Current status of branched stent-graft technology in treatment of thoracoabdominal aneurysms

Endovascular aortic aneurysm repair has been established as an alternative to open surgical reconstruction in appropriately selected patients. Until recently, this approach has been limited to aneurysms not involving critical aortic branches due to the complex nature of designing devices that would preserve important end-organ flow. This article reviews the current status of endovascular approaches to aneurysms involving the thoracoabdominal aorta. The evolution of fenestrated devices and further developments, including reinforced fenestrated branched grafts and directional branches for more complex aneurysms are discussed.     

Transcaval embolization of a type I gutter endoleak after three-vessel chimney endovascular aneurysm repair

Chimney endovascular aneurysm repair provides an endovascular treatment for complex aortic aneurysms. However, type I gutter endoleaks can complicate this approach and prevent full aneurysm exclusion. Treatment of these leaks can be challenging. We report successful embolization of a type I gutter endoleak after (chimney endovascular aneurysm repair) via a transcaval approach.     

复杂腹主动脉瘤对近端锚定区的要求及不同技术的评价

近年来,随着腔内技术和器材的迅猛发展,腔内修复术已逐渐取代传统开放手术,成为治疗腹主动脉瘤的首选方法。但是,不良近端锚定区仍然制约着腹主动脉瘤腔内修复术的发展。笔者结合"烟囱技术"、"开窗技术"以及"多分支支架技术",对复杂腹主动脉瘤对近端锚定区的要求及相关临床证据进行简要讨论,为复杂腹主动脉瘤的处理提供些许参考。     

Aortoenteric Fistula Development following Endovascular Abdominal Aortic Aneurysm Repair: A Case Report

Aortoenteric fistulae (AEF) are now known to occur following endovascular repair of abdominal aortic aneurysms (AAA), presumably because of mechanical forces of dislodged or migrating devices. We present an unusual case of fistula development between the ileum and an AAA presenting as a graft infection following endovascular AAA repair in the absence of direct mechanical strain. Continued pressurization of the aneurysm sac due to endoleak may predispose to this event, especially in large aneurysms. Aggressive surveillance and early interventions are necessary following all endovascular AAA repairs.     

Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels

We performed a one-stage hybrid surgical and endovascular procedure to manage a 6.5-cm right aortic arch aneurysm associated with anomalous origin of the supra-aortic vessels in a 70-year-old man. Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of the right aortic arch aneurysm with a Zenith TX2 stent graft (Cook, Bloomington, Ind) and Z-track plus introducer system. The procedure was successfully completed with exclusion of the aortic arch aneurysm, and the patient was discharged on postoperative day 7. Aortic arch aneurysms with complex anatomy may be successfully treated with a less invasive hybrid approach using new generation devices.     

Branch thoracic stent graft repair for arch aneurysm

Aortic arch aneurysms involving the major vessels of the neck pose great challenges in their repair. Open repair of these aneurysms are associated with a significant morbidity and mortality. The major challenge for endovascular repair of these complex aneurysms is the maintenance of cerebral perfusion during stent implantation and long‐term durability. This paper discusses preoperative planning and technical aspects to successful endovascular repair of a large aortic arch aneurysm involving the distal take‐off of the left subclavian artery.     

The history and current status of thoracic endovascular aneurysm repair in Japan

Japan has a long and successful history of performing thoracic endovascular aneurysm repair (TEVAR). While commercial endovascular grafts were being used worldwide, Japan developed and distributed custom and semi-order made triple-branched one-piece grafts and fenestrated devices for the treatment of arch aneurysms. Historically, Japan also innovated and proposed hybrid procedures such as debranching with stent grafting to treat arch aneurysms and thoracoabdominal aneurysms. Since its introduction, Japan has been at the forefront of performing TEVAR for complicated acute aortic dissection and uncomplicated chronic aortic dissection for patients with predicted aortic enlargement. In this review, the authors discuss the many issues surrounding successful TEVAR, focusing on devices, operative methods, and prevention of complications.     

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively

ObjectiveA rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy.MethodsWe used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival.ResultsAssessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men.ConclusionsWomen and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.     

