Endovascular Graft Research Articles

Emergency use of Physician-modified Fenestrated Endograft in a Symptomatic Patient Who was Waiting for a Manufactured Graft to Treat Chronic Post-dissection Thoracoabdominal Aneurysm

Introduction - Fenestrated-branched endovascular repair (F-BEVAR) using custom manufactured devices (CMDs) has been applied to treat post-dissection thoracoabdominal aortic aneurysms (TAAA), but the long wait period for device manufacturing limits its application in patients with symptomatic or contained ruptured aneurysms. Methods - A 59-year-old female patient who was waiting for CMD (Cook Medical, Brisbane, Australia) presented with a symptomatic post-dissection TAAA. The patient had undergone a successful first stage thoracic endovascular repair with creation of a fenestration in the distal aortic septum to perfuse the right kidney, which originated from the false lumen. Repeat computed tomography angiography revealed compression of the true lumen below the level of the fenestration with pressurization of the false lumen (Figure A). The patient was treated emergently using a physician-modified endovascular graft (PMEG) with four fenestrations and preloaded guidewires. The technique of PMEG using low-profile Zenith Alpha™ Thoracic stent graft (Cook Medical, Copenhagen Denmark) is presented with video and illustrations. Results - The thoracic stent-graft was modified onsite under strict sterile technique using the same measurements obtained for the original CMD request. The active fixation bards were removed to facilitate re-sheathing. Four fenestrations were created with ophthalmologic cautery and reinforced using a double layer of nitinol wire (Figure B). Radiopaque markers were added for orientation. Four 0.014-inch preloaded guidewires were added exiting via the top of the delivery system (Figure C). Diameter-reducing sutures were applied and the device was reintroduced into the original 18Fr sheath. Using bilateral femoral and right brachial approach, a long 5Fr sheath was introduced via the brachial approach exiting via the femoral approach. The PMEG was loaded into a through-and-through wire, while the four preloaded guidewires were loaded into a long 5Fr brachial sheath. The device and sheath were advanced into position and deployed in a stepwise fashion allowing sequential catheterization of the celiac axis, superior mesenteric artery and both renal arteries in the compressed true lumen (Figure D). Once all vessels were catheterized, the bifurcated device and iliac limbs were added and flow was restored to the lower extremities. Sequential renal-mesenteric stenting was done. A completion cone beam computed tomography revealed successful aneurysm exclusion. The repair was completed with a total endovascular time of 133 minutes and the patient was dismissed on postoperative day 10. Follow-up CTA showed patent stent-graft with type 2 endoleak. A total of 6 PMEG repairs with low profile Zenith Alpha™ Thoracic stent grafts were performed at our institution between 2016 and 2018, representing 2% of the 280 patients treated by F-BEVAR during this period. All six patients who had PMEGs did not meet inclusion criteria for an ongoing prospective study using CMDs Conclusion - PMEGs remain a valuable option to treat TAAAs, including chronic post-dissection aneurysms, in patients with symptoms or contained rupture who are not ideally suited for off-the-shelf devices. Compared to tighter stainless-steel Z stents, the widely spaced nitinol stents of the Zenith Alpha™ Thoracic endograft offer more space for fenestration placement.

Hemodynamic and Metabolic Determinants of End-Organ Perfusion and Microcirculation in an Animal Model of Thoracoabdominal Aortic Repair

Introduction - Open repair of thoracoabdominal aorta (TAA) requires prolonged aortic crossclamping and extracorporeal circulation. Hybrid repair with proximal endovascular graft fixation can reduce ischemic time and eliminate the need for the pump. We measured the effects of hybrid approach on intraoperative and recovery hemodynamics in an experimental pig model. Methods - Four approaches were compared; group 1: open surgical TAA repair, group 2: 1st generation SPIDER graft, group 3: 2nd generation SPIDER with loop graft for implantation of lumbar arteries, and group 4: 3rd generation SPIDER graft with volume-based resuscitation. Hemodynamic variables, tissue perfusion, branch vessel flow, and clinical laboratory values were measured at baseline, at end-operation and at six hours (6H) postoperatively. Organ microperfusion was measured by gold-standard fluorescent microsphere (MS) technique. Data were analyzed by hierarchical linear mixed models to account for multilevel repeated measurements. Results - 27 pigs (75-85 kg) were studied. Total ischemic times were significantly longer for open grafts than SPIDER grafts for all branch vessels (p<0.0001). Branch vessel flows were not present in the OSR group during crossclamping, but recovered at clamp release and 6H postoperatively. Perfusion of the visceral organs measured by fluorescent microsphere varied significantly between baseline, post-implant and 6H postoperatively in all groups (p<0.0001). Between graft types, highly significant time-by-group interactions were observed for liver and bowel (all p<0.015). Hierarchical modeling demonstrated significant multilevel correlational influence of macro-hemodynamic changes (celiac or SMA flow and ischemic time) on microcirculation (end-organ perfusion) of hepatic and mesenteric beds (multilevel R2 0.61). Lactate levels were strongly correlated with bowel but not liver perfusion. Conclusion - Hybrid grafts significantly reduce intraoperative ischemia, end-organ perfusion abnormalities and metabolic derangements during thoracoabdominal aortic repair.

