David E. Timaran

Upper Extremity Access for Fenestrated Endovascular Aortic Aneurysm Repair Is not Associated with Increased Morbidity

OBJECTIVE Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms who are neither fit nor suitable for standard open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives but frequently require bilateral upper extremity access that has been associated with a 3% to 10% risk of stroke. However, upper extremity access is also frequently required for FEVAR because of the caudal orientation of the visceral vessels. The purpose of this study was to assess the use of upper extremity access for FEVAR and the associated morbidity. METHODS During a 5-year period, 148 patients underwent FEVAR, and upper extremity access for FEVAR was used in 98 (66%). Outcomes were compared between those who underwent upper extremity access and those who underwent femoral access alone. The primary end point was a cerebrovascular accident or transient ischemic attack, and the secondary end point was local access site complications. The mean number of fenestrated vessels was 3.07 ± 0.81 (median, 3) for a total of 457 vessels stented. Percutaneous upper extremity access was used in 12 patients (12%) and open access in 86 (88%). All patients who required a sheath size >7F underwent high brachial open access, with the exception of one patient who underwent percutaneous axillary access with a 12F sheath. The mean sheath size was 10.59F ± 2.51F (median, 12F), which was advanced into the descending thoracic aorta, allowing multiple wire and catheter exchanges. RESULTS One hemorrhagic stroke (one of 98 [1%]) occurred in the upper extremity access group, and one ischemic stroke (one of 54 [2%]) occurred in the femoral-only access group (P = .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0%) compared with the left being accessed 92 times with one stroke (1%; P = .8). Four patients (4%) had local complications related to upper extremity access. One (1%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath, and two patients (2%) with small hematomas did not require intervention. Two (two of 12 [17%]) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (two of 86 [2%]; P = .02). CONCLUSIONS Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.

Fenestrated endovascular aneurysm repair among octogenarians at high and standard risk for open repair

Background: Octogenarians with complex abdominal aortic aneurysms are at higher risk of death and morbidity after open repair. Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair for high‐risk patients, such as octogenarians. The aim of this study was to evaluate perioperative and midterm outcomes of FEVAR among octogenarians at high and standard risk for open repair. Methods: During a 2‐year period, 85 patients (68 men [78%] and 17 women [22%]) underwent FEVAR using Zenith (Cook Medical, Bloomington, Ind) Fenestrated AAA Endovascular Grafts (70%), Zenith p‐Branch (7%), and fenestrated custom‐made devices (22%). Demographics and perioperative and follow‐up outcomes of patients aged >80 years (n = 18 [21%]) and patients aged <80 years (n = 67 [79%]) were compared. The χ2 or Fisher test was used for categorical variables, and nonparametric tests were used for continuous variables. Kaplan‐Meir curve was used for survival analysis. Results: Median age was 73 years (interquartile range [IQR], 68‐79 years) for the entire cohort, 84 years (IQR, 81‐86 years) among octogenarians, and 71 years (IQR, 67‐75) for younger patients. Median aneurysm size was 56 mm (IQR, 53‐62 mm). The median number of fenestrations was three. Preoperatively, octogenarians had higher Society for Vascular Surgery score (5.5 [IQR, 5‐7] vs 5 [IQR, 3‐6]; P = .01) and lower body mass index (26 [IQR, 21‐27] vs 28 [24‐32]; P = .04). Intraoperatively, technical success was 100% for both groups. The median operative time for octogenarians was 224 minutes (IQR, 160‐272) vs 212 minutes (IQR, 177‐281) in patients <80 years (P = .59). The median hospital length of stay was 3.5 days (IQR, 2‐5) for octogenarians vs 4 days (IQR, 2‐5) in younger patients (P = .87). Intensive care unit length of stay was 2 days for patients from both groups (IQR, 1‐3). The rate of postoperative complications was 28% for octogenarians and 36% for patients aged <80 years (P = .5). None of the patients in this series required dialysis. No 30‐day deaths occurred. The 20‐month estimated survival rate was 75% in octogenarians and 91% in patients <80 years (P = .1). The rate of reinterventions at 20 months was 10% for octogenarians and 57% for younger patients (P = .09). Conclusions: FEVAR is a safe and effective procedure in octogenarians at high and standard risk for open repair and those who are not eligible for standard endovascular aneurysm repair. Octogenarians have a similar technical success and low major adverse events similar to patients younger than 80 years.

The sequential catheterization amid progressive endograft deployment technique for fenestrated endovascular aortic aneurysm repair

&NA; Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms. Despite promising short‐term results, the technical complexities of this procedure remain a considerable challenge. The risk of technical failure with loss of visceral or renal arteries is ubiquitous even in the most experienced hands, and thus many patients with unfavorable anatomy are frequently denied FEVAR. We have adopted a new technique for FEVAR that involves retrograde brachial artery access and stepwise deployment of the endograft during target vessel catheterization, overcoming many anatomic limitations encountered from a transfemoral approach. This technique, termed sequential catheterization amid progressive endograft deployment, has become our preferred approach for FEVAR and is described in this article. Of note, currently available Food and Drug Administration‐approved fenestrated endografts may not be amenable to sequential catheterization amid progressive endograft deployment as this technique requires preloaded wires incorporated into the endografts.

