Fenestrated-branched Endovascular Aneurysm Repair Research Articles

The Effect of Family History of Aortic Disease on Outcomes of Fenestrated-Branched Endovascular Aneurysm Repair of Complex Aortic Aneurysms

The Effect of Family History of Aortic Disease on Outcomes of Fenestrated-Branched Endovascular Aneurysm Repair of Complex Aortic Aneurysms

The semi-compliant balloon bounce technique for total femoral approach during fenestrated-branched endovascular aortic aneurysm repair

A total femoral approach for fenestrated-branched endovascular aortic aneurysm repair has been increasingly favored to minimize risks of aortic arch manipulation. We describe a novel technique to support the advancement of endovascular devices into a target vessel. Following catheterization of the intended target artery and deployment of the diameter-reducing ties, a Coda semi-compliant balloon (Cook Medical) is advanced and inflated immediately above the target artery. It is used as a support as the wire, catheter, or sheath “bounces” on the balloon, stabilizing the support wire to advance stent grafts, balloons, or sheaths into the downward renal or mesenteric vessels.

Current state of endovascular repair of thoracoabdominal aortic aneurysms

Thoracoabdominal aortic aneurysm (TAAA) is a severe and complex condition with multifactorial etiology that can lead to life-threatening complications. Its treatment is genuinely complex irrespective of the chosen technique, open or endovascular repair. Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has been increasingly accepted in patients with suitable anatomy, resulting in outcomes compared to or superior to open repair. The selection of patients, judicious surgical planning, and device selection are paramount to achieving successful treatment. The field of TAAA repair is continuously evolving with ongoing research and the development of new techniques and devices to further improve patient outcomes. This paper aims to present a review of endovascular TAAA treatment, summarizing anatomical and clinical features relevant to technical performance and treatment indications.

How We Would Treat Our Own Thoracoabdominal Aortic Aneurysm

This manuscript is intended to provide a comprehensive review of the current state of knowledge on endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The management of these complex aneurysms requires an interdisciplinary and patient-specific approach in high-volume centers. An index case is used to discuss the diagnosis and treatment of a patient undergoing fenestrated-branched endovascular aneurysm repair (FB-EVAR) for a TAAA.

Dual-Lumen Stenting of Dissected Superior Mesenteric Artery During Fenestrated Branched Endovascular Repair of a Post-dissection Thoracoabdominal Aortic Aneurysm.

Long-segment aortic branch dissections have been considered a relative contraindication for fenestrated-branched endovascular aneurysm repair (FB-EVAR). This case report describes a technique of dual-lumen stenting of a fully-dissected superior mesenteric artery (SMA) to preserve patency of the true and false lumens during FB-EVAR. A 67-year-old man presented with a 6.0 cm extent III chronic post-dissection thoracoabdominal aortic aneurysm. The patient had highly-complex anatomy including dissection of the entire SMA. The true and false lumens of the dissected SMA were noted to be supplying different branches, requiring preservation of both lumens. The patient underwent a staged physician-modified FB-EVAR. A modified endograft containing 5 fenestrations and 1 branch cuff was introduced and the celiac, true-lumen SMA, and 3 renal arteries were sequentially catheterized using staggered deployment of the modified endograft. The false lumen SMA stent was catheterized via the branch cuff. Molded parallel grafting ("eye-of-the-tiger") technique was used to achieve double D configuration between the true and false lumens of the SMA. This case demonstrates feasibility of dual-lumen stenting to incorporate dissected target vessels during FB-EVAR while preserving flow to both the true and false lumens and the second-order branches they supply. We report a novel technique that allows incorporation of branch vessels affected by long segment dissection during fenestrated branched endovascular aortic repairs. This has potential advantage of preserving flow to all secondary branches of the dissected target vessels, while reducing the risk of type Ic endoleak.

Fiber Optic RealShape imaging using upper extremity and transfemoral access for fenestrated-branched endovascular aortic aneurysm repair.

We report our initial experience using Fiber Optic RealShape (FORS), an innovative real-time three-dimensional visualization technology that uses light instead of radiation, to achieve upper extremity (UE) access during fenestrated/branched endovascular aortic aneurysm repair (FBEVAR). An 89-year-old male patient with a type III thoracoabdominal aortic aneurysm, unfit for open aortic repair, underwent FBEVAR. Dual fluoroscopy, intravascular ultrasound, and three-dimensional fusion overlay were used, in addition to FORS. All target artery catheterizations were successfully accomplished using FORS, from UE access, without radiation. Our experience demonstrates that FBEVAR with FORS using UE access can be used for target artery catheterization without radiation.

