Repair Of Complex Aortic Aneurysms Research Articles

Single-Center Experience with the Femoral-to-Brachial Preloaded Delivery System for Fenestrated-Branched Endovascular Repair of Complex Aortic Aneurysms

To assess technical aspects and outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using a femoral-to-brachial (FTB) preloaded delivery system (PDS) with two separate configurations. Clinical data of all consecutive patients enrolled in a prospective study to evaluate FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms (CAAAs & TAAA) between 2013 and 2020 were reviewed. Patients treated with FTB-PDS were included. The two configurations included 4 trans-brachial preloaded wires (4BR) or 2 trans-brachial and 2 transfemoral preloaded wires (2BR-2FE). Outcome measures included technical success, procedural metrics, 30-day or in-hospital mortality, major adverse events (MAEs), and target-vessel outcomes. There were 115 patients with a mean age of 73.8 ± 8years, treated with FTB-PDS. Of these, 62 patients (54%) had 4BR and 53 patients (46%) had 2BR-2FE FTB-PDS. There were 106 TAAA (92%) and 9 CAAAs (8%). Technical success, defined as successful implantation of the stent-graft and all intended target-vessel stents without type I or III endoleak, was 97%, with no differences in total operating time, endovascular time, and radiation dose between groups. There were 3 deaths (3%) at 30days. MAEs were noticed in 21 patients (18%) with no difference between groups, including new-onset dialysis (2% vs. 4%, P = 0.59), and paraplegia (7% vs. 11%, P = 0.51), for 4BR and 2BR-2FE, respectively. Patient survival and freedom from aortic-related mortality at 2-years were 79 ± 5% and 97 ± 1.7%, respectively, with no difference between groups. The use of FTB-PDS for FB-EVAR is safe with high technical success and a reasonable rate of MAEs. Each configuration provides specific benefits based on patient anatomy, while having similar procedural metrics and clinical outcomes.

Characterization of Secondary Interventions After Fenestrated-branched Endovascular Repair of Complex Aortic Aneurysms and Its Effect on Quality of Life and Patient Survival.

To assess the impact of secondary intervention (SI) on health-related quality of life (HR-QOL) after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. The effect of SI after FB-EVAR on physical and mental HR-QOL has not been described. A cohort of 430 consecutive patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR (2013-2020) was assessed with 1325 short-form 36 HR-QOL questionnaires preoperatively and during follow-up visits. SIs were classified as major or minor procedures. Endpoints included patient survival, freedom from aortic-related mortality (ARM), freedom from SIs, and changes in HR-QOL physical component score (PCS) and mental component score. There were 302 male with mean age 74±8 years treated by FB-EVAR for 133 complex abdominal aortic aneurysms and 297 thoracoabdominal aortic aneurysms. After a mean follow up of 26±20 months, 97 patients (23%) required 137 SIs. At 5 years, freedom from any SI was 64%±4%, including freedom from minor SIs of 77%±4% and major SIs of 87%±3%. There was no difference in patient survival and freedom from ARM at same interval. On adjusted analysis, minor SIs correlated with improved survival. SIs had a negative correlation with PCS ( r =-0.8). There were no significant changes in mental component score with SIs. Predictors for SIs were fluoroscopy time, graft design, and aneurysm sac change. SIs were needed in nearly 1 out of 4 patients treated by FB-EVAR with no effect on patient survival or ARM. SI resulted in decline in PCS.

Endovascular Aneurysm Repair With Superior Mesenteric Artery Chimney and Renal Artery In Situ Laser Fenestration

Urgent and emergency situations require creative off-the-shelf solutions for complex aortic aneurysm repair. In situ laser fenestrated repair has been described to fill this need; however, there is a period of ischemia to the visceral vessels during endograft placement, laser fenestration, and bridging stent placement. This video shows a simplified approach that obviates the need for target vessel prestenting to demonstrate the origins for laser fenestration and facilitating renal protection with cold perfusion solution through the visceral sheaths during endograft coverage.

Female Sex is Associated with Worse Outcomes following Complex Fenestrated or Branched Endovascular Aortic Repair

Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) which underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. Our analysis included 1,521 patients, 1,180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On a multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (odds ratio (OR) 3.339, 95% confidence interval (CI): 2.173-5.132, P < 0.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, P = 0.003), complications (OR 1.747, 95% CI: 1.282-2.381, P < 0.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, P = 0.001). Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of chronic obstructive pulmonary disease (COPD) and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study

A review of the Dutch Surgical Aneurysm Audit between January 2016 and January 2020. Of 694 patients who underwent complex aortic aneurysm repair with fenestrated (n = 539) or branched (n = 155) endografts, the postoperative complication rates were 30% and 49%, respectively. The highest volume hospitals treated significantly more complex patients. Perioperative mortality of complex endovascular aneurysm repair was significantly higher in hospitals with an annual volume of fewer than 9 cases (9%) compared with hospitals with an annual volume of 13 or more cases (3%). This nationwide registry shows that high-volume complex endovascular aneurysm repair centers demonstrate lower mortality rates.

