Endovascular Treatment Of Aortic Pathologies Research Articles

Elucidating the Role of the AFX2 Endograft in Endovascular Treatment of Aortic Pathology

The purpose of this study is to elucidate the role of the AFX2 platform in the endovascular treatment of aortic pathology. All procedures by a single surgeon resulting in implantation of a bifurcated unibody stent graft were reviewed retrospectively. Indications for selection of the AFX2 endograft in each case were evaluated. Aortic anatomy was determined via review of pre-operative computed tomography (CT) scans. Cumulative event probabilities for endoleak, reintervention, and mortality were estimated. Patient and procedural details were described using mean, standard deviation, medians, and interquartile range (IQR). Kaplan-Meier survival analysis estimated freedom from mortality and reintervention. Cumulative incidence probabilities were calculated as one minus the Kaplan-Meier estimator. Between March 2018 and December 2020, the author (NN) used 142 aortic endografts in 142 patients. Of these, 46 (32.4%) were AFX2 endografts and the remaining were modular bifurcated devices, predominantly Medtronic Endurant II and Terumo Treo. No AFX-Strata or AFX-Duraply devices were placed. Amongst the patients who received an AFX2, mean age was 71.3 +/- 9.8years with 84.8% male. Median operative time was 116 (86-166) min, with contrast dose of 79 (41-120) milliliters and fluoroscopy time of 12 (8.6-18) min. Overall, 78.3% (n=36) of AFX2 devices were placed in aortas with maximum true lumen diameter <5.0cm. Median postoperative follow-up was 1.7years (IQR 1.0-2.4years), with a maximum follow-up of 3.6years. There was 1 patient lost to follow-up at 5months. The 2-year incidence of type II endoleak, reintervention, and all-cause mortality was 12.7% (95% confidence interval CI, 0-29.6%), 2.2% (95% CI, 0-6.3%), and 11.3% (95% CI, 0.1-2.1.2%), respectively. There were no type I or III endoleaks. The AFX2 endograft plays a safe and effective role in treatment of infrarenal aortic pathologies that may be otherwise more technically challenging for traditional modular, bifurcated devices.

Neoaortoiliac system in treating aortic graft infections: a single center long-term experience and review of the literature.

Aortic graft infection represents one of the most challenging and life-threatening complication of surgical and endovascular treatment of aortic pathologies. The aim of this study was to report the results of a single center with in-situ revascularization for the treatment of aortic graft infections using the neo-aorto-iliac system (NAIS) and to review the literature about this surgical technique. We retrospectively reviewed our aortic graft infection case series and in-situ revascularization using the neo-aorto-iliac system. The study was conducted from January 2009 to June 2020. The primary outcomes analyzed were early mortality (<30 days), late mortality (>30 days), reinfection rate. Secondary outcomes were the primary patency rate, the secondary patency rate, and the lower limb salvage rate. A literature review of the last twenty years was performed on international medical databases Pubmed (Medline), Scopus and Web of Science. During study period, 12 patients, all male (median age of 69 years [range: 52-87 years]), underwent to infected graft explantation and revascularization by NAIS using femoral-popliteal veins. Six cases were complicated by aorto-enteric fistulas, five were duodenal and one was colon. Patients spent the immediate postoperative period in the Intensive Care Unit for a median time of 4 days (range: 0-9 days). The median length of hospital stay was 27.5 days (range: 1-66 days). The mean follow-up was 21.5 months (range: 0-120). The 30-day mortality rate was 25% (3 patients) due to postoperative complications. No patient dropped out of the follow-up protocol. The primary patency rate was 92% while the secondary patency rate was 100%. No patient underwent lower limb amputation. Persistence of infection occurred in 1 case (8.3%). Overall Kaplan-Meier survival estimates were 75% for 30 days, 50% for 1 year, 48% for 5 years. Literature analysis identified 19 case series. The literature regarding NAIS has low statistical evidence due to retrospective design of the studies. Our results are in agreement with retrospective studies in the literature. When the surgical team is confident with NAIS, this technique should be considered the preferred method, considering an acceptable and comparable mortality rate with other techniques and a better rate of patency, resistance to graft degeneration, recurrent infections and amputation rate.

