Aortic Endograft Research Articles

Conservative Management of Aortic Endograft Infection: A Case Series

Conservative Management of Aortic Endograft Infection: A Case Series

Ultra Low-profile Aortic Endograft: Early and Mid Term Outcomes from the Italian Triveneto Incraft Registry

Ultra Low-profile Aortic Endograft: Early and Mid Term Outcomes from the Italian Triveneto Incraft Registry

Geometric Analysis of Fenestrated and Multibranched Aortic Endografts – Relevance of Branches’ Angulation for Type III Endoleaks and Branch Thrombosis

Introduction: Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) is the gold standard procedure in most vascular centers. The goal of this study is to determine geometric risk factors for the development of type III endoleaks and branch thrombosis in patients treated with fenestrated (F-) or multibranched (B-) endovascular aneurysm repair (EVAR). The primary endpoint was the post-operative end-stent angulation for both FEVAR and BEVAR and its relevance in type III endoleak and branch thrombosis. Methods: From November 2013 to March 2018, consecutive patients with TAAA treated with a FEVAR of BEVAR were selected. Demographic variables, aneurysm anatomy and endografts’ conformation were analyzed retrospectively. Results: 24 patients underwent CTA before and after FEVAR (n=8) and BEVAR (n=16), and 86 vessels were successfully catheterized (celiac artery n=14, superior mesenteric artery n=24, right renal artery n=24, left renal artery n=22, polar renal artery n=2). All patients were considered ASA III and the median age was 72 years (49-81). The mean aneurysm diameter was 67.4mm (54.4-92.7). The mean follow-up period was 22.7 months and the rate free of type III endoleak and thrombosis at 24 months were 89% and 88%, respectively. All the FEVAR vessels (n=26) were catheterized using 1 stent, while 16.7% (n=10) of the BEVAR vessels (n=60) required 2 stents. The total stent longitude in FEVAR was significantly shorter than in BEVAR (26.67±4.4mm vs 6.50.63±8.51mm, p=0.000), as was the radius of curvature (FEVAR 34.75±18.7º; BEVAR 64.92±18.2º, p=0.000). There were no significant differences between FEVAR and BEVAR in terms of rate of type III endoleak (p=0.240) or branch thrombosis (p=0.544). The overall rate of branch thrombosis was 9.3% (n=8) and was more frequent in smaller vessels (5.00±1.25mm vs 7.30±1.8mm, p=0.001) and in vessels with higher stent oversizing (36.87±23.6% vs 3.57±13.8%, p=0.000). The overall rate of type III endoleaks was 11.6% (n=10), and all cases were associated with 4-branch endografts (p=0.030). 60% of the vessels that required 2 stents showed a type III endoleak, which was significantly higher than the vessels treated with 1 stent (5.3%) (p=0.000). A higher rate of type III endoleak was observed in greater vessels (7.63±0.59mm vs 7.04±2.0mm, p=0.029) and with wider stents (8.40±1.1mm vs 7.18±1.2mm, p=0.002). A positive correlation was found between the presence of endoleak and the need for 2 stents per vessel (p=0.000) but not with the total longitude of the stent (p=0.103). The end-stent angulation, the radius of curvature and the total stent longitude did not entail a higher rate of endoleak (p=0.719; p=0.634; p=0.314 respectively) or thrombosis (p=0.424; p=0.102; p=0.205 respectively). Conclusion: In our series, the end-stent angle does not relate with a higher risk of type III endoleak nor with branch thrombosis, neither does the radius of curvature or the total stent longitude. Care must be taken when measuring the vessel’s diameter, in order to choose the adequate stent size, as small vessels and excessive stent oversizing entail a higher risk of branch thrombosis. Longer stents should be considered rather than using more than one, since a higher number of stents per vessel associates a higher risk of endoleak.

