Juxtarenal Abdominal Aortic Aneurysm Research Articles

Outcomes of elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms in Sweden.

A juxtarenal abdominal aortic aneurysm is defined as a short (less than 4 mm) or no-neck aneurysm, which is often treated with open or complex endovascular repair. The evidence to support the best treatment strategy is scarce. The aim of this study was to assess the short- and mid-term outcomes of elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms in Sweden. Patients who underwent elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms between 2018 and 2021 were identified in the Swedish Vascular Registry. Demographics, practice patterns, and operative details were assessed. The primary outcome was 30-day mortality. Secondary outcomes included perioperative complications and mid-term survival. Among 3777 aortic aneurysm repairs performed, 418 involved juxtarenal abdominal aortic aneurysms (open surgical repair 228 (54.5%), fenestrated endovascular aneurysm repair 176 (42.1%), chimney endovascular aneurysm repair 6 (1.4%), and branched endovascular aneurysm repair 8 (1.9%)). Some 25 centres performed juxtarenal abdominal aortic aneurysm repairs with open surgical repair and fenestrated endovascular aneurysm repair. The caseload varied from 2 to 54 repairs per centre. The mean aneurysm diameter was 61 mm. Endovascularly treated patients were older and had more pulmonary co-morbidities. The 30-day mortality rate was 2.2% (open surgical repair 2.6% and fenestrated endovascular aneurysm repair 1.7%; P = 0.397). Perioperative major complications occurred in 14.1% of patients (open surgical repair 19.3% and fenestrated endovascular aneurysm repair 7.4%; P < 0.001) and perioperative vascular complications occurred in 12.1% of patients (open surgical repair 8.8% and fenestrated endovascular aneurysm repair 11.9%; P = 0.190). The survival rate (estimated using Kaplan-Meier analysis) at 1 year and 3 years was 93.1% and 85.9% respectively for open surgical repair and 95.2% and 80.9% respectively for fenestrated endovascular aneurysm repair (P = 0.477). This nationwide study reveals considerable variations in volume and treatment strategy between Swedish centres performing juxtarenal abdominal aortic aneurysm repairs. Survival is comparable for open surgical repair and fenestrated endovascular aneurysm repair, although there are significant baseline demographic differences between patients selected for the two treatment modalities.

Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for the open repair of juxtarenal abdominal aortic aneurysm repair with shaggy aorta

Shaggy aorta is severe luminal surface degeneration of the aorta leading to an increased risk of plaque destabilization and embolization to the peripheral or visceral vessel beds. It represents a challenging clinical entity for both endovascular and open repair owing to potential atheroembolization, increased early morbidity and mortality, and poor long-term survival. Patients may be denied repair owing to its high risks. Herein, we present a novel approach to open repair of a juxtarenal abdominal aortic aneurysm with shaggy aorta using moderate hypothermic circulatory arrest with antegrade cerebral perfusion and concurrent flow modification to mitigate the risk of atheroma embolism.

Fenestrated and Branched Endovascular Aortic Aneurysm Repair for Treating Juxtarenal Aneurysms: An Update.

Fenestrated and branched endovascular aortic aneurysm repair (f-EVAR, b-EVAR, respectively) are technically challenging procedures that have evolved over the last decade for complex aortic aneurysms. They are alternatives to surgical repair for suprarenal and juxtarenal aortic aneurysms. A Pubmed database was reviewed by searching keywords related to f-EVAR, b-EVAR, and juxta renal abdominal aortic aneurysm (AAA) from the last five years to see current indications, contemporary techniques, and results of these techniques for juxtarenal aneurysms. Over the years, f-EVAR and b-EVAR have improved, with high technical success (>95%) and mortality rates of 1-5% for pararenal and 5-10% for thoracoabdominal aortic aneurysms. Key Words: Fenestrated-branched endovascular repair, Fenestrated EVAR, Branched EVAR, Juxtarenal aortic aneurysm.

Long-Term Results of Physician-Modified Endografts for the Treatment of Elective, Symptomatic, and Ruptured Juxtarenal Abdominal Aortic Aneurysms.

