Fenestrated Endovascular Aortic Aneurysm Repair Research Articles

Renal and Visceral Artery Configuration During the First Year of Follow-Up After Fenestrated Aortic Aneurysm Repair Using the Anaconda Stent-graft: A Prospective Longitudinal Multicenter Study With ECG-Gated CTA Scans.

The performance of fenestrated endovascular aortic aneurysm repair (FEVAR) may be compromised by complications related to the dynamic vascular environment. The aim of this study was to analyze the behavior of FEVAR bridging stent configurations during the cardiac cycle and during follow-up to improve our understanding on treatment durability. Twenty-one patients presenting with complex abdominal aortic aneurysms (AAAs; 9 juxtarenal/6 pararenal/3 paravisceral/1 thoracoabdominal aortic aneurysm type IV), treated with a fenestrated Anaconda (Terumo Aortic, Inchinnan, Scotland, UK) with Advanta V12 bridging stents (Getinge, Merrimack, NH, USA), were prospectively enrolled in a multicenter observational cohort study and underwent electrocardiogram (ECG)-gated computed tomographic angiography (CTA) preoperatively, at discharge, 7-week, and 12-month follow-ups. Fenestrated endovascular aortic aneurysm repair stability was assessed considering the following variables: branch angle as the angle between the aorta and the target artery, end-stent angle as the angle between the end of the bridging stent and the native artery downstream from it, curvature and tortuosity index (TI) to describe the bending of the target artery. Body-bridging stent stability was assessed considering bridging stent flare lengths, the distances between the proximal sealing stent-ring and fenestrations and the distance between the fenestration and first apposition in the target artery. Renal branch angles significantly increased after FEVAR toward a perpendicular position (right renal artery from median 60.9°, inter quartile range [IQR]=44.2-84.9° preoperatively to 94.4°, IQR=72.6-99.8°, p=0.001 at 12-month follow-up; left renal artery [LRA], from 63.7°, IQR=55.0-73.0° to 94.3°, IQR=68.2-105.6°, p<0.001), while visceral branch angles did not. The mean dynamic curvature only decreased for the LRA from preoperative (3.0, IQR=2.2-3.8 m-1) to 12-month follow-up (1.9, IQR=1.4-2.6 m-1, p=0.027). The remaining investigated variables did not seem to show any changes over time in this cohort. Fenestrated endovascular aortic aneurysm repair for complex AAAs using the Anaconda fenestrated stent-graft and balloon-expandable Advanta V12 bridging stents demonstrated stable configurations up to 12-month follow-up, except for increasing renal branch angles toward perpendicular orientation to the aorta, yet without apparent clinical consequences in this cohort. This study provides detailed information on the cardiac-pulsatility-induced (dynamic) and longitudinal geometry deformations of the target arteries and bridging stents after fenestrated endovascular aortic aneurysm repair (FEVAR) up to 12-month follow-up. The configuration demonstrated limited dynamic and longitudinal deformations in terms of branch angle, end-stent angle, curvature, and tortuosity index (TI), except for the increasing renal branch angles that go toward a perpendicular orientation to the aorta. Overall, the results suggest that the investigated FEVAR configurations are stable and durable, though careful consideration of increasing renal branch angles and significant geometry alterations is advised.

Abstract 14516: Combined Platelet Morphology and Clinicoradiological Features to Predict Type II Endoleaks Following Endovascular Abdominal Aortic Aneurysm Surgery

Introduction: Persistent endoleak and associated endotension following endovascular abdominal aortic aneurysm repair (EVAR) can compromise successful repair and lead to continued sac expansion and eventual life-threatening rupture event. Hypothesis: A risk-stratification algorithm of the inherent anatomical and systemic cellular characteristics of patients might predict the incidence of type II endoleaks on abdominal aortic aneurysm (AAA) patients undergoing EVAR or fenestrated endovascular aortic aneurysm repair (FEVAR) procedures. Methods: Single-center retrospective study includes 146 AAA patients undergoing primary elective EVAR and FEVAR procedures between September 2013 and July 2021. A review of institutional medical records was conducted for the analysis. Patients who or who did not developed a type II endoleaks were included in this study. Results: Mean platelet volume (MPV) was significantly increased in patients with type II endoleaks and was associated with lower endoleak-free survival. Receiver operating characteristic (ROC) curve analysis showed that MPV demonstrated satisfactory predictive performance in distinguishing patients who developed type II endoleaks, yielding an area under the curve (AUC) value of 0.64. A risk-stratification panel consisting of postoperative MPV, history of type II diabetes, and number of preoperative patent lumbar arteries achieved an AUC value of 0.72 and predicted endoleak-free survival rate with HR of 4.88. We built an easy-to-use nomogram for predicting the risk of postoperative type II endoleak and revealed that MPV had the highest scoring weight of any variable in our model. Conclusions: We refined the anatomical and systemic traits in the blood that identified MPV as a significant predictor for type II endoleaks, which might facilitate post-surgical monitoring using complete blood count (CBC) as a supplement to imaging practice.

