Complex Endovascular Repair Research Articles

CO2 Angiography in the Standard and Complex Endovascular Repair of the Abdominal Aorta-A Narrative Review of the Literature.

Background/Objectives: Carbon dioxide digital-subtraction angiography (CO2-DSA) is an increasingly adopted technique in endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/B-EVAR); it is used to reduce the amount of iodinate contrast medium (ICM) and prevent postoperative renal function worsening (PO-RFW). Our aim is to report results from the literature on EVAR and F/B-EVAR procedures using CO2-DSA, together with wider applications in aortic endovascular treatment. Methods: We performed a literature review by searching electronic databases for published data on CO2-DSA during EVAR and F/B-EVAR procedures. The endpoints were postoperative renal function worsening (PO-RFW) and efficacy of intraoperative arterial visualization. Further, applications of CO2 for thoracic endovascular aortic repair (TEVAR) were described. Results: Seventeen studies reporting results on CO2-DSA in EVAR (644 patients) were retrieved. Overall, 372 (58%) procedures were performed with CO2 alone, and 272 (42%) were performed with CO2+ICM. Eight studies analyzed the effect of CO2-DSA angiography on PO-RFW; four studies showed a significantly lower rate of PO-RFW compared to ICM. Five studies (153 patients) analyzed intraoperative arterial visualization with CO2-DSA; renal and hypogastric arteries were effectively visualized in 69% and 99% of cases, respectively. The use of CO2-DSA in F/B-EVAR has not been widely investigated. The largest series reported that PO-RFW was lower in the CO2 vs. ICM group. Conclusions: Carbon dioxide is widely applied in modern aortic endovascular treatment. CO2-DSA for EVAR and F/B-EVAR is an efficient technique for reducing PO-RFW while allowing acceptable arterial intraoperative visualization.

The Importance of Cell Saver Usage in Complex Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms

The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver usage in patients undergoing complex endovascular procedures. Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion [CSBT]), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality. A total of 170 patients (77.1% male, mean age 71.2±9.2years) were included, with a median blood loss of 700mL (interquartile range [IQR] 400-1,200mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282mL (IQR, 194.5-508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25±1.55 vs. 10.36±1.88mg/dL; P<0.001), both groups presented similar postoperative hemoglobin (Hb) levels. Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.

The rise of endovascular repair for abdominal, thoracoabdominal, and thoracic aortic aneurysms

BackgroundGiven changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAAs), thoracoabdominal aortic aneurysms (TAAAs), and thoracic aortic aneurysms (TAAs). MethodsWe identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample between 2004 and 2019. We then examined the use of open, endovascular, and complex endovascular repair (OAR, EVAR, and cEVAR) for each aortic aneurysm location (AAA, TAAA, and TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician-modified endografts. Results715,570 patients were identified with AAA (87% intact repairs and 13% rupture admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215, P < .01; ruptured 7175-4625, P = .02). Of all AAA repairs performed in a given year, the use of EVAR increased (2004-2019: intact 45%-66%, P < .01; ruptured 10%-55%, P < .01) as well as cEVAR (2010-2019: intact 0%-23%, P < .01; ruptured 0%-14%, P < .01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%, P < .01), whereas mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%, P < .01). In the study, 27,443 patients were identified with TAAA (80% intact and 20% ruptured). In the same period, intact TAAA repairs trended upward (2004-2019, 1435-1640, P = .055), and cEVAR became the most common approach (2004-2019, 3.8%-72%, P = .055). A total of 141,651 patients were identified with ascending, arch, or descending TAAs (90% intact and 10% ruptured). Intact TAA repairs increased significantly (2004-2019, 4380-10,855, P < .01). From 2017 to 2019, the mortality after OAR of descending TAAs increased and mortality after thoracic endovascular aneurysm repair decreased (2017-2019, OAR 1.6%-3.1%; thoracic endovascular aneurysm repair 5.2%-3.8%). ConclusionsBoth intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAA repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone increased to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.

The Impact of Sarcopenia in the Long-Term Survival of Patients following Complex Endovascular Aortic Surgery for Thoracoabdominal Aortic Aneurysms.