Persistent Thrombocytopenia Indicates Endoleak After Complex Endovascular Aneurysm Repair

High-pressure endoleaks (types I or III) after fenestrated-branched endovascular aneurysm repair (F-BEVAR) pose an ongoing risk of rupture. Early identification of such endoleaks may facilitate appropriate reintervention and mitigate that risk. The purpose of this study was to determine if persistent thrombocytopenia after F-BEVAR correlates with the presence of a high-pressure endoleak in the early postoperative period. Sequential patients enrolled in a physician-sponsored investigational device exemption study of physician modified and Cook manufactured F-BEVAR endografts were evaluated. Patients with type I endoleak or type III endoleak identified on computed tomography imaging within the first 6 months of follow-up were categorized as high-pressure endoleaks; any type II endoleaks were classified as low-pressure endoleaks. Univariable and multivariable analysis was performed to assess if thrombocytopenia was associated with the presence of endoleaks. We treated 185 patients. Twenty-six patients (14%) developed a high-pressure endoleak and 30 (16%) developed a low-pressure endoleak (Table I). Age, gender, race, indications for the procedure, and preoperative medications did not significantly differ between the endoleak groups. To maximize sensitivity and clinical utility, we selected a cut point of daily average platelet count of <100,000/μL (Table II). The proportion of high-pressure endoleak patients with platelet counts of <100,000/μL was significantly greater compared to patients with low-pressure and no endoleaks on postoperative day (POD) 1 through 4 (POD 4: high-pressure 42%, low-pressure 27%, no endoleak 10%; P ≤ .001). After adjusting for demographics and comorbidities, patients with high-pressure endoleak were over 12-times more likely to have a platelet count of <100,000/μL on POD 4 compared to patients with no endoleak (odds ratio, 12.3; 95% confidence interval, 3.5-43.0). F-BEVAR patients who developed high- or low-pressure endoleak were significantly more thrombocytopenic in the postoperative period. Consideration should be made to perform computed tomography imaging in patients with platelet counts of <100,000/μL persisting at POD 4 after F-BEVAR as these patients have a 35% chance of having a high-pressure endoleak requiring reintervention.Table IProportion of patients with platelet count under 100,000/μL at preoperative (day 0), and postoperative days (POD) 1-7 after F-BEVAR among the type I, II, and III endoleak and no endoleak groupsDay 0Day 1Day 2Day 3Day 4Day 5Day 6Day 7No endoleak (n = 125)12 (10)17 (14)27 (22)28 (22)13 (10)11 (9)4 (3)4 (3)T1E/T3E (n = 26)7 (27)12 (46)15 (58)12 (46)11 (42)3 (12)1 (4)1 (4)T2E (n = 30)5 (17)10 (33)11 (37)13 (43)8 (27)5 (17)3 (10)1 (3)P value.06<.001.001.02<.001.8.6a1.0aT1EL/T3EL, Type I endoleak/type III endoleak; T2EL, type II endoleak.Data presented as number (%).aFisher's exact was used. Open table in a new tab Table IIComparison of the test characteristics of a cutpoint of <100,000/μL at different postoperative days (POD) for predicting the presence of a high-pressure endoleakSensitivity (95% CI)Specificity (95% CI)PPV (95% CI)NPV (95% CI)ROC area (95% CI)Average platelets <100,000/μL on POD 30.46 (0.29-0.66)0.77 (0.70-0.84)0.30 (0.18-0.46)0.87 (0.80-0.92)0.61 (0.51-0.72.)Average platelets <100,000/μL on POD 40.42 (0.26-0.63)0.89 (0.83-0.94)0.45 (0.29-0.67)0.88 (0.82-0.93)0.66 (0.55-0.76)Average platelets <100,000/μL on POD 3 or 40.50 (0.33-0.70)0.76 (0.68-0.83)0.31 (0.19-0.47)0.87 (0.80-0.93)0.62 (0.52-0.73)95% CI, 95% Confidence interval; NPV, negative predictive value; PPV, positive predictive value; ROC, receiver operating characteristic. Open table in a new tab

