Eric L.G. Verhoeven

Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?

Purpose To review the literature reporting open surgical and endovascular treatment of juxtarenal aortic aneurysm (JAA). Methods A systematic search of the PubMed database was carried out to identify English-language articles published between January 2001 and July 2012 on the management of JAA with open surgery, fenestrated endovascular aneurysm repair (F-EVAR), and the chimney graft technique (Ch-EVAR). The search found 20 studies with a total of 1725 patients (76% men; age range 66–74 years) undergoing open surgery, 10 studies detailing 931 patients (87.6% men; age range 72–75 years) receiving F-EVAR, and 5 studies comprising 94 patients (75% men; age range 68–82) reporting Ch-EVAR. Results A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR: p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR: p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR: p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR: p=0.002; F-EVAR vs. Ch-EVAR: p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002). Conclusion Open surgery remains a safe and effective treatment option for good risk patients with JAA. F-EVAR is associated with low operative mortality, compares favorably to open surgery in terms of morbidity, and current midterm data indicate that it can be a valid treatment option in both low- and high-risk patients. Early results of Ch-EVAR demonstrate feasibility only. In view of the limited number of reports and the lack of long-term data, the technique should be considered only in acute poor surgical risk patients, as a bailout in case of unintentional renal artery coverage, or in elective poor surgical cases that are not suitable for F-EVAR.

Visceral stent patency in fenestrated stent grafting for abdominal aortic aneurysm repair

OBJECTIVEnFenestrated endovascular abdominal aortic aneurysm repair (F-EVAR) has been introduced for treatment of aneurysms in which visceral arteries are incorporated. Patency of target vessels has been reported to be excellent. Results of the use of stent grafts to accommodate visceral arteries in F-EVAR are presented in this study, including an overview of factors that affect outcome.nnnMETHODSnAll patients treated with fenestrated stent grafts in a single center between November 2001 and October 2011 were reviewed. Patients treated for suprarenal, juxtarenal, and infrarenal short-necked aortic aneurysms were included. Patients with thoraco-abdominal aneurysms or aneurysms treated with grafts with fixed side branches were excluded. Polytetrafluoroethylene covered stents were used routinely since June 2005. Target vessels and stents were examined using computed tomography angiography reconstructions. Primary end points were primary patency, defined as the absence of occlusion, and loss of renal function. Secondary end points were technical success, stenosis (defined as a ≥50% angiographic diameter reduction), stent fracture, and mortality.nnnRESULTSnA total of 138 patients with a median age of 73 years (range, 50-91 years) met the inclusion criteria. Median computed tomography angiography follow-up was 13 months (range, 1-97 months). In total, 392 target vessels were provided with 140 scallops and 252 fenestrations. Visceral stents (-grafts) were placed in 254 target vessels. Technical success was obtained in 249 arteries (98.0%). Overall stent patency of target vessels was 95.7% at 1 year and 88.6% at 4 years. Renal artery stent patency was 97.4% at 1 year and 91.2% at 4 years (96.8% and 89.1% for uncovered stents; 97.3% and 92.4% for covered stents, respectively). There was no significant difference in patency between covered and uncovered stents in renal arteries (P = .71). Renal artery stenosis occurred in 26 stented arteries (11.3%) and occlusion in seven arteries. Renal artery stent stenosis occurred significantly more in uncovered than in covered stents (P = .04). Stent fractures occurred more in uncovered than in covered stents (P = .01) and was associated with a significantly lower visceral stent patency rate (P < .01). During follow-up, 13 patients developed permanent renal function impairment (9.4%), of which two required permanent dialysis (1.4%). Renal dysfunction was significantly associated with renal stent occlusion or stenosis (P < .01).nnnCONCLUSIONSnPatency rates of visceral artery stent (-grafts) in F-EVAR were 95.7% at 1 year and 88.6% at 4 years. Patency rates were affected by stent fractures, which occurred more in uncovered compared with covered stents. Renal artery stent stenosis occurred more in uncovered compared with covered stents. Renal dysfunction was significantly associated with renal stent occlusion or stenosis.