Image-based sarcopenia has been the subject of recent studies, hypothesized as a prognostic factor for patients with thoracoabdominal aortic aneurysms. We conducted a single-center retrospective analysis of patients who underwent complex endovascular repair for thoracoabdominal aortic aneurysms between 2008 and 2016. CT image assessment was performed and patients were classified as sarcopenic and non-sarcopenic using two stratification methods: skeletal mass index (SMI) and total psoas muscle index (TPMI). According to sex, each patient was defined as sarcopenic if their SMI or TPMI was in the lowest third of the study group. The primary endpoint was impact of sarcopenia on perioperative mortality and long-term survival. Secondary endpoints were perioperative complications. From a total of 155 patients, 135 were eligible for study. Overall, in-hospital mortality was 5.9% (8/135). The 30-day, 1-year, 3-year and 5-year mortality was 10.4% (14/135), 20% (27/135), 28.1% (38/135) and 31.1% (42/135), respectively. There was no difference in the long-term mortality rates between sarcopenic and non-sarcopenic patients regardless of the stratification method used (p = 0.4 for SMI and p = 0.2 for TPMI). According to SMI, 30-day mortality of sarcopenic patients was significantly lower in comparison to non-sarcopenic patients (1/45, 2.2% vs. 13/90, 14.4%, p = 0.028). Based on the total psoas muscle index, sarcopenic patients were at higher risk for development of pulmonary complications in comparison to non-sarcopenic patients postoperatively (p = 0.03). Using SMI and TPMI, sarcopenia was not associated with reduced long-term survival in patients undergoing complex endovascular repair for thoracoabdominal aortic aneurysms.

Outcome of Endovascular and Open Treated Penetrating Aortic Ulcers.

Penetrating aortic ulcer (PAU) is a rare etiology of acute aortic syndrome. Few studies exist regarding the perioperative outcome. The aim was to analyze clinical outcome and risk factors of mortality in this treatment population. Retrospective, monocentric study from 2010 to 2021. Clinical data of endovascular or open treated PAU were analyzed. In-hospital mortality was selected as the primary study endpoint. Angio-morphologies were analyzed and risk factors for mortality were identified by using univariate analysis. Overall, 133 patients were identified. 29% (n=38) of patients presented symptomatically. In 64% (n=85), the PAU was localized in the thoracic aorta. On average, PAUs had a depth of 15.4±10.1 mm and a width of 17.9±9.6 mm. The patients had a median of 2 (95% confidence interval [CI]=2-3) high-risk features (HRF) as PAU depth >10 mm, PAU width >20 mm, aortic diameter >40 mm, symptomatic, intramural hematoma (IMH), pleural effusion. Significantly more HRF were observed in symptomatic patients (p=0.01). 53% (n=71) of patients were treated with thoracic endovascular aortic repair (TEVAR), 41% (n=54) by endovascular aortic repair (EVAR), and 6% (n=8) by open surgery. A hybrid procedure with cervical debranching was performed in 16% (n=21) and complex endovascular repair with fenestrated or branched endografts in 15% (n=20). Overall, complications greater than grade II according to the Clavien-Dindo classification occurred in 19% (n=25) and of the patients. In-hospital mortality manifested in 6% (n=8). Factors associated with increased mortality were the diameter of the aorta >40 mm (88% vs 39%, p=0.03), as well as symptomatic patients (63% vs 26%, p=0.04), coincident IMHs (38% vs 10%, p=0.05), and complex endovascular procedures (50% vs 50% p<0.01). Penetrating aortic ulcer width >20 mm tended to show higher mortality (75% vs 40%, p=0.06). Routine follow-up was available for 89% (n=117) for a median of 39 months (95% CI=25-42). One-year and 5-year survival were 83% and 60%, respectively, with 1 aortic pathology-related death. Treatment of PAU is associated with an acceptable perioperative morbidity and mortality. Risk factors associated with increased mortality are an elevated aortic diameter, the presence of IMHs, clinical symptomatology at presentation, and complex endovascular procedures.

Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms

ObjectiveEndovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen (TL), and target vessels frequently originating in the false lumen. We have used transcatheter electrosurgical aortic septotomy (TEAS) before stent graft implantation under intravascular ultrasound (IVUS) and fusion guidance. The purpose of this study is to assess the outcomes of TEAS during complex endovascular repair of dissecting aneurysms. MethodsFrom 2021 to 2023, 17 patients underwent TEAS. The primary end point was technical success, with secondary end points of proximal and distal seals, target vessel instability, aortic and iliac TL and cross-sectional area (CSA) expansion, and aortic-related death. During the procedure, the aortic septum is crossed through a pre-existing entry or via electrocautery-activated 0.018-in. Astato XS20 wire (Asahi-Intecc) under IVUS and fusion guidance. The penetrated wire is then snared in the false lumen and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded the inner surface of the wire using a no. 15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with 0.018-in. microcatheters, and the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60 to 80 W. ResultsThe technical success of the septotomy was 100%. No incidence of visceral or lower extremity malperfusion, vascular injury, or distal embolization occurred. Of the 17 patients, 4 underwent thoracic endovascular aneurysm repair, 2 underwent endovascular aortic repair, and 11 underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with exclusion of the false lumen was achieved in 16 of the 17 patients (94.1%). One patient required embolization of the false lumen of the celiac artery after septotomy. The TL mean diameter and CSA of the descending thoracic aorta after septotomy was expanded by 7.01 ± 1.9 mm (relative mean diameter expansion, 42.3%; P < .0001) and 2.71 ± 0.4 cm2 (relative mean CSA expansion, 57.3%, P<.0001). For patients who required septotomy through the common iliac arteries, the mean TL was expanded by 8.1 ± 3.7 mm (relative mean diameter expansion, 76%; P < .0001) and 1.76 ± 0.91 cm2 (relative mean CSA expansion, 209%; P < .0001). The 1-year freedom from target vessel instability was 91%. ConclusionsThe use of IVUS and fusion-guided TEAS offers a promising technique to facilitate TL expansion and false lumen exclusion in chronic dissecting aortic aneurysms before repair. The durability and long-term outcomes of this technique in a larger cohort remain to be elucidated.

The Complementary Roles of Open and Endovascular Repair of Extent I – III Thoraco-abdominal Aortic Aneurysms in a United Kingdom Aortic Centre

A multidisciplinary approach offering both open surgical (OSR) and complex endovascular repair (cEVAR) is essential if patients with thoraco-abdominal aortic aneurysms (TAAAs) are to receive optimal care. This study reports early and mid-term outcomes of elective and non-elective OSR and cEVAR for extent I - III TAAA in a UK aortic centre. Retrospective study of consecutive patients treated between January 2009 and December 2021. Primary endpoint was 30 day/in hospital mortality. Secondary end point was Kaplan-Meier estimates of mid-term survival. Data are presented as median (IQR). In total, 296 patients (176 men; median age 71 years [IQR 65, 76]; aneurysm diameter 66 mm [61, 75]) underwent repair (222 elective, 74 non-elective). OSR patients (n = 66) were significantly younger with a higher incidence of heritable disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher prevalence of coronary, pulmonary, and renal disease. Overall, in hospital mortality after elective and non-elective repair was 3.2% (n = 7) and 23.0% (n = 17), respectively, with no significant difference between treatment modalities (elective OSR 6.5% vs. cEVAR 2.3%; p = .14; non-elective OSR 25.0% vs. cEVAR 20.3%; p = .80). Major non-fatal complications occurred in 15.3% (33/215) after elective repair (OSR 39.5%, 17/43, vs. cEVAR 9.3%, 16/172; p < .001) and 14% (8/57) after non-elective repair (OSR 26.7%, 4/15, vs. cEVAR 9.5%, 4/42; p = .19). Median follow up was 52 months (IQR 23, 78). Estimated survival ± standard error at one, three, and five years for the entire cohort was 89.6 ± 2.0%, 76.6 ± 2.9%, and 69.0% ± 3.2% after elective repair, and 67.6 ± 5.4%, 52.1 ± 6.0%, and 41.0 ± 6.2% after non-elective repair. There was no difference in five year survival comparing modalities after elective repair for patients less than 70 years, and those with post-dissection aneurysms. A multidisciplinary approach offering OSR and cEVAR can deliver comprehensive care for extent I - III TAAA with low early mortality and good mid-term survival. Further studies are required to determine the optimal complementary roles of each treatment modality.

Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms

Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71±11 vs. 74±7years, P=0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P=0.02) and had a different race distribution compared to the elective cohort (P<0.01). Thirty-day mortality was 4% (n=6) in elective repairs and 7% (n=3) in nonelective repairs. One-year mortality was 13% (n=22) in elective repairs and 18% (n=8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P=0.40) or1-year mortality (P=0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P<0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P<0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P<0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P>0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P=0.03). Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.

Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms

ObjectiveSpinal cord ischemia (SCI) is a devastating complication after thoracoabdominal aortic aneurysm (TAAA) repair. The benefit of prophylactic cerebrospinal fluid drainage (pCSFD) to prevent SCI is still under investigation. The aim of this study was to evaluate the SCI rate and the impact of pCSFD following complex endovascular repair (fenestrated or branched endovascular repair [F/BEVAR]) for type I to IV TAAA. MethodsThe STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A single-center retrospective study was conducted, including all consecutive patients, managed for TAAA type I to IV using F/BEVAR, between January 1, 2018, and November 1, 2022, for degenerative and post-dissection aneurysms. Patients with juxta- or pararenal aneurysms were excluded, as well as cases managed urgently for aortic rupture or acute dissection. After 2020, pCSFD in type I to III TAAAs was abandoned and replaced by therapeutic CSFD (tCSFD), performed only in patients presenting SCI. The primary outcome was the perioperative SCI rate for the entire cohort and the role of pCSFD for type I to III TAAAs. ResultsIn total, 198 patients were included (mean age, 71.1±3.4 years; 81.8% males), including 50.5% with type I to III TAAA. The primary technical success was 94.9%. The perioperative mortality was 2.5%. and the major adverse cardiovascular event (MACE) rate was 10.6%; 4.5% presented SCI of any type (2.5% paraplegia). When comparing the SCI group with the remaining cohort, patients with SCI presented higher MACE (66.7% vs 7.9%; P < .001) rate and longer intensive care unit stay (3.5 vs 1 day; P = .002). Following type I to III repair, similar SCI, paraplegia, and paraplegia with no recovery rates were reported in the pCSFD and tCSFD groups (7.3% vs 5.1%; P = .66; 4.8% vs 3.3%; P = .72; and 2% vs 0%; P = .37). ConclusionsThe incidence of SCI after TAAA I to IV endovascular repair was low. SCI was associated with significantly increased MACE and intensive care unit stay. The prophylactic use of CSFD in type I to III TAAAs was not associated with lower SCI rates and may not be justified routinely.

Proximal Instructions for Use Violations in Elective Endovascular Aneurysm Repair in the Vascular Quality Initiative: Retrospective Analysis.

Endovascular aneurysm repair (EVAR) is often attempted in patients with marginal anatomy. These patients' midterm outcomes are available in the Vascular Quality Initiative for analysis. Retrospective analysis of prospectively collected data in the Vascular Quality Initiative from patients who underwent elective infrarenal EVAR between 2011 and 2018. Each EVAR was identified as either on- or off-instructions for use (IFU) based on aortic neck criteria. Multivariable logistic regression models were used to assess associations between aneurysm sac enlargement, reintervention, and type Ia endoleak with IFU status. Kaplan-Meier time-to-event models estimated reintervention, aneurysm sac enlargement, and overall survival. We identified 5,488 patients with at least 1 follow-up recorded. Those treated off-IFU included 1,236 patients ([23%] mean follow-up 401 days) compared with 4,252 (77%) treated on-IFU (mean follow-up 406 days). There was no evidence of significant differences in crude 30-day survival (96% vs 97%; p = 0.28) or estimated 2-year survival (97% vs 97%; log-rank p = 0.28). Crude type Ia endoleak frequency was greater in patients treated off IFU (2% vs 1%; p = 0.03). Off-IFU EVAR was associated with type Ia endoleak on multivariable regression model (odds ratio 1.84 [95% CI 1.23 to 2.76]; p = 0.003). Patients treated off IFU vs on IFU experienced had increased risk of reintervention within 2 years (7% vs 5%; log-rank p = 0.02), a finding consistent with results from the Cox modeling (hazard ratio 1.38 [95% CI 1.06 to 1.81]; p = 0.02). Patients treated off IFU were at greater risk for type Ia endoleak and reintervention, although they had similar 2-year survival compared with those treated on IFU. Patients with anatomy outside IFU should be considered for open surgery or complex endovascular repair to reduce the probability for revision.