Target Vessel Catheterization With Fiber Optic Realshape Using Upper Extremity vs Transfemoral Access for Fenestrated-Branched Endovascular Aortic Aneurysm Repair

The Fiber Optic RealShape (FORS) technology uses pulses of light delivered through specially designed guidewire and catheters that allow the operator to navigate through the vasculature without radiation. Traditionally, and because of length constraints, FORS has been used primarily for transfemoral (TF) access. The purpose of this study is to report the feasibility and benefits of using FORS during fenestrated-branched endovascular aortic aneurysm repair (FBEVAR), including cannulation times of target vessels (TV) and radiation measures comparing upper extremity (UE) (Figure) vs TF access. A single-center retrospective study with prospectively collected data was performed. Patients undergoing FBEVAR with FORS guidance for TV catheterization were included. Custom-made devices, off-the-shelf (TAMBE, tBranch), Zfen, and physician-modified endografts were used. Navigation data was reported per task, including duration, dose area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) required to accomplish each catheterization. The primary end point included technical success, defined as the navigation accomplishment with no need to switch from FORS to conventional fluoroscopy, and overall radiation exposure. During an 11-month period, 74 patients (70.3% male) underwent FBEVAR with FORS, including 50 custom-made devices, 15 physician-modified endografts, 7 tBranch, 1 TAMBE, and 1 Zfen. Among 370 navigation tasks reported, 350 (94.6%) were performed with FORS, including catheterizations for 225 (64.3%) fenestrations, 61 (17.4%) branches, 50 (14.3%) contralateral gates, and 14 (4%) vessels for preemptive embolization or prestenting. Technical success was 90.3%. Mean time required to deem the catheterization as failure was 8.4 ± 5 minutes. FORS guidewires were used for all procedures. UE access, steerable sheath, and FORS catheters were used in 54.3%, 17.7%, and 13.7%, respectively. The median task duration, RAK, DAP, and FT required for TV cannulation were 5 minutes (interquartile range [IQR], 3-7 minutes), 9.4 mGy (IQR, 4.3-23.7 mGy), 1.0 GyCm2 (IQR, 0.4-2.5 GyCm2), and 1.5 minutes (IQR, 0.8-3.2 minutes), respectively. Among 186 UE TV cannulations and 168 TF TV cannulations, the mean RAK was significantly higher for UE access (25.6 mGy vs 12.5 mGy; P < .00). There were no significant differences in DAP, FT, and TV technical success between UE vs TF access. Overall radiation levels are included in the Table. FBEVAR with FORS technology is feasible using both UE and TF access and facilitates target artery catheterization with acceptable technical success and potentially reduced radiation. Further experience is required to optimize the use of FORS during FBEVARTableFiber-Optic RealShape (FORS) procedural data during fenestrated-branched endovascular aortic aneurysm repair (FBEVAR)VariablesProcedures with FORS technology (n = 74)Cannulation technical success316 (90.3)Procedure duration, minutes313 [246.8-380.8]Total DAP, Gycm2179.5 [116.3-232.5]Total RAK, mGy1327.5 [840.4-1872.3]Fluoroscopy time, minutes71.3 [57.5-92.1]Operator radiation, μSv93 [43-178]Fellow radiation, μSv36.5 [17.3-64.8]Circulator nurse radiation, μSv2 [0-4]Scrub tech radiation, μSv4 [1-9]Anesthesia radiation, μSv5 [2-18]Cannulation time, minutes5 [3-7]Cannulations UE183 (57)Cannulations TF168 (47)Cannulations measuresUETFP valueTotal DAP, Gycm21.0 (0.4-2.10)1.5 (0.5-1.5)NSTotal RAK, mGy8.8 (4.7-20.9)10.5 (4-33.5)<.001Fluoroscopy time, minutes1.6 (0.9-3.2)1.5(0.7-1.5)NSCannulation time, minutes5 (3-7)4 (3-8)NSDAP, Dose area product; N, not significant; RAK, reference air kerma; TF, transfemoral; UE, upper extremity.Values are median [interquartile range] or number (%). Open table in a new tab

Impact of Using Endografts From Multiple Manufacturers on the Mid-term Outcomes of Physician-Modified Fenestrated-Branched Endovascular Aneurysm Repair

