Aurélia Bianchini

Endovascular treatment of thoracoabdominal aortic aneurysms

BACKGROUND Development in endograft design has extended endovascular treatment to include thoracoabdominal aortic aneurysms (TAAA). We report our experience using fenestrated and branched endografts in the management of TAAA. METHODS We analyzed a cohort of consecutive patients treated electively for TAAA using endovascular techniques between 2006 and 2011. All data were collected prospectively. The relationships between preoperative risk factors and clinical outcome were examined using univariate and multivariate statistical techniques. We also compared the outcomes between 33 previously published early cases (EC) with the last 56 later cases (LC). RESULTS Eighty-nine patients (83 men) were treated. Median age was 69 years. All patients were deemed unfit for open surgery. The 30-day and in-hospital mortality rates were 8.9% and 10%, respectively. Multivariate analysis showed in-hospital mortality was associated with preoperative chronic renal failure and advanced age. Higher postoperative mean arterial blood pressure was a protective factor. Technical success rate was 96.6% (94% and 98% in the EC and LC groups, respectively; P = .14). The spinal cord ischemia (SCI) rate was 7.8% (15% and 3% in the EC and LC groups, respectively; P = .063) and was associated with chronic obstructive pulmonary disease and procedure duration. Six patients (6.7%) required temporary filtration, but none required permanent renal support (associated with left ventricular ejection fraction <40% and procedure duration). Median procedure duration decreased from 232 to 203 minutes (P = .01) in the EC and LC groups, respectively. Actuarial survival was 86.8% ± 3.7% at 1 year and 74.7% ± 6% at 2 years. CONCLUSIONS Although we have treated a cohort at high operative risk, our midterm results compare favorably with the published series of conventional surgery. Accurate hemodynamic control represented by high-normal perioperative blood pressure seems to protect against severe postoperative complications.

Anatomic Study of Juxta Renal Aneurysms: Impact on Fenestrated Stent-Grafts

BACKGROUND Fenestrated stent-grafts allow for treatment of patients with juxtarenal aneurysms (JRA) when they present with contraindications for conventional treatment. The fenestrated module is a custom-made module, specially designed to fit a specific patient, using computed tomographic scan measurements, which entails manufacturing delay and high cost. The aim of our study was to evaluate the possibility to reproduce the interrenal aorta anatomy to design a standard fenestrated module that would fit the maximum number of patients with JRA. METHODS On a three-dimensional working station, we analyzed 289 preoperative computed tomographic scan results of patients with JRA and who were treated with fenestrated stent-grafts comprising two fenestrations for the renal arteries and a scallop for the superior mesenteric artery (SMA). On curvilinear reconstructions, we successively measured the interrenal aorta diameter, its orientation, as well as the height of each renal ostium, taking the ostium center of the SMA as a reference mark. Later, a statistical analysis of these measures distribution was performed so as to design a fenestrated module that would fit the maximum number of patients. RESULTS The center of the left renal artery presented with a median orientation of 82.5° (range, 37.5-150) and a median distance of 9 mm (range, 0-30), in relation to the SMA ostium. The ostium center of the right renal artery presented with a median orientation of 285° (range, 240-337.5) and a median distance of 8 mm (range, 3-30), in relation to the SMA ostium. By positioning the current renal fenestrations (6-mm wide), on the basis of the calculated median positions, in our series, only 20% of the patients could be treated with a standard fenestrated module. Should the diameter of these fenestrations be increased by 10 mm, it would then be possible to treat 50% of our patients. CONCLUSION The anatomy of the interrenal aorta and its branches is quite reproducible to design standard fenestrated stent-grafts that could treat half of the patients with JRA.

Challenging treatment of a secondary endoleak in a fenestrated endograft.

