), which was confirmed selectively for TAAAs (100% vs 87% ± 6%; P = .04). The use of AVPs did not affect long-term visceral patency.ConclusionsEarly and late VVL was infrequent in complex aortic procedures but seemed to occur more frequently in branches than in fenestration, especially for renal arteries. AVPs were often required to correct artery kinking but this did not affect the long-term patency.     

Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs

BackgroundOperative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution.MethodsAll AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed.ResultsWe had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more.ConclusionsOSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.     

A 12-year experience of endovascular repair for ruptured abdominal aortic aneurysms in all patients

ObjectiveEndovascular aneurysm repair (EVAR) has been increasingly performed for ruptured abdominal aortic aneurysms (rAAAs). However, multiple randomized trials have failed to demonstrate a survival benefit compared with open aortic surgery. During a 12-year period, 100% of patients without a history of aneurysm surgery had undergone EVAR for a rAAA at Örebro University Hospital, with no emergent open aortic surgery performed. In the present study, we evaluated the mortality and technical success during this “EVAR-only” period.MethodsA single-center, retrospective observational study was conducted. We identified all patients who had presented to Örebro University Hospital with a rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic, and thoracoabdominal aortic ruptures were not included. Patients who had received previous aortic interventions (open or endovascular) and patients who had received palliative treatment instead of surgical intervention were also excluded. The patient characteristics, perioperative and postoperative data, and mortality rate were investigated.ResultsEVAR had been performed in 100 patients. Preoperative hemodynamic instability had been present in 54 patients (54%), and 18 (18%) had undergone aortic balloon occlusion. The aneurysm location was infrarenal in 89 patients (89%). Bifurcated stent grafts had been used in 97 patients (97%), and adjunct endovascular techniques had been used for 27 patients (27%). Of 98 patients, EVAR had been performed with the patient under local anesthesia for 62 patients (63%). Peri- and postoperative complications at 30 days had occurred in 20 of 100 patients (20%) and 22 of 79 patients (28%), respectively. The overall mortality at 30 days was 27% (27 of 100 patients), and the mortality for those with an isolated infrarenal rAAA was 24% (21 of 89 patients). The overall mortality at 1 year was 39% (39 of 100 patients) and for those with an isolated infrarenal rAAA was 37% (33 of 89 patients). The presence of preoperative hemodynamic instability and the use of ABO were statistically significantly and independently associated with increased 30-day mortality on multivariate logistic regression analysis.ConclusionsAll 100 patients who had undergone surgery for a rAAA had been treated using EVAR and endovascular adjuncts, with a relatively low mortality rate, thus continuing the “EVAR-only” approach. A low proportion of rAAA patients were considered surgically unsuitable. These findings support the applicability of EVAR for the treatment of all rAAAs at suitable centers.     

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs

ObjectiveTo review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR).MethodsBetween February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods.ResultsThirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m²), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m², previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004).ConclusionsOpen surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.     

Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair

ObjectiveTo determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during first stage and completion fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms.MethodsWe reviewed the outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR, or completion of temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if they were life threatening, escalated the level of care, or prolonged the hospital stay. Presence of substantial degenerative lumbar disease (DLD) was identified based on review of preoperative computed tomography. End points included technical difficulties during CSFD placement and CSFD-related complications.ResultsA total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs, and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 CSFD-related complications after 21 aortic procedures (9%). Complications were graded as severe to moderate in 17 patients (9%). There were 12 patients (6%) with intracranial hypotension, including three (2%) who had intracranial hemorrhage and nine (5%) with post dural puncture headache requiring blood patches in six. Another six patients (3%) developed spinal hematomas resulting in paraplegia in two (1%) and transient paraparesis in two (1%). One patient had CSF leakage from the puncture site (no intervention required). Four patients had bleeding during attempted drain placement, which required postponement of F-BEVAR. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD than in those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 drain placements (18%) with a lower rate of technical difficulties compared with the blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of 13 study patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD.ConclusionsAlthough CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. One-third of spinal cord injuries were caused by CSF drain placement. The use of fluoroscopic guidance may decrease the risk of CSFD-related complications.