Complex endovascular aortic repairs can involve interactions of multiple aortic endografts from different device manufacturers. This may be due to the repair of failed previous endografts, intentional staging of extensive thoracoabdominal aortic repairs, and different manufacturers offering distinct device features suitable for specific purposes. However, there are limited data evaluating the interactions between aortic components from different manufacturers and their impact on clinical outcomes. Thus, we evaluated the impact of mixing aortic endografts from multiple manufacturers by comparing the rate of type IIIA endoleaks and clinical outcomes after physician-modified fenestrated-branched endovascular aortic repairs (PM-FBEVAR) using endografts from a single vs multiple manufacturers. A single-institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and December 2022 was performed. Patients with a single aortic component were excluded. The remaining patients were divided into single- or multimanufacturer groups. Patient demographics, aneurysm extent, and operative details were compared. The primary outcome was type IIIA endoleak. The secondary outcomes included reintervention for type IIIA endoleak, major adverse events, and mortality. These outcomes were compared out to 2 years. Freedom from type IIIA endoleak-related reintervention was estimated using the Kaplan-Meier analysis and compared between the groups using a log-rank test. Data from this cohort include those reported to the Food and Drug Administration in the physician-sponsored investigational device exemption application, and those enrolled in the physician-sponsored investigational device exemption (FDA#: G200159, NCI#:APP-20-04282). Of 232 patients included in this study, 44 patients received a single-manufacturer and 188 patients received multimanufacturer aortic components. Baseline demographics and aneurysm extent were similar between the groups. The majority of concomitant iliac aneurysms repaired with Iliac Branch Endoprosthesis were in the multimanufacturer group (24 of 25). Procedure time, contrast usage, fluoroscopy time, estimated blood loss, and transfusion were significantly lower for the multimanufacturer group (Table). The overall 30-day mortality (2.3% single vs 3.2% multimanufacturer, P = .99) and major adverse events (20.5% vs 20.2%, P = .97) were similar between the groups. At 2-year follow-up, type IIIA endoleak occurred in 3 (6.8%) in the single- and 4 patients (2.1%) in the multimanufacturer groups (P = .128). These endoleaks were repaired in 2 of 3 and 4 of 4 patients in each group (P = .319) (Fig). Two-year mortality was similar between the groups (15.9% vs 13.3%, P = .651). Aortic endografts from multiple manufacturers can be used to facilitate PM-FBEVAR without a significant increase in type IIIA endoleaks, major adverse events, and reinterventions at 2 years. Continued follow-up is planned to assess long-term durability.TableCharacteristics, operative metrics, and outcomes of single vs multimanufacturerTotalSingle manufacturerMultimanufacturerP value23244188Aneurysm characteristics, No. (%) Presentation.113Asymptomatic167 (72.3)27 (61.4)140 (74.9)Symptomatic59 (25.5)15 (34.1)44 (23.5)Ruptured5 (2.2)2 (4.5)3 (1.6) Anatomical classification.160Juxtarenal19 (8.2)3 (6.8)16 (8.5)Pararenal/paravisceral76 (32.8)9 (20.5)67 (35.6)Pseudoaneurysm2 (0.9)0 (0)2 (1.1)TAAA135 (58.2)32 (72.7)103 (54.8)TAAA extent.463Extent I20 (14.8)4 (12.5)16 (15.5)Extent II54 (40.0)11 (34.4)43 (41.7)Extent III23 (17.0)6 (18.8)17 (16.5)Extent IV35 (25.9)9 (28.1)26 (25.2)Extent V3 (2.2)2 (6.3)1 (1.0) Iliac aneurysms requiring IBE25 (10.8)1 (2.3)24 (12.8).055 Aneurysm max diameter68.2 (16.7)66.5 (12.0)68.6 (17.6).336Intraoperative metrics Procedure time, minutes287.9 ± 108.7329.1 ± 115.6278.3 ±105.0.005 Iodinated contrast, cc121.6 ± 58.3154.6 ± 72.9113.9 ± 51.5<.001 Fluoroscopy time, minutes63.9 ± 33.579.5 ± 34.660.3 ± 32.3<.001 Estimated blood loss, cc [median, IQR]150 [262.5]400 [487.5]100 [250]<.00130-day outcomes, No. (%) Mortality7 (3.0)1 (2.3)6 (3.2)1.000 Major adverse events47 (20.3)9 (20.5)38 (20.2).9712-year outcomes, No. (%) All-cause mortality32 (13.8)7 (15.9)25 (13.3).651 Type IIIA endoleak7 (3.0)3 (6.8)4 (2.1).128IBE, Iliac Branch Endoprosthesis; IQR, interquartile range; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab

European Multicentric Experience With Fenestrated Branched Endovascular Stent Grafting After Previous Failed Infrarenal Aortic Repair

Objective: To report the midterm outcomes of fenestrated branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR).

