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1.
《The surgeon》2015,13(5):286-291
BackgroundCure of aneurysms which involve the aorta at the level of the visceral arteries and the thoracoabdominal segment remains a considerable surgical enterprise with a relatively high mortality and morbidity despite improvements of the surgical procedure and anesthetic technique. Fenestrated and branched endovascular stent grafts are currently available offering an attractive less invasive option especially for most frail patients. These grafts are relatively recent, technically more demanding to insert than the current stent graft for infrarenal aneurysm and besides, given the relative low frequency of the disease, they are much less used by practitioners. Thus, unconditional widespread of this sophisticated technique may not necessarily benefit patients.MethodsWe reviewed our experiences and articles regarding this concern, 1) who should perform this new technique and 2) in what kind of setting.ConclusionBased on the combined complexities of 1) patients selection, 2) proper planning and manufacturing of the graft, 3) the need for outstanding imaging and operating facilities, 4) and the required endovascular skill of physicians involved in the procedure, we feel that only highly specialized centers should be allowed to perform this complex procedure. 相似文献
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Muhammad Zamir Michael Jenkins Nicholas Burfitt Colin Bicknell Richard Gibbs Mohamad Hamady 《Journal of vascular and interventional radiology : JVIR》2019,30(4):546-553
Purpose
To review short-term and midterm results of the fenestrated Anaconda stent graft in management of patients with pre-existing endovascular aortic stent graft and persistent type 1a endoleak.Materials and Methods
This single-center retrospective study assessed all consecutive patients with type 1a endoleak and pre-existing endovascular aneurysm repair (EVAR) treated with fenestrated Anaconda stent grafts. Ten patients (9 males; mean age 78 y) with mean follow-up of 22.4 months ± 13 were included. Average aneurysm size was 80.1 mm (range, 62–101 mm). Mean time for conversion to fenestrated EVAR following original EVAR was 53.7 months (range, 22–101 months; median 54 months). Technical and clinical success; anatomic features, including aortic tortuosity, side vessel angulation, and stenosis; complications; and reinterventions were recorded.Results
The technical success rate was 90%. There was no open conversion and no 30-day mortality, leading to a clinical success rate of 100%. Five of 10 patients demonstrated an aortic tortuosity index of grade 2 or 3. Additional hostile anatomy that made side vessel catheterization challenging was observed in 15 vessels (45%) with a stenosis of ≥ 50% (related to atherosclerotic disease or struts of indwelling prosthesis) and 21 vessels (66%) with ≤ 70° angulation. Two reinterventions, renal artery stent angioplasty and renal artery covered stent extension, were observed at 2 and 13 months.Conclusions
Use of the fenestrated Anaconda endograft in patients with type 1a endoleaks following previous EVAR is safe, feasible, and offers some technical features that facilitate overcoming certain anatomic difficulties. 相似文献5.
Yolanda Bryce Wonho Kim Barry Katzen James Benenati Shaun Samuels 《Journal of vascular and interventional radiology : JVIR》2018,29(7):1011-1016
Purpose
To assess differences in outcome in an early and later time period in patients with hostile neck anatomy who underwent endovascular aneurysm repair (EVAR).Materials and Methods
This single-center, institutional review board-approved retrospective study assessed patients who underwent EVAR between 2004 and 2013, divided into 2 time periods: 2004–2008 and 2009–2013. One hundred twenty-five patients had at least 1 hostile neck parameter that met inclusion criteria: 61 of 216 (28%) patients in the early period and 64 of 144 (44%) patients in the late period. Patients in the late group were younger compared to patients in the early group (late group, 74.5 ± 8.8 years vs early group, 77.5 ± 7.5 years; P = .046). No significant differences were observed in hostile neck anatomic factors between the early and late periods.Results
No statistical difference was observed in periprocedural factors or outcome measures, except for abdominal aortic aneurysm (AAA) sac regression in the late period compared to the early period (late period, 73.5% vs early period, 55.7%; P = .038). A statistically significant increase was observed in type 1a endoleaks in patients in the late group with suprarenal fixation compared to patients with infrarenal fixation (suprarenal, 27.0% vs infrarenal, 7.9%; P = .025) and in the overall time studied (suprarenal, 20.3% vs infrarenal, 7.6%; P = .045).Conclusions
Except for AAA sac regression, no changes were observed in periprocedural factors and outcome measures over time in patients with hostile neck who underwent EVAR. 相似文献6.
《Journal of vascular surgery》2023,77(2):396-405.e7
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. 相似文献
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Konstantinos Spanos Tilo Kölbel Jens C. Kubitz Sabine Wipper Nikolaos Konstantinou Franziska Heidemann Fiona Rohlffs Sebastian E. Debus Nikolaos Tsilimparis 《Journal of vascular surgery》2019,69(2):357-366
Objective
The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication.Methods
A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors.Results
Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]).Conclusions
The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI. 相似文献8.
《Journal of vascular surgery》2019,69(6):1679-1684
ObjectiveAcute kidney injury (AKI) is a common physiologic complication after fenestrated endovascular aneurysm repair (FEVAR). This investigation was initiated to determine the unknown impact of post-FEVAR AKI on long-term renal function after index hospital discharge.MethodsA retrospective review was performed of an institutional FEVAR database capturing preoperative, intraoperative, and postoperative variables related to the implantation of consecutive Zenith Fenestrated endografts (ZFEN; Cook Medical, Bloomington, Ind) between October 2012 and April 2018. AKI in this study was bimodally defined as qualification by either Risk, Injury, Failure, Loss of kidney function, and End-stage (RIFLE) criteria or a postoperative serum creatinine (sCr) concentration increase of 0.5 mg/dL from baseline. Glomerular filtration rate (GFR) was calculated using the validated Modification of Diet in Renal Disease (MDRD) study equation.ResultsDuring the study period, 120 FEVARs were performed at our institution. Twenty-four (20%) patients exhibited postoperative AKI by our established definitions. Two in-hospital deaths occurred in the AKI cohort compared with none in the remaining FEVARs (P = .04). Four (16.7%) AKI patients required perioperative (<30-day) renal replacement therapy, three of whom were successfully weaned before discharge. FEVARs uncomplicated by AKI exhibited no differences in sCr concentration from baseline to 1-month, 6-month, 1-year, and 2-year follow-up (mean, 1.8 ± 1.4 years). In contrast, patients exhibiting AKI experienced an sCr concentration increase of 57.1% (P = .01) at 1 month after the procedure. This elevation decreased to 14.3% (P = .35) at 6 months after the procedure and was maintained at baseline values at 1- and 2-year office visits (follow-up, 1.3 ± 1.5 years). A similar pattern of gradual recovery during follow-up was also observed with respect to calculated GFR.ConclusionsAKI is common after FEVAR but rarely results in permanent renal dysfunction as both sCr concentration and GFR return to baseline by 6 months after the procedure. 相似文献
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Matteo Orrico Sonia Ronchey Carlo Setacci Alessio Vona Mario Marino Fabrizio Nesi Alessia Giaquinta Nicola Mangialardi 《Journal of vascular surgery》2019,69(6):1655-1663
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. 相似文献