Invited commentary

Abstract

Donas et al have reported their experience with parallel grafts and cuffs to treat proximal type I endoleak due to endovascular aneurysm repair migration. Notably, all patients were classified as high-risk for open repair. Alternatives for open repair of type I endoleak are of vital importance in these patients. Although only 18 patients were described, this series is the largest to date and it seems to justify the use of this technique as an off-the-shelf, endovascular alternative for fenestrated cuffs or conversion to open repair. The authors should be congratulated on achieving technical success in all but one case. However, before adopting this technique, one must be well aware of the many limitations of this paper precluding injudicious generalization. The patients described are a highly selected subset of tertiary referrals to a university center with extensive fenestrated and chimney-graft experience. The authors refer to this study as a prospective cohort study, but, in fact, it is a retrospective analysis of an apparently prospectively maintained database. There is little information about the previous endovascular history of the included patients, why and when the migration and type I endoleak occurred, and what treatment attempts preceded referral. This information is essential for the reader to understand case selection and device planning, the two most important determinants of success. Furthermore, initial resolution of the endoleak can be referred to as a technical success, but proof of complete aneurysm exclusion is still mandatory before considering the treatment successful. Presumably, the initial endovascular aneurysm repair procedure had also been considered a technical success in most of these patients. Yet, subsequently, migration and type I endoleak did occur. Patient-related factors may be responsible for late failure of the proximal seal. The authors are too optimistic when they believe initial technical success renders this procedure promising. Gutter-related endoleak is the Achilles' heel of parallel grafts. While the authors present aneurysm shrinkage as a secondary outcome measure in the methods, no such data are provided. As the series started in 2009, the authors should have been able to report the sac shrinkage rate at 1, 2, and 3 years. In Fig 1, at 24 months already, merely three patients remain at risk. Apparently, many patients are unaccounted for and mid-to long-term data are missing. This paper shows that in a small and highly selected subgroup of high-risk patients with migration and type I endoleak, parallel grafts and cuffs in experienced hands can have excellent immediate technical success. If it works remains to be determined. Use of parallel grafts to save failed prior endovascular aortic aneurysm repair and type Ia endoleaksJournal of Vascular SurgeryVol. 62Issue 3PreviewThe aim of this study was the evaluation of the clinical and radiologic outcomes of parallel grafts in the treatment of patients with failed prior endovascular aneurysm repair and type Ia endoleak. Full-Text PDF Open Archive