Endovascular Treatment of Aortic Pathologies in Patients With Marfan Syndrome: Single-Center Experience

Objectives: To study the outcome of endovascular treatment of aortic pathologies in patients with Marfan syndrome (MFS) at a single institution. Methods: Consecutive MFS patients who underwent endovascular repair or hybrid procedures for aortic pathologies from January 2010 to May 2020 were identified. Several endovascular and hybrid strategies have been used. Technical success, short- and mid-term survival, complications, and re-interventions were retrospectively analyzed. Results: During the study period, 24 patients with MFS (median age, 48 [13–78] years; 58% males) were treated. Indications for intervention were chronic aortic dissection with aneurysm degeneration in 16 patients (67%), acute type B aortic dissection in 4 patients (17%), aortic aneurysm without any dissection in 3 patients (13%), and aortic intramural hematoma in 1 patient (4%). Most patients were asymptomatic (83%), three (13%) were symptomatic and one (4%) had a contained rupture. The median aneurysm diameter was 56 (35–86) mm. Hybrid procedures were performed in 7 (29%) patients. Thoracic endovascular repair was performed in 12 (50%) patients, a fenestrated or branched endovascular aortic repair in 4 (17%) patients, and placement of an iliac artery stent-graft in 1 (4%) patient. Procedures were staged in 12 (50%) patients. Technical success was achieved in all patients. The median intensive care unit stay was 6 (range, 1–30) days, and the median hospital stay was 23 (range, 3–112) days. Early mortality was reported in 1 (4%) patient. Wound infection was seen in 7 (29%) patients and gastrointestinal complications in 3 (13%) patients. The median follow-up was 42 (range, 1–127) months. The cumulative survival rate was 87% at 24 months. The cumulative freedom from re-intervention was 77% at 12 months. Conclusions: Endovascular treatment of aortic pathologies in patients with MFS appears feasible with acceptable early and mid-term outcomes in terms of mortality and re-intervention rates. Endovascular therapy plays an increasing role in MFS patients with aortic pathology.

Proximal Sealing Length in TEVAR: Dependent on Aortic Arch Type?

The proximal landing zone is of paramount importance in the endovascular treatment of aortic pathologies. Elaborating the ideal proximal landing zone in the thoracic aorta and especially in the aortic arch is difficult for several reasons: 1) biomechanical forces are influenced by anatomical variations of the aortic arch and the proximity to the beating heart; 2) the supra-aortic vessels bring the risk of neurological complications when de-branching or endovascular alternatives are considered to extend the proximal landing zone; 3) the diversity of aortic pathologies including aneurysms, dissections, intramural haematoma, or traumatic ruptures hinders homogeneous cohorts.

Percutaneous Access with Larger Introducers Sheaths (&gt;21f) During Endovascular Repair of Thoracic and Thoraco-Abdominal Pathology: A Propensity Matched Analysis

Introduction: To evaluate the feasibility and safety of an off-label percutaneous approach during the endovascular treatment of thoracic and thoracoabdominal pathology with large sheaths (>21F), even in the presence of predictors of technical failure. Methods: From December 2015 to December 2018, all patients receiving a percutaneous approach for endovascular treatment of aortic pathology (EVAR: 389 cases - 60.9%; TEVAR: 163 cases - 25.5 %, FEVAR= 87 cases - 13.6%) were enrolled in an ambispective study called PEVAR-PRO (clinicaltrials.gov: NCT03484013). The entire retrospective arm of the study was analyzed to identify the predictors of technical failure at univariate analysis. The identified predictors were used to create a 1:2 propensity matched cohort to compare the technical success rate of cases receiving a large sheath (LS) to small sheath (SS) percutaneous closure. All the enrolled PEVAR-PRO patients received two suture-mediated vascular closure devices, employing the “pre-close technique” with ProGlide (Abbott Vascular, Santa Clara, Calif) and the 30-day technical success was defined as a successful hemostasis without evidence of bleeding, pseudoaneurysm formation, arterial occlusion or dissection requiring secondary intervention. Results: The univariate analysis of the 639 femoral arteries in 363 patients (Male 84%, median age: 72 years IQR: 68-78) enrolled in the study observed that the failure predictors were: Diabetes (RR: 3.4, p< .001), SVS score >12 (RR: 2.3; p=.017), common femoral artery stenosis ≥5 0% (RR: 6.0, p< .001), femoral calcifications involving more than 33% of the vessel circumference (RR: 2.6, p=.002) and femoral anterior calcifications (RR: 2.3, p=.031). At univariate analysis a borderline lower technical success (90.8% vs 95.0%, p=.057) was observed comparing LS group (191 cases) to SS group (448 cases). After 1: 2 propensity score matching we obtained a SS group (n=346 patients: male 85%, median age: 75 years IQR: 70-79) and LS group (n=173 male: 80%, median age: 71 years IQR: 65-77) with no significative differences regarding other preoperative risk factors. The technical success rate did not differ between the two groups (LS group 90.8% vs SS Group 94.2%, RR: 1.6, IC95%: 0.85-3.01, p=.143). Interestingly, in LS group a technical failure for bleeding (6 cases - 38%) or vessel occlusion (11 cases - 62%) did not show an increased need for postoperative blood transfusions (11.4% vs 7.8%). Moreover, a previous open (42 cases - 24.3%) femoral or percutaneous (35 cases - 20.2%) access did not affect the technical success rate (open: 90.5% vs 90.8% and percutaneous: 88.6% vs 91.3%). Conclusion: An off-label percutaneous approach with pre-close technique to thoracic and thoraco-abdominal aortic pathology employing large sheath (> 21F) is feasible and safe even in presence of redo accesses. Technical success rate is not different when compared to an in-label use of the closure devices even after propensity matching toward failure predictors. Prospective controlled studies are needed to include large sheath access into the instructions for use of the device. Disclosure: Nothing to disclose