The objective of this study was to report long-term results of an ongoing physician-sponsored, investigational device exemption (IDE) pivotal clinical trial using physician-modified endovascular grafts (PMEGs) for the treatment of patients with juxtarenal aortic aneurysms. Data from a nonrandomized, prospective, consecutively enrolling IDE clinical trial were used. Data collection began on April 1, 2011, and data lock occurred on January 2, 2024, with outcomes analysis through December 31, 2023. Primary safety and effectiveness end points were used to measure treatment success. The safety end point was defined as the proportion of subjects who experienced a major adverse event within 30 days of the procedure. The effectiveness end point was the proportion of subjects who achieved treatment success. Treatment success required the following at 12 months: technical success, defined as successful delivery and deployment of a PMEG with preservation of intended branch vessels; and freedom from: type I and III endoleak, stent graft migration >10mm, aortic aneurysm sack enlargement >5mm, and aortic aneurysm rupture or open conversion. Over the 12-year study period, 228 patients were enrolled; 205 began the implant procedure, and 203 received PMEG. Thirteen patients withdrew prior to PMEG. Two withdrew (<1.0%) after failure to deploy due to tortuous iliac anatomy and are tracked as intent to treat, and a total of 24 withdrew after receiving the PMEG implant. Forty-four patients died during the study period. A total of 14 were deemed lost to follow-up. Fifty-nine completed the 5-year follow-up period, and 62 remain active in follow-up visits.Aneurysm anatomy, operative details, and lengths of stay were recorded and included: aneurysm diameter (mean, 67.5mm; range, 49-124mm), proximal seal zone length (mean, 41.6mm; range, 18.9-92.9mm), graft modification time (mean, 48.7min), procedure time (mean, 137.7min), fluoroscopy time (mean, 33.8min), contrast material use (mean, 93.0mL), estimated blood loss (mean, 118.8mL), length of hospital stay (mean, 3.7d), and intensive care unit length of stay (mean, 1.6d).A total of 575 fenestrations were created for 387 renal arteries, 181 superior mesenteric arteries (SMAs), and 7 celiac arteries. Renal arteries were in 96% of patients and included 410 renal artery stents in 203 patients. The SMA was stented as needed and included one patient with an SMA stent placed before the procedure, 19 during the procedure, and 2 patients who underwent stent placement after the procedure. There were no open conversions or device migrations and 1 partial explant due to late distal graft occlusion. Three ruptures (1.4%) were recorded on days 830, 1346, and 1460. There was 1 presumed graft infection at 750 days (<0.5%) treated with? Thirty-day all-cause mortality was 2.9% (6/204). One type Ia, 1 type Ib, and 7 type III endoleaks were identified during follow-up and treated with successful reintervention at the 1-year period. The overall rate of major adverse events at 30 days was 15% (29/194). Technical success was 93.7%, and overall treatment success was 82.6%. PMEG can be performed with low rates of long-term morbidity and mortality, confirming our early and midterm reports that endovascular repair with PMEG is safe, durable, and effective for managing patients with juxtarenal aortic aneurysms. While historically considered experimental, these results suggest that PMEG is a safe and durable option and should be considered for patients where off-the-shelf devices are not available.

Midterm Results of Physician-Modified Endograft in Juxtarenal Abdominal Aortic Aneurysm Using Three-Dimensional Model-Assisted Planning and Intraoperative Three-Dimensional Image Analysis

Midterm Results of Physician-Modified Endograft in Juxtarenal Abdominal Aortic Aneurysm Using Three-Dimensional Model-Assisted Planning and Intraoperative Three-Dimensional Image Analysis

Successful chimney endovascular aortic repair with reconstruction of three visceral branches for huge saccular juxtarenal abdominal aortic aneurysm after trans-thoracoabdominal esophagectomy

BackgroundConventional graft replacement for a juxtarenal abdominal aortic aneurysm (JRAAA) remains challenging for high-risk patients since it often requires the reconstruction of some visceral arteries.Case PresentationA 76-year-old woman was diagnosed with an 87 × 48 mm saccular JRAAA. Open graft replacement was contraindicated because of frailty and a past history of trans-thoracoabdominal esophagectomy. Chimney endovascular aortic repair (ChEVAR) with three chimney endografts was successfully performed without any endoleaks, and each visceral circulation was kept intact. The patient was discharged uneventfully on postoperative day 8. Significant shrinkage of the aneurysmal sac and preservation of flow through each chimney graft were observed on computed tomography 6 months postoperatively, with no significant increase in serum creatinine levels on laboratory testing.ConclusionsChEVAR can be a useful surgical option instead of conventional operations, especially for high-risk cases.

