The Italian Multi-centre Experience of Fenestrated Anacondatm Endograft for Juxta/Para-renal Aortic Aneurysms

Abstract

Introduction - Aim of this study is to describe the outcomes of “AnacondaTM-Fenestrated Endograft (Vascutek, Inchinnan, UK) Italian registry” for challenging abdominal aortic aneurysms (AAA), unfit for standard endovascular aortic repair (EVAR). Methods - Between 2012 and 2017, patients with proximal neck unsuitable for standard EVAR were prospectively enrolled. Clinical (demographic, cardiovascular risk factors, co-morbidities) and morphological aortic-iliac features were collected. Intra and peri-operative data were analyzed. Early endpoints were technical success (TS defined as absence of endoleaks (EL) I-III, patency of target visceral vessels (TVV) and iliac legs and 24-hour survival). Late endpoints were survival, endoleaks, TVV patency and limb occlusion/stenosis, freedom from re-interventions and AAA-related mortality during the follow-up. Results - Seventy-eight patients (male 92%(62); mean age 74±4 years, ASA III-IV:73-27%) were submitted to Fenestrated-AnacondaTM in 25 Italian Vascular Surgery Units (73 juxta/para-renal AAA, 4 Type IV TAAA and 1 EL 1A post-EVAR). The mean AAA diameter was 58mm ± 3mm (range: 50-70mm). Configuration with 1, 2, 3 and 4 fenestrations were used in 3 (4%), 40 (51%), 25 (32%) and 10 (13%) cases, respectively for a total of 198 visceral vessels, (3.6±1TVV/patient). Sixty-six (85%) bifurcated and 12 (15%) tube endograft were implanted. The endograft was repositioned during the procedure in 42% (33/78) of cases. From the brachial access, at least 1 TVV was cannulated in 54% (27/52) of cases. TS was 90% (70/78) due to 5 type I EL, 1 type III EL (between fenestration and vessel stent) and 2 renal artery occlusions. All the target visceral vessels were cannulated and stented. The 30-day mortality was 5.1% (4/78). One patient died for a multiple organ disfunction syndrome (MOF) after renal artery ligature ad nephrectomy; one patient died for sepsis after embolization of the renal artery for artery perforation, two patients died for cardiological reasons. Two of the 5 type I EL solved spontaneously at 30-day for adaptation of the sealing ring of the device to the aortic neck. Two type III endoleak detected at the completion angiography were treated by relining of renal artery. At a median follow-up of 20 months (range:1-60) there were 3 type I EL, 2 type III EL and 3 occlusions of renal artery. The reintervention free-survival was 91% and no AAA-related mortality occurred. One patients had a bilateral renal artery occlusion so he has subjected to thrombolysis combined with angioplasty. A patient with type II EL underwent to open hypogastric ligature and another to lumbar embolization. There was an aortic rupture due to a proximal progression of AAA in a patient with two fenestrations for renal arteries; the patient was treated by suprarenal extension with chimney technique for celiac trunk and upper mesenteric artery. The survivor at 36 months was 77% (no AAA-related mortality hasn’t been reported). Conclusion - AnacondaTM-Fenestrated Endograft is an effective treatment of challenging AAA. The repositionability, the brachial access and the adaptation during the follow-up of the proximal ring are useful for complex anatomies and increase the technical success of the procedure.