The Association of Sarcopenia and ASA Score to Spinal Cord Ischemia in Patients Treated With the t-Branch Device.

Sarcopenia has been identified as an independent predictor of mortality in patients with infrarenal abdominal aortic aneurysm and may also affect outcomes in patients with complex aortic pathologies. The aim of this study was to assess sarcopenia, combined with the American Society of Anesthesiologists (ASA) score, as predictors for spinal cord ischemia (SCI) in patients treated with the t-Branch off-the-shelf device. A single-center retrospective observational study was conducted including elective and urgent patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) between January 1, 2018, and September 30, 2020. Data were collected according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement. The psoas muscle area (cm2) and attenuation (Hounsfield units, HU) were measured in the arterial phase of the pre-operative computed tomography angiography for each patient. The lean psoas muscle area (LPMA) was used to stratify patients into 3 groups, and further stratification was performed with a combination of the ASA score and LPMA. Eighty patients were included (mean age at 71±9 years; 62.5% males). Thoracoabdominal aneurysms were managed in 72.5% of cases (42.5% for type I-III). Thirty-seven (46%) were treated urgently. Eleven patients died within 30 days (14%). Twelve patients (15%) presented SCI of any severity. Among the LPMA groups, the only statistically significant difference was recorded in age; group 3 was older compared with groups 1 and 2 (67.1 years vs 72.1 years vs 73.5 years, p=0.004). After ASA combined LPMA categorization, 28 patients were considered as low risk, 16 as moderate risk, and 36 as high risk. A statistically significant difference was recorded in terms of SCI (3.5% [1/28] in low risk vs 12.5% [2/16] in moderate risk vs 25% [9/36] in high risk, p=0.049). Multivariate analysis showed that moderate-risk patients were at risk to evolve to SCI (p=0.04). Low-risk patients, with ASA score I-II or LPMA>350cm2HU, are at lower risk for developing SCI after BEVAR using the t-Branch device. Patients' stratification according to the combination of ASA score and psoas muscle area and attenuation may identify a group at higher risk of SCI after branched endovascular aneurysm repair. Sarcopenia has been identified as a factor of increased mortality in patients managed for aortic aneurysm repair. However, significant heterogeneity has been recorded in the tools assessing its presence. In this analysis, an already used method, combining the ASA score and psoas muscle area and attenuation, has been used to assess the impact of sarcopenia in patients managed with the t-branch device. This analysis showed that patients at low risk, with an ASA score I-II or LPMA>350cm2HU were at lower risk to evolve spinal cord ischemia. Along this line, sarcopenia may be a valuable marker for the prediction of perioperative adverse events , other than mortality, in patients managed using complex endovascular repair.

