Georgios Vourliotakis

Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience.

OBJECTIVES To present an 8-year clinical experience in the endovascular treatment of short-necked and juxtarenal abdominal aortic aneurysm (AAA) with fenestrated stent grafts. METHODS At our tertiary referral centre, all patients treated with fenestrated and branched stent grafts have been enrolled in an investigational device protocol database. Patients with short-necked or juxtarenal AAA managed with fenestrated endovascular aneurysm repair (F-EVAR) between November 2001 and April 2009 were retrospectively reviewed. Patients treated at other hospitals under the supervision of the main author were excluded from the study. Patients treated for suprarenal or thoraco-abdominal aneurysms were also excluded. All stent grafts used were customised based on the Zenith system. Indications for repair, operative and postoperative mortality and morbidity were evaluated. Differences between groups were determined using analysis of variance with P < 0.05 considered significant. RESULTS One hundred patients (87 males/13 females) with a median age of 73 years (range, 50-91 years) were treated during the study period; this included 16 patients after previous open surgery or EVAR. Thirty-day mortality was 1%. Intra-operative conversion to open repair was needed in one patient. Operative visceral vessel perfusion rate was 98.9% (272/275). Median follow-up was 24 months (range, 1-87 months). Twenty-two patients died during follow-up, all aneurysm unrelated. No aneurysm ruptured. Estimated survival rates at 1, 2 and 5 years were 90.3 +/- 3.1%, 84.4 +/- 4.0% and 58.5 +/- 8.1%, respectively. Cumulative visceral branch patency was 93.3 +/- 1.9% at 5 years. Visceral artery stent occlusions all occurred within the first 2 postoperative years. Four renal artery stent fractures were observed, of which three were associated with occlusion. Twenty-five patients had an increase of serum creatinine of more than 30%; two of them required dialysis. In general, mean aneurysm sac size decreased significantly during follow-up (P < 0.05). CONCLUSIONS Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm appears safe and effective on the longer term. Renal function deterioration, however, is a major concern.

Fenestrated and branched endograft repair of juxtarenal aneurysms after previous open aortic reconstruction

OBJECTIVE Para-anastomotic aortic aneurysms and progressive aneurysmal degeneration of the aorta after previous open aortic reconstruction pose a challenging clinical scenario. Due to the proximity to the visceral arteries, endovascular exclusion is typically not an option. However, the development of fenestrated and branched endografts has provided a less invasive means of repair. We sought to evaluate our experience using fenestrated endografts in the management of juxtarenal aortic aneurysms after previous open aortic reconstruction. METHODS This is an analysis of patients who have undergone fenestrated endovascular repair specifically for juxtarenal aneurysms in the setting of previous infrarenal open aortic surgery. Patients were treated with customized Cook (William A. Cook Australia, Ltd, Brisbane, Australia) endografts manufactured based on preoperative 3-dimensional (3-D) imaging. All patients underwent repair under the direction of a single surgeon. RESULTS Eighteen patients were treated from March 2004 to November 2008. All patients had a previous open aortic reconstruction, and 3 patients had two prior reconstructions. The mean time since the last operation was 8.5 years (range, 1-15 years). Mean patient age was 72-years-old (range, 57-80 years). All patients were considered high risk for open surgery due to pre-existing medical co-morbidities and/or the redo nature of their surgery. The mean number of fenestrations per patient was three vessels, including proximal graft scallops. All but one operation (94%) was completed by totally endovascular means. One operation required a planned celiotomy for retrograde access to a left renal artery. Of 56 target vessels, all were successfully revascularized using a combination of: fenestrations with stents (12), or stent grafts (25), as well as graft scallops (18), and directional graft branches with a bridging stent graft (1). Mean operative time was 215 minutes (range, 135-420 minutes) and mean blood loss was 560 cc (range, 100-1500 cc). Thirty-day and 1-year mortality was 0 and 11%, respectively. Perioperative complications occurred in 2 patients. One patient developed a congestive heart failure exacerbation and myocardial infarction, and the other patient a groin wound infection. Mean follow-up time was 23 months and cumulative primary patency was 95% (53/56 vessels), with no follow-up interventions. CONCLUSION Endovascular treatment of juxtarenal aneurysms after prior aortic reconstruction is a viable alternative to open repair with high success and low reintervention rates. These devices will broaden the available treatment modalities for these conditions, and will likely significantly decrease the complication rate of treatment in these high-risk patients.