Stent graft modification with mini-cuff reinforced fenestrations for urgent repair of thoracoabdominal aortic aneurysms

Fenestrated endografts require 6 to 8 weeks for device customization, and off-the-shelf devices are not yet available and may not be of easy access for urgent repair of complex aneurysms. We describe a technique of stent graft modification in a high-risk male patient with two prior open aortic repairs, end ileostomy, and a rapidly enlarging 10-cm supra-graft type IV thoracoabdominal aortic aneurysm. A Z-stent thoracic stent graft was modified on-site using mini-cuff reinforced fenestrations to incorporate the visceral arteries and improve overlap at the side branch attachment sites. After successful repair, the patient was discharged at 4 days without complications and with patent branched stent grafts without endoleak. On-site modifications of endografts may allow urgent endovascular treatment of complex aortic aneurysms in high-risk patients who are not good candidates for open repair or who do not have access to manufactured fenestrated devices.     

Endovascular treatment of abdominal aortic aneurysms

The management of abdominal aortic aneurysms has been revolutionized by the development of endovascular stent grafts. The deployment of these devices requires precise clinical and endovascular skills. This review aims to provide an overview of the essential aspects of an endovascular repair of an abdominal aortic aneurysm (EVAR), from initial presentation and assessment for the procedure through to follow-up and long-term outcomes. Consideration is also given to the newer devices, e.g. fenestrated and branched stent grafts, which have further expanded the numbers of patients who are suitable for treatment by EVAR. Abdominal aortic aneurysm etiology, screening and open repair is dealt with in the previous article.     

Lessons learned in adopting endovascular techniques for treating abdominal aortic aneurysm

HYPOTHESIS: Endovascular exclusion of abdominal aortic and common iliac aneurysms can be performed safely, and in the short term represents a feasible alternative to traditional, open aneurysm repair. PATIENTS AND METHODS: Forty-one patients were treated with endovascular grafts for 39 abdominal aortic and 2 common iliac artery aneurysms. RESULTS: All devices were successfully deployed. The size of the abdominal aortic aneurysms varied from 4.9 to 11.9 cm (average, 6.13 cm). The median procedure time was 195 minutes. There was one iliac artery rupture, which required celiotomy for repair. The hospital stay varied from 2 to 39 days (average, 6.7 days). The perioperative mortality rate was 2.4%. Sixteen patients (39%) had groin wound complications. Ten patients (24%) had evidence of contrast (endoleak) within the aneurysm sac on completion of the procedure. There were no obvious direct leaks from either the point of proximal or distal fixation. Seven of these endoleaks have resolved spontaneously. Two patients required additional procedures in the postoperative period to treat endoleak. The final patient has evidence of persistent endoleak on 3-month surveillance computed tomography scan. Major late problems occurred in 3 patients. CONCLUSION: Patients with large abdominal aortic aneurysms and considerable cardiac comorbidity can safely undergo endovascular aneurysm repair. Femoral groin wound complications resulting in prolonged hospitalization remain the major cause of perioperative morbidity. In contradistinction to open aneurysm repair, long-term surveillance is essential to detect migration of the device and identify flow within the residual aneurysm sac-complications that could lead to aneurysm rupture following endovascular repair.     

Stent grafting for aortic aneurysms

Endovascular stent grafting for aortic aneurysms/dissections using metallic stents covered with conventional vascular grafts has attracted attention as a minimally invasive alternative to open surgery. Since the first clinical experience of endovascular stent grafting for abdominal aortic aneurysm was reported in 1991, numerous clinical applications have been undertaken worldwide. Although several commercial bifurcated stent grafts for abdominal aortic aneurysm are available in various countries, including Europe, the USA, and Australia at present, none of the devices are approved for clinical use in Japan. Particularly for thoracic aortic aneurysms, hand-made devices are still used in individual institutions. Endovascular stent grafting is feasible for aneurysm repair within limited conditions. Although further investigation is necessary to clarify the indications, it is clear that aortic aneurysms could be successfully treated with precise stent-graft deployment and proper patient selection based on our 10-year follow-up results.     