The Association Between Operative Times and Outcomes in Complex Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Endovascular aortic repairs of aneurysms involving the thoracoabdominal aorta (eTAAA) are becoming increasingly common. However, there are no commercially available grafts in the United States for these repairs, and as a result, experience and repair methods vary widely and data are limited. We therefore sought to explore the impact of operative time on perioperative outcomes following eTAAA. We studied all eTAAA repairs (Crawford types 1-3) from 2014 to 2021 in the Vascular Quality Improvement database, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes. We identified 921 complex endovascular thoraco-abdominal aortic repairs. Operating times ranged from <204 minutes in quartile 1 (Q1), to >360 minutes in Q4. Patient demographics, procedural urgency, and aneurysm extent were similar across quartiles. However, repairs in the first quartile were more often staged procedures, with fewer target vessels incorporated, lower usage of spinal drains, and less often utilized parallel grafts or upper extremity access. High volume surgeons and high volume hospitals were more likely to have lower procedure times. In adjusted analysis, procedures in Q3 (270-360 minutes) were associated with double the odds of almost every major perioperative outcome compared to Q1, and Q4 was associated with 3- to 8-fold higher odds. This included mortality (Q3: odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.8; P = .5; Q4: OR, 4.2; 95% CI, 2.1-8.5; P < .001), thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and dialysis) (Q3: OR, 2.2; 95% CI, 1.1-4.1; P = .02; Q4: OR, 8.0; 95% CI, 4.3-15.0; P < .001), spinal cord ischemia (Q3: OR, 2.4; 95% CI, 1.02-5.6; P = .045; Q4: OR, 5.2; 95% CI, 2.3-11.6; P < .001), and acute kidney injury (Q3: OR, 2.2; 95% CI, 1.2-4.0; P = .009; Q4: OR, 5.0; 95% CI, 2.8-8.9; P < .001). Similar trends were seen for rates of major adverse cardiac events, myocardial infarction, and need for dialysis (Table, Figure). Results were consistent when surgeons were analyzed by median procedure time, as surgeons who ranked in the fourth quartile were associated with higher odds of perioperative death, thoracoabdominal life-altering events, major adverse cardiac events, and acute kidney injury. In this study, longer operative time in eTAAA was associated with a higher risk of adverse perioperative outcomes. These results suggest that expeditious repairs, with a focus on avoiding prolonged renal/visceral, pelvic and leg ischemia, are important in achieving optimal results in these challenging repairs, and suggest that strategies such as staged repairs may improve outcomes by decreasing procedure times.TableOdds ratios for perioperative outcomes based on operating time.First quartile (<204 minutes)Second quartile (205-269 minutes)P valueThird quartile (270-360 minutes)P valueFourth quartile (>360 minutes)P valueMortalityRef0.6 [0.2-1.5J0.271.3 [0.6 -2.8]0.454.2 [2.1-8.5]<.001TALERef1.6 [0.8-3.110.22.2 [1.1-4.110.0218.0 [4.3-15.01<.001StrokeRef2.5 [0.4-14.610.321.6 [0.3 -9.7]0.613.6 [0.6-20.2[.15MIRef0.8 [0.2 – 2.9]0.773.7 [1.3 -10.3]0.0143.1 [1.1-8.9].032MACERef1.2 [0.6-2.3)0.581.9 [1.03 – 3.5]0.0384.8 [2.7-8.76]<.001AKIRef0.9 [0.5-1.810.762.2 [1.2 -4.0]0.0095.0 f2.8-8.91<.001SCIRef1.6 [0.6-3.9)0.312.4 [1.02 – 5.5]0.0455.2 [2.3-11.6]<.001Permanent SCIRef1.6 [0.5-5.8]0.452.6 [0.8-8.5]0.116.3 [2.0-19.6].001DialysisRef0.9 [0.2-3.9J0.932.2 [0.6 -7.8]0.215.8 [1.8-18.51.003AKI, Acute kidney injury; MACE, major adverse cardiac event; MI, myocardial infarction; SCI, spinal cord ischemia.Values are adjusted by total operating time. Open table in a new tab

Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability. All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage. There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p < .001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p < .001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p= .018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p= .055), and types 1and 3 endoleak at completion (17% vs. 10%, p= .035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p < .001). Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures.

Complex Endovascular or Open Repair in Juxtarenal and Pararenal Aneurysms: The Best of Both Worlds

Complex Endovascular or Open Repair in Juxtarenal and Pararenal Aneurysms: The Best of Both Worlds

A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.