Haemodynamics of Different Configurations of a Left Subclavian Artery Stent Graft for Thoracic Endovascular Aortic Repair

Branched stent grafts represent a viable option for left subclavian artery (LSA) revascularisation in patients treated by thoracic endovascular aortic repair (TEVAR) for Zone 2 lesions. This study investigated the haemodynamic performance of different LSA branched stent graft configurations as potential determinants of thrombotic and stroke risks. A three dimensional aortic arch geometry extracted from post-operative computed tomography images of a TEVAR patient using a single LSA branched aortic endograft was modified in silico to obtain ten potential LSA branched stent graft configurations: five down facing (0-5 - 10mm aortic protrusion with 10-12mm internal diameter), four curved (30-60° with antegrade/retrograde orientation), and one LSA orifice misalignment. The 0mm down facing stent graft was considered base configuration. Computational fluid dynamic analyses were performed to identify differences in pressure, energy, and wall shear stress (WSS) based parameters. Total pressure drop and energy loss variations among configurations were not greater than 5mmHg (6% of mean arterial pressure) and 5.7mW (0.7% of cardiac power), respectively. Protrusions up to 5mm created clinically insignificant flow disturbances. However, stent graft protrusions further into the aortic lumen created more complex haemodynamics, characterised by larger energy loss and more prominent flow recirculation. Protrusion greater than 5mm into the lumen was associated with larger areas of elevated maximum WSS (>20Pa) along the outer surface of the branched stent graft. Arterial haemodynamic characteristics are affected by LSA branched stent graft configurations, with pressure drops and energy losses likely to be clinically insignificant. The length of the stent graft protrusion into the aortic lumen generated the largest haemodynamic variations in the aortic system. Protrusions up to 5mm have smaller risk of potential thrombus generation. Conversely, larger protrusions into the aortic lumen showed more disturbed haemodynamics, suggesting a greater risk of potential thrombus formation, which may be clinically important over time.

Surgical treatment strategy for endograft infection after thoracic endovascular aortic repair

Objective: To examine the results of surgical treatment for endograft infection after thoracic endovascular aortic repair (TEAVR). Methods: Clinical data of 7 patients underwent surgical treatment for endograft infection after TEAVR at Department of Cardiothoracic Surgery, Changhai Hospital, the Navy Medical University between January 2016 and December 2018 were analyzed retrospectively. There were 6 males and 1 female, aging (51.5±16.7) years (range: 25 to 68 years). The origin of the aortic disease was descending aortic aneurysm in 5 cases, and Stanford B aortic dissection in 2 cases. Abdominal aorta below the level of the diaphragm was not involved in all patients. Two patients received "chimney technology" for left subclavian artery procedures. Time to infection was 5(3) months (M(Q(R))) (range: 1 to 24 months). Aortic endograft infection was diagnosed with a combination of microbiology (positive blood cultures, except one with mycotic), radiological evidence and clinical evidence of sepsis. Two patients suffered from aorto-esophageal fistula received emergency surgery, others were treated with elective surgery. Extra-anatomic prosthetic graft bypass was used for reconstruction of aorta, infected endogarft and aorta was removed, sac drainage was performed. Aorto-esophageal fistula was procedured according to the degree of lesions. All patients received antibiotics with specialist advice for 6 to 8 weeks. Results: One patient died due to septic shock. In the follow-time (range: 6 to 24 months), 1 patient suffered from thoracic infection in 3 months after surgery, an other patient got iliac abscess after a month. Conclusions: Endograft infection after TEAVR is high risk but may be curative. Appropriate selection of patients for infected endograft explantation could get a satisfied results.

Combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair for complicated type B aortic dissections.

Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but life-threatening condition. The incidence of aortic dissection is 3 to 6 per 10,000 per year in the Western population, and can be up to 43 per 10,000 per year in the Eastern population. Over 20% of people with an aortic dissection do not reach a hospital alive. After admission, the mortality rates for people with an aortic dissection are between 10% and 20% for those who received endovascular treatment, and between 20% and 30% for those who had open surgery. Thoracic endovascular aortic repair (TEVAR) is the standard endovascular method to treat complicated type B aortic dissection (aortic dissections without involvement of the ascending aorta). Although TEVAR is less invasive than open surgery and has a better long-term aortic remodeling effect than conservative medical treatment, favourable aortic remodelling is usually limited to the thoracic aortic segment. TEVAR cannot be extended into the abdominal aorta because it could cover the ostia of the reno-visceral arteries. Thus, the abdominal aorta is still at risk of progressive aneurysmal degeneration. The PETTICOAT (provisional extension to induce complete attachment) technique, with proximal endograft and distal bare metal stent, was proposed in 2006 to address this issue. The concept of this technique was to implant a distal bare metal stent into the aortic true lumen, distal to the proximal endograft, to stabilize the distal collapsed intimal flap, while allowing blood flow to reno-visceral arteries. Therefore, the PETTICOAT technique was considered to be related to a more extensive aortic remodelling for people with type B aortic dissection, especially in the area of the abdominal aorta. However, it is still unclear whether the PETTICOAT technique is superior to standard TEVAR. To assess the effects of combined proximal descending aortic endografting plus distal bare metal stenting versus conventional proximal descending aortic stent graft repair for treating complicated type B aortic dissections. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2018. We also undertook reference checking and citation searching to identify additional studies. We considered all randomised controlled trials which compared the outcome of complicated type B aortic dissection, when treated by combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair. Two independent review authors assessed all references identified by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We found no trials that met the inclusion criteria for this review. We identified no randomised controlled trials and therefore cannot draw any definite conclusion on this topic. Evidence from non-randomised studies appears to be favourable in the short-term, for combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) to solve the problem of unfavourable distal aortic remodeling. Randomised controlled trials are warranted to provide solid evidence on this topic. Evidence from cohort studies with large sample sizes would also be helpful in guiding clinical practice.

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment

The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20 cm was performed in 42.1% (n = 351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p = .001). LSA coverage (hazard ratio [HR] 3.31, p = .005) and hypercholesterolaemia (HR 2.96, p = .024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p = .044). In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

AAA 7. Ultra-Low-Profile Aortic Endograft: Early and Midterm Outcomes From the Italian Triveneto Incraft Registry

AAA 7. Ultra-Low-Profile Aortic Endograft: Early and Midterm Outcomes From the Italian Triveneto Incraft Registry

The need to improve our understanding of long-term outcomes after endovascular aneurysm repair

Reports of open surgical conversions after aortic endografting are becoming increasingly prevalent,1 concomitant with the increasing prevalence of endovascular aortic repair (EVAR) over the past decade.2 The increasing need for open surgical conversion after EVAR is concerning owing to some reports describing the increased risks of perioperative morbidity and mortality of open surgical conversion relative to primary open aortic repairs.3 Some authors have attributed the loss of late survival benefit after EVAR to the increased morbidity and mortality associated with open surgical conversion after EVAR.

Health Care Costs of Endovascular Compared With Open Thoracoabdominal Aortic Aneurysm Repair

To compare 1-year health care costs of open and endovascular thoracoabdominal aortic aneurysm (TAAA). Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and March 2017. All health care costs incurred by the Ministry of Health were included. Costs of the aortic endografts and devices for the index procedure were C$44,000 per case versus C$1000 for open cases. Costs (2017 Canadian $) were calculated in phases (1, 1-3, 3-6, 6-12 months) with censoring for death. Propensity score matching based on 26 preoperative characteristics was used. The association between preoperative characteristics and 1-month cost were characterized through multivariable analysis. Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]) and 241 open/endovascular propensity score-matched pairs were formed. At 1 month, the mean [median] total cost for the pre propensity score matched open TAAA group was C$46,575 [C$36,647] (77% hospital cost, 14% physician billings, 3% graft cost, 6% other), whereas for the endovascular group, total cost was C$72,581 [C$64,892] (67% graft cost, 27% hospital cost, 5% physician billings, 1% other; P < .01). At 1 to 3 months, 3 to 6 months, and 6 months to 1 year postprocedure intervals, there were no significant difference in health care costs between groups (Table). The mean [median] cumulative cost for patients alive at 1-year were C$91,571 [C$52,003] versus C$103,740 [C$83,242]; P < .01 for open (n = 264) and endovascular (n = 206) TAAA repair, respectively. On multivariable analysis, older age (P < .01), nonelective procedures (P < .01), and preoperative stroke (P = .05) were associated with increased costs at 1 month. While devices led to higher 1-month costs of endovascular TAAA repair, total cumulative health care costs after the first month and up to 1 year were not significantly different, including re-interventions. Higher 1-month costs occurred with older age, preoperative stroke, and nonelective procedures.TableHealth care costs of endovascular versus open thoracoabdominal aortic aneurysm (TAAA) repairCostBefore propensity score matchingAfter propensity score matchingOpenEndovascularP valueOpenEndovascularP valueMean [median]Mean [median]Mean [median]Mean [median]1 month46,575 [36,647]72,581 [64,892]<.0146,556 [33,605]72,786 [64,892]<.011-3 months19,826 [2024]11,292 [1977].6218,828 [1832]11,454 [1992].613-6 months12,289 [1173]11,453 [1508].169456 [1144]12,153 [1298].846 months-1 year11,985 [2427]12,087 [2998].978840 [2524]12,016 [3050].34 Open table in a new tab

