Zoran Rancic

10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned.

Objective:To evaluate a single centers 10-year experience with emergency endovascular aneurysm repair (eEVAR) in 102 patients with ruptured abdominal aortoiliac aneurysms (RAAA). Methods:Data from 102 patients (mean age, 73 ± 9 years) with RAAA treated by eEVAR from January 1998 to April 2008 were retrospectively reviewed. From January 2000, all patients were treated according to an intention-to-treat protocol. The only exclusion criterion was unsuitable anatomy. 31/102 patients had moderate shock and 14/102 patients had severe shock with a systolic blood pressure <70 mm Hg or <50 mm Hg, respectively. 71/102 procedures were carried out under local anesthesia. Endograft types used were mainly bifurcated (92/102). Open abdomen treatment (OAT) because of abdominal compartment syndrome (ACS) was used when signs of organ failure occurred and/or bladder pressure rose >20 mm Hg. Results:The 30-day mortality for eEVAR was 13% (13/102). Technical success (defined as successful deployment of the endograft, absence of extravasation in the postprocedural contrast enhanced CT scan and hemodynamic stabilization) was 99% (101/102). Nineteen unstable patients (19%) required transfemoral supraceliac aortic balloon occlusion. ACS was detected and treated by OAT in 20 patients (20%). 16 type I, 26 type II and 1 type III endoleaks were detected on postoperative CT examination. Two patients had a combined type I and II endoleak. 11 patients were retreated for immediate correction of 10 type I and 2 type II endoleaks. 6 type I and 1 type III low-flow endoleaks were observed and resolved spontaneously within 30 days. Major 30-day morbidity was 35%. Conclusion:In this 102 patient contemporary series of eEVAR for RAAA, endografting proved to be safe with a 30-day mortality of 13%. Key components of this favorable outcome result were adequate preoperative diagnostic imaging, hypotensive hemostasis, selective transfemoral supraceliac aortic balloon occlusion, predominantly local anesthesia, detection and treatment of ACS, and attention to logistics. Widespread adoption of these treatment components is recommended.

Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks.

BACKGROUND To present the clinical experience of consecutive series with use of balloon-expandable and self-expanding chimney endografts (balloon-expandable covered stent group [BECS] vs self-expanding covered stent group [SECS]) in the endovascular treatment of challenging aortic pathologies requiring renal and/or visceral revascularization. METHODS Between January 2009 and May 2011, data for 37 high-risk patients from one center and 35 patients from another institution, with pararenal aortic pathologies treated by the chimney endovascular technique, were prospectively collected. The chimney-graft technique is based on the deployment of a covered or bare-metal stent parallel to the aortic endograft, thereby creating a conduit that runs outside the aortic main endograft, and has been proposed to ensure secure proximal fixation extending the sealing zones. RESULTS Forty-six consecutive target vessels (43 renal arteries and 3 superior mesenteric arteries) were revascularized by the Advanta (Atrium, Hudson, NH) BECS (1.2 chimneys/patient); in contrast, 81 consecutive target vessels (64 renal arteries, 11 superior mesenteric arteries, and 6 celiac trunks) were revascularized by the Viabahn (Gore, Flagstaff, Ariz) SECS (2.3 chimneys/patient). The success rate for target vessel preservation was 97.8% for the BECS group and 100% for the SECS group in the entire follow up. There was one symptomatic left renal artery occlusion of the BECS group treated by open thrombectomy of the left renal artery and placement of 8-mm Dacron (BBraun, Aesculap AG, Tuttlingen, Germany) iliorenal bypass. Additionally, one patient underwent repeat balloon angioplasty with a 5-mm balloon due to high-grade in-stent stenosis of a 6 × 59 Advanta stent graft 12 months postoperatively. Overall, one perioperative (and not present in the computed tomography angiography at discharge) type Ia endoleak was detected in the BECS group. In contrast, five perioperative type Ia endoleaks were present in the SECS group; however, only one of them was persistent in the radiological imaging and was treated by proximal extension of a 5-mm cuff, 1 year postoperatively, due to continuous aneurismal sac increase. No patient of any subgroup developed postoperative persistent renal insufficiency with need of hemodialysis. Thirty-day and during the follow-up procedure-related mortality was 0% for both BECS and SECS groups. CONCLUSIONS In summary, midterm results of use of covered chimney stents for pararenal aortic pathologies show safety and feasibility with excellent patency and low incidence of endoleaks.

Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair : a two-center 14-year experience

Objective:To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months. Background:Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair. Methods:We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an “EVAR-whenever-possible” approach until April 2009 (EVAR/OPEN period) and thereafter according to a “100% EVAR” approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2. Results:Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4–7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9–16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3–3.7). Conclusions:The “EVAR-ONLY” approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.

Open abdomen treatment following endovascular repair of ruptured abdominal aortic aneurysms

BACKGROUND Open abdomen treatment (OAT) is considered a lifesaving procedure in patients with abdominal compartment syndrome (ACS) after endovascular or open intervention for ruptured abdominal aortic aneurysms (RAAA). Standardized treatment methods and algorithms for its use are still lacking. The high, published mortality rates may reflect difficulties in detecting and treating ACS, especially in patients treated by emergency endovascular aneurysm repair (eEVAR). Presented are standardized algorithms for OAT, including a new technique using the vacuum-assisted closure (VAC) system developed during 10 years of experience with eEVAR for RAAA. METHODS We retrospectively analyzed 102 patients with RAAA treated by eEVAR from January 1998 to April 2008. Abdominal decompression was done when intravesical pressure >20 mm Hg or when abdominal perfusion pressure was <50 to 60 mm Hg and concomitant organ deterioration occurred. OAT was initially done with a subcutaneously sutured plastic bag or with a nonsutured zipper drape combined with a VAC device (VAC/ETHIZIP; KCI International Inc, Amstelveen, The Netherlands; Ethicon, Somerville, NJ). All patients were switched to VAC/ETHIZIP as soon as possible. Dressings were generally changed every 3 to 5 days. Intra-abdominal pressure was monitored until stability was observed after delayed direct abdominal closure. RESULTS Overall 30-day mortality for eEVAR was 13% (13 of 102); 8% (7 of 82) for patients without ACS and 30% (6 of 20) for those with ACS. Decompression for ACS was needed in 20 patients (20%) primarily during the intervention (n = 14) or secondarily in the intensive care unit (n = 6). Six of 20 (30%) patients requiring OAT died <or=30 days (4 primary, 2 secondary). A mean of 3.6 (range, 1-12) planned second-look interventions were done per patient at an interval of 3 to 5 days. No bowel lesions were observed. Four patients required antibiotic therapy for abdominal infection, and all infections resolved. Delayed abdominal wall closure (direct closure, 11; closure with polypropylene mesh, 3; bilateral anterior rectus abdominis sheath turnover flap, 1) was achieved after a median of 6 days (range, 1-47 days). CONCLUSION The use of standardized novel techniques and a treatment protocol and algorithm for OAT after eEVAR for RAAA were feasible and safe. It decreased the workload of the medical and nursing staff, enhanced patient comfort because the need for dressing changes was minimized, and likely contributed to lower overall mortality in RAAA patients. Delayed direct fascial closure was possible in most patients.

Multiple periscope and chimney grafts to treat ruptured thoracoabdominal and pararenal aortic aneurysms.

Purpose To report midterm outcomes after urgent endovascular repair of ruptured pararenal or thoracoabdominal aortic aneurysms using multiple periscope and chimney grafts to preserve renovisceral branch perfusion and facilitate aneurysm exclusion. Methods Nine consecutive men (mean age 72±14 years, range 40–88) presenting with ruptured thoracoabdominal (n=6), pararenal (n=2), or infrarenal (n=1) aortic aneurysm underwent urgent endovascular repair with at least 1 periscope graft delivered via a transfemoral access; chimney grafts were installed from an axillary access. In all, 17 periscope and 7 chimney grafts were used to reperfuse 11 renal and 13 visceral arteries in the 9 patients. The aortic aneurysms were excluded using thoracic devices (n=7), an aortic extension cuff (n=1), and bifurcated stent-grafts (n=2). Results All procedures were completed without technical complications except for a dislocated stent-graft from the right renal artery; the artery could not be re-accessed, and the right kidney was sacrificed. One patient died of multiple organ failure (11% 30-day mortality). At a mean follow-up of 10 months (range 3–24), 5 of the 9 patients had recovered completely; 3 patients died of unrelated causes. Imaging showed no aneurysm growth in any patient, with a mean 20% shrinkage in aneurysm size. All periscope and chimney grafts remained patent, and no aortic stent-graft migration was observed. Renal function and the glomerular filtration rate remained stable in all patients. Conclusion The periscope and chimney graft technique provides a simpler, less invasive way to maintain blood flow to the renovisceral arteries during urgent endovascular aortic repairs. The very low 30-day mortality rate and the stability of the repairs in the midterm are encouraging. This technique has the potential to profoundly influence the treatment of acute aortic pathologies.