Purpose: To describe the novel use of an Amplatzer occluder device to seal a secondary endoleak arising at a scallop in a fenestrated stent-graft. Case Report: A 67-year-old man with comorbidities precluding standard endovascular repair of a pararenal aortic aneurysm was treated with a fenestrated endoprosthesis containing one fenestration for the left renal artery and one scallop for the celiac trunk; the right renal and superior mesenteric arteries were occluded at presentation. Interval imaging at 2 years showed a proximal type I endoleak at the celiac trunk scallop associated with expansion of the aneurysm sac. Attempted repair with an aortic extension cuff and a “chimney” stent was unsuccessful. An Amplatzer Patent Foramen Ovale occluder device was deployed across the endoleak to provide aneurysm sac exclusion, which has been maintained at 6-month follow-up. Conclusion: Treatment of a secondary type I endoleak after implantation of a fenestrated endoprosthesis is challenging. The novel use of an Amplatzer occluder in this setting may be applicable to other situations in which an endovascular solution is desirable for complications of complex endovascular aneurysm repair.

Inverted Limbs in Fenestrated and Branched Endografts

Purpose: To describe our experience with the use of custom-designed branched or fenestrated endoprostheses incorporating an inverted contralateral limb in the bifurcated component. Methods: Retrospective analysis was performed of a prospectively maintained database of all patients undergoing endovascular aneurysm repair using modular branched or fenestrated devices at a university teaching hospital between January 2004 and February 2010. Of 102 cases, 7 male patients (mean age 69 years) were treated with modular devices that incorporated an inverted contralateral limb in the bifurcated component. Five patients had thoracoabdominal aortic aneurysm (4 type IV and 1 type II), 1 patient had a pararenal abdominal aortic aneurysm, and another had type I endoleak from a migrated AneuRx stent-graft. The technique was used primarily because of an existing bifurcated prosthesis (n=5), but in 2 patients without prior open surgery, this technique was needed because of anatomical constraints. Results: All devices were implanted as planned. There was no mortality. One patient required temporary hemodialysis prior to discharge; another patient developed permanent paraplegia, likely related to extensive aortic coverage. No device migration, component separation, or type I or III endoleaks were detected during a mean follow-up of 25 months, and no reinterventions have been necessary. Conclusion: The use of an inverted limb in the bifurcated component of modular endografts may allow endovascular treatment in scenarios where there is insufficient space to deploy a standard bifurcated component. This design modification allows an adequate sealing zone between the iliac extension limbs and the bifurcated component.

FT05. Risk Factors for Early and Late Mortality Following Complex Aneurysm Repair With F-BEVAR

an overall in-hospital mortality of 7.2% (7 of 97). Follow-up data were obtained from all patients, and the mean follow-up time was 43.36 25.5 months. The 5-year survival rate by Kaplan-Meier analysis was 86. 6%. Three patients with type I endoleak was successfully resolved during the operation. No endograft caudal migration occurred. Late aortic rupture was found in two patients, and two patients received reoperations during the follow-up period. No postoperative paraplegia was found. Conclusions: The long-term outcomes of hybrid total arch repair for dissecting aneurysms are satisfactory. This procedure may be an alternative for conventional total arch replacement for high-risk patients.

Mid-term Results of Femoro-popliteal Stenting for Chronic Critical Ischemia

well as the primary and secondary persistence of the clinical improvement at one year. The analysis of survival was carried out according to the method of Kaplan-Meier. Results: Thirty-three lower extremities among 31 patients younger than 55 years (25 men, mean age 46.33±5.3 years) had femoro-popliteal stenting for a Rutherford 3 claudication (66.7%) or a critical ischemia Rutherford 4, 5 or 6 (32.3%). The lesions were classified as TASC A (39.4%), B (24.2%), C (15.2%) and D (21.2%). The stents used were exclusively nitinol stents. The average length of the stenting was 127.5 mm (40 300) with a diameter of 5 or 6 mm. The median follow-up was 21.2 months (2.5 91.2). The absence of intrastent restenosis was 40.7% (95% CI 1⁄4 22.9 58.5) at 1 year. SP rate at one year was 70.5% (95% CI 1⁄4 54.23 86.77). The absence of reintervention as TLR and TER was 65.2% (95% CI 1⁄4 47.56 82.84) and 65.5% (IC95% 1⁄4 48.06 82.94) at one year, respectively. Persistent primary and secondary clinical improvement were 52% (95% CI 1⁄4 34.4 70.0) and 87.3% (95% CI 1⁄4 75.54 99.0) at one year, respectively. Conclusion: Femoro-popliteal stenting young patients present a high risk of restenosis at one year requiring additional procedures in order to obtain a perennial clinical improvement. These results are to be considered before stenting in the treatment of early atheroma.