The Semicompliant Balloon Bounce Technique for Total Femoral Approach during Fenestrated-Branched Endovascular Aortic Aneurysm Repair

The Semicompliant Balloon Bounce Technique for Total Femoral Approach during Fenestrated-Branched Endovascular Aortic Aneurysm Repair

Techniques of antegrade in situ laser fenestration for endovascular aortic repair of complex abdominal and thoracoabdominal aortic aneurysms.

Antegrade in situ laser fenestration allows for incorporation of visceral and renal arteries during endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms. This technique can be particularly useful for urgent and emergent cases and for centers without access to manufactured fenestrated-branched endovascular aneurysm repair devices. In the present report, we have described two techniques of antegrade in situ fenestration, the common pitfalls, and the anatomic considerations for each technique.

The Financial Burden Associated with Endovascular Repair of Thoracoabdominal and Pararenal Aortic Aneurysms Utilizing Physician-Modified Fenestrated-Branched Endografts

Endovascular thoracoabdominal and pararenal aortic aneurysm repair require more devices than infrarenal endografting and are reimbursed by different Current Procedural Terminology/diagnosis-related codes. The objective of this study was to determine the finances of fenestrated-branched endovascular aneurysm repair (FB-EVAR) physician-modified endograft (PMEG) repairs.

European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair: The EU-FBENDO-FAIL Registry.

To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR). Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5mm. Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes. There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4-12) years, 5 (3-8) for pEVAR, and 10 (6-14) for pOAR, P <0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P =0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P =0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P =0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P =0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%). Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.

Preoperative Predictors of Nonhome Discharge After Fenestrated-Branched Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms

Nonhome discharge (NHD) to skilled nursing facilities or rehabilitation units has significant implications for patient counseling and discharge planning and is frequently required following fenestrated-branched endovascular aneurysm repair (FB-EVAR) of complex abdominal (CAAA) and thoracoabdominal aortic aneurysms (TAAA). We aimed to identify preoperative predictors of NHD after elective FB-EVAR for CAAA and TAAA. A retrospective review of prospectively collected data on all patients undergoing FB-EVAR between January 2010 and December 2020 at a single institution was performed. Patients undergoing elective repair who were residing at home at the time of index operation were included. Univariate and multivariate analysis was performed to identify factors associated with NHD. From the initial cohort of 612 patient having FB-EVAR during the study period, 575 (74% male; mean age, 74.6 ± 7.8 YEARS) patients had elective surgery, including 403 for CAAA (70%) and 172 for TAAA (30%). Early mortality occurred in seven patients (four in CAAA three 3 in TAAA) and mean total length of hospital stay was 7.1 days (5.9 for CAAA and 10.0 for TAAA). There were 482 patients (84%) who were discharged home and 93 (16%) had NHD. NHD was associated with increasing age (mean age 77 years in NHD group vs 74 years), female gender (27% of females vs 12% of males), a history of congestive heart failure (CHF; 28% vs 15%) or peripheral arterial disease (23% vs 14%), and extent I, II, and III TAAA (27%, 24%, and 25%, respectively; all P = .004). Body mass index, race, prior stroke, device type, and number of target vessels were not associated with NHD. On multivariate analysis, older age (odds ratio [OR], 1.08 per year), female gender (OR, 2.51), CHF (OR, 2.59), and extent I (OR, 3.27), II (OR, 3.77), and III (OR, 3.13) TAAAs were associated with NHD (Figure). Older female patients with CHF and more extensive aneurysms are at higher risk of NHD following FB-EVAR. Following further internal validation, these data will be used to develop a predictive calculator of NHD, therefore allowing preoperative counselling of these patients and initiation of referrals with appropriate facilities that may expedite postoperative discharge.

