Cannulation of Visceral Vessels Using a Steerable Sheath in Fenestrated and Branched Aortic Endografts

Abstract

A critical step in the endovascular treatment of complex aortic aneurysms is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR). Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or nonchallenging TV. Fifty-three patients (median age 73 (Q1, Q3 (68-80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n=26; 49%), juxtarenal aneurysms (n=23; 43.5%) and penetrating aortic ulcers (PAU) (n=4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of 3TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus nonchallenging TV (P=0.457). One patient died within 30days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36months, the survival rate was 87%, 87%, and 81%, respectively. Primary patency after 12months was 98.6%, and 97.9% of vessels remained FFR during follow-up. Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.