Morphometric Study of the Aortic Arch, with Application to the Endovascular Treatment of Aortic Pathologies

The endovascular treatment of the aortic arch (AA) is a modern therapeutic and technological challenge, mainly because of its anatomical complexity. The objective of this work was to carry out a morpho-anatomical study of the AA and supra aortic trunks (SAT) in healthy patients and patients presenting a disease of the thoracic aorta, with a surgical orientation applied to the development of stentgrafts dedicated to the AA.

Arterial Stiffness Alterations and Inflammatory Response Following Endovascular Aortic Repair

Endovascular abdominal aortic aneurysm repair (EVAR) and thoracic aortic aneurysm repair (TEVAR) have been widely incorporated into clinical practice. However, changes in arterial stiffness and post-implantation syndrome after aortic endografting remain important issues under investigation. The aneurysm sac wall motion after successful EVAR and TEVAR reflects complex interactions between all the components of the excluded aneurysm, including true compliance of the aneurysm wall itself, intra-aneurysm sac pressure, remodeling of the thrombus, and mechanical characteristics of the endograft. Experimental and clinical studies have shown that aortic endografting results in increased arterial stiffness in animal models. It can be assumed that the alterations of aortic mechanical properties can have a direct impact on heart output. The long-term impact of these mechanical changes on cardiovascular outcomes and the potential effects of different endografts on hemodynamics are important issues under investigation. Post-implantation syndrome (PIS) is a systemic inflammatory response frequently observed after endovascular treatment of aortic pathologies. The main features of PIS include fever, leukocytosis, elevated C-reactive protein levels, and coagulation disturbances. Endograft design appears to influence this inflammatory response following aortic endografting; woven polyester endografts have been shown to be associated with greater inflammatory response compared to PTFE stent grafts. The purpose of this paper is to review the literature to elucidate arterial stiffness alterations and inflammatory response after EVAR and TEVAR and the impact of endograft design on aortic stiffness and the post-inflammatory response.

Optimal management of acute type A aortic dissection with mesenteric malperfusion.

Acute type A aortic dissection (TAAD) remains a morbid condition; although overall outcomes have improved, patients presenting with preoperative malperfusion syndromes continue to have excessive mortality following conventional open surgical repair. Mesenteric malperfusion is generally associated with the worst prognosis and postoperative mortality in this group. With advances in the endovascular treatment of aortic pathology, options now exist to percutaneously manage mesenteric malperfusion prior to central aortic repair. This strategy may be associated with improved outcomes. To review this, a best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with acute type A aortic dissections with mesenteric malperfusion, does management of the malperfusion prior to central aortic repair reduce perioperative mortality'. Overall, more than 309 papers were found as a result of the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that, in patients with acute TAAD complicated by mesenteric malperfusion, initial management with percutaneous interventional procedures to reverse the malperfusion followed by delayed central aortic repair is a reasonable strategy; this is because of the extremely poor prognosis associated with immediate central aortic repair in this group.