Chimney and Periscope Grafts Observed Over 2 Years After Their Use to Revascularize 169 Renovisceral Branches in 77 Patients With Complex Aortic Aneurysms

Purpose To evaluate the performance of periscope and/or chimney grafts (CPGs) in the endovascular treatment of pararenal or thoracoabdominal aneurysms using off-the-shelf devices. Methods Between February 2002 and August 2012, 77 consecutive patients (62 men; mean age 73±9 years) suffering from pararenal aortic (n=55), thoracoabdominal (n=16), or arch to visceral artery aneurysms (n=6) were treated with aortic stent-graft implantation requiring chimney and/or periscope grafts to maintain side branch perfusion. CPGs were planned in advance and were not used as bailout. A standardized follow-up protocol including computed tomographic angiography, laboratory testing, and clinical examination was performed at 6 weeks; 3, 6, and 12 months; and annually thereafter. Results Technical success was achieved in 76 (99%) patients; 1 branch stent-graft became dislocated from a renal artery, which could not be re-accessed. Overall, 169 target vessels (121 renal arteries, 30 superior mesenteric arteries, 17 celiac trunks, and 1 inferior mesenteric artery) were addressed with the chimney graft configuration in 111 and the periscope graft configuration in 58. In total, 228 devices were used for the CPGs: 213 Viabahn stent-grafts and 15 bare metal stents. Over a mean 25±16 months (range 1–121), 9 patients died of unrelated causes. Nearly all (95%) of the patients demonstrated a decreased or stable aneurysm size on imaging; there was a mean 13% shrinkage in aneurysm diameter. Twenty patients had primary type I/III endoleaks at discharge; in follow-up, only 3 of these were still present (no secondary or recurrent endoleaks were noted). Additional endovascular maneuvers were required for CPG-related complications in 13 patients from intervention throughout follow-up. Overall, 4 CPGs occluded (98% target vessel patency); no stent-graft migration was observed. Renal function remained stable in all patients. Conclusion In this series, the use of CPGs has proven to be a feasible, safe, and effective way to treat thoracoabdominal and pararenal aneurysms with maintenance of blood flow to the renovisceral arteries. Nearly all of the aneurysms showed no increase in diameter over a >2-year mean follow-up, which supports the midterm adequacy of the CPG technique as a method to effectively revascularize branch vessels with few endoleaks or branch occlusions.

Complete endovascular renal and visceral artery revascularization and exclusion of a ruptured type IV thoracoabdominal aortic aneurysm.

Purpose: To present a technique for renal and visceral revascularization allowing complete endovascular treatment of a ruptured type IV thoracoabdominal aneurysm using devices already stocked in most centers performing endovascular aneurysm repair. Technique: Open arterial access is obtained to both common femoral arteries and the left subclavian artery (LSA). Access to the visceral and renal arteries is obtained through separate 8-F sheaths for each visceral and renal branch. Both visceral arteries (celiac trunk and superior mesenteric artery) are accessed through 2 separate sheaths placed into the LSA, and both renal arteries are accessed through 2 separate sheaths placed into the left common femoral artery. Corresponding covered stents are introduced and positioned in the celiac trunk, superior mesenteric artery, and both renal arteries but not deployed. The aortic stent-graft is then introduced and deployed through the right common femoral artery. Once the aneurysm exclusion is completed, the stent-grafts to the branches are deployed so that they are positioned between the aortic wall and the aortic stent-graft. Finally, the branch stent-grafts as well as the aortic stent-graft are fully expanded with balloon catheters inflated simultaneously as in the kissing balloon technique. Conclusion: To our knowledge, no one has reported using this technique to successfully treat a ruptured thoracoabdominal aneurysm and revascularize all 4 major renovisceral arteries. A main advantage of this technique over use of branched stent-grafts is that it can be performed even in the emergency setting with devices that are in stock in most institutions performing endovascular aneurysm exclusion.

