Fenestrated-branched Endovascular Aneurysm Repair Research Articles

Effects of Chronic Obstructive Pulmonary Disease on the Outcomes of Fenestrated-Branched Endovascular Aortic Aneurysm Repair.

Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. 387 patients (71% male, age 72 years, interquartile range [68-79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P = .022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P = .83) and MAE rates (P = .87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P = .13) and were more frequently discharged on oxygen (P = .002). There were no differences in intensive care unit or hospital length of stay between groups (P = .29; P = .85, respectively). 5-year survival was similar between groups (P = .10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P = .048). FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level 3, non-randomized controlled cohort/follow-up study.

Impact of class of obesity on clinical outcomes following fenestrated-branched endovascular aneurysm repair

BackgroundObesity represents a prevalent and escalating health concern among vascular surgery patients. Evidence pertaining to the influence of body mass index (BMI) on clinical outcomes after fenestrated-branched endovascular aneurysm repair (B/FEVAR) remains unclear. This study aims to assess the effect of obesity on short- and midterm clinical outcomes among individuals undergoing B/FEVAR. MethodsThis was a single-center retrospective analysis of all patients who underwent B/FEVAR from 2007 to 2020, with a median follow-up of 3.3 years (interquartile range, 1.6-5.3 years). Obesity was defined as a BMI of ≥30 kg/m2. Patients were divided into nonobese (NO) and obese cohorts according to their BMI. Outcomes were compared between the two groups subsequently. ResultsA total of 264 patients, 96 obese and 168 NO, were included. Patients with obesity were younger (72.8 ± 6.9 years vs 76.0 ± 7.3 years; P < .001), but had a higher prevalence of diabetes mellitus (27.1% vs 12.0%; P = .01) and dyslipidemia (80.2% vs 68.5%; P = .03). Both cohorts had similar rates of percutaneous access (37.5% for obese vs 35.1%; P = .7), and no significant differences in the rate of conversion to open access (8.3% for obese vs 4.2% for NO; P = .16). Technical success was similar between the cohorts (89% for obese vs 86%; P = .59). Major adverse events (MAEs) were higher in the NO group (13.1% vs 4.2%; P = .02). Patients in the obese cohort suffered more access site related infections (7.3% vs 1.2%; P = .01). All-cause mortality over 5 years was significantly higher in the NO group (35.1% vs 21.9%; P = .02). No statistical differences were found in spinal cord injury or dialysis requirement rates. Furthermore, on follow-up at 5 years, endoleak, branch instability, and reintervention rates were not statistically different between the two cohorts. ConclusionsPatients with obesity are on average younger; however, they were more likely to suffer access site infections compared with NO patients. They had increased survival rates on follow-up, although rates of reinterventions and endoleaks were similar between the two cohorts. Our study demonstrates that, despite higher comorbidities, patients with obesity had similar intraoperative success with decreased postoperative mortality; however, access site infections remains a significant clinical concern.

Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair

ObjectivesAneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. MethodsFBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. ResultsAmong 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. ConclusionsAneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.

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

The clinical significance of family history (FH) of aortic disease on the outcomes of fenestrated/branched endovascular aneurysm repair (FB-EVAR) has not been well described. This study aimed to assess how FH of aortic disease affects outcomes following FB-EVAR for complex aortic aneurysms (CAAs). This study retrospectively reviewed the clinical data of consecutive patients enrolled in 10 ongoing, prospective, non-randomised, physician sponsored, investigational device exemption studies to evaluate FB-EVAR (2005 - 2022) in the United States Aortic Research Consortium database. Patients were stratified by presence or absence of FH of any aortic disease in any relative. Patients with confirmed genetically triggered aortic diseases were excluded. Primary outcomes were 30 day major adverse events (MAEs) and late survival. Secondary outcomes included late secondary interventions and aneurysm sac enlargement. During the study period, 2 901 patients underwent FB-EVAR. A total of 2 355 patients (81.2%) were included in the final analysis: 427 (18.1%) with and 1 928 (81.9%) without FH of aortic disease. Patient demographics, clinical characteristics, and aneurysm extent were similar between the groups. Patients with FH of aortic disease more frequently had prior open abdominal aortic repair, but less frequently had prior endovascular aneurysm repair (p < .050). There were no statistically significant differences in 30 day mortality (4% vs. 2%; p = .12) and MAEs for patients with or without FH of aortic disease (12% vs. 12%; p = .89). Three year survival estimates were 71% (95% confidence interval [CI] 0.67 - 0.78%) and 71% (95% CI 0.68 - 0.74%), respectively (p = .74). Freedom from secondary intervention and aneurysm sac enlargement were also not statistically significantly different between groups. A family history of aortic disease had no impact on 30 day and midterm outcomes of FB-EVAR of CAAs. In the absence of an identified genetically triggered aortic disease, treatment selection for CAAs should be based on clinical risk and patient anatomy rather than FH of aortic disease.

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.

Spinal Cord Protection During Thoracic and Thoracoabdominal Endovascular Aortic Repair: 5-Year Results of a Preventive Protocol Including Prophylactic Cerebrospinal Fluid Drainage in High-Risk Patients

Purpose: Spinal cord injury (SCI) is a devastating complication of thoracoabdominal aortic (TAA) repair. The use of prophylactic cerebrospinal fluid drainage (CSFD) as part of a protective protocol during endovascular repair is controversial. This article reports the results of the prophylactic use of CSFD as part of the of a prevention protocol implemented in 2016. Methods: Retrospective review of spinal cord outcomes (SCI rate and CSFD-related complications) in patients treated endovascularly for TAA disease at a single institution from 2016 (implementation of an institutional SCI risk reduction protocol) to 2021. Patients were classified as high risk (≥2 factors), intermediate risk (1 factor), or low risk (0 factor). Only high-risk patients without contraindications underwent a prophylactic CSFD placement. Results: One hundred eighty-one patients were analyzed (124 males; 69.6 years): 130 (69%) aneurysms (n=24 thoracic, n=28 Crawford 1–2–3, and n=78 Crawford 4/pararenal), 35 (19.9%) chronic aneurysmal dissections, and 16 (8.8%) acute complicated type B dissections. Interventions were staged in 31 (17.2%) cases, and consisted of 74 (41%) Thoracic EndoVascular Aneurysm Repair (TEVAR) and 107 (59%) Fenestrated Branched EndoVascular Aneurysm Repair (F-BEVAR). Sixty-nine (38.1%) patients were identified as being at high risk of SCI and CSFD was used prophylactically in 64 of them (4 failures and 1 contraindication). Spinal cord injury occurred in 8 cases (4 paraparesis, 4 paraplegias including 2 permanent), of which 3 had a prophylactic CSFD and 5 underwent rescue drainage. In addition, 4 patients developed SCI related to prophylactic CSFD (intradural hematoma), resulting in 1 paraparesis and 3 paraplegias. Other CSFD-related complications were mild (6) or moderate (2), for a total of 12 complications (17%). Factors associated with major drain complications were: curative anticoagulation 36 hours after drain removal (n=1), multiple punctures (n=1), platelet count &lt;100 000 at drain removal (n=1), and bipolar disorder (n=2). Overall, 4 patients had permanent paraplegia and 1 had sphincter dysfunction at the last follow-up. Mean follow-up was 17 months. Mortality was 4.4% at 30 days and 13.3% at 18 months, including 3 (1.6%) aortic-related deaths. Conclusions: With the protocol we used to protect the spinal cord, we report results comparable with the SCI literature and highlight the risks associated with prophylactic CSFD use, which requires a better understanding of contraindications.

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.