Mid-term proximal sealing zone evaluation after fenestrated endovascular aortic aneurysm repair.

Fenestrated endovascular aortic aneurysm repair (FEVAR) is used in pararenal abdominal aortic aneurysms to achieve a durable proximal seal. This study investigated the mid-term course of the proximal fenestrated stent graft (FSG) sealing zone on the first and latest available post-FEVAR computed tomographic angiography (CTA) scan in a single-center series. In 61 elective FEVAR patients, the shortest length of circumferential apposition between the FSG and the aortic wall (shortest apposition length [SAL]) was retrospectively assessed on the first and last available postoperative CTA scans. Patient records were reviewed for FEVAR-related procedural details, complications, and reinterventions. The median (interquartile range) time between the FEVAR procedure and the first and last CTA scan was 35 (30-48) days and 2.6 (1.2-4.3) years, respectively. The median (interquartile range) SAL was 38 (29-48) mm, and 44 (34-59) mm on the first and last CTA scans, respectively. During follow-up, the SAL increased >5 mm in 32 patients (52%), and decreased >5 mm in six patients (10%). Reintervention was performed for a type 1a endoleak in one patient. Twelve other patients needed 17 reinterventions for other FEVAR-related complications. Good mid-term apposition of the FSG in the pararenal aorta was achieved post-FEVAR, and the occurrence of type 1a endoleaks was low. The number of reinterventions was substantial, however, but for reasons other than loss of proximal seal.

Editor's Choice – Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms

The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre. Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed. A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088). Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.

Technological Advances to Address the Challenging Abdominal Aortic Aneurysm Neck

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or “hostile” infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore &amp; Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results.

Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms.

The impact of stent-graft complexity on clinical outcome after fenestrated endovascular aortic aneurysm repair (FEVAR) has been conflicting in the literature. The objective of this study was to compare mid-term results of stent-grafts with renal fenestrations alone with more complex stent-grafts including mesenteric fenestrations. A single center retrospective study was conducted on 154 patients, who underwent FEVAR from 2006 to 2020 at our institution. There were 54 (35.1%) patients in the renal FEVAR group and 100 (64.9%) patients in the complex FEVAR group. Median follow-up of the total group was 25 months (IQR 7-45). There were no significant differences in technical success and perioperative mortality. Intraoperative complications (4% vs. 18%, P=0.001), operative time (145 min vs. 191 min, P=0.001), radiation dose (119372 mGy*cm2 vs. 159573 mGy*cm2, P=0.004) and fluoroscopy time (39 min vs. 54 min, P=0.007) were significantly lower in the renal FEVAR group. During follow-up target vessel instability, endoleaks and reinterventions were not significantly different between the two groups. In this single center retrospective study, renal FEVAR was a safe and effective treatment for patients with juxtarenal AAA demonstrating fewer intraoperative complications and similar mid-term outcomes as complex FEVAR. If the anatomy is compatible for renal FEVAR, it might be unnecessary to expose patients to potentially more complications by choosing a complex FEVAR strategy.

Geometrical Analysis on Flared Section of Stainless-Steel Bridging Stent Grafts for Fenestrated Endovascular Aneurysm Repair

Our study aims to identify new predictive factors of target vessel instability (TVI) by performing a geometrical analysis on stainless-steel bridging stent grafts (BSGs) employed in fenestrated endovascular aortic aneurysm repair (FEVAR), focusing on their flared portion.

Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases.

Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility. This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR. One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak. This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.