Fenestrated Stent-Grafts for Salvage of Prior Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVESnTo review our experience with fenestrated endovascular aneurysm repair (F-EVAR) to treat complications after previous standard infrarenal endovascular aneurysm repair (EVAR).nnnMETHODSnA prospectively maintained database including all consecutive patients with juxtarenal abdominal aortic aneurysm that were treated with F-EVAR after failed previous EVAR within the period March 2002 to November 2012 at the University Medical Center of Groningen, Netherlands (up to October 2009), and the Klinikum Nürnberg Süd, Germany (from November 2009) was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity, and late procedure-related events with regard to survival, target vessel patency, endoleak, renal function, and reintervention.nnnRESULTSnA total of 26 patients (24 male, mean age 73.2 ± 6.5 years) were treated. All patients had proximal anatomies precluding endovascular reintervention with standard techniques. In 23 patients a fenestrated proximal cuff was used, and in three patients a bifurcated fenestrated stent graft. Technical success was achieved in 24 (92.3%) patients. One patient required on-table open conversion because of impossibility to retrieve the top cap as a result of twist of the ipsilateral limb. In the second patient the right kidney was lost due to inadvertent stenting in a smaller branch of the renal artery. Catheterization difficulties, all related to the passage through the limbs or struts of the previous stent graft, were encountered in 11 (42.3%) cases, including five (19.2%) patients with iliac access problems and six (23.1%) with challenging renal catheterization. Operative target vessel perfusion success rate was 94.6% (70/74). Operative mortality was 0%. Mean follow-up was 26.8 ± 28.5 months. No proximal type I endoleak was present on first postoperative CTA. The mean aneurysm maximal diameter decreased from 73 ± 20 mm to 66.7 ± 21 mm (p < .05). There were six late deaths, one of them aneurysm related. Estimated survival rates at 1 and 2 years were 94.1 ± 5.7% and 87.4 ± 8.4%, respectively. Patency during follow-up for the target vessels treated successfully with a fenestrated stent graft was 100% (70/70). Reintervention was required in four cases, including one acute conversion due to rupture, one for iliac limb occlusion and two for type Ib and II endoleak. Renal function deterioration was observed solely in the two cases of primary technical failure.nnnCONCLUSIONSnF-EVAR represents a feasible option for the repair of juxtarenal abdominal aortic aneurysm after prior EVAR failure. It is advantageous in terms of mortality and less morbid than open surgery, but is associated with increased technical challenges because of the previously placed stent graft. Outcome seems related to initial technical success.

Outcomes of Fenestrated/Branched Endografting in Post-dissection Thoracoabdominal Aortic Aneurysms

OBJECTIVESnFenestrated/branched thoracic endovascular repair (F/Br-TEVAR) is increasingly applied for atherosclerotic thoracoabdominal aortic aneurysm (TAAA); however, use in post-dissection TAAAs is still very limited. Experience with F/Br-TEVAR in the treatment of post-dissection TAAA is presented.nnnMETHODSnData were analysed from prospectively maintained databases including all patients with post-dissection TAAAs that underwent F/Br-TEVAR within the period January 2010 to July 2013 in two vascular institutions. Evaluated outcomes included initial technical success, operative mortality and morbidity, late survival, endoleak, aneurysm diameter regression, renal function, and reintervention during follow-up (FU).nnnRESULTSnA total of 31 patients (25 male, mean age 65 ± 11.4 years) were treated. Technical success was 93.5% and 30-day mortality 9.6%. Temporary spinal cord ischaemia occurred in four (12.6%) patients, with no case of permanent paraplegia. Mean FU was 17.0 ± 10 months. There were seven late deaths, all aneurysm unrelated. Estimated overall survival rates were 83.9 ± 6.7, 76.4 ± 7.9 and 71.6 ± 8.7% at 6, 12, and 18 months, respectively. Impairment of renal function occurred in two (6.4%) patients. Endoleaks were diagnosed in 12 patients during FU, including six type IB endoleaks and six type II endoleaks. Reintervention was required in seven (22.5%) patients. Mean aneurysm sac regression was 9.3 ± 8.7 mm, with a false lumen thrombosis rate of 66.7% and 88.2% for patients with a FU longer than 6 and 12 months respectively.nnnCONCLUSIONSnF/Br-EVAR is feasible for patients with a post-dissection TAAA. Although associated with additional technical challenges, and a significant need for reintervention, it leads to favourable aneurysm morphologic changes, and may play a more prominent role in the future for this type of pathology if long-term results confirm the good initial outcome.

Fenestrated and Branched Stent-Grafts to Treat Post-Dissection Chronic Aortic Aneurysms After Initial Treatment in the Acute Setting

Purpose To present our initial experience treating post-dissection thoracoabdominal aneurysms with fenestrated and branched grafts. Methods Six patients (all men; mean age 62 years, range 44–71) with post-dissection thoracoabdominal aortic aneurysms were selected for treatment with fenestrated and branched grafts. All patients were initially treated with open surgery or endovascular treatment for their acute dissection. In total, 21 visceral arteries were targeted (3 celiac arteries, 6 superior mesenteric arteries, 12 renal arteries). Results Technical success was achieved in all cases, with no mortality or paraplegia. At completion angiography, all target vessels were patent, and no type I endoleak was seen. A type II endoleak was present in 4 patients, with the false lumen still partially perfused. During follow-up (mean 9 months, range 3–15), no patients died. One targeted renal artery occluded at 1 month. One type lb endoleak in a left renal artery was successfully treated with additional stenting. Five of the 6 patients had a 6-month follow-up. On abdominal ultrasound, 3 type II endoleaks were still seen. In 2 of these patients, the endoleak was resolved, the false lumen was completely thrombosed, and the maximum aortic diameter had regressed on the 1-year CTA. Conclusion Although longer follow-up results are needed, treatment with fenestrated and branched stent-grafts seems feasible and may be a promising option for the treatment of chronic post-dissection aortic aneurysms.