Balloon expandable covered stents as primary therapy for hemodynamically stable traumatic aortic injuries in children.

To expand on the limited available literature regarding the use of balloon expandable covered stents for the treatment of traumatic aortic injuries (TAI) in the pediatric population. Although endovascular grafts have largely replaced surgery for TAI repair, there are significant limitations to the use of these grafts in pediatric patients. Multicenter, retrospective chart review of pediatric patients with TAI following blunt chest wall trauma. Procedural characteristics, follow-up, and reinterventions are described. Six covered stents implanted in five patients. Median patient age was 12 years (11-13 years) and median weight 50 kg (44-54 kg). Procedural success was achieved in all cases. No procedural or postprocedural complications were noted. Median follow-up time was 24 months (11-36 months). Balloon expandable covered stent treatment of pediatric patients with TAI is a feasible alternative to open surgical repair, and preferred over endovascular grafts due to graft size limitations and the large delivery systems.

Long-term outcomes of endovascular aortic aneurysm repair with the Zenith AAA endovascular graft: a single-center study.

To present long-term results obtained with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) using the Zenith AAA endovascular graft from a single institution. Between 2007 and 2013, 95 consecutive patients (median age 77years) underwent EVAR using Zenith. Data were prospectively collected and retrospectively analyzed until 2019. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late (> 30days) re-intervention and surgical conversion, and freedom from aneurysm sac growth (> 5mm). The initial technical success rate was 96.8%. There were no deaths or intraoperative conversions. Overall survival at 1, 3, 5, and 10years was 90.8%, 81.7%. 74.3%, and 57.2%, respectively. AAA rupture occurred in one patient (1.1%). Freedom from AAA-related death was 100% during the follow-up period. Freedom from aneurysm sac growth at 1, 3, 5, and 10years was 98.8%, 86.4%, 76.9%, 53.0%, respectively. Freedom from late re-intervention and open surgical conversion at 1, 3, 5, and 10years was 98.9%, 88.9%, 86.7, and 57.9%, respectively. EVAR with Zenith endografts represents a safe and durable means of AAA repair, and risk of rupture and aneurysm-related death are low.

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

2013 Thoracic Aortic Erosion Into the Esophagus With Aortoesophageal Fistula

INTRODUCTION: Aortoesophageal fistula is a rare but well described life-threatening cause of upper gastrointestinal bleeding. Primary aortoesophageal fistula is predominately caused by descending thoracic aortic aneurysms (52.4%), followed by foreign body ingestion and esophageal carcinoma.1–3 Secondary aortoesophageal fistula is an increasingly recognized complication of thoracic endovascular aortic repair (TEVAR), occurring in 1.7-1.9% of cases.4,5 CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of known 6cm thoracic aortic aneurysm was transferred to our facility for one day of hematemesis and hematochezia to undergo upper endoscopy. On arrival the patient had an emergent esophagogastroduodenoscopy which revealed a visible thoracic aorta through a large transmural defect adjacent to an aortoesophageal fistula in the middle esophagus (Figure 1). After the procedure, the patient underwent emergent CTA of the aorta, which revealed corresponding images to the endoscopic findings with an aortoesophageal fistula directly superior to an area of thoracic aorta protruding into the esophagus (Figure 2). The patient then had an emergent endovascular repair of the aortoesophageal fistula and thoracic aortic aneurysm with fluoroscopic images demonstrating successful graft deployment and fistula closure (Figure 3). DISCUSSION: Aortoesophageal fistula is a life-threatening condition that must be on a gastroenterologist’s differential for upper GI bleeding, in particular in patients with a known aortic aneurysm. Proper and rapid identification of the diagnosis is essential to allow for emergent vascular intervention and hemostatic control. Additionally, literature review highlights a paucity of evidence on the options for endoscopic intervention with esophageal stents. In this particular case, there was fortunately no active gastrointestinal bleeding at time of endoscopy and the patient had successful endovascular grafting; however, there are a number of case reports suggesting that esophageal stenting may be another therapeutic option if there is active esophageal hemorrhage, albeit more of a temporizing measure and one associated with a number of complications.3,6,7