Anatomic characteristics associated with superior mesenteric artery stent graft placement during fenestrated para/suprarenal aneurysm repair

ObjectiveAccording to the instructions for use, fenestrated endovascular aortic aneurysm repair (FEVAR) with the Zenith fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) requires ≥4 mm of nonaneurysmal infrarenal neck length, and superior mesenteric artery (SMA) stenting is optional. In the present study, we evaluated the outcomes of FEVAR with SMA stent grafting relative to SMA scallops or unstented fenestrations and their anatomic differences. MethodsWe performed a single-institution retrospective analysis of patients who had undergone FEVAR with an SMA scallop or large fenestration with and without SMA stent grafting from June 2012 to May 2020 after institutional review board approval. ResultsOf the 203 aneurysms repaired with ZFENs, 127 were included in our analysis. Of these 127 aneurysms, 55 had stent grafted SMA fenestrations, 38 unstented SMA fenestrations, and 34 SMA scallops. Technical success was achieved in all patients. The operative times were longer (335.5 ± 16.4 minutes vs 265.0 ± 12.8 minutes vs 269.0 ± 12.7 minutes; P < .001) and the transfusion rates were higher (33% vs 8% vs 18%; P = .01) in the SMA stent graft group. However, the fluoroscopy time (65.4 ± 3.76 minutes vs 58.3 ± 3.94 minutes vs 51.4 ± 4.75 minutes; P = .05) and contrast volume (92.2 ± 5.17 mL vs 87.1 ± 6.73 mL vs 93.1 ± 5.89 mL; P = .84) were not significantly different. Anatomically, the patients who had undergone FEVAR with a ZFEN and SMA stent grafting had had shorter infrarenal neck (1.73 ± 1.18 mm vs 4.92 ± 1.16 mm vs 6.28 ± 1.42 mm; P = .03) and infra-SMA neck (10.3 ± 1.39 mm vs 23.9 ± 1.24 mm vs 26.8 ± 1.67 mm; P < .001) lengths. In the SMA stent graft group, one patient had developed small bowel necrosis after embolization of an intraoperatively perforated jejunal branch and two had developed colonic ischemia of unclear etiology with patent SMA stent grafts found on imaging. Endograft migration and SMA occlusion with bowel ischemia occurred in one patient in the SMA fenestration group. Overall mortality (24% vs 21% vs 18%; P = .82) and 30-day mortality (5% vs 3% vs 3%; P = .80) were comparable between the three groups. In addition, the incidence of type III endoleak (5% vs 3% vs 3%; P = .45) and the need for reintervention (20% vs 18% vs 12%; P = .60) were similar across all three groups. The mean follow-up duration was longer for the SMA scallop group, which can be attributed to 82% of these occurring in the first one half of the study period. ConclusionsDespite the added technical complexity, SMA stenting enabled FEVAR in patients with pararenal and suprarenal aneurysms with high rates of technical success and no increased risk of mortality, major adverse events, type III endoleaks, or reintervention.

Editor's Choice – Four Fenestration Endovascular Aortic Aneurysm Repair Without Stenting of the Coeliac Artery in Selected Cases

Editor's Choice – Four Fenestration Endovascular Aortic Aneurysm Repair Without Stenting of the Coeliac Artery in Selected Cases

Current role of physician-modified endovascular grafts for fenestrated endovascular aortic aneurysm repair

Fenestrated endovascular aortic aneurysm repair (FEVAR) is becoming the preferred treatment option for complex aortic aneurysms. In the United States, the limited access to fenestrated endografts delayed the adoption of FEVAR. Physician-modified endovascular grafts (PMEGs) were the answer to such limitations. In this issue of the Journal of Vascular Surgery, Hemingway et al1 review their initial experience with the use of modified Treo devices. They report acceptable 30-day outcomes and early technical and clinical success.

Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair

Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR). A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared. Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n=26) or F-EVAR (n=33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86mm (65-100) and 70mm (60-80), respectively (p=.008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p=.016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%). Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.