Aneurysm extent-based mortality differences in complex endovascular repair of thoracoabdominal aneurysms in the Vascular Quality Initiative and the United States Aortic Research Consortium

BackgroundEndovascular management of thoracoabdominal aneurysms (TAAA) is becoming more common. Technological advances including custom devices under the Physician-Sponsored Investigational Device Exemption (PS-IDE), physician-modified endografts (PMEG), and parallel stenting techniques have expanded the extent of disease that is amenable to endovascular treatment. Patients within the PS-IDE studies are a highly selected group of patients, whereas patients treated with PMEG as captured within the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) represent a real-world experience. Research within both the SVS VQI on PMEG and the US Aortic Research Consortium (US-ARC) has demonstrated a relationship between extent of aneurysmal disease and mortality after complex endovascular TAAA repair, but no direct comparison of these cohorts has been conducted. In this study, we sought to compare outcomes of custom PS-IDE devices with off-label uses of commercially available devices for the endovascular management of TAAAs. MethodsA retrospective review of patients presenting for elective endovascular TAAA repair for asymptomatic disease between 2011 and 2019 was conducted within both the SVS VQI registry and the US-ARC. Patients within the SVS VQI registry were treated with either PMEG or with parallel stenting techniques. Patients within the US-ARC were treated with PS-IDE custom devices. The extent of aneurysm disease was defined by the deployment zones documented for the devices entered in the registry using Crawford extents I to V. Primary outcomes were 30-day and 1-year mortality rates. ResultsA total of 3212 patients were included in the study: 1571 PMEG/parallel stenting within the VQI registry and 1641 with PS-IDE within the US-ARC database. The majority of patients presented with extent IV aneurysms (n = 1827 [57%]), with extent IV aneurysms being slightly more prevalent within the US-ARC cohort. Maximal aneurysm diameter within each extent did not vary between the US-ARC and VQI cohorts. Across all patients, the 30-day mortality was 4.4% and the 1-year mortality was 12.2%. Unadjusted mortality at 30-days was 6.7% within the VQI, and 2.2% in the US-ARC (P < .001). The unadjusted 1-year mortality was 14.3% within the VQI and 10.2% within the US-ARC (P < .001). When adjusted for aneurysm extent, similar differences in 30-day and 1-year survivals were identified. ConclusionsPatients treated in PS-IDE studies had better 30-day and 1-year survival rates compared with those treated with a similar extent of disease using off-label approaches in a real-world registry. These differences are complex and likely associated with a number of factors, including arterial anatomy, patient comorbidities, device construct, and volume outcomes, as well as complex and unmeasurable surgeon- and patient-specific factors.

Total Percutaneous Endovascular Aortic Arch Repair With a Triple Inner-Branch Device (the Innominate Approach)

Purpose: To describe a completely percutaneous approach for endovascular arch repair (arch–percutaneous endovascular aortic repair [PEVAR]) with a triple inner-branch device: the “Innominate Approach.” Technique: After right axillary and single common femoral arteries percutaneous access, the arch stent-graft is introduced and deployed transfemorally using fusion overlay. The brachiocephalic artery (BCA) and the corresponding inner branch are cannulated from the axillary access. Through this access, a steerable-sheath guides antegrade cannulation of the left common carotid artery (LCCA) through its inner branch. Optionally, a wire preloaded through the left subclavian artery (LSA) and the LCCA branch, is snared from the BCA access providing LCCA through and through access. A 10 Fr sheath is then positioned from the BCA branch in the LCCA branch and a second, trans-axillary wire through the same sheath is used to catheterize the LCCA. The LCCA is then stented antegradely (regardless of approach). Finally, the BCA and LSA are bridged to complete the procedure. An additional novelty described is the use of VBX (W. L. Gore) as a bridging stent for the BCA. Conclusion: Arch-PEVAR is feasible with the use of adjuncts that are well-known for physicians performing complex endovascular repair. The “Innominate Approach” avoids access and exposure of the carotid arteries. Clinical Impact We aim to describe the feasibility of the axillary artery as the main route to perform the brachiocephalic artery (BCA) and the left common carotid artery bridging stenting in case of arch endovascular repair (arch-EVAR) with a triple Inner-Branch Device. According to the present “Innominate Approach”, percutaneous arch-EVAR is feasible using either a steerable sheath or a preloaded through-&-through wire. The Innominate approach, including a VBX bridging stent for the BCA, avoids carotid access and exposure, reduces the number of vascular accesses, and allows the downsizing of the trans-axillary devices.