Preoperative Planning for Physician-Modified Endografts Using a Three-Dimensional Printer.

The medical uses of three-dimensional (3D) printing are evolving at a rapid pace. The current roles and the future outlooks of this technology for physician-modified endovascular graft (PMEG) in patients with juxtarenal aneurysm are discussed. Fenestrations of PMEG are designed taking into account the geometry of the stent graft. Designing of such stent grafts is extremely complicated, especially when PMEG is planned for the angulated portion of the aorta. A 3D model enables the designing of branch fenestrations, with consideration for the geometrical adaptation of the stent graft in a complex aortic anatomy. With the aid of 3D-printing technology, patients with juxtarenal aortic pathologies can be treated using fenestrated stent grafts, preserving the vital organ circulation and securing a robust length of proximal sealing zone.

Device profile of the Zenith Dissection Endovascular System for aortic dissection

ABSTRACTIntroduction: Thoracic endovascular aortic repair has been increasingly used to treat type B aortic dissection (TBAD) when it is indicated, offering better outcome in terms of mortality and morbidity compared to open repair. Accepted goals for endovascular treatment of aortic dissections are the closure of the primary intimal entry tear, depressurization, and thrombosis of the false lumen.Areas covered: This is a descriptive review on the Zenith Dissection Endovascular System (Cook Medical Inc., Bloomington, IN) which is a modular system specifically designed to treat TBAD, consisting of a proximal component, the Zenith TX2 TAA Endovascular Graft, and a distal component, the Zenith Dissection Endovascular Stent. The distal stents are uncovered to avoid blockage of dominant spinal cord intercostal arteries and allow for the deployment of the stents across branch vessel origins as needed to treat the dissection.Expert opinion: The Zenith Dissection Endovascular System has already been used for the treatment of TBAD for the last decade mostly in experienced centers. Current evidence suggests that this is a feasible and safe technique with relative low early mortality and morbidity rates. It is important to highlight the potential benefit of Zenith Dissection Endovascular System on the remodeling the dissected aorta during the follow-up period.

Endovascular graft exclusion for treating Stanford type B acute aortic dissection in aged population

The aim of this study was to investigate the efficiency of endovascular graft exclusion for treating Stanford type B acute aortic dissection (AAD) in aged population.Forty-six consecutive patients aged ≥65 years with Stanford type B AAD underwent endovascular therapy in Tianjin Chest Hospital between 2010and 2015 were included in this study. All patients received echocardiography, contrast-enhanced CT, hepatic and renal functions tests, and the blood and urine routine examinations. After the procedure, annual review of the whole aortic computed tomography (CT) was performed for all patients before discharge, as well as 3 months, 6 months and12 months after surgery. All patients were followed up until December, 2015. The outcomes of the whole aortic CT and survival rate were analyzed.Five patients (10.87%) died. Among the 5 cases, 2 showed perioperative death induced by cerebral infarction, 1 died because of newly developed AD 8 months after surgery, and 2 died because of acute myocardial infarction (n = 1) and renal/cardiac failure (n = 1). The other 41 patients (89.13%) were symptom-free with satisfactory conditions.Endovascular stent-graft placement was effective for treating the senior patients with Stanford type B AAD.