Results of Endovascular Repair of TAAA in the First 50 Patients

BACKGROUND Developments 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. METHODS A literature review and results of first 50  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 71 mm and extent of the aneurysm was type  I (n = 9), type  II (n = 13), type  III (n = 19), and type  IV (n = 9), respectively. RESULTS Primary and primary assisted technical successes in our series were 88 % (44 / 50) and 92 % (46 / 50), respectively. One patient died on day  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 8 %. Estimated survival at 6  months, 1  year, and 2  years was 91.2 %, 79.8 %, and 69.7 %, respectively. Freedom of reintervention of all kinds at 1 and 2  years was 81.9 % and 73.7 %, respectively. CONCLUSION Results 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.

Hybrid Endograft Solution for Complex Iliac Anatomy: Zenith Body and Excluder Limbs

The purpose of this study was to evaluate single-center results with selective use of Gore Excluder limbs (W.L. Gore & Associates, Flagstaff, AZ) in a Cook Zenith body (Cook Inc, Bloomington, IN) for elective endovascular abdominal aortic aneurysm (AAA) repair. A prospectively held database for patients with AAA, who were treated endovascularly between March 1999 and July 2008, was queried for patients treated with a Cook Zenith body and one or two Gore Excluder limbs. Indication, technical success, late limb occlusion, and disconnection were evaluated. From 276 patients who were treated with a Zenith body, 29 underwent repair with hybrid graft components with, in total, 41 Gore Excluder limbs. The indication was always complex iliac anatomy. The primary technical success rate in this group was 89% (26 of 29 patients), with a primary assisted technical success rate of 100%. Mortality at 30 days was 0%. The mean follow-up was 19.4 months (range 2–64 months). Late mortality was 13.8% (4 of 29), with no aneurysm-related death. No graft limb occlusion or disconnection occurred during follow-up. No reintervention was needed in the hybrid endograft group. The use of a Cook Zenith body with Gore Excluder limb(s) in case of adverse iliac anatomy is feasible and showed no adverse effects at the midterm follow-up.

Intraoperative salvage of a renal artery occlusion during fenestrated stent grafting

A 79-year-old man with a 6-cm juxtarenal abdominal aortic aneurysm was treated by endovascular means with a fenestrated stent graft. The completion angiogram revealed a left renal artery occlusion. A retroperitoneal surgical approach allowed for retrograde catheterization of the occluded covered stent through the left renal artery. The covered stent was reopened by balloon angioplasty. After 2 months, the left renal artery was patent and renal function normal. At 6 months, both renal arteries were fully open on duplex imaging. The open retroperitoneal approach with retrograde catheterization is a bailout technique to avoid loss of a kidney in fenestrated stent grafting.

Endovascular reconstruction of iliac artery bifurcation atherosclerotic disease with the kissing technique.

A 71-year-old male patient with severe left buttock and lower-extremity claudication due to iliac artery bifurcation stenoses was referred to our institution for endovascular treatment. A ‘kissing’ technique was used in order to dilate the proximal parts of both internal and external iliac arteries and avoid compromization of the internal iliac artery during proximal external iliac artery stenting. A balloon expandable stent was inserted via a left ipsilateral retrograde access to the narrowed origin of the left external iliacartery and a balloon catheter via a right contralateral access inside the origin of the left internal iliac artery. Simultaneous balloons inflation restored full patency of both vessels. Twelve months later the patient is doing well, free of buttock or lower-extremity claudication symptoms. For iliac artery bifurcation atherosclerotic disease, endovascular repair with the ‘kissing’ technique can achieve a complete bifurcation reconstruction offering significant clinical benefit in selected patients.