Dysphagia Lusoria: A Rare Entity and Underrecognized Cause of Dysphagia

Abstract Management of dysphagia lusoria (DL), dysphagia caused by esophageal compression by an aberrant right subclavian artery (ARSA), is a clinical challenge. Sixty percent of patients with ARSA develop an aneurysm in the aberrant artery, which increases the risk of developing worsening dysphagia, tracheal compression, aortic dissections, and aneurysmal ruptures. Surgical management of ARSA has been studied, but no definitive standards have been established. As a result, most patients elect for surgery only when compressive symptoms become too severe. We present the case of a 68-year-old male found to have worsening dysphagia from an enlarging ARSA aneurysm. A bilateral carotid-subclavian bypass with embolization of both subclavian arteries and aortic endograft placement was performed. Despite imaging showing successful bypass of the aneurysm, the patient’s compressive symptoms worsened. The patient had a prolonged postoperative course that was complicated by pneumonia and tracheal compression, requiring stent placement. On postoperative day 45, the patient went into cardiac arrest and expired. Postmortem examination revealed an ARSA aneurysm measuring 7.8 × 4.5 × 4.3 cm. All grafts and embolization plugs were in place, without evidence of failure or migration. The aneurysmal sac contained a firm, well-organized clot, occupying 80% of the lumen. Diffuse ulcerative atherosclerotic disease was noted in the aorta. The lungs had gross and histologic findings consistent with pneumonia. Final cause of death was determined to be acute pneumonia with mass effect of the ARSA aneurysm as a contributing factor. Although the cause of the aneurysmal clot formation could not be identified, it raised the question of whether the degree of aortic atherosclerosis and aneurysmal size should be considered while developing indications for surgery. With the increased detection of ARSA, this case suggests the degree of aortic atherosclerosis and size of the aneurysm should be considered in the establishment of surgical guidelines.

Through-and-Through Suture Technique to Stabilize a Sheath in Branched Endovascular Aortic Repair

Purpose: To describe a technique to catheterize antegrade branches of a branched thoracoabdominal endograft from a femoral access with the help of standard sheaths and a vascular suture. Technique: The technique is demonstrated in a patient who underwent successful complex thoracoabdominal branched endovascular aortic repair. After the deployment of an aortic endograft with two antegrade branches for the targeted renovisceral vessels, a standard braided sheath was preloaded with a 3/0 polypropylene suture and introduced inside an additional sheath from the groin to the thoracic aorta. Simultaneous gentle traction on the suture as the preloaded sheath was advanced achieved a very stable 180° curve of the proximal end of the sheath. It was possible to selectively catheterize the antegrade branches and respective target vessels sequentially, as well as deploy the planned bridging stents for each branch. Conclusion: The through-and-through suture technique is a helpful tool in branched endovascular aortic repair. It saves time, radiation, and materials; no snare is needed, and it can be preloaded into a sheath.