Complex Endovascular Repair of Paravisceral Infective Native Aortic Aneurysms

Objective: To report the early and mid-term outcome of complex endovascular repair (EVAR) for paravisceral infective native aortic aneurysms (INAA). Methods: Interrogation of a prospectively maintained database identified consecutive patients who underwent non-elective complex EVAR for paravisceral INAAs in a single institution between December 2013 and June 2020. All patients were considered to have definite INAAs based on diagnostic criteria. Patients who had prior aortic repair were excluded. Results: A total of 26 patients (19 men; mean age 67 years [SD = 11.4]; median diameter 60 mm [IQR: 55–73]) with acute symptomatic (n = 24) or contained ruptured (n = 2) aneurysms underwent surgeon-modified fenestrated EVAR (SM-FEVAR; n = 24) or chimney-periscope EVAR (CHIMPS; n = 2). Median observed follow-up was 36.2 months (18.3–53.5). Nine patients had positive venous blood cultures and a further seven had recent or concomitant infection. All patients received pre- and post-operative antibiotic therapy and rifampicin-soaked endografts. A total of 95 vessels were targeted for preservation and 86 were stent-grafted. One vessel occluded intra-operatively and a further 3 occluded within 30 days. The 30-day/in-hospital mortality was 11.5% (n = 3), and the estimated 1- and 3-year survival (±SD) was 85% ± 7%. Infection-related complications (IRCs) occurred in two patients: both developed new INAA within 30 days of index repair and were treated by EVAR with no mortality. Estimated 3-year freedom from late re-intervention was 100%. One patient required infrarenal EVAR for a non-infective aneurysm at 43 months. Conclusion: Complex EVAR for paravisceral INAAs is associated with acceptable early and mid-term outcomes and is an acceptable alternative to open surgery. We propose that these patients are managed with long-term antimicrobials, impregnation of graft material with rifampicin, and rigorous post-operative surveillance. Clinical Impact A multi-disciplinary approach is required to deliver the best possible outcome for patients with this challenging aortic pathology.

Fenestrated Endovascular Aortic Repair With Chimney Graft for Thoracoabdominal Aneurysm.

Thoracoabdominal aneurysms pose technical challenges for endovascular repair due to involvement of visceral and renal vessels. We report a case series of four patients diagnosed with thoracoabdominal aneurysm who underwent complex endovascular repair with Fenestrated Device and chimney grafts (FEVARCh). FEVARCh is a technically feasible approach for repair of thoracoabdominal aneurysms that involve renal, superior mesenteric, and celiac arteries for patients not appropriate for open surgical repair. Further studies are needed to understand the implications of resultant Type 1a endoleaks and strategies to minimize the displacement of the main body graft with adjunct chimneys.

Realignment of Migrated Celiac Stent Graft After Branched Stent Graft Implantation Through Retrograde Cannulation of the Superior Mesenteric Artery Using a Single Vascular Access

Purpose: The purpose of the study was to present an endovascular management of a type IIIc endoleak (EL) in a patient with migration of the bridging stent graft of the celiac trunk (CT) after branched aortic aneurysm repair with retrograde cannulation of the superior mesenteric artery (SMA). Technique: The therapy was applied in a 62-year-old man who underwent a branched EVAR 2 years ago. Meanwhile, the patient was treated due to type Ia EL 6 months ago. The patient suffered in the last days from unclear hemorrhage clinically correlated with weakness. In the computed tomography angiography (CTA), an EL IIIc with a migration of the bridging stent graft from the CT branch was displayed. As vascular access, the left axillar artery was used. Due to the misaligned bridging stent graft, an antegrade cannulation was impossible, so cannulation was performed retrograde through the SMA using pancreaticoduodenal and gastroduodenal arteries. Thereafter, the EL could be repaired with bridging stent grafts. The postinterventional control showed a satisfying reconstruction without EL or embolization. Conclusion: Most of the complications such as type IIIc EL after complex endovascular repair can also be treated endovascularly. This sophisticated treatment requires that necessary materials and experience are available.