Endovascular stent graft]

Endovascular stent grafting for aortic aneurysms using metallic stents covered with conventional vascular grafts has attracted attention as a catheter-based, minimally invasive alternative to open surgery. Since the first clinical experience with endovascular stent grafting for an abdominal aortic aneurysm was reported in 1991, experimental and clinical investigations have between undertaken world wide. Although several commercial bifurcated stent grafts for abdominal aortic aneurysms are currently available in Europe and Australia, none of the devices are approved for clinical use in Japan and the USA. Hand-made devices are still used in each institution particularly for thoracic aortic aneurysms. Endovascular stent grafting is feasible for aneurysm repair within limited conditions. However, several unsolved issues remain concerning not only delivery devices which require precise skill in stent-graft deployment, but also concerning patient selection and proper indications. Further investigation is necessary to clarify graft durability, aneurysmal neck enlargement, and the fate of the excluded aneurysm sac for long follow-up periods.     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Complex Thoracic Aortic Aneurysm: A Combined Open and Endovascular Approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Endovaskul?re Therapie infrarenaler Aortenaneurysmen

Endovascular treatment of patients with infrarenal aortic aneurysms is usually indicated for an aneurysm diameter >5?cm and is adapted from the indications for open repair. When deciding between aneurysm repair or surveillance the operative risk is balanced against the risk of rupture. The minimally invasive character of endovascular aneurysm repair (EVAR) combined with a reduced perioperative mortality compared to open repair raises the question whether patients with small aneurysms might benefit from an endovascular treatment instead of surveillance. This article reviews recent publications to illustrate the rationale and results of endovascular treatment of patients with infrarenal aortic aneurysms <5.0-5.5?cm compared to a surveillance strategy.     

Endovascular repair for multiple Salmonella mycotic aneurysms of the thoracic aorta presenting with Cardiovocal syndrome.

Salmonella mycotic thoracic aortic aneurysm is a rare but life-threatening condition. We report a 59-year-old man with two Salmonella mycotic thoracic aortic aneurysms, presented with fever and chills associated with hoarseness due to left vocal cord palsy (Cardiovocal syndrome). Successful endovascular repair was performed using two Talent thoracic stent-graft devices deployed separately to cover the two mycotic aneurysms. Subsequent computed tomography at 12 months after the operation confirmed exclusion of the two pseudoaneurysms with no endoleak. With potent antibiotics and careful surveillance program, endovascular repair is a possible alternative to conventional open surgery in the management of mycotic thoracic aortic aneurysms, especially in high-risk patients.     

The development and potential implications of the US Fenestrated and Branched Aortic Research Consortium

The endovascular repair of thoracoabdominal aortic aneurysms has evolved during the last 2 decades, making fenestrated and branched endovascular aortic repair the preferred method to repair thoracoabdominal aortic aneurysms in high-risk patients. Single-center publications have given vascular specialists a significant amount of data, but patient numbers and clinical event rates remain limited. Statistical power to answer important clinical questions is often limited in the single-center studies published to date. In 2018, the principal investigators at the 10 physician-sponsored Investigational Device Exemption centers in the United States decided to coordinate and collect their data in a similar fashion. This effort would allow for the development of the largest cohort of patients in the world treated with complex endovascular devices. By combining efforts and resources, a much larger dataset was compiled to help resolve some of the unanswered questions about patients with complex aortic pathology. To date, the US Aortic Research Consortium has collected data from 2,281 patients and 9,124 target vessel treatment with complex aortic aneurysms treated with custom-manufactured fenestrated and branched endovascular aortic repair devices. These data have resulted in the publication of seven peer-reviewed articles describing various aspects and outcomes of complex endovascular aortic treatment.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

Lessons learned over 2 decades of fenestrated-branched endovascular aortic repair

Fenestrated-branched endovascular repair has been disseminated worldwide from a technique used to treat high-risk patients to a valid alternative in almost any patient who is anatomically suitable and has complex abdominal and thoracoabdominal aortic aneurysms. As with any new procedure, there is a steep learning curve that goes beyond proficiency with deployment. Ultimately, patient selection, team performance, surgeon's ability to adapt to unexpected events, and the constant evolution of improvements in technical aspects all affect the early outcomes and durability of the repair. This article reviews the importance of the learning curve, evolution of complex endovascular techniques, and factors affecting outcomes of complex endovascular aneurysm repair.