Stefano Ancetti

Fenestrated and Branched Endograft after Previous Aortic Repair

BACKGROUND Para-anastomotic aneurysms (P-AAA) and proximal aortic aneurysmal degeneration after previous aortic open repair (OR) or endovascular repair (EVAR) are challenging clinical scenarios. OR is technically demanding, and standard EVAR could be impossible due to the absence of proximal landing zone. The aim of the study is to report midterm results of fenestrated and branched endografts (FB-EVAR) to treat proximal aortic lesions after previous aortic repair. METHODS Since 2010, patients that underwent FB-EVAR after previous aortic repair were prospectively enrolled. Clinical or morphologic or intraoperative or postoperative data were collected and retrospectively analyzed. Primary end points were technical success and clinical success. Secondary end points were procedure-related events (endoleaks, target visceral vessels occlusion, mortality), midterm survival and freedom from FB-EVAR-related reinterventions. RESULTS Twenty patients (Male: 98%, age: 75 ± 6 years, American Society of Anesthesiologists [ASA] ≥ III: 100%) were enrolled. Fifteen patients (75%) underwent previous aortic OR and 5 (25%) standard EVAR. The mean time since the previous treatment was 12 ± 10 years. Present aortic lesions included thoracoabdominal aneurysms 12 (60%) and juxtarenal and pararenal aneurysms 8 (40%). The mean aortic aneurysm diameter was 67 ± 15 mm. All patients were at high risk for OR and had anatomies precluding standard EVAR. Seventy-two visceral vessels (renal arteries: 34, superior mesenteric artery: 20, celiac trunk: 18) were targeted: 49 fenestrations, 19 branches, and 4 scallops. An FB-EVAR tube and trimodular endograft was planned in 17 and 3 cases, respectively. Technical success was 95%; operative target vessel perfusion was 98.5%. Thirty-day mortality was 0%. Clinical success was 80% because there was a transient renal function worsening in 4 patients (>30% of baseline). One distal type I endoleak was detected and treated at 1-month. The mean follow-up was 15 ± 11 months. There were not proximal type I endoleaks, target visceral vessel occlusions, or aneurismal-related mortality. Survival at 1 year was 85 ± 5%. One late FEVAR-related reintervention occurred. CONCLUSIONS According to the reported data, FB-EVAR for treating P-AAA or proximal aneurysmal degeneration after previous aortic OR/EVAR in high-risk patients is a safe and/or effective solution.

Off-the-shelf multibranched endograft for urgent endovascular repair of thoracoabdominal aortic aneurysms

Objective: The aim of this paper was to report early and midterm results of endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) by the off‐the‐shelf multibranched Zenith t‐Branch endograft (Cook Medical, Bloomington, Ind). Methods: Between January 2014 and April 2016, all patients with urgent TAAAs (asymptomatic with diameter >8 cm, symptomatic, or ruptured TAAAs) and aortoiliac anatomic feasibility underwent endovascular repair by t‐Branch and were prospectively enrolled. Clinical, morphologic, intraoperative, and postoperative data were recorded. Follow‐up was performed by duplex ultrasound, contrast‐enhanced duplex ultrasound, and computed tomography angiography. Early end points were technical success (absence of type I or type III endoleak, loss of target visceral vessels [TVVs], conversion to open repair, or 24‐hour mortality), spinal cord ischemia, and 30‐day mortality. Follow‐up end points were survival, TVV patency, type I or type III endoleaks, and freedom from reintervention. Results: Seventeen patients (male, 71%; age, 73 ± 6 years; American Society of Anesthesiologists class 3/4, 60%/40%) affected by type II (47%), III (29%), and IV (24%) TAAAs were enrolled. The indications for t‐Branch were as follows: contained TAAA rupture, four (24%); symptomatic TAAA (pain or peripheral embolism), four (24%); and TAAA diameter ≥8 cm, nine (52%). The mean TAAA diameter was 80 ± 19 mm, with 63 TVVs. Fifteen patients (87%) needed adjunctive intraoperative procedures: 14 proximal thoracic endografts (thoracic endovascular aortic repair), 1 left carotid‐subclavian bypass, 2 endovascular hypogastric branches, and 2 surgical iliac conduits. In four cases (24%), a significant malorientation (≥60 degrees) of the main body occurred during t‐Branch deployment. Technical success was achieved in 14 cases (82%), with technical failures consisting of the loss of three renal arteries (TVV patency, 95%). Spinal cord ischemia occurred in one case (6%) with temporary paraparesis. The 30‐day mortality was 6% (one patient with ruptured type II TAAA died on postoperative day 7 of respiratory failure). Renal function worsening occurred in four patients (25%), with one case requiring permanent hemodialysis. The mean follow‐up was 11 ± 9 months. Survival at 1 month, 6 months, and 12 months was 94%, 82%, 82%, respectively. No TAAA‐related mortality and TVV occlusion occurred in the follow‐up. One type III endoleak was detected at 3 months and successfully treated. Freedom from reintervention at 1 month, 6 months, and 12 months was 88%, 82%, and 82%, respectively. Conclusions: The off‐the‐shelf multibranched endograft is a safe and effective therapeutic option for urgent total endovascular TAAA repair for which a custom‐made endograft is not obtainable in due time. However, the complex anatomy of these aneurysms needs a number of adjunctive and complex intraoperative procedures to achieve a durable repair.

Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair

Objective: Fenestrated and branched endovascular aneurysm repair (FB‐EVAR) is a valid option to treat juxtarenal and pararenal abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Because successful deployment depends on complex maneuvers, hostile iliac artery anatomy (HIA) can prejudice the FB‐EVAR outcome. The aim of the study was to evaluate the impact of HIA on FB‐EVAR outcome. Methods: Between 2010 and 2015, all patients undergoing FB‐EVAR were prospectively categorized according to iliac anatomy (friendly iliac artery anatomy [FIA] or HIA). HIA was defined as the presence of one of the following: severe (>90‐degree) iliac angle, extensive (>50%) iliac circumferential calcification, hemodynamic iliac stenosis or obstruction, external iliac artery diameter <7 mm, or previous aortoiliac/femoral graft. Early end points were technical success (absence of type I or type III endoleak, target visceral vessel [TVV] loss, conversion to open repair), intraoperative adjunctive maneuvers (IAMs; iliac percutaneous transluminal angioplasty/stenting, surgical iliac conduit, intra‐aortic graft rotations, several attempts of TVV cannulation), intraoperative technical problems (iliac rupture, significant endograft twisting, difficult TVV cannulations, TVV injuries, TVV loss), and 30‐day mortality. Follow‐up end points were survival, TVV patency, and freedom from reintervention. Results: Ninety‐four patients (male, 87%; age, 73 ± 6 years) with 59 (63%) juxtarenal and pararenal abdominal aortic aneurysms and 35 (37%) thoracoabdominal aortic aneurysms underwent FB‐EVAR, for a total of 324 TVVs; 60 (64%) patients had HIA and 34 (36%) had FIA. Patients with HIA and FIA had similar preoperative clinical characteristics, except for coronary artery disease, peripheral artery occlusive disease, and American Society of Anesthesiologists class 4 (47% vs 24% [P = .03], 12% vs 0% [P = .04], and 28% vs 9% [P = .03], respectively). Technical success was 96% (HIA, 97%; FIA, 95%; P = .6). In HIA, adjunctive iliac procedures were performed in 32 cases (surgical conduit, 14 [15%]; percutaneous transluminal angioplasty/stenting, 27 [29%]). Endograft twisting and difficult TVV cannulation occurred in 13 (14%) and 33 (35%) cases, respectively (HIA 18% vs FIA 15% [P = .09]; HIA 28% vs FIA 21% [P = .03]). TVV cannulation failed in nine cases and injury occurred in five (TVV patency rate, 97.8%; HIA 94.7% vs FIA 98.3%; P = .3). One (1%) iliac rupture occurred in HIA, needing surgical repair. Overall, 44 (47%; HIA 55% vs FIA 25%; P = .03) IAMs were necessary. Perioperative mortality was 4% (HIA 3% vs FIA 5%; P = .9). At multivariate analysis, predictors of IAMs were external iliac diameter <7 mm (odds ratio [OR], 12.5; 95% confidence interval [CI], 2.2–71.4; P = .004) and extensive iliac calcifications (OR, 8.3; 95% CI, 1.4–50.0; P = .02). The mean follow‐up was 24 ± 17 months, with an overall survival of 87% and 71% at 1 year and 3 years, respectively, significantly lower in HIA compared with FIA (at 3 years, HIA 60% vs FIA 92%; P = .02). On multivariate analysis, HIA was a significant predictor of late mortality (OR, 3.6; 95% CI, 1.1–13.2; P = .04). Freedom from reintervention (87%) and 3‐year TVV patency (92%) were similar in the two groups. Conclusions: HIA does not significantly affect the early outcome of FB‐EVAR. However, in patients with HIA, procedures are technically more demanding and late mortality is increased. Iliac characteristics should be taken into account to correctly stratify the surgical risk in FB‐EVAR.

