E.L.G. Verhoeven

Editor's Choice – Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients

OBJECTIVEnTo present a 10 year experience with endovascular thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent grafts.nnnMATERIALS AND METHODSnConsecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004-December 2013. Data were collected prospectively.nnnRESULTSn166 patients (125 male, 41 female, mean age 68.8xa0±xa07.6 years) were treated. The mean TAAA diameter was 71xa0±xa09.3xa0mm. Types of TAAA were: type I, nxa0=xa012 (7.2%), type II, nxa0=xa050 (30.1%), type III, nxa0=xa053 (31.9%), type IV, nxa0=xa041 (24.8%), and type V, nxa0=xa010 (6%). Fifteen (9%) patients had an acute TAAA (11 contained rupture, 4 symptomatic). One hundred and eight (65%) patients were refused for open surgery earlier. Seventy eight (47%) patients had previously undergone one or more open/endovascular aortic procedures. Technical success was 95% (157/166). Thirty day operative mortality was 7.8% (13/166), with an in hospital mortality of 9% (15/166). Peri-operative spinal cord ischemia (SCI) was observed in 15 patients (9%), including permanent paraplegia in two (1.2%). Mean follow up was 29.2xa0±xa021 months. During follow up 40 patients died, two of them probably from aneurysm related cause. Re-intervention, mostly by endovascular means, was needed in 40 (24%) patients. Estimated survival at 1, 2, and 5 years was 83%xa0±xa03%, 78%xa0±xa03.5%, and 66.6%xa0±xa06.1%, respectively. Estimated target vessel stent patency at 1, 2, and 5 years was 98%xa0±xa00.6%, 97%xa0±xa00.8%, and 94.2%xa0±xa01.5%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 88.3%xa0±xa02.7%, and 78.4%xa0±xa04.5%, respectively.nnnCONCLUSIONSnEndovascular repair of TAAA with fenestrated and branched stent grafts in high volume centers appears safe and effective in the mid-term in a high risk patient cohort. A considerable reintervention rate should be acknowledged, however.

Fenestrated Endovascular Aortic Aneurysm Repair as a First Line Treatment Option to Treat Short Necked, Juxtarenal, and Suprarenal Aneurysms.

OBJECTIVESnThe outcomes of fenestrated endovascular aneurysm repair (FEVAR) as a first line strategy is reported.nnnMETHODSnAll consecutive patients treated with FEVAR for short neck, juxtarenal, or suprarenal aortic aneurysms under the guidance of the senior author within the period January 2010 to December 2014 were included. Data were collected from a prospectively maintained database. Analyzed outcomes included technical success, defined by successful stent graft implantation with patent stented target vessels and no Type I/III endoleak, operative mortality and morbidity, target vessel patency, endoleak, re-intervention, and death. Survival, target vessel stent patency, and re-intervention during follow up were calculated by Kaplan-Meier analysis.nnnRESULTSnA total of 281 patients (245 male, mean age 72.1xa0±xa07.7 years) were treated. The mean aneurysm diameter was 60.2xa0±xa09.3xa0mm and median proximal neck length 2xa0mm (range 0-10xa0mm). Technical success was 96.8% (272/281). Technical failure included one intra-operative death due to embolization and cardiac arrest, one open conversion due to iliac rupture, and seven target vessel complications. The thirty day mortality was 0.7% (2/281). Mean follow up was 21xa0±xa015.9 months. Estimated survival at 1 and 3 years was 94.7%xa0±xa01.6% and 84.6%xa0±xa03.0%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 96.1%xa0±xa01.4%, and 90%xa0±xa02.7%. Estimated target vessel stent patency at 1 and 3 years was 98.6%xa0±xa00.5%, and 98.1%xa0±xa00.6%, respectively. Mean aneurysm sac diameter decreased from 60.2xa0±xa09.3xa0mm pre-operatively to 53.2xa0±xa012.8xa0mm (pxa0<xa0.001).nnnCONCLUSIONSnFEVAR as a first line strategy was associated with high technical success and a low operative mortality rate. Efficacy and durability in the mid-term appear very good, with significant regression of aneurysm sac diameter, high target vessel patency, and acceptable rate of re-intervention.