Three-dimensional printing-guided fenestrated endovascular aortic aneurysm repair using open source software and physician-modified devices

Fenestrated endovascular aneurysm repair is frequently used for juxtarenal and pararenal aortic aneurysms. In urgent cases, however, the use of premanufactured patient-specific devices is not an option. Physician-modified endografts may be used to treat these patients but require experience and a steep learning curve for accurate planning to position fenestrations and to perform the graft modifications. Despite experience, a margin of error in placing fenestrations always exists, and a mismatch possibility between the fenestration and vessel ostium can lead to increased cannulation time and stent complications, including target vessel loss. Aortic three-dimensional printing has been widely described in medicine for simulation, training, and surgical planning. Commercial software is currently under investigation for planning of fenestrated endovascular aneurysm repair at high costs. We describe an effective and inexpensive technique using free computer-aided design software to create a real 1:1 aortic 3D model that can easily be printed and quickly sterilized. This aortic model can be used to create a physician-modified endograft and to place fenestrations in an accurate way, with potential for shorter and more precise procedures and better long-term results. Two cases are presented to illustrate the technique, demonstrating that 3D printing is a valuable tool to plan, design, and create fenestrated devices more accurately.

A reliable method for renal volume measurement and its application in fenestrated endovascular aneurysm repair

ObjectiveRenal volume has been shown to correlate with renal function. Renal volume and renal function both decline steadily in the sixth decade of life and beyond. We sought to assess (1) the inter-rater reliability for manually measuring renal volume using computed tomography and (2) change in renal volume over time as it relates to renal function in fenestrated endovascular aortic aneurysm repair (FEVAR). MethodsThis study was conducted as part of a physician-sponsored investigational new device (#NCT01538056). First, 30 consecutive kidneys of preoperative FEVAR patients were independently measured by two raters using manual segmentation and three-dimensional modeling software. Renal volumes were calculated and compared. Intraclass correlation was calculated between the two observers. Second, renal volumes were then recorded for 85 patients undergoing FEVAR with follow-up out to 5 years. Demographic data, comorbidities, creatinine, glomerular filtration rate (GFR), renal artery stenosis or occlusion, and bilateral renal volume measurements were analyzed. Multivariate analysis was performed to delineate association of these variables with total renal volume (TRV). ResultsThe intraclass correlation coefficient for our renal volume measurements was 0.97 (95% confidence interval, 0.81-0.99), indicating excellent correlation. Renal volume was strongly correlated with GFR. Our multivariate analysis model predicts a 17.9 mL/min increase in GFR with each 20% increase in TRV. After adjustment for all other known correlates of renal function, renal volume remained as the only significant predictor of renal function. ConclusionsRenal volume can be measured with high reliability using manual segmentation and computed tomography scans. In our baseline analysis, TRV was strongly correlated with renal function. These findings support the potential for renal volume as a surrogate for renal function.

IF08. Fate of the Unstented Superior Mesenteric Artery in Fenestrated Endovascular Aortic Aneurysm Repair

The objective of this study was to evaluate the patency of the unstented superior mesenteric artery (SMA) after fenestrated EVAR (F-EVAR) using duplex ultrasound (DUS) and computed tomography angiography (CTA). Patients with SMA fenestrations or crossing struts were identified from a database of patients who underwent F-EVAR at our institution between 2011 and 2017 as part of an investigational device exemption clinical trial (NCT01538056). Mesenteric DUS and CTA data were obtained at baseline and at 30 days, 6 months, and annually out to 5 years. The DUS parameter of SMA peak systolic velocity (PSV) of 275 cm/s was used to detect 70% SMA stenosis. CTA was used to evaluate the patency of the SMA when DUS PSV was elevated or if DUS was not performed. There were 107 patients who underwent endograft placement involving the SMA in association with F-EVAR. There were 87 SMA fenestrations and 20 bare-metal struts crossing the SMA; 79 patients had baseline and at least 30-day follow-up DUS SMA PSV measurements (64 fenestrations, 15 struts). Mean follow-up was 18.6 months (range, 30 days-5 years). SMA PSVs are listed in the Table. Mean PSVs remained well below the threshold velocity of 275 cm/s for native atherosclerotic 70% SMA stenosis. Nine patients had at least one SMA PSV >275 cm/s during follow-up. All were observed and showed no subsequent clinical sequelae. All patients had at least 30-day follow-up with CTA, and all had widely patent SMAs at last follow-up. Mean total seal zone length was 41.4 mm. There was a single secondary intervention for asymptomatic SMA stenosis requiring stent placement 1 year after F-EVAR. There were no Type IA endoleaks and no endoleaks related to SMA fenestrations. Five patients of the entire cohort (4.7%) required SMA stenting at the index procedure. Three of these patients had prior EVAR (n =2) or open repair (n = 1), One patient had a pre-existing critical SMA stenosis and underwent planned SMA stenting, and in one patient, the graft was deployed imprecisely and low, and the SMA was successfully stented from a brachial approach. The unstented SMA in association with F-EVAR remains widely patent in the presence of fenestrations or struts and is not associated with endoleaks. The need for adjunctive SMA stenting may be related to prior aortic intervention and case complexity. Follow-up DUS and CTA surveillance confirms that SMA patency remains in the normal or <70% stenosis range after F-EVAR regardless of whether it is encompassed by a large fenestration or crossing struts.TableSuperior mesenteric artery (SMA) peak systolic velocity (PSV)Fenestrations (n = 64)Struts (n = 15)Overall mean PSV (N = 79)Baseline128 ± 57153 ± 41133 ± 5530 Days115 ± 56155 ± 63123± 596 Months121 ± 80128 ± 82122 ± 801 Year131 ± 7799 ± 55124 ± 732 Years138 ± 89124 ± 58134 ± 813 Years145 ± 11399 ± 63129 ± 1004 Years134 ± 112120 ± 61129 ± 965 Years96 ± 61191 ±147122 ± 90Values are reported as mean ± standard deviation. Open table in a new tab