Portal/Superior Mesenteric Vein Reconstruction during Pancreatic Resection Using a Cryopreserved Arterial Homograft.

Background: Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice. Methods: From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed. Results: Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period. Conclusion: The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients.

IF07. The Impact of Branches and Fenestrations on Early and Long-Term Visceral Vessel Patency in Complex Aortic Endograft Revascularization

Objective: The majority of late endovascular aneurysm repair (EVAR) complications can be easily managed by endovascular means. Nevertheless, a late open conversion (LOC) is sometimes required. The aim of the study was to report the outcomes and technical aspects of a multicenter experience of LOC after EVAR performed electively. Methods: All LOCs performed from 1996 to 2016 in 10 Italian Vascular Centers were reviewed. LOC was defined as a total or partial endograft explantation >30 days after the initial EVAR. Patients’ demographics, clinical risk factors, time elapsing from EVAR, type of endograft, previous attempts of endovascular correction, indication for LOC, operative technique (clamping site, partial or complete graft removal), 30-day mortality, and postoperative major complications were analyzed. Long-term survival was evaluated by Kaplan-Meier method. Results: During the study period, 175 patients underwent LOC. Among these, 121 were operated on electively and were therefore analyzed. Mean age at conversion was 73.5 6 7.5 years; 90% were male. Grafts were excised after a median of 40.2 months (range, 1.2-150.1 months). The number of LOCs increased significantly during the period of the study (correlation R 1⁄4 0.66; P 1⁄4 .0015). Types of explanted endografts were 109 bifurcated, 5 aortouni-iliac, 4 tubes, 2 chimney grafts, and 1 iliac side branch device. An endovascular attempt to repair the failing EVAR was performed in 40 of 121 patients before LOC. The reason for LOC was endoleak (83%), endograft infection (12%), and graft thrombosis (5%). Proximal aortic cross-clamping site was infrarenal in 42% of the cases, suprarenal in 17%, supraceliac in 39%, and thoracic in 2%. Complete removal of the stent graft was performed in 68% of the patients. Reconstructions were performed with Dacron grafts in 110 of 121 cases, cryopreserved arterial allografts in 6 of 121, endograft removal associated with prosthetic axillobifemoral bypass in 4 of 121, and autologous superficial femoral vein in 1 of 121. Overall 30-day mortality was 7.4%. Infected EVAR was significantly associated with a higher morbidity (P 1⁄4 .022), and longer length of stay (24.9 6 14.8 vs 13.9 6 10 days; P 1⁄4 .0023). During the median follow-up of 24.5 months (range, 0-212.1 months), five aneurysm-related deaths occurred (two reinfections, two allograft ruptures, one rupture of an aortic stump). The estimated 1and 5-year survival rates were 83.2% and 61.9%, respectively. Long-term survival was significantly lower for infected endografts (57.4% vs 87.3% at 1 year; log-rank P 1⁄4 .0028). Conclusions: Number of LOCs after EVAR increased significantly over time. Elective LOC has satisfactory postoperative and long-term outcomes. LOCs for infected endografts are associated with a complicated postoperative period and poor long-term survival.

PC026 Impact of Previous Open Aortic Repair on the Outcome of Thoracoabdominal Fenestrated and Branched Endografts

case of distal type I endoleak and device migration (>10 mm) of a right iliac leg component was noted during longer-term follow-up. No other limb-related endoleak, migration, component separation, or stent fracture was reported during a mean follow-up of 10.8 6 5.6 months. Conclusions: Results from this postmarket registry under routine clinical care demonstrate infrequent limb occlusions and limb-related reintervention, supporting the excellent performance of the Spiral-Z leg graft.

IP067. The Clinical Impact of Splanchnic Ischemia in Thoracoabdominal Aortic Aneurysm Repair With Fenestrated and Branched Endografts

Objectives: Length of stay (LOS) is a quality metric used for pathway development to improve hospital efficiency. We sought to define the predictors of prolonged LOS in patients undergoing thoracic endovascular aortic repair (TEVAR) for dissection or aneurysm by comparing demographic, operative, and postoperative factors in the National Surgical Quality Improvement Program (NSQIP). Methods: Patients undergoing TEVAR from 2005 to 2015 in the NSQIP were separated into dissection and aneurysm populations using International Classification of Diseases-Ninth Revision diagnosis codes. Groups were compared with c analysis and t-tests. Prolonged LOS was defined as those patients at or above the 75th percentile for LOS (

Endovascular Repair of Thoracoabdominal Aortic Aneurysm in High-Surgical Risk Patients: Fenestrated and Branched Endografts

11 days). Univariate and multivariate logistic regression identified factors associated with prolonged LOS.