Endovascular Repair of Ascending Aortic Pathologies With Tubular Endografts: A Single-Center Experience

Purpose: To investigate the endovascular treatment of ascending aortic pathologies of high-risk patients unsuitable for open repair. Materials and Methods: From 2010 to 2017, 24 patients (mean age 70±15 years, range 29–90; 18 men) were treated at a single center for various pathologies of the ascending aorta, including acute or chronic type A aortic dissections (n=16), pseudoaneurysms (n=6), fixation of a dislocated percutaneous aortic valve (n=2), and miscellaneous indications (n=3). The patients were selected following an interdisciplinary case evaluation, attended by cardiologists and cardiac and vascular surgeons. The Zenith Ascend TAA Endovascular Graft was implanted; simultaneous procedures were performed in 13 patients. Of the total 27 Ascend TEVAR procedures (24 primary and 3 reinterventions), 17 were performed urgently and 10 electively. The primary outcome measure was 30-day survival. The secondary outcomes were cardiovascular complications, midterm survival, and reintervention rate. Results: Clinical success was achieved in all but 1 case. The 30-day survival was 79% (19/24); of the 5 deaths only 1 was directly related to the endograft implanted. In the 30-day postoperative period, there was 1 myocardial infarction, 2 major strokes, a mycotic pseudoaneurysm, a case of Ascend TEVAR–induced high-grade aortic insufficiency, and a minor stroke; 1 patient developed paraplegia after concurrent implantation of a 4-branched abdominal stent-graft. Two patients had a reintervention within 30 days for the pseudoaneurysm and the aortic insufficiency, respectively. During a mean follow-up of 11 months (0–35 months), there was 1 late death (cancer) and 1 additional reintervention at 10 months for a late type Ia endoleak (12.5% reintervention rate). Conclusion: Endovascular repair of ascending aortic pathologies with stent-grafts is a feasible treatment option with acceptable early and midterm outcomes in high-risk patients unsuitable for open surgery. The complexity of Ascend TEVAR might justify higher reintervention rates.

VS07. Endovascular Repair of Anastomotic Pseudoaneurysm After Aortomesenteric Bypass With an Inner Branch Physician-Modified Endovascular Graft

This video demonstrates complex endovascular repair of a symptomatic anastomotic pseudoaneurysm after an aortoceliac and superior mesenteric artery bypass. This was repaired with a physician-modified stent graft with two inner branches, with preloaded wire oriented for upper extremity access. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMjJjMzY2OWE2OTJmNGJiNmM1MGViNWM3YWQzZjUxYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MTA3OTE4fQ.dx_AuwblTa-MzFW6OQgZ-FXDGtN6aRcm0nvQNwfHbvD_vklB-Ql_N9WjKhrY4XZJ9z3iPUGGwOTtZ5VbxlD5KbaVoWJw8hNUyy2-n8cl2S6_Wty1N1IQR4KUkrIq5TfU7T9ZXs3Z-kVcg_NEONG506Epr8Bjch6GNxKU_I5y2oIThF02oP2N8Rpz6fFwqfoflOuoOqs1uskpQW2-rFWme19NTunFNQXjnu6CdZPcGvQqA__oDbcjCBEf7gx3b_8mCTKME1gptbEm4C_ezz5iTzVomRA88RsEJAaOZ8pjyt0rrlcxGvA3G08OoPpMmeIxDz0lgwvocrFNBfhKtnnumw Download .mp4 (76.89 MB) Help with .mp4 files Video

PC040. Endovascular Graft Infections Present Earlier Than Open Graft Infections but Have Similar Management and Outcomes

PC040. Endovascular Graft Infections Present Earlier Than Open Graft Infections but Have Similar Management and Outcomes

Hybrid open and endovascular repair of a blunt traumatic thoracic aortic injury in a 7 year old boy

We describe a 7-year-old boy who sustained a blunt thoracic aortic injury following a rollover motor vehicle crash where the vehicle fell 200 feet down an embankment. The chest x-ray on arrival showed widening of the superior mediastinum, a left-sided hemothorax, and first rib fracture. The screening CTA of the chest revealed bilateral pulmonary contusions, a large left hemothorax, and evidence of aortic injury with active contrast extravasation. The patient was intubated due to respiratory distress and had a left chest tube placed. The patient became hypotensive with greater than 1.5 L of blood from the chest tube, so a resuscitative thoracotomy was performed. Bleeding was controlled with a sponge stick initially and definitively with a Satinsky vascular clamp. Next the patient was transported to the hybrid OR at the adjacent adult hospital with an open chest for endovascular graft placement. The patient was admitted to the PICU post-operatively, transferred to the floor on POD 4, and discharged home on POD 9. Aortic injury after blunt trauma in pre-adolescent children is uncommon and often fatal. Endovascular repair of traumatic thoracic aortic injury in adults is currently the standard of care, but there is a paucity of clinical data to guide management of these types of injuries in pediatric patients.