Fenestrated and Branched Stent-Grafting: a 5-Years Experience

Abstract Fenestrated stent-grafts aim at treating short-necked aneurysms. As a result of customized fenestrations, patency of vital side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft over these aortic side branches. Over the years, the technique has been refined. Results in a few experienced centers are good, with excellent patency rates of targeted side branches. Suprarenal and thoraco-abdominal aneurysms can only be treated by endovascular means with branched grafts. This can be achieved with fenestrated grafts, but with the use of covered stents through the fenestrations, or by fully branched grafts. Both options are feasible and present with specific advantages and disadvantages. This report gives an overview of our 5-years experience with fenestrated and branched grafts, and discusses the following aspects of the technique: indications, technical principles, results, and limitations.

Results of Endovascular Repair of TAAA in the First 50 Patients

BACKGROUNDnDevelopments with fenestrated and branched stent grafts have opened the way to treat complex aortic aneurysms involving the visceral arteries. First reports on endovascular treatment of thoracoabdominal aneurysms have demonstrated the feasibility of the technique.nnnMETHODSnA literature review and results of first 50u200a patients treated with a custom-made Zenith device with fixed branches are presented. Most of the patients were refused open surgery mainly for the extent of the disease combined with co-morbidity, which included in most patients a combination of several risk factors. Mean aneurysm size was 71u200amm and extent of the aneurysm was type u200aI (nu200a=u200a9), type u200aII (nu200a=u200a13), typeu200a III (nu200a=u200a19), and type u200aIV (nu200a=u200a9), respectively.nnnRESULTSnPrimary and primary assisted technical successes in our series were 88u200a% (44u200a/u200a50) and 92u200a% (46u200a/u200a50), respectively. One patient died on dayu200a 1 from an intraoperative aneurysm rupture. In two patients a renal artery was lost, one due to rupture and one due to malpositioning of the bridging stent graft. In a fourth patient, a celiac artery could not be catheterised and was lost. Finally, in two more patients, catheterisation of in total three renal arteries proved impossible. This was solved by a retrograde approach for two renal arteries via laparotomy in one patient, and a spleno-renal bypass in the other patient. Thirty-day mortality was 8u200a%. Estimated survival at 6 u200amonths, 1 u200ayear, and 2 u200ayears was 91.2u200a%, 79.8u200a%, and 69.7u200a%, respectively. Freedom of reintervention of all kinds at 1 and 2 u200ayears was 81.9u200a% and 73.7u200a%, respectively.nnnCONCLUSIONnResults of fully endovascular repair of thoracoabdominal aneurysms in a high-risk cohort are promising. A learning curve should be expected. Although longer term results need to be awaited, it is likely that endovascular repair of thoracoabdominal aneurysms will become a preferential treatment option for many patients in the future.

Randomized clinical trial of continuous sutures or non-penetrating clips for radiocephalic arteriovenous fistula

Despite several modifications to the original design, patency rates of radiocephalic arteriovenous fistulas have changed little since the first report in 1966. The use of non‐penetrating clips for vascular anastomosis on the outcome of such fistulas was studied.

Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms

AIMnThe aim was to conduct a systematic review of the literature investigating outcomes after interruption or preservation of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR).nnnMETHODSnA systematic review was undertaken using the MEDLINE and EMBASE databases to identify studies reporting IIA management during EVAR. The search identified 57 articles: 30 reported on IIA interruption (1468 patients) and 27 on IIA preservation (816 patients).nnnRESULTSnThe pooled 30 day buttock claudication (BC) rate was 29.2% (95% CI 24.2-34.7). Patients undergoing bilateral IIA interruption had a higher incidence of BC than patients with unilateral IIA interruption (36.5% vs. 27.2%, OR 1.7, 95% CI 1.11-2.6, pxa0=xa0.01). During a median follow up of 17 months, the pooled rate of persistent BC was 20.5% (95% CI 15.7-26.2). Of the patients, 93.9% underwent an endovascular revascularization procedure for IIA preservation. Most patients (87.6%) had an iliac branched device, and technical success was 96.2%. Within 30 days of EVAR, 4.3% of internal iliac branches occluded. During a median follow up of 15 months, the pooled occlusion rate at the site of IIA revascularization was 8.8% (95% CI 6.8-11.3). In patients treated with an iliac-branched device, 5.2% of internal iliac branches and 1.7% of external iliac arteries occluded. The pooled BC rate on the side of the IIA revascularization during follow up was 4.1% (95% CI 2.9-5.9). Pooled rates of late device related endoleak type I or III and secondary procedures on the side of the previous IIA revascularization were 4.6% (95% CI 3.2-6.5) and 7.8% (95% CI 5.7-10.7) respectively.nnnCONCLUSIONnUnilateral or bilateral IIA occlusion during EVAR seems to carry a substantial risk of significant ischemic complications in nearly one quarter of patients. Bilateral IIA occlusion was related to a significantly higher rate of BC. IIA preservation techniques represent a significant improvement in the treatment of aorto-iliac aneurysms and have been associated with high technical success and low morbidity.