Durability of fenestrated endovascular aortic repair for juxta-renal abdominal aortic aneurysm repair.

The aim of this study was to evaluate the long term durability of fenestrated endovascular aortic aneurysm repair (F-EVAR) of juxta-renal aortic aneurysms (JAAAs) in terms of mortality, target visceral vessel (TVV) patency and Reintervention rates. A systematic review and meta-analysis was performed. MEDLINE, CENTRAL, and Cochrane databases were searched with PRISMA methodology for studies reporting on F-EVAR of JAAA presenting follow-up >36 months. Articles with <15 patients, follow-up <36 months, comparison of F-EVAR with other treatment modalities were excluded. Seven non-randomized retrospective studies of prospectively collected data were analysed including 772 patients (mean age and diameter ranging from 71.5 to 74 years and from 60 to 65mm, respectively) underwent F-EVAR for JAAA during 2001-2015. The pooled mortality rates during 12, 24, 36, 48 and 60 months were 0.080 (0.060-0.106), 0.129 (0.097-0.169), 0.211 (0.158-0.277), 0.279 (0.193-0.386) and 0.405 (0.303-0.517), respectively. The pooled Reintervention rates during 12, 24, 36 and 48 months were 0.097 (0.066-0.140), 0.131 (0.082-0.203), 0.281 (0.182-0.406) and 0.244 (0.103-0.477), respectively. The pooled loss of TVV patency rates during 12, 24, 36, 48 and 60 months were 0.046 (0.035-0.060), 0.081 (0.058-0.110), 0.088 (0.060-0.127), 0.123 (0.067-0.214) and 0.132 (0.081-0.207). F-EVAR for the treatment of patients with JAAA is a durable procedure with good long term outcomes in terms of mortality and visceral vessels patency. During long term period the need for a Reintervention continues to exists, thus follow-up of those cases may be important for preserving the good results.

Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels

ObjectiveAlthough few studies have reported outcomes after branched or fenestrated endovascular aortic aneurysm repair (FEVAR) of abdominal aortic aneurysms involving visceral vessels (AAA-Vs), no multi-institutional study has compared FEVAR with open surgery (OS) for AAA-Vs. Our objective was to compare 30-day outcomes after FEVAR vs OS for AAA-Vs. MethodsPatients who underwent FEVAR (n = 535) and OS (n = 1207) for elective AAA-Vs were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2008 to 2013 database. Thoracoabdominal aneurysms were excluded. Univariable and multivariable logistic regression analyses were performed. ResultsThere were more men (82% vs 72%; P < .0001), diabetic patients (16% vs 11%; P = .005), patients with dependent functional status (4% vs 2%; P = .002), and nonsmokers (70% vs 56%; P < .0001) in the FEVAR group vs OS. There was no difference in rates of chronic obstructive pulmonary disease, cardiac history, peripheral artery disease, hypertension, and dialysis (P > .05). FEVAR had fewer major postoperative pulmonary complications (3.0% vs 19.0%; P < .0001), less renal failure requiring dialysis (1.9% vs 6.4%; P < .0001), less frequent cardiac arrest or myocardial infarction (2.2% vs 5.8%; P = .001), less bleeding with major transfusion (17.4% vs 50.2%; P < .0001), and decreased incidence of return to the operating room (4.5% vs 9.6%; P < .0001) and death (2.4% vs 4.7%; P = .02). The median length of stay was also significantly shorter for FEVAR (2 days vs 7 days; P < .0001). On multivariable analyses, OS was associated with higher risk than FEVAR for 30-day death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.0), pulmonary complications (OR, 8.8; 95% CI, 5.1-15.0), cardiac complications (OR, 3.4; 95% CI, 1.8-6.6), renal failure needing dialysis (OR, 3.8; 95% CI, 1.9-7.7), and return to the operating room (OR 2.5; 95% CI, 1.6-4.0). ConclusionsFEVAR is associated with a lower risk for 30-day mortality and adverse events compared with OS for AAA-Vs.

Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair.

The purpose of this study is to determine the incidence and clinical significance of renal infarcts after fenestrated endovascular aortic aneurysm repair (FEVAR). All patients who underwent FEVAR with unenhanced and contrast-enhanced CT angiography during a 4-year period were retrospectively reviewed. Two staff radiologists reviewed pre- and post-FEVAR CT examinations for the presence of renal infarcts. Pre- and postoperative serum creatinine levels were examined to determine statistical significance. The incidence of renal infarct and percentage of renal volume reduction were calculated. Ninety patients were included for analysis. All patients had a mild progressive increase in serum creatinine level after FEVAR. Twenty-three patients (26%) had a renal infarct identified on post-FEVAR CT, nine (39%) of which were secondary to intentional exclusion of an accessory renal artery and 14 (61%) of which were presumed to be embolic. Two patients with presumed embolic infarcts and three with exclusion of an accessory renal artery had an increase in serum creatinine level of greater than 0.3 mg/dL at 1 month after FEVAR. Although renal infarcts are common after FEVAR, the clinical relevance of these events appears to be limited, with less than one-quarter of patients with renal infarcts experiencing a decline in renal function.

Fenestrated Aortic Endografts in the Last 3 Years: An Update

Fenestrated endovascular aortic aneurysm repair (FEVAR) is an accepted treatment option for patients who are not suitable for conventional endovascular aortic aneurysm repair or open surgical repair (OSR). Five years ago, the FDA approved the use of FEVAR in patients with inadequate infrarenal aortic seal zones (short necks). This procedural paradigm continues to gain in popularity compared to OSR for complex aortic disease. We seek to define the current state of fenestrated endovascular repair by reviewing relevant literature over the past 3 years. FEVAR continues to prove to be efficacious with reasonable durability as a therapy for patients who are not candidates for OSR. As a second-line treatment, FEVAR is less morbid in the short-term with trade-off of high reintervention rates in the follow-up period. Mid- to long-term outcomes have proven to be comparable to OSR in selected patients with persistent excellent patency of the visceral target vessels. Recent publications have thrust FEVAR into consideration as the primary interventional modality in juxtarenal abdominal aortic aneurysms, a traditional indication for OSR. As FEVAR continues to evolve from surgeon-modified devices to custom built and eventually off-the-shelf grafts, it is anticipated to be employed widely for managing complex aortic aneurysms. Compared to OSR, FEVAR carries a low risk of perioperative morbidity while demonstrating continued safety and durability in early to mid-term reports.

Transbrachial branch cannulation during Zenith fenestrated endovascular aortic aneurysm repair using a robotically guided body-floss technique

Caudal angulation and stenosis of the renal arteries pose significant challenges in branch cannulation during the standard fenestrated endovascular aortic aneurysm repair (FEVAR). We describe an alternative technique of branch cannulation during FEVAR in a patient with a 6.5-cm juxtarenal abdominal aortic aneurysm, renal artery stenosis, and bilateral caudally oriented renal arteries. A brachiofemoral or access was established by traversing the top scallop. The brachial sheath was deflected toward the target fenestration using a steerable robotic femoral sheath, enabling transbrachial cannulation of the downgoing target renal artery. Postoperatively, the patient was discharged without complications. Steerable sheath-guided body-floss technique may facilitate cannulation of severely downgoing branch vessels during FEVAR.