Outcomes of standard EVAR for juxtarenal abdominal aortic aneurysm in patients unsuitable for fenestrated EVAR and open repair.

To evaluate the long-term outcomes of standard endovascular aneurysm repair (S-EVAR) of juxtarenal abdominal aortic aneurysms (JAAAs). Data of patients with JAAAs who were unsuitable for fenestrated endovascular aneurysm repair (F-EVAR) and open repair (OR) and underwent treatment from January 2015 to December 2021 were retrospectively reviewed. Computed tomography angiography and ultrasonography of the aorta were performed before discharge, at 6 and 12months postoperatively, and annually thereafter. The main outcome measures were mortality, type Ia endoleaks, and reintervention. A total of 62 patients (mean age, 72.1 ± 7.3years) underwent S-EVAR. The mean aneurysm length and diameter and the proximal neck length and diameter were 110.4 ± 30.9mm, 57.2 ± 15.9mm, 8.09 ± 0.97mm, and 26.05 ± 0.49mm, respectively. The mean suprarenal and infrarenal aortic angles were 162.9 ± 26° and 144.1 ± 31°, respectively. The mean follow-up duration was 40.6 ± 23.4 months and the 5-year survival rate was 62.2%. Six (9.8%) patients experienced type Ia endoleaks, of whom three underwent endovascular repair at 12, 18, and 24months, one underwent conversion to OR for AAA rupture at 7days and died, two had minor endoleaks and were kept under observation, and one declined reintervention at 36months. The 5-year freedom from reintervention rate was 84.4%. The aneurysm diameter shrank in 50 cases (81%), remained stable in 5 cases (8%), and increased in 7 cases (11.3%). A suprarenal aortic angle <114° was associated with type Ia endoleak (p = .005). In patients unsuitable for F-EVAR and OR and with a suprarenal aortic angle >114°, the use of S-EVAR for JAAAs can be considered safe and effective. In this study, early and long-term postoperative outcomes demonstrated that S-EVAR achieved satisfactory results in the prevention of aneurysm rupture and associated mortality.

Emergent Repair of Ruptured Juxtarenal Abdominal Aortic Aneurysm With Antegrade In Situ Laser Fenestration is Feasible; How to Do It?

Emergent Repair of Ruptured Juxtarenal Abdominal Aortic Aneurysm With Antegrade In Situ Laser Fenestration is Feasible; How to Do It?

Endovascular Repair of Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using a Novel Low-Profile Fenestrated Custom-Made Endograft: Technical Details and Short-Term Outcomes.

The aim of this study is to share preliminary experiences and outcomes with a novel custom-made fenestrated TREO® Abdominal Stent-Graft System to treat juxtarenal and pararenal abdominal aortic aneurysms (AAAs). Juxtarenal and pararenal AAA patients treated with the custom-made fenestrated TREO® Abdominal Stent-Graft System were included from 4 high-volume European academic medical centers from June 2021 to September 2023. Technical success and 30-day/in-hospital mortality and complications were analyzed. Technical success was defined as successful endovascular implantation of the stent graft with preservation of antegrade flow to the target vessels, and absence of type 1 or 2 endoleak (EL) at the first postoperative computed tomography angiography (CTA). Forty-two consecutive patients were included. The majority of the devices were constructed with 2 (N=4; 9.5%), 3 (N=9; 21.4%), or 4 (N=27; 64%) fenestrations. In 1 case, the device was constructed with a single fenestration (2.4%) and 1 device contained 5 fenestrations (2.4%); 17% had previous AAA repair. Target vessel cannulation with placement of a bridging stent was successful in all but 1 vessel (99, 3%). One aneurysm-related death occurred in the direct postoperative period and 2 limb occlusions necessitated reintervention during admission. In the median follow-up period of 101 (2-620) days, 3 more patients died due to non-aneurysm-related causes. Technical success was achieved in 90% of the cases. Nineteen ELs were seen on the first postoperative CT scan: 1 type 1b EL (N=1; 2%), 15 type 2 ELs (N=15; 36%), and 3 type 3 ELs (N=3%). Eleven patients received more than 1 CT scan during a median follow-up of 361 days (82-620): 3 type 2 ELs resolved and 1 type 3 EL was treated in this period. In the follow-up, 1 patient had a coagulation disorder that caused occlusions of the branches. The results of the first experiences using the custom-made fenestrated TREO® Abdominal Stent-Graft System in Europe are promising. There was a low short-term mortality and morbidity rate in these patients of which 17% had previous AAA repair. Mid-term and long-term follow-up data are needed to evaluate endograft durability and performance. This study shows the first experiences and short-term results of a novel low-profile custom-made device: the custom-made fenestrated TREO® Abdominal Stent-Graft System. Showing these results and experiences can help the physicians in clinical decision-making for their patients.