Fabric Tears and Type IIIb Endoleaks After Fenestrated-Branched Endovascular Aortic Aneurysm Repair

Type IIIb endoleaks from fabric tears after fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR) are rare. The aim of this study was to evaluate patients who had undergone F-BEVAR with investigational devices between 2015 and 2021 in our institution. A total of 268 patients who had undergone F-BEVAR between 2015 and 2021 were analyzed. All patients with type IIIb endoleaks were included in the data collection. The end points were presentation of type IIIb endoleaks and secondary interventions. Three patients had developed type IIIb endoleaks (2 women and 1 man; mean age, 75 years). The first patient was a 74-year-old woman who had undergone F-BEVAR for a thoracoabdominal aortic aneurysm with a device with two branches and two fenestrations. The 4-year postoperative computed tomography angiography (CTA) demonstrated an endoleak behind the branches, which was confirmed to be a fabric tear using dynamic volumetric CTA (Fig 1, A). The patient underwent successful redo F-BEVAR. The second patient was a 74-year-old woman who had undergone branched repair with a device with four branches and an inverted limb bifurcated device after failed endovascular repair. On the 30-day follow-up CTA, an endoleak of indeterminate origin was detected. Further imaging studies, including CTA, dynamic volumetric CTA, and diagnostic angiography confirmed a tear in the graft posterior to a renal branch (Fig 1, B). A redo branched repair was successfully performed. The last patient was a 78-year-old man who had undergone four-vessel F-BEVAR with an inverted limb custom-made device after failed endovascular repair. On the 30-day follow-up visit, a type IIIb endoleak around the crutch of the inverted limb device was identified by CTA, contrast-enhanced ultrasound, and color-Doppler ultrasound (Fig 2). The defect was excluded with an iliac limb extension. Technical success of the reinterventions was 100%, with no deaths. Sac growth before reintervention was identified in all three patients. The mean follow-up was 30 months. Endoleak development had occurred at an average of 17 months after the index operation. The overall frequency of type IIIb endoleaks in our series was 1.1%. Type IIIb endoleaks after F-BEVAR are rare. The management of these cases is technically challenging. Proper multimodality imaging and redo F-BEVAR are crucial for the proper diagnosis and treatment of this rare complication.Fig 2Endoleak around the crutch of inverted limb custom-made device.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

Purpose: The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). Materials and Methods: All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. Results: A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69–162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53–21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55–12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12–26.18). Conclusion: The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.

Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair

ObjectiveUpper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access. MethodsDuring an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. ResultsUE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74). ConclusionsRight UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

Endovascular repair of intercostal and visceral aortic patch aneurysms following open thoracoabdominal aortic aneurysm repair

PurposeReoperative open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs) is associated with high morbidity and mortality. The aim of this study was to analyze outcomes of fenestrated–branched endovascular aneurysm repair (F-BEVAR) for the treatment of intercostal or visceral aortic patch aneurysms after OSR of TAAAs. MethodsWe reviewed the clinical data and outcomes of consecutive patients treated at 8 academic centers by F-BEVAR for visceral and intercostal aortic patch aneurysms after OSR of TAAAs (2011-2019). All patients had involvement of at least one target vessel requiring incorporation by a fenestration or directional branch. End points were technical success, 30-day and/in-hospital mortality, major adverse events, patient survival, target vessel patency/instability, and freedom from reintervention. ResultsThere were 29 patients with a median age of 70 (interquartile range, 63-74) years. Seven patients (24%) had connective tissue disorders. Technical success was 100%. There were no 30-day/in-hospital mortalities. Major adverse events occurred in 5 patients (17%), including estimated blood loss >1 L in 3 patients (10%), acute kidney injury and respiratory failure in 2 patients (7%) each, and transient paraparesis in 1 patient (3%). Median follow-up was 14 (interquartile range, 7-37) months. At 2 years, primary and secondary patency, freedom from target artery instability, freedom from reintervention, and patient survival were 95%, 100%, 83%, 61%, and 96%, respectively. ConclusionsF-BEVAR could be considered as an alternative to reoperative OSR in patients with visceral or intercostal aortic patch aneurysms. This series showed no mortality and a low rate of major adverse events, but a significant need for reintervention.

Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium

ObjectiveFenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs. MethodsThe data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia). ResultsOf the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P < .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P < .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P < .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46). ConclusionsWomen undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.