In Vitro Evaluation of Balloon-Expandable Chimney Grafts in the Renal Arteries Combined With the Endurant Endograft

Purpose: To compare balloon-expandable covered stents (BECS) available for use as renal chimney grafts to the Advanta V12 approved for use with the Endurant endograft. Materials and Methods: A silicone model was manufactured based on preoperative computed tomography angiography (CTA) scans of a patient with a 7-cm juxtarenal aneurysm treated with an Endurant bifurcated endograft and an Advanta V12 covered stent for the 6-mm-diameter right renal artery. The model was placed in a flow box filled with a 37°C blood-mimicking solution equipped with a pulsatile pumping system (140/60 mm Hg). The tested BECS were the Advanta V12, the VBX, and the BeGraft+. A 36-mm-diameter Endurant II endograft with a 16-mm-diameter contralateral limb and a 6×59-mm BECS chimney graft were used in 9 consecutive tests (3 for each combination). After each implantation, the model was placed in the CT scanner, and 2 radiologists blinded to the test device independently measured the gutter areas and the patent chimney graft lumen at the level of the Endurant’s suprarenal stent, at the level of the chimney’s maximum curvature, and 10 mm inside the renal artery. The intraclass correlation coefficients (ICC) were calculated to assess interreader reliability. Results: The mean gutter areas were 19.3±7, 20.2±8, and 22.3±8 mm2 for the Advanta, VBX, and BeGraft+, respectively (all p>0.05). At the level of the aortic endograft’s suprarenal stent struts, the mean diameter of the Advanta V12, VBX, and BeGraft+ were 4.46±0.3, 4.12±0.4, and 4.12±0.3 mm, respectively (all p>0.05). At the level of the maximum chimney graft angulation, the mean diameters were 3.77±0.3, 4.16±0.1, and 3.74±0.3 mm, respectively (all p>0.05). In the right renal artery, the mean diameters were 3.91±0.2, 4.05±0.9, and 4.3±0.4 mm, respectively (all p>0.05). The ICCs varied between 0.7 and 0.9, indicating good agreement between readers. Conclusion: These in vitro findings showed comparable results between the Advanta V12 and the available BECS used in conjunction with the Endurant endograft according to the instructions for use. Further clinical evaluation is needed to confirm these results.

Outcome of Tubular Aortoaortic Endografts in Infrarenal Aneurysmal Disease and Penetrating Abdominal Aortic Ulcers—a Long-Term Follow-up

We describe the long-term follow-up of patients treated for infrarenal abdominal aortic aneurysms and penetrating ulcers by placement of tubular aortic endografts at our institution from 2010 to present. This is a retrospective study using clinical data of patients treated from 2010 to present by placement of either a single aortic tubular endograft or by two overlapping endografts, using the "trombone technique." Aortic dimensions were measured from the preoperative computed tomography scans using three-dimensional reconstruction. The primary outcome was aortic reintervention. Secondary outcomes were aorta-related mortality, endoleaks, and postoperative complications. Twenty-eight patients were identified. Nine patients were treated for saccular aneurysms, and nineteen patients presented with penetrating aortic ulcers. The median follow-up was 31months (range: 4-99). Twenty patients were treated with a single tubular device, while eight patients were treated using two overlapping devices. Aortic reintervention occurred in four patients (14.3%), all were treated initially with a single device. No aortic mortality occurred during follow-up. No aneurysm ruptures occurred. Four patients died during follow-up of unrelated causes. Endoleaks occurred in ten patients (35%). Five endoleaks were of type I (17.8%), of which three were of distal type (10.7%). Five endoleaks were of type II (17.8%). Shorter distal landing zones than 20mm were present in two of the cases with a distal typeI endoleak (P=0.0232). Postoperative complications occurred in three (10.7%) patients including one myocardial infarction and two wound complications from a surgical cut down in the groin. The technique shows an acceptable postoperative complication rate but is characterized by high rate of occurrence of type I endoleaks and aortic reintervention in our series. Endovascular techniques using tubular endografts should be limited to cases with long proximal and distal sealing zones. The trombone technique seems preferable.