Urgent endovascular treatment of juxtarenal aneurysm using a parallel grafts technique.

Abdominal aortic aneurysms can constitute a therapeutic challenge in several anatomical scenarios, making endovascular treatment more complex. A juxtarenal abdominal aortic aneurysm (JR-AAA) is defined by the absence of a proximal landing zone in the infrarenal segment and, therefore, techniques must be used to obtain an adequate neck for fixing the endoprostheses without provoking occlusion of renal arteries and visceral branches. The parallel grafts technique, physician-modified stent-graft, industry customized endoprostheses, and off-the-shelf branched endoprosthesis are techniques used in abdominal aneurysms with inadequate proximal neck, but each technique has its indications, limitations, and risks. In this therapeutic challenge, we present a case of urgent endovascular treatment of a JR-AAA using a parallel grafts technique, with good medium-term results, and discuss the therapeutic options.

Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm.

Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.

First-in-Human Clinical Trial of the WeFlow-JAAA Endograft System in Patients With Juxtarenal Abdominal Aortic Aneurysms.

To preliminarily evaluate the safety and efficacy of the WeFlow-JAAA endograft, a novel off-the-shelf device designed for the repair of juxtarenal abdominal aortic aneurysms (JRAAAs) and pararenal abdominal aortic aneurysms (PRAAAs). This prospective single-arm first-in-human clinical trial included patients with JRAAAs (infrarenal necks ≤10 mm) or PRAAAs with at least a 5 mm sealing zone below the superior mesenteric artery (SMA) who underwent endovascular repair using the WeFlow-JAAA endograft system. With this system, the celiac artery was addressed with a wide scallop, the renal arteries (RAs) were addressed with 2 standard inner branches, and the SMA was addressed with a "mini-inner-cuff" reinforced fenestration. The primary efficacy endpoint was the clinical success at 12 months. The primary safety endpoint was the freedom from major adverse events (MAEs) in the first 30 days after surgery. Fifteen patients (all men; mean age 68.5±6.0 years) were enrolled between October 2019 and August 2021. The median infrarenal neck length was 0 mm (IQR, 0-4 mm). Technical success was achieved in all patients. No MAEs occurred in the first 30 days. The mean fluoroscopy time was 73.1±27.8 minutes, and the mean volume of contrast media was 130.7±29.4 mL. Clinical success was maintained in all patients at 12 months. No aortic-related deaths, aneurysm rupture, type I or type III endoleak, or open surgery conversion occurred during the follow-up period. The secondary intervention was required only in 1 patient who developed an occluded right RA stent 14 months after the procedure. The WeFlow-JAAA endograft device appears to be safe and efficacious in selected patients with JRAAAs or PRAAAs with more than 5 mm sealing zone below SMA. Large-scale, multicenter, and prospective studies with long-term follow-ups are ongoing to validate our findings in China. Clinicaltrials.gov identifier: NCT04745546 (URL: Guo's Visceral Arteries Reconstruction: The First in Man Study of WeFlow-JAAA Stent Graft System-Full-Text View-ClinicalTrials.gov). The first-in-human clinical trial of the WeFlow-JAAA endograft system demonstrates promising safety and efficacy in treating juxtarenal abdominal aortic aneurysms (JRAAAs) and partial pararenal abdominal aortic aneurysms (PRAAAs). This innovative off-the-shelf device offers a potential alternative to traditional endovascular aortic repair. The successful outcomes, including technical success in all patients, freedom from major adverse events, and maintenance of clinical success at 12 months, suggest a potential shift in clinical practice towards using the WeFlow-JAAA endograft system for selected patients. This study paves the way for larger-scale, multicenter, prospective studies to further validate its long-term safety and efficacy, offering clinicians a new option for managing complex abdominal aortic aneurysms.