Ruptured Solitary Iliac Artery Aneurysm

A 50-year-old man with right sided abdominal pain was referred to our emergency department. On clinical examination there was right lower quadrant peritonitis with no palpable mass. Body temperature was 37.9 8C and the patient had a leukocytosis of 18.1 (10/l). Acute appendicitis was suspected and a laparoscopy was performed. The view was poor and a laparotomy was performed. There was a normal appendix and a retroperitoneal hematoma on the lateral side of the cecum. There were no palpable aneurysms. Because the patient was hemodynamically stable the operation was terminated with a diagnosis of spontaneous haemorrhage into the psoas muscle. Postoperative CT showed a right iliac artery aneurysm with a diameter of 3.2 cm and a retroperitoneal hematoma (Fig. 1). The diameter of the left iliac artery was 2.5 cm; there was no aneurismal dilation of the aorta. A second laparotomy was performed. The right common iliac artery was clamped and the aneurysm was opened. This revealed a large dorso-lateral tear contained by the iliac vein (Fig. 2). A 10 mm interposition Dacron graft (Meadox Hemashield, Boston Scientific, USA) was used to exclude the aneurysm. The internal iliac artery was ligated. The patient made a good recovery.

Chimney-Graft bei komplexen Aortenaneurysmen

ZusammenfassungZielEvaluierung der Literatur der Chimney-Graft- (CG-)Technik zur Behandlung von komplexen abdominellen Aortenaneurysmen (AAA). In der vorliegenden Übersicht wurden Studien eingeschlossen, wenn während der endovaskulären Prozedur von komplexen AAAs die Revaskularisation von viszeralen Ästen der Aorta mit der CG-Technik durchgeführt wurde.ResultateFünf Publikationen mit einer Gesamtzahl von 94xa0Patienten erfüllten die Einschlusskriterien. In 78,7% der Fälle fand die CG-Prozedur Anwendung bei der Behandlung von primären pararenalen oder juxtarenalen AAAs. In 19,2% der Fälle kam die CG-Technik bei an der Anastomose gelegenen Pseudoaneurysmen nach vorausgegangener offener Operation oder bei Endoleaks nach endovaskulärer Behandlung zum Einsatz. Zwei (2,1%) Patienten wurden wegen einer atheromatösen Verschlusskrankheit der Aorta operiert. Bei 16 (17%) Patienten kam die CG-Technik wegen dringlicher Operationsindikationen zum Einsatz. Insgesamt wurden 148 (1,57 pro Patient) viszerale Äste mit der CG-Technik behandelt (124 [83,8%] Nierenarterien, 21 [14,2%] A.xa0mesenterica superior (AMS); 3 [2%] Truncus coeliacus (TC)). Der primäre technische Erfolg lag bei 96,8%. Frühe TYP-I-Endoleaks wurden bei 11% der Patienten beobachtet. Die Mortalität in den ersten 30 postoperativen Tagen betrug 5,3% (5,1% bei elektiven Eingriffen und 6,3% bei dringlichen- bzw. Notfallindikationen). Die Offenheitsrate des CG während der Nachuntersuchungen (durchschnittlich 9,9xa0Monate) lag bei 97,3%. Eine postoperative Verschlechterung der Nierenfunktion zeigte sich in 16% der Fälle. Zu kardialen Komplikationen kam es bei 7,4% und zum Apoplex bei 3,2%.SchlussfolgerungDie frühen Ergebnisse der CG-Technik zeigen die Praktikabilität der Methode. Da aber Langzeitergebnisse fehlen, sollte diese Technik primär auf Bail-out-Situationen oder akute Fälle beschränkt bleiben. Für Patienten mit elektiven Eingriffen bleiben die fenestrierten Stentgrafts bzw. die konventionelle offene Operation die Methode der Wahl.AbstractPurposeThe aim of this article is to review the literature reporting the use of the chimney graft (CG) technique for the treatment of complex abdominal aortic aneurysms (AAA).MethodsStudies were included in the present review if revascularization of visceral branches during endovascular treatment of complex AAAs was accomplished with the CG technique. Case reports and non-consecutive series with less than ten patients were excluded.ResultsA total of 5 publications with a total number of 94 patients fulfilled the inclusion criteria. The CG procedure was applied for the treatment of primary pararenal or juxtarenal AAAs in 78.7xa0% and for the repair of para-anastomotic pseudoaneurysms or endoleaks after prior open or endovascular repair in 19.2%. Of the patients 2 (2.1xa0%) were operated on for atheromatous aortic occlusive disease and 16 (17%) in an urgent setting. A total of 148 (average 1.57 per patient) visceral vessels were treated with CGs: 124 (83.8xa0%) renal arteries, 21 (14.2xa0%) superior mesenteric arteries (AMS) and 3 (2xa0%) celiac arteries (CT). Primary technical success was 96.8xa0% with an early type I endoleak rate of 11xa0%. The 30-day in-hospital mortality was 5.3xa0% (5.1xa0% and 6.3xa0% for elective and urgent cases, respectively) and CG patency during follow-up (mean 9.9 months) was 97.3xa0%. Postoperative renal function impairment occurred in 16xa0%, cardiac complications in 7.4xa0% and ischemic stroke in 3.2xa0% of patients.ConclusionsEarly results of the CG method demonstrate feasibility but due to the lack of long-term outcome data this technique should be currently limited to bail-out procedures or acute situations. For elective cases, fenestrated stent grafting or open repair remain the treatments of choice.