Use of a Custom-made Four-Vessel Fenestrated Endograft to Repair an Enlarging Juxtarenal Aneurysm With Type IA Endoleak After Prior ZFEN Repair

A 73-year-old woman with a history of a 6-cm juxtarenal abdominal aortic aneurysm who underwent a fenestrated endovascular aortic repair using the Zenith fenestrated endovascular (ZFEN) device (Cook Medical, Bloomington, Ind) presented with a type IA endoleak found on routine surveillance computed tomography angiography (CTA). The previously placed ZFEN device included a scallop for the superior mesenteric artery (SMA) and bilateral stented fenestrations to the renal arteries. A custom-made fenestrated endovascular aortic endograft was designed on the basis of measurements obtained from high-resolution CTA images on a three-dimensional workstation using standard centerline flow orthogonal techniques (TeraRecon, Foster City, Calif). The graft design included fenestrations to the celiac artery, SMA, and bilateral renal arteries. The main body fenestrated graft was designed with a modified preloaded delivery system using a preloaded cannulation catheter for the bilateral renal artery fenestrations. Balloon-expandable bridging stent grafts were deployed through the fenestrations to the SMA and bilateral renal arteries. The celiac artery was found to be occluded and covered with an aortic cuff to eliminate the potential for an endoleak. Completion angiography showed excellent stent graft architecture with no kinks or component separations, no evidence of endoleak, and patent visceral branches. The 1-month surveillance imaging demonstrated elimination of the type IA endoleak, patent stent grafts, and a small type II endoleak arising from a lumbar artery. Type IA endoleak from prior ZFEN repair can be successfully treated with a custom-designed fenestrated endovascular aortic endograft.

First/Preliminary Experience of Gore Viabahn Balloon-Expandable Endoprosthesis as Bridging Stent in Fenestrated and Branched Endovascular Aortic Repair

The aim of this study is to evaluate the preliminary outcomes of the Gore® Viabahn® balloon-expandable endoprosthesis (VBX) as bridging stent for fenestrated/branched aortic endograft. Between April and June 2018, patients undergoing fenestrated and branched-endovascular aortic repair were prospectively collected. Anatomical, procedural, and postoperative data of patients treated with VBX as bridging stents to connect fenestrations/branches to target visceral vessels (TVVs) were analyzed. Technical success and any TVV-related adverse event were assessed before discharge, at 30 days, and after 6months of follow-up. Fifteen patients undergoing fenestrated and branched-endovascular aortic repair for juxta/pararenal aneurysms (11), proximal type I endoleak after endovascular aortic repair (1), and thoracoabdominal aneurysms (3) were included in the study. Overall, 60 TVVs-celiac trunk (n=14), superior mesenteric artery (n=13), renal arteries (n=30), hypogastric artery (n=3)-were accommodated by fenestrations (n=51), branches (n=7), and scallops (n=2). The bridging stent graft was a VBX in 40 (67%) TVVs. A renal artery dissection was successfully managed by a self-expandable bare metal stent. Overall, relining of a bridging stent graft was required in 2 TVVs revascularized by fenestrations (superior mesenteric artery: n=1, renal artery: n=1). One intraoperative type III endoleak from renal fenestration was detected and successfully sealed by an adjunctive flaring maneuver. Technical success was achieved in all cases. At 5-day, 1 VBX (1/40: 2.5%) lost its sealing in a renal artery revascularized by a branch (type II thoracoabdominal aortic aneurysm) and required reintervention and relining with a self-expandable stent graft. No TVV occlusion or reintervention occurred <30 days or after 6months of follow-up. According to these preliminary results, the Gore Viabahn VBX balloon-expandable endoprosthesis can be safely used as bridging stent graft for fenestrated or branched endografts. A longer follow-up with a larger case load is necessary in order to validate this preliminary experience.

Effect of Different EndoAnchor Configurations on Aortic Endograft Displacement Resistance: An Experimental Study

