W. T. G. J. Bos

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.

Present and Future of Branched Stent Grafts in Thoraco-abdominal Aortic Aneurysm Repair: A Single-centre Experience

BACKGROUND Recent developments with fenestrated and branched stent grafts have opened the way to treat complex aortic aneurysms involving the visceral arteries. Early reports on endovascular treatment of thoraco-abdominal aneurysms have demonstrated the feasibility of the technique. Given the sparse literature, its safety has not been established yet. METHODS A literature review was conducted, and the results of our own series of 30 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. The mean aneurysm size was 70 mm and the extent of the aneurysm was type I in eight cases, type II in five, type III in 12 and type IV in five patients. RESULTS Technical success in our series was achieved in 93% (28/30). Two out of 97 (2%) targeted vessels were lost. In one patient, a renal artery ruptured during insertion of the bridging stent graft. In a second patient, a coeliac artery could not be catheterised and was lost. The 30-day mortality was 6.7% and corroborated with 5.5% in the largest series reported so far. The 6 months and 1-year survival were 89.3% and 76.0%, respectively. CONCLUSION The results of fully endovascular repair of selected thoraco-abdominal aneurysms are promising. A learning curve should be expected. Anatomical limitations such as extremely tortuous vessels and access problems should be taken into account, as well as the quality of the targeted side branches. Although longer-term results need to be awaited, it is likely that endovascular repair of thoraco-abdominal aneurysms will become a preferential treatment option for many patients in the future.

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.

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 Abdominal Aortic Aneurysm Repair with the Zenith stent-graft

OBJECTIVE To evaluate single center results of the Zenith stent-graft for elective abdominal aortic aneurysm repair. METHODS Data from all patients treated with a Zenith graft between March 1999 and December 2006 were retrospectively analyzed from a prospective database. Outcome measures were technical success, all-cause and aneurysm related mortality, late complications, and re-interventions. RESULTS A total of 234 patients were included, of which 216 were male. Mean age was 72.1+/-6.9 years. Mean diameter of the aneurysm was 60.9+/-10mm. Technical success rate was 98.3%. Thirty day mortality was 1.7%. Median follow-up was 26.9 months (range, 1-104). Overall survival was 92.2+/-1.8% at 1 year, 87.2+/-2.3% at 2 years, and 69.9+/-4.6% at 5 years. During follow-up, one aneurysm ruptured due to limb disconnection, which was treated by bridging stent-grafting. Re-interventions were performed in 9.2% of the patients, with 79% by endovascular means. There was no mortality related to re-intervention. CONCLUSIONS Endovascular abdominal aortic aneurysm repair with the Zenith device provides excellent results with a low risk for aneurysm-related death and rupture, and a low re-intervention rate in the mid-term.

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.

Emergency endovascular stent grafting for thoracic aortic pathology.

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease. From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm (n = 13), pseudoaneurysm (n = 6), aortic rupture (n = 5), type B dissection (n = 5), aortobronchial or aortoesophageal fistula (n = 4), and intramural hematoma (n = 1). The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures. The mean follow-up was 31 ± 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections. Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft. Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.

Fenestrated Endovascular Stent-Grafts: Current Applications

Fenestrated stent-grafts are designed to treat short-neck abdominal aortic aneurysms. Thanks to customized fenestrations, patency of side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft across these aortic branches.