Aktuelle Therapieoptionen beim rupturierten abdominellen Aortenaneurysma@@@Current treatment options for ruptured aortic aneurysms

ZusammenfassungDie endovaskuläre Behandlung von rupturierten Bauchaortenaneurysmen (rEVAR) hatte in Beobachtungsstudien großer Zentren mit entsprechender Erfahrung vielversprechende Überlebensraten gezeigt, die denen der offenen Operation überlegen waren. Die hierzu durchgeführten randomisiert-kontrollierten Studien zeigten vergleichbare Ergebnisse, die jedoch den breiteren Einsatz der rEVAR assoziiert nahelegen. Für den Einsatz der rEVAR und für die bestmögliche Versorgung von rupturierten Bauchaortenaneurysmen sowohl mit rEVAR, aber auch offener Operation ist ein standardisiertes Behandlungsprotokoll mit der entsprechenden Schulung aller beteiligter Berufsgruppen sowie eine adäquate räumliche, technische und materialtechnische Ausstattung im Gefäßzentrum notwendig.AbstractObservational studies from high-volume centers have shown promising results for endovascular repair of ruptured abdominal aortic aneurysms (rEVAR), with superior survival rates compared to open repair. Randomized controlled trials show similar outcomes for both techniques. Axa0standardized protocol along with sufficient training of all involved personnel and adequate technical equipment and material availability are necessary in order to improve outcomes after both open and endovascular repair of ruptured abdominal aortic aneurysms.

Aktuelle Therapieoptionen beim rupturierten abdominellen Aortenaneurysma

ZusammenfassungDie endovaskuläre Behandlung von rupturierten Bauchaortenaneurysmen (rEVAR) hatte in Beobachtungsstudien großer Zentren mit entsprechender Erfahrung vielversprechende Überlebensraten gezeigt, die denen der offenen Operation überlegen waren. Die hierzu durchgeführten randomisiert-kontrollierten Studien zeigten vergleichbare Ergebnisse, die jedoch den breiteren Einsatz der rEVAR assoziiert nahelegen. Für den Einsatz der rEVAR und für die bestmögliche Versorgung von rupturierten Bauchaortenaneurysmen sowohl mit rEVAR, aber auch offener Operation ist ein standardisiertes Behandlungsprotokoll mit der entsprechenden Schulung aller beteiligter Berufsgruppen sowie eine adäquate räumliche, technische und materialtechnische Ausstattung im Gefäßzentrum notwendig.AbstractObservational studies from high-volume centers have shown promising results for endovascular repair of ruptured abdominal aortic aneurysms (rEVAR), with superior survival rates compared to open repair. Randomized controlled trials show similar outcomes for both techniques. Axa0standardized protocol along with sufficient training of all involved personnel and adequate technical equipment and material availability are necessary in order to improve outcomes after both open and endovascular repair of ruptured abdominal aortic aneurysms.