Recommendations for management of infected aortic pathology based on current evidence

The management of infection involving the abdominal aorta requires clinical decisions based on patient factors and the nature of the infectious process. Any infection occurring after endovascular aortic aneurysm repair or open aortic replacement grafting should be treated promptly with appropriate systemic antibiotic therapy. Once a vascular prosthesis becomes infected, surgical treatment is necessary. There should be a low threshold for graft excision and extra-anatomic bypass in the presence of fistula or abscess cavity, when feasible entire graft should be excised. In selected patients, graft excision with in situ aorta reconstruction is an appropriate option using an autogenous femoral vein, cryopreserved allograft, or a prosthetic graft impregnated with antibiotic. The replaced in situ aortic graft should be covered with an omental pedicle. For primary aortic graft infections, endovascular treatment may act as a bridge to more definitive treatment; or, in the absence of gross retroperitoneal infections, endovascular grafting alone with prolonged systemic antibiotic therapy is a viable option, particularly in patients not fit for open surgical procedures.

Thoracoabdominal aortic aneurysm surgery: a different perspective on stent grafts failure

Endovascular repair of the descending and thoracoabdominal aortic aneurysm (TAAA), which is generally considered to be associated with lower morbidity and mortality than conventional open repair, appeals to both patients and clinicians. However, commonly this concept has been under continual evaluation and issues with long-term durability, disease progression and repair failure, including endoleak with all its types and not to forget aneurysm expansion, catastrophe of aortic rupture, and stent-graft infection are handing like ringing bells after every endovascular approach. In this literature review, we will review the current evidence of graft failure and delineate the actual and proposed theorems regarding the cause of failure of endovascular graft failure.

Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously

ObjectiveThe Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. MethodsWe performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. ResultsFifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. ConclusionsWhereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.

Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms

ObjectiveThe Zenith Fenestrated Endovascular Graft (ZFEN; Cook Medical, Bloomington, Ind) has expanded the anatomic eligibility of endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysms (AAAs). Current data on ZFEN mainly consist of single-institution experiences and show conflicting results. Therefore, we compared perioperative outcomes after repair using ZFEN with open complex AAA repair and infrarenal EVAR in a nationwide multicenter registry. MethodsWe identified all patients undergoing elective AAA repair using ZFEN, open complex AAA repair, and standard infrarenal EVAR between 2012 and 2016 within the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Open complex AAA repairs were defined as those with a juxtarenal or suprarenal proximal AAA extent in combination with an aortic cross-clamping position that was above at least one renal artery. The primary outcome was perioperative mortality, defined as death within 30 days or within the index hospitalization. Secondary outcomes included postoperative renal dysfunction (creatinine concentration increase of >2 mg/dL from preoperative value or new dialysis), occurrence of any complication, procedure times, blood transfusion rates, and length of stay. To account for baseline differences, we calculated propensity scores and employed inverse probability-weighted logistic regression. ResultsWe identified 6825 AAA repairs—220 ZFENs, 181 open complex AAA repairs, and 6424 infrarenal EVARs. Univariate analysis of ZFEN compared with open complex AAA repair demonstrated lower rates of perioperative mortality (1.8% vs 8.8%; P = .001), postoperative renal dysfunction (1.4% vs 7.7%; P = .002), and overall complications (11% vs 33%; P < .001). In addition, fewer patients undergoing ZFEN received blood transfusions (22% vs 73%; P < .001), and median length of stay was shorter (2 vs 7 days; P < .001). After adjustment, open complex AAA repair was associated with higher odds of perioperative mortality (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4-18), postoperative renal dysfunction (OR, 13; 95% CI, 3.6-49), and overall complication rates (OR, 4.2; 95% CI, 2.3-7.5) compared with ZFEN. Compared with infrarenal EVAR, ZFEN presented comparable rates of perioperative mortality (1.8% vs 0.8%; P = .084), renal dysfunction (1.4% vs 0.7%; P = .19), and any complication (11% vs 7.7%; P = .09). Furthermore, after adjustment, there was no significant difference between the odds of perioperative mortality, postoperative renal dysfunction, or any complication between infrarenal EVAR and ZFEN. ConclusionsZFEN is associated with lower perioperative morbidity and mortality compared with open complex AAA repair, and outcomes are comparable to those of infrarenal EVAR. Long-term durability of ZFEN compared with open complex AAA repair warrants future research.