Physician-Modified Single-Fenestrated EndoSuture Aneurysm Repair (FESAR) for Urgent Juxtarenal AAA Repair.

To describe the endovascular treatment of a symptomatic juxtarenal abdominal aortic aneurysm (JAAA) using a combination of endoanchors (Heli-FX EndoAnchor, Medtronic, Minneapolis, Minnesota) and a physician-modified single-fenestrated endograft. An 85 year-old patient unfit for open aortic repair presented for a symptomatic JAAA, characterized by an infrarenal neck with 0.6 cm in length and 23 mm in diameter. A 28 mm-diameter Endurant aortic cuff (Medtronic, Minneapolis, Minnesota) was modified with a single fenestration for the left renal artery (LRA) and diameter-reducing tie, then re-sheathed and deployed. The LRA was cannulated with a 7F sheath and the constraining wire was withdrawn. Being the shortest neck length on the right side of the cuff, the endograft was anchored to the aortic wall on this side with 2 endoanchors. The LRA was stented and flared, then a distal physician-modified (without free-flow) bifurcated Endurant graft (Medtronic, Minneapolis, Minnesota) was overlapped with the proximal cuff and stabilized with 6 endoanchors. Correct positioning with complete aneurysm exclusion was confirmed with a 30 day and 9 month computed tomography angiograms. In extremely selected cases, association of endoanchors and single-fenestrated physician-modified graft may be useful to treat complex urgent aortic aneurysm using readily available devices. This technical note demonstrates the feasibility of a single-fenestrated physician-modified Endurant endograft deployed in combination with endosuture fixation (FESAR), to urgently treat a juxtarenal aortic aneurysm unfit for open repair and not suitable for standard endovascular repair nor off-the-shelf endografts.

Multidisciplinary approach to the treatment of a patient with juxtarenal, abdominal aortic aneurysm and renal cell cancer

Currently, strategies for the management of tumor diseases of the urinary tract in combination with cardiovascular pathologies are controversial. In domestic literature, only isolated reports are found concerning the treatment of combined oncological and cardiovascular pathologies, and the global experience is limited to individual clinical observations and small retrospective series, primarily describing the experience of individual centers. The current challenge for specialists is to establish the ideal treatment sequence with regard to the optimal timing of each surgical procedure and the initial priority of treatment, or the possibility of performing them simultaneously. The article presents a case of successful simultaneous surgical intervention for juxtarenal abdominal aortic aneurysm (AAA) and renal cell carcinoma (RCC) of the left kidney. The patient underwent resection of an abdominal aortic aneurysm with the replacement of the left renal artery, resection of the left kidney under pharmaco-cold ischemia, with thrombectomy from the renal vein. The postoperative period proceeded satisfactorily. After 6 months, on the control computed tomography of the abdominal organs with contrast enhancement (CT) of the abdominal cavity with CU, the prosthesis of the abdominal aorta and the left renal artery are functioning. According to color duplex scanning (CDS) of the renal vessels, the blood flow in the left kidney is preserved to the periphery with normal speed indicators. No data on the recurrence of the oncological process were received.

Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era.

Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes. A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward. A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666). Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.

Editor's Choice -- Age Stratified Midterm Survival Following Endovascular Versus Open Repair of Juxtarenal Abdominal Aortic Aneurysms