Purpose: This study investigated the effect of different EndoAnchor configurations on aortic endograft displacement resistance in an in vitro model. Materials and Methods: An in vitro model was developed and validated to perform displacement force measurements on different EndoAnchor configurations within an endograft and silicone tube. Five EndoAnchor configurations were created: (1) 6 circumferentially deployed EndoAnchors, (2) 5 EndoAnchors within 120° of the circumference and 1 additional, contralateral EndoAnchor, (3) 4 circumferentially deployed EndoAnchors, (4) 2 rows of 4 circumferentially deployed EndoAnchors, and (5) a configuration of 2 columns of 3 EndoAnchors. An experienced vascular surgeon deployed EndoAnchors under C-arm guidance at the proximal sealing zone of the endograft. A constant force with increments of 1 newton (N) was applied to the distal end of the endograft. The force necessary to displace a part of the endograft by 3 mm was defined as the endograft displacement force (EDF). Two video cameras recorded the measurements. Videos were examined to determine the exact moment 3-mm migration had occurred at part of the endograft. Five measurements were performed after each deployed EndoAnchor for each configuration. Measurements are given as the median and interquartile range (IQR) Q1, Q3. Results: Baseline displacement force measurement of the endograft without EndoAnchors resulted in a median EDF of 5.1 N (IQR 4.8, 5.2). The circumferential distribution of 6 EndoAnchors resulted in a median EDF of 53.7 N (IQR 49.0, 59.0), whereas configurations 2 through 5 demonstrated substantially lower EDFs of 29.0 N (IQR 28.5, 30.1), 24.6 N (IQR 21.9, 27.2), 36.7 N, and 9.6 N (IQR 9.4, 10.0), respectively. Decreasing the distance between the EndoAnchors over the circumference of the endograft increased the displacement resistance. Conclusion: This in vitro study demonstrates the influence EndoAnchor configurations have on the displacement resistance of an aortic endograft. Parts of the endograft where no EndoAnchor has been deployed remain sensitive to migration. In the current model, the only configuration that rivaled a hand-sewn anastomosis was the one with 6 EndoAnchors. A circumferential distribution of EndoAnchors with small distances between EndoAnchors should be pursued, if possible. This study provides a quantification of different EndoAnchor configurations that clinicians may have to adopt in clinical practice, which can help them make a measured decision on where to deploy EndoAnchors to ensure good endograft fixation.

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment

The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20cm was performed in 42.1% (n=351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p=.001). LSA coverage (hazard ratio [HR] 3.31, p=.005) and hypercholesterolaemia (HR 2.96, p=.024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p=.044). In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts

BackgroundAcute type A aortic dissection (ATAD) remains associated with substantial short-term mortality, and despite increasing rates of surgical repair, as many as 10% to 20% of patients do not undergo surgery because of comorbidities and dissection-related complications. For patients unable to undergo open repair, previous attempts at endovascular treatment of ATAD used devices originally designed for deployment in the descending thoracic aorta. Industry has begun to support early investigational devices meant specifically for placement within the ascending aorta. We evaluated relevant aortic parameters to examine which patients may be candidates for repair with an ascending aortic endograft. MethodsWe reviewed 100 consecutive patients in our institutional ATAD database with contrast-enhanced computed tomography imaging on an Aquarius iNtuition workstation (TeraRecon, San Mateo, Calif), using curved planar reformatting (vessel tracking) and orthogonal views for measurements. We compared relevant aortic measurements against proposed criteria for future ascending endografts, including various landing zone diameters and intimal tear distances from the distal coronary ostium. ResultsOf the 100 patients examined, 39% had proximal intimal tears located outside the tubular ascending aorta. In all, 30% were excluded on the basis of either the presence of a prosthetic aortic valve or significant aortic insufficiency, and 6% were excluded on the basis of the presence of patent coronary artery bypass grafts from the ascending aorta. Many patients had multiple exclusion criteria, and based on various proposed criteria, overall candidacy ranged from 2% to 23%. If a maximum landing zone diameter of 42 mm and intimal tears as little as 20 mm distal to the distalmost coronary were considered treatable, only 8% of patients would have been candidates compared with 20% candidacy if aortic diameters up to 46 mm and intimal tears as little as 10 mm distal to the distalmost coronary were considered treatable. The most frequent single cause for exclusion was inadequacy of the proximal landing zone. Iliofemoral vascular access was also assessed and deemed adequate in >90% of cases. ConclusionsA minority of patients suffering ATAD would currently qualify for ascending aortic endografting on the basis of anatomic criteria alone. Future device designs should take into account these common anatomic exclusion criteria so that more versatile devices may be developed and commercially available to treat a larger number of patients.

VESS28. Imaging Characteristics of Acute Type A Aortic Dissection and Candidacy for Repair With Ascending Aortic Endografts

VESS28. Imaging Characteristics of Acute Type A Aortic Dissection and Candidacy for Repair With Ascending Aortic Endografts