Intravascular Ultrasound to Guide Complex Endovascular Aortic Repair

Intravascular ultrasound (IVUS) is a useful and accurate imaging modality in determining the location of target vessels during fenestrated endovascular aortic aneurysm repair (FEVAR). IVUS may also assist in improving the operative plan in many procedures. Although IVUS is less reliable for the precise location of visceral and renal vessels in thoracoabdominal aortic aneurysms, it can accurately predict target vessel location in most juxtarenal and suprarenal aneurysms, which may facilitate safe and expeditious FEVAR.

IP103. Visceral Stent Patency After Fenestrated Endovascular Aneurysm Repair (FEVAR) Using Covered/Uncovered Stent Extensions vs Covered Stents Only

(Z-Fen) endograft (Cook Medical, Bloomington, Ind) represents the first commercially available product in the United States for fenestrated aortic repair. Given the novelty of this technology and the training required to use, there is uncertainty about the most appropriate settings for use. We aim to quantify practice patterns in Z-Fen use during the first 5 years of commercial availability, and we identify predictors of high and low uptake. Methods: Complete order records for Z-Fen endografts between June 2012 and November 2016 were obtained from the device manufacture. We performed descriptive analysis of practice patterns as well as univariate and multivariate regressions of predictors of annual Z-Fen volume, including academic vs community status, number of Z-Fen-trained surgeons per site, early adoption, and proximity to other Z-Fen sites. Results: A total of 750 surgeons have been trained to use Z-Fen, and 4133 cases have been performed at 447 centers since 2012 since Food and Drug Administration approval. Z-Fen centers were spread across the country but had a greater density in the Eastern states (Fig 1). The average annual number of cases per trained surgeon is 4.46; however, many surgeons performed zero or very few cases following training. In the first year of training, academic programs performed an average of 3.38 cases (95% confidence interval, 2.88-.88) whereas community programs performed an average of 2.29 cases (95% confidence interval, 2.072.51). Over time, these annual averages diverged (Fig 2): while there was no statistically significant increase in the annual case volume over time for community centers, academic centers increased their annual volume after training. In a multivariate stepwise regression, predictors of high annual use in the years following training included: academic center (adjusted odds ratio, 1.77; P 1⁄4 .001) and training within the first 2 years of availability (adjusted odds ratio, 3.834; P < .001). The number of surgeons at a given center and the number of local centers were not associated with annual volume. Conclusions: While the opportunities for Z-Fen training were available equally to academic centers and community center and while more community centers became trained, uptake of Z-Fen has proven the greatest at early-adopting academic centers, where annual volumes have been steadily increasing.

Resultados em longo prazo de embolização de endoleaks tipo II

Contexto Endoleaks tipo II sao frequentes apos o reparo endovascular de aneurismas de aorta. Objetivo O objetivo deste estudo foi comparar o sucesso da embolizacao de endoleaks tipo II utilizando diferentes tecnicas e materiais. Metodos Entre 2003 e 2015, 31 pacientes foram submetidos a embolizacao de endoleak tipo II, totalizando 41 procedimentos. Esses procedimentos foram conduzidos por acesso translombar, acesso femoral ou uma combinacao de ambos, utilizando Onyx®18, Onyx®34, coils, plugue vascular Amplatzer® e trombina como material emboligenico. Sucesso foi definido como ausencia de reintervencao. O teste de qui-quadrado e o teste exato de Fisher foram utilizados para a analise estatistica. Resultados O tempo medio entre a correcao do aneurisma de aorta e a embolizacao foi de 14 meses. Quinze (36%) das intervencoes utilizaram Onyx®18; sete (17%) utilizaram coils e Onyx®34; seis (14%) utilizaram Onyx®34; quatro (10%) utilizaram coils e Onyx®18; quatro (10%) usaram Onyx®18 e Onyx®34; e tres (7%) usaram coils e trombina; um (2%) usou coils e um (2%) usou Amplatzer®. Onze pacientes (35%) necessitaram de reintervencao. A taxa de sucesso foi de 71,43% (10) para os pacientes com as arterias lombares como fonte do endoleak, 80% (8) quando a fonte era a arteria mesenterica inferior e 40% (2) quando havia combinacao de ambas (p & 0,05). Nao houve diferenca estatisticamente significativa com relacao ao tipo de embolizacao, material emboligenico e tipo de reparo da aorta para a correcao do aneurisma. Conclusoes A terapia endovascular de endoleaks tipo II e um desafio, sendo necessaria reintervencao em ate 36% dos casos. A taxa de sucesso e menor quando o endoleak e nutrido pela combinacao das arterias lombares e da arteria mesenterica inferior.