Age stratified mortality was examined following fenestrated endovascular aneurysm repair (F-EVAR) vs. open repair of juxtarenal abdominal aortic aneurysms (AAAs) METHODS: All patients undergoing first time elective F-EVAR and complex open aneurysm repair (c-OAR) for juxtarenal AAA in the Vascular Quality Initiative between 2014 and 2021 were identified. Open repairs were compared with commercially available fenestrated endovascular aneurysm repair and physician modified endografts (PMEGs). Patients were stratified into three age groups (< 65, 65 - 75, > 75 years). Primary outcomes were peri-operative and five year mortality, and inverse probability weighted risk adjustment was performed to account for baseline differences. Overall, 1 961 patients underwent F-EVAR (82% commercial F-EVAR, 18% PMEG) and 3 385 patients underwent c-OAR. Across age groups, the distribution of F-EVAR (vs. c-OAR) was: < 65 years: 23%, 65 - 75 years: 33%, > 75 years: 52%. After adjustment, among patients < 65 years, compared with c-OAR, F-EVAR was associated with similar peri-operative mortality (0.9% vs. 2.1%; hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.07 - 1.44], p= .22), and five year mortality (13% vs. 9.5%; HR 1.44, 95% CI 0.71 - 2.90, p= .31). Among patients aged 65 - 75 years, between juxtarenal AAA repair modalities, compared with c-OAR, F-EVAR was associated with a significantly lower risk of peri-operative mortality (2.2% vs. 5.0%; HR 0.50, 95% CI 0.30 - 0.79, p= .004), and five year mortality (13% vs. 13%; HR 0.94, 95% CI 0.65 - 1.36, p= .74). Similarly, among patients > 75 years, compared with c-OAR, F-EVAR was associated with lower peri-operative mortality (2.2% vs. 6.5%; HR 0.26, 95% CI 0.13 - 0.47, p < .001), but with similar five year mortality (18% vs. 21%; HR 0.83, 95% CI 0.57 - 1.20, p= .31). Among patients with a juxtarenal AAA, F-EVAR was associated with a lower peri-operative mortality compared with c-OAR in patients ≥ 65 years, but was similar in those < 65 years. At five years, F-EVAR was associated with similar mortality in all age groups, though there was a non-significant trend for a higher mortality rate in younger patients.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Fenestrated endovascular aortic repair to eliminate a juxtarenal abdominal aortic aneurysm with concomitant horseshoe kidney

Fenestrated endovascular aortic repair to eliminate a juxtarenal abdominal aortic aneurysm with concomitant horseshoe kidney

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms.

There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.

Midterm Results of Supraceliac vs Infraceliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

The complexity of fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms has increased over time including a more proximal sealing zone despite a similar disease extent. Prior studies demonstrated that supraceliac sealing is associated with higher perioperative morbidity, although mortality seems to be similar. Durability of sealing at a supra celiac level vs an infraceliac level remains unknown. The aim of our study was to examine outcomes of FEVAR for juxtarenal abdominal aortic aneurysms comparing a supraceliac vs an infraceliac sealing zone. We included patients undergoing elective juxtarenal FEVAR from 2008 to 2021 at two large hospitals in the Netherlands. The definition of a supraceliac sealing zone was incorporation of the celiac trunk by either a scallop or fenestration. The primary outcome was 5-year aneurysm-related procedures. Secondary outcomes included perioperative complications, 5-year mortality and 1-year aneurysm sac dynamics. These outcomes were analyzed using t tests, Kaplan-Meier methods, multivariable Cox regression analysis, and χ2 tests. One-year aneurysm sac dynamics were evaluated between the groups with imaging data (sac regression/stable sac/sac expansion, based upon 5% volume change compared with 30-day volume). Among 173 patients identified, 114 (66%) had a supraceliac and 59 (34%) had an infraceliac sealing zone. Patients with supraceliac sealing more often had prior EVAR (26.3% vs 12%; P = .045). Furthermore, supraceliac sealing had similar rates of perioperative complications and mortality. No differences were found in one-year aneurysm sac dynamics. Supraceliac sealing was associated with significantly lower risks of secondary aneurysm-related procedures at 5 years compared to use of infraceliac sealing (25% vs 45%; hazard ratio, 0.37; 95% confidence interval, 0.17-0.79; P = .012) (Figure). Finally, supraceliac sealing had similar risks of 5-year mortality compared with infraceliac sealing (hazard ratio, 0.93; 95% confidence interval, 0.49-1.74; P = .813). FEVAR with supraceliac sealing is more durable with less secondary aneurysm-related procedures as compared to infraceliac sealing for juxtarenal aneurysms. Future research has to examine whether supraceliac sealing should be the standard for juxtarenal aneurysms.