Primary Right External Iliac Artery to Small Bowel Fistula Treated with Endovascular Graft

Primary Right External Iliac Artery to Small Bowel Fistula Treated with Endovascular Graft

1087. Aortic Graft Infections Caused by Propionibacterium acnes at the Minneapolis Veterans Affairs Health Care System (MVAHCS) 2007–2017

Background Propionibacterium acnes is a Gram-positive microaerophilic bacterium and part of the human skin flora. The ability of P. acnes to cause infections has been recognized, particularly in the presence of hardware. We aimed to define the frequency of P. acnes infections, with a focus on aortic graft infection.MethodsWe used microbiology laboratory records at the Minneapolis Veterans Affairs Health Care System to identify all P. acnes cultures from January 2007 to January 2017. We retrospectively reviewed all adult (≥18 years) patient’s medical records to identify associated infectious syndromes. Case definitions by the management of Aortic Graft Infection Collaboration were used to classify aortic graft infection cases.ResultsWe identified 328 positive P. acnes cultures during the study period. P. acnes was classified as a pathogen in 48 (15%), a pathogen of undetermined significance in 70 (21%), and a contaminant in 210 (64%) cases. We identified three cases aortic graft infection which accounted for (2.5%) of infections caused by P. acnes. Median age (range) at presentation was 74 years (67–83). Symptoms included pain (n = 3), fever (n = 2), and altered mental status (n = 1). None were hypotensive. All patients had at least one revision for endoleak prior to presentation. Median time from symptom onset to diagnosis was 120 days (78–140). Microbiological diagnosis was obtained by blood cultures, percutaneous peri-graft tissue aspiration, and operative culture in each patient, respectively. Infection was complicated by metastatic abscess in one patient. All cultures grew on Day 7. All patients were treated with IV ceftriaxone, and two were transitioned to life-long oral suppressive antibiotic therapy. Two patients had complete removal of infected material. No relapse was documented and survival was 100% at 1 year follow-up.ConclusionAortic graft infection is an uncommon subset of infections caused P. acnes. Clinical course is indolent and diagnosis is delayed due to nonspecific clinical presentation. In contrast to endovascular graft infection caused by other organisms, mortality is low when treated with appropriate antibiotic therapy and removal of infected material. The current laboratory practice of holding blood cultures for 5 days may need to be altered when P. acnes is a potential cause of infection.Disclosures All authors: No reported disclosures.

Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair

ObjectiveLong-term outcomes after endovascular aneurysm repair (EVAR) are threatened by aortic neck dilation (AND), graft migration, and subsequent endoleak development. The aim of this study was to determine the rate of AND and the occurrence of endoleaks after fenestrated EVAR of juxtarenal aneurysms with physician-modified endovascular grafts (PMEGs). MethodsThe study included 77 patients presenting with asymptomatic and ruptured juxtarenal abdominal aortic aneurysms treated with PMEGs who received radiologic follow-up. Analysis of computed tomography images took place on a three-dimensional workstation (TeraRecon, San Mateo, Calif). Aortic neck diameter was measured before and after EVAR at the lowest patent renal artery outer wall to outer wall. Significant AND was defined as >3-mm increase between baseline and follow-up, and sac regression >5 mm was considered significant. The patient's 1-month initial postoperative computed tomography measurement was considered baseline. The rate of AND was measured by comparing the baseline measurement with measurements at 6 months, 12 months, and annually thereafter up to 4 years. ResultsIn this cohort of patients, 75% were men with a mean age of 74 ± 7.9 years. Median preoperative aneurysm size was 62 (57-73) mm, and median follow-up was 12 (3.5-30) months. Mean endograft oversizing was 17% ± 12.5%, and mean seal zone length was 41 ± 11 mm. At 1-year follow-up, the median aortic neck increase was 1.7 (0-3) mm. Maximum aneurysm size decreased dramatically during the first postoperative year, with significant sac regression in 65% of the patients. Aortic neck diameter at 1 year did correlate positively with the percentage of device oversizing. No other correlations were found. During the 4-year follow-up, there were no cases of type IA endoleaks. ConclusionsAND does not influence outcome after endovascular repair of juxtarenal aneurysms using PMEGs. These midterm results support the applicability of PMEGs in juxtarenal aneurysm repair.