Céline Perot

Comparison of Short- and Mid-Term Follow-Up Between Standard and Fenestrated Endografts

BACKGROUND This study compared early and mid-term results of endovascular treatment for abdominal aortic aneurysms (AAAs) and pararenal aneurysms (PRAs). METHODS Using data from a prospective database, patients treated with endografts for AAA and PRA between January 2007 and December 2009 were analyzed. In both groups, mortality, endoleak rates, evolution of renal function, reintervention rate at 30 days and at mid-term follow-up, and aneurysmal sac evolution at 1 year were compared. RESULTS In total, 379 patients were included: 264 treated for AAA and 115 for PRA. Median follow-up was 24 months (range 12-46 months) in both groups. Risk factors and medical history were comparable in both groups, except for chronic renal failure (higher in the PRA group; P = 0.003). The mortality rates at 30 days were 1% and 3% in the AAA and APR groups, respectively (P = 0.10). During follow-up, the mortality rates were 11.1% and 12.8% in the AAA and PRA groups, respectively (P = 0.72). The reoperation rates at 30 days were 8% and 10% in the AAA and PRA groups, respectively (P = 0.72). During follow-up, the reoperation rates were 9.2% and 9.9% in the AAA and PRA groups, respectively (P = 0.85). At 1 year, retraction of the aneurysmal sac was diagnosed in 48% of the patients in the AAA group and in 56% of the patients in the PRA group (P = 0.41). The incidence rates of new postoperative cases of renal insufficiency were 19.3% and 8.1% in the AAA and PRA groups, respectively (P = 0.008). At 30 days, the endoleak rates were 27.5% and 12.7% in the AAA and PRA groups, respectively (P = 0.001). At 1 year, the endoleak rates were 19.4% and 7.3% in the AAA and PRA groups, respectively (P = 0.007). When type II endoleaks were excluded, the endoleak rates were comparable in both groups (P = 0.5). At 1 year, in both groups, a retraction of the aneurysmal sac was significantly correlated to the absence of endoleak (P = 0.001). CONCLUSION Early and mid-term results of AAA treatment with standard endografts and PRA treatment with fenestrated endografts are comparable.

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.

Challenging catheterization of a branch in an endovascular thoracoabdominal aneurysm repair.

Purpose: To describe a novel technique of cannulating a side branch during endovascular repair of a thoracoabdominal aneurysm (TAAA). Technique: The approach evolved during endovascular repair of a type III TAAA in which a custom-designed graft with 3 caudally directed branches was being deployed in a patient who had a prior surgical repair for a type IV TAAA. Two of the branches were successfully cannulated and stented, but repeated efforts to cannulate the left renal branch and artery via the standard brachial approach were unsuccessful. A catheter positioned between the graft and the aneurysm sac was used to gain retrograde access to this branch. From a left brachial access this guidewire was snared and used to allow bridging stent deployment between the branch and the renal artery, thus completing the procedure. Conclusion: This report describes a novel technique to deal with challenging side branch cannulation that may be encountered during branched stent-graft deployment.

Compressive Pancreaticoduodenal Artery Aneurysm Associated With Celiac Artery Stenosis

Peripancreatic artery aneurysms are a rare condition, representing <2% of all splanchnic artery aneurysms, and have been significantly related to celiac axis stenosis. While they are most often asymptomatic, those aneurysms have a strong tendency to rupture (52% rupture rate at the initial presentation) and, in this case, the outcome is often dramatic. Given that reports of this disease are rare, appropriate guidelines are difficult to formulate and different treatment strategies have been proposed. Endovascular management seems to be efficient in the large majority of most recent reports, but open surgery still remains necessary for complex cases, especially when associated with celiac axis stenosis. We report a new occurrence of a symptomatic compressive aneurysm related to common bile duct compression that we treated using a hybrid procedure.