Endovascular Treatment Of Juxtarenal Aneurysms Research Articles

Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair.

Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.

Consequences of the coverage of polar renal arteries during the treatment of juxtarenal aneurysms with fenestrated stentgrafts

To evaluate the short and midterm consequences on the renal function and the mortality of the coverage of polar renal arteries during the endovascular treatment of juxtarenal aneurysms (JRA) with fenestrated stentgrafts.

Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution

ObjectiveDespite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs. MethodsThis retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests. ResultsSeventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months). ConclusionsParallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.

Developing a new endograft for the treatment of juxtarenal aortic aneurysms: definition and experimentation

OBJECTIVES:To analyze angiotomographic parameters of juxtarenal aneurysms to assess the applicability of an endograft model to patients and to create in vitro and in vivo models to assess the new endograft.METHODS:A total of 49 patients with juxtarenal aneurysms were submitted to angiotomographic evaluation, and parameters such as the aortic diameter, the length of the neck, and the angulations of the celiac trunk, superior mesenteric artery and renal arteries; the distances between them; and anatomic variations were analyzed. Based on these parameters, an endograft model was developed and tested in a newly created in vitro model of juxtarenal aneurysm. An experimental model of juxtarenal aneurysm was then established in six pigs weighing 50–60 kg to assess the new endograft model.RESULTS:The angiotomographic parameters of juxtarenal aneurysm measured in this study were similar to those reported in the literature and allowed the development of an endograft based on the hourglass concept, which was applicable to 85.8% of the patients. The in vitro model of juxtarenal aneurysm evidenced good radiopacity and functionality and permitted adjustments in the new device and technical improvements in the procedures for treating these aneurysms. In addition, the porcine model of juxtarenal aneurysm was successfully created in all six animals using a bovine pericardial patch, and use of the new endograft in three pilot procedures evidenced its feasibility.CONCLUSIONS:The Hourglass endograft was rendered applicable to treatment of the majority of patients with juxtarenal aneurysms simply by changing its diameter. Moreover, the new in vitro and in vivo models were shown to be effective for assessing both the presented endograft and experiments assessing the endovascular treatment of juxtarenal aneurysms.

Management of Perioperative Endoleaks During Endovascular Treatment of Juxta-Renal Aneurysms

Evolution of stentgraft and vascular imaging technologies allows endovascular treatment (ET) of juxta-renal aneurysms (JRA). However, endoleaks rates and implants stability are not well documented. The aim of this study was to report the incidence and the perioperative treatment of the endoleaks occurring during ET for JRA. Between January 2000 and April 2010, a total of 957 treated aneurysms were prospectively collected in a database. ET cases for JRA were selected from this database. Pre- and postoperative imaging was retrospectively analyzed to determine the incidence, localization, and treatment of the endoleaks detected following this technique. The series included 50 patients (5%; age, 73 ± 12 years; 44 men). Mean diameter was 60 ± 12 mm. The ET included 38 fenestrated and/or branched endografts and 12 endografts implanted according to the chimney technique. One hundred and forty-three target vessels were perfused. Immediately after endograft deployment, angiography showed endoleaks in 15 patients (30%): 11 type Ia, 1 type II, and 3 type III endoleaks. These endoleaks were treated by aortic endograft modeling and/or stenting in 11 patients, and by placing an aortic extension in two patients. Despite modeling, two patients had a persistent type Ia endoleak and were respectively treated by placing a Palmaz stent and by performing proximal embolization. Despite these procedures, completion angiography showed five residual endoleaks (10%): two type Ia, two type II, and one type III. Immediate postoperative computed tomography (CT) angiography showed endoleaks in 13 patients (28%): six type I, six type II, and one mixed type II/III. Among these 13 patients, on the initial angiography, nine presented with an endoleak, three with a type II and one with a type Ib. Early mortality (<30 days) was 8% (four patients). With a mean follow-up of 12 months, (range, 1-42), six patients presented with a persisting endoleak (four type II, one type Ia, and one multiple type). Aneurysm growth (≥5 mm) was reported in two patients (4%), and nine secondary endovascular procedures were performed to treat these endoleaks. Endoleaks are frequent during ET of JRA. They are treated not only according to their type but also according to the implant characteristics (fenestrated or chimney). Although most endoleaks can be perioperatively treated with simple endovascular means, treatment of persisting type Ia endoleaks remains challenging.