The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies

Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data.

Importance of Aortic Morphology in Planning Aortic Interventions

Traditionally, preoperative assessment for open aortic interventions has focused on patient factors, such as cardiopulmonary status and the presence of comorbidities. These are the principal determinants of success because morbidity and mortality from such procedures is due to factors related to the incision, duration and location of the cross clamp, and the postoperative inflammatory response. These factors have been shown consistently to predict the outcome of open surgical repair of abdominal aortic aneurysms (AAA) and are incorporated in preoperative risk prediction systems, such as the Glasgow Aneurysm Score and the POSSUM predictor equation. Endovascular treatment of aortic pathology does not present such a physiological insult, as incisions are smaller and no cross-clamping is required. The postoperative inflammatory response is much less marked, and some patients can return directly to general wards after their procedure without the need for stabilization in a high-dependency environment. Perioperative and short-term mortality is reduced in endovascular repair, but increased emphasis is placed on mediumto long-term outcomes due to device failure of different types and subsequent re-intervention. The general consensus that anatomy of the diseased aorta and its branches is more important than physiological status in predicting the success of endovascular intervention has been illustrated by work showing that physiology-based risk prediction systems are not valid in endovascular aneurysm repair (EVAR) and probably not in thoracic endovascular aortic repair (TEVAR). Several classifications systems for the anatomy of the diseased aorta have been proposed. However, many existing methods are surprisingly nebulous. Dividing pathology into thoracic, thoracoabdominal, and abdominal is a useful start, as there are certain challenges unique to interventions in each area. Sub-classification into groups, particularly in relation to the visceral aortic branches, has proven difficult. For example, the meaning of ‘‘juxtarenal’’ in terms of an AAA simply means that a crossclamp cannot be applied below the renal arteries. This is not a particularly objective definition. The traditional Crawford type classificationofdescending thoracicaneurysms isnot necessarily applicable to endovascular repair, but the length of aortic coverage is important from the perspective of postoperative paraplegia. It is known that certain anatomical features predispose to the risk of adverse outcome. At present, there is no universally accepted classification system for the anatomyof the aorta with regards to location of interventions.

Oversizing of Aortic Stent Grafts for Abdominal Aneurysm Repair: A Systematic Review of the Benefits and Risks

Sizing of aortic endografts is an essential step in successful endovascular treatment of aortic pathology, although consensus regarding the optimal sizing strategy is lacking. Some proximal oversizing is necessary to obtain a seal between the stent graft and the aortic wall and to prevent the graft from migrating, but excessive oversizing might influence the results negatively. In this systematic review, we investigated the current literature to obtain an overview of the risks and benefits of oversizing and to determine the optimal degree of oversizing of stent grafts used for endovascular abdominal aortic aneurysm repair. PUBMED, EMBASE and Cochrane Library databases were searched for articles related to the impact of proximal endograft oversizing on complications after endovascular aneurysm repair. After in- and exclusion, 23 relevant articles reporting on 8415 patients remained for analysis and critical appraisal. Most studies that investigated neck dilatation are flawed by poor methodology. No clear relationship between proximal oversizing and neck dilatation relative to the first post-operative scan was found. None of the studies described a positive relationship between the degree of oversizing and the incidence of endoleaks. On the contrary, oversizing up to 25% seems to decrease the risk of proximal endoleaks. There are conflicting data regarding the risk of graft migration when oversizing by more than 30%. Based on the best available evidence, the current standard of 10-20% oversizing regime appears to be relatively safe and preferable. Oversizing >30% might negatively impact the outcome after EVAR. Studies of higher quality are needed to further assess the relationship between proximal oversizing and the incidence of complications, particularly regarding the impact on aneurysm neck dilatation.

Percutaneous Thoracic and Abdominal Aortic Aneurysm Repair: Techniques and Outcomes

Endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become a widely accepted treatment modality. The conventional approach of an EVAR involves bilateral groin incisions to expose the femoral arteries followed by introducer sheath placement, which is typically performed with the use of general or epidural anesthesia. As technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. In this review, we present a brief history of percutaneous closure devices for common femoral artery access, factors important in patient selection, the technique of performing a percutaneous EVAR procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.