Practical points of attention beyond instructions for use with the Zenith fenestrated stent graft

Fenestrated stent grafting for endovascular repair (F-EVAR) aims to treat patients with abdominal aortic aneurysms that are unsuitable for standard EVAR because of a short or absent infrarenal neck. F-EVAR has been used initially in patients with higher surgical risk with pararenal abdominal aortic aneurysms, but F-EVAR is now increasingly considered a treatment alternative to open surgery in anatomically suitable patients. F-EVAR has benefitted from ongoing technical refinements and accumulating clinical experience but remains a relatively complex procedure. Correct indication, accurate preoperative planning, and meticulous execution are the key to long-term success. Considering the growing interest in F-EVAR worldwide, including the United States, we discuss current indications and provide advice for planning and technical execution on the basis of the senior authors 13xa0years of experience.

Fenestrated endografting of juxtarenal aneurysms after open aortic surgery

INTRODUCTIONnJuxtarenal aneurysms after previous surgical aortic reconstruction constitute a complex clinical scenario. Open redo surgery is technically demanding and usually requires suprarenal or supraceliac clamping. Standard endovascular repair is prohibited due to the lack of a proximal landing zone. We present our experience with fenestrated endovascular aneurysm repair (F-EVAR) in the treatment of juxtarenal aneurysms after previous open surgery.nnnMETHODSnA prospectively maintained database including all patients with juxtarenal abdominal aortic aneurysm after previous surgical reconstruction that underwent F-EVAR within the period from November 2003 to February 2013 under the instruction of the senior author. Evaluated outcomes included initial technical success and operative mortality and morbidity as well as late survival, target vessel patency, aneurysm diameter regression, renal function, and reintervention.nnnRESULTSnA total of 35 patients (33 male; mean age, 71.5 ± 6.2 years) were treated. Median interval from the primary surgical reconstruction was 126 months (range, 48-223 months). All patients had proximal anatomies precluding standard endovascular techniques and were considered high risk for open repair due to their comorbidities and redo nature of the operation. In total, 111 vessels were targeted: 77 with small fenestrations, 33 with scallops, and 1 vessel with a downward branch. The operation was completed by totally endovascular means in 34 patients (97.1%). In one patient, a retroperitoneal approach was needed to gain retrograde access to a renal artery. Operative target vessel perfusion success rate was 100%. Operative mortality was 0% and median hospital stay 6 days (range, 2-40 days). Mean follow-up (FU) was 37.5 ± 25 months. Mean aneurysm maximal diameter decreased from 60 ± 4 mm to 47 ± 8 mm (P < .05). No type I endoleak was diagnosed, and no reintervention was required during FU. There were eight late deaths, all unrelated to the aneurysm. Estimated survival rates at 1, 2, and 4 years were 92.0% ± 5.5%, 82.8% ± 7.9% and 76.9% ± 9.3%, respectively. Three target vessel occlusions occurred during FU. One patient suffered a bilateral renal artery occlusion resulting in dialysis. In a second patient, one renal artery occluded without clinical symptoms. No other cases of renal function deterioration were observed.nnnCONCLUSIONSnF-EVAR is a valid treatment option for juxtarenal aneurysms after previous surgical reconstruction. F-EVAR represents a less morbid alternative to redo open surgery, has a high technical success rate, and shows durability in mid-term FU.

Incomplete Expansion of Chimney Stent Graft during Chimney-Thoracic Endovascular Aneurysm Repair

BACKGROUNDnTo report a technical complication during a chimney-thoracic endovascular aneurysm repair (Ch-TEVAR) procedure.nnnMETHODSnA 77-year-old female patient underwent Ch-TEVAR for a symptomatic thoracic aortic aneurysm with a short and angulated proximal neck. Deployment of the aortic stent graft over the left subclavian artery (LSA) was followed by placement of a balloon-expandable covered stent as a chimney for the LSA.nnnRESULTSnChimney deployment failed due to balloon perforation. Additional attempts with several balloons all failed, albeit gaining some additional expansion of the chimney stent graft. The technical complication was solved by deploying a self-expanding bare stent inside the chimney stent. This enabled additional ballooning and further expansion of the chimney stent graft leading to an acceptable end result.nnnCONCLUSIONSnCh-TEVAR with a balloon-expandable chimney stent graft can be complicated by incomplete chimney deployment due to balloon perforation. Relining of the chimney stent graft with a self-expanding stent improved the deployment with acceptable patency.