Early and midterm outcome of a novel technique to simplify the hybrid procedures in the treatment of thoracoabdominal and pararenal aortic aneurysms

BACKGROUND To evaluate the effectiveness of the Viabahn Open Revascularization Technique (VORTEC) in the treatment of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PAAAs) by hybrid procedures. METHODS Between December 2004 and March 2009, 58 patients (45 male, mean age, 74 years) were diagnosed with TAAA (n = 30) and PAAA (n = 28) and treated electively by combined hybrid techniques. Hybrid procedure includes bypass surgery of the visceral and renal arteries (debranching or rerouting), followed by endovascular exclusion of the aortic aneurysm. One hundred thirteen renovisceral vessels were revascularized in a retrograde fashion (ie, 98 renal and 15 visceral arteries), using VORTEC. The novel technique consists of the placement of self-expanding stent-grafts (Viabahn graft, Gore and Associates, Flagstaff, Ariz) in Seldinger technique into the renal and visceral arteries after surgical identification of the origin of the arteries. The end of the stent outside of the renal artery was sutured end to side directly with the main feeding graft, bypassing the aneurysm, or was fixed into an interposition branch graft on the main bypass. All cases were treated by two-staged approach (endovascular aneurysm repair [EVAR] performed after recovery from the debranching procedure). Computed tomography angiography and clinical follow-up were obtained before discharge, at six weeks, and three, six, and 12 months after the procedure and then annually. RESULTS Primary technical success of VORTEC was achieved in all patients. Overall primary patency rate of the novel technique was 97% during a mean follow-up of 22.1 +/- 12.9 months (range, 1-52 months); the primary patency of the subgroups PAAAs and TAAAs was 97.7% and 96.4%, respectively; the assisted primary patency rate was 98%, as two occluded Viabahn grafts were reopened by thrombolysis and thrombus aspiration. No patient required long-term hemodialysis. Thirty-day mortality rate was 8.6% (5/58) and 25.8% (15/58) for the entire follow up. Permanent neurologic deficit occurred in two cases (3.4%; paraplegia, n = 1; paraparesis, n = 1). The overall endoleak rate was 17.1% as three patients presented early (30-day) type I endoleak, treated by cuff-implantation, and six patients presented type II endoleak, three of them treated by coil embolization of the patent vessel and the others treated conservatively with radiological surveillance. CONCLUSION VORTEC allows performance of easy, safe, and minimally invasive revascularization of renal and visceral arteries and may represent a significant technical advance in the hybrid repair of TAAAs and PAAAs. However, the questions of reproducibility by other centers and long-term results are mandatory to establish this alternative revascularization option.

Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study

Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection. # CLINICAL PERSPECTIVE {#article-title-32}Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection.

New Technique to Facilitate Renal Revascularization with Use of Telescoping Self-Expanding Stent Grafts: VORTEC

This article describes a new, less invasive prosthetic graft anastomotic technique that uses self-expanding stent grafts that are “telescoped” into aortic branches. This method, the VORTEC (Viabahn Open Revascularization TEChnique), obviates the need for potentially difficult complete vessel exposure and graft anastomoses, thereby reducing the duration of flow interruption and simplifying the performance of complex aortic reconstructions and so-called debranching procedures requiring reconstruction of major branches such as renal arteries. Minimal exposure of one surface of the renal artery allowed introduction and deployment of a self-expanding Viabahn (W.L. Gore & Associates, Flagstaff, AZ) device using the Seldinger technique. The Viabahn devices used were 5 to 8 mm in diameter and 5 to 15 cm in length depending on individual anatomy (assessed by preoperative computed tomographic angiography). Overall, 82 renal arteries have been revascularized in 58 patients using the VORTEC. The technical success rate was 100%, with all of the stent grafts implanted as intended with maintenance of flow. The patency rates were 97% after 30 days and 96% after a mean follow-up of 18 months (range 1–38 months). The VORTEC allows performance of safe and expeditious revascularization of renal arteries. This new technique may represent significant improvement over the standard approach of surgical exposure and sutured anastomosis.