Outcomes of multibranched off-the-shelf stent graft in elective and urgent/emergent repair of complex aortic aneurysms with narrow internal aortic lumen

ObjectivesTo assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft in the treatment of complex aortic aneurysms with narrow internal aortic lumen. MethodsBetween 2016 and 2020, 48 patients (mean age, 73 years) underwent elective or urgent or emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in two Italian vascular centers. Among these, 20 patients presented a paravisceral or pararenal luminal diameter of less than 25 mm. Major clinical and radiologic outcomes of patients with narrow aortic lumen were compared with patients with a larger lumen in a multicenter, nonrandomized, retrospective fashion. ResultsThe in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range, 1-63 months), late t-Branch procedure-related mortality and the need for reintervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (group 1) with patients with small lumen (group 2), no significant difference was found regarding fluoroscopy time (P = .3); technical success (P = 1); early (P = .4) and late (P = 1) mortality; spinal cord ischemia (P = .2); bowel ischemia (P = .5); renal (P = .7), cardiac (P = 1), and respiratory complications (P = 1); reintervention rate (P = 1); and primary patency rate of stented target vessels (P = 1). ConclusionsThe use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible when maneuverability is decreased, with low mortality and morbidity, and acceptable reintervention rates. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.

Physician-modified endografts are associated with a survival benefit over parallel grafting in thoracoabdominal aneurysms

ObjectivePhysician-modified endografts (PMEG) and parallel grafting (PG) are important techniques for endovascular repair of complex aortic aneurysms using off-the-shelf devices. However, there are few data regarding the relative efficacy and outcomes of these techniques in thoracoabdominal extent aneurysms. This study sought to compare the outcomes of PG and PMEG across different extents of thoracoabdominal aneurysms (TAAAs) for which they can be used. MethodsThe Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair/complex endovascular aortic repair module was queried for all patients undergoing repair of an unruptured, TAAA (extents I-IV) from 2012 to 2020; aneurysm types were defined by repair extent as determined by proximal and distal seal zones. Patients were differentiated based on whether they underwent repair with a PMEG or PG. The primary outcomes for this study were overall survival and freedom from aneurysm- or procedure-related mortality at 1 year determined via Kaplan-Meier analysis, with a Cox hazard regression analysis conducted to examine the independent association of repair modality with primary outcomes. ResultsThere were 813 patients who met the inclusion criteria (TAAA I-III, n = 362; TAAA IV, n = 451; PG, n = 426; PMEG, n = 387). PMEG repairs were performed at centers with a nearly two- to three-fold higher annual volume of endovascular TAAA repairs. Type Ia endoleaks were reduced with PMEG repair, most significantly in TAAA IV (TAAA I-III, 2.2% PMEG vs 10% PG [P = .2]; TAAA IV, 1.2% PMEG vs 21.6% PG [P < .001]). Thoracoabdominal repairs demonstrated improved survival at 1 year with PMEG devices, significant for TAAA I to III repairs (TAAA I-III, PMEG 85% vs PG 74% [P = .01]; TAAA IV, 84% PMEG vs PG 78% [P = .08]). Freedom from aneurysm- or procedure-related mortality was also improved with PMEG repairs, remaining significant at 1 year in the case of TAAA IV (TAAA I-III:, PMEG 94% vs PG 86% [P = .06]; TAAA IV, PMEG 94% vs PG 88% [P = .02]). PMEG demonstrated decreases in several measures of postoperative morbidity, including stroke, death, major adverse cardiovascular events, and postoperative complications. In the multivariate analysis, repair modality was not associated with either primary outcome; rather, several perioperative complications conveyed the greatest hazard for both primary outcomes across repair extents. ConclusionsSurvival after endovascular TAAA repair is improved with the use of PMEG compared with PG. Several key factors of this study demonstrate the shortcomings of PG in complex aneurysm repair, namely, high rates of critical endoleaks, the need for adjunctive access sites, and an increase in perioperative complications that influence longer term outcomes.

Chimney endovascular aneurysm repair (ChEVAR) for hostile neck complex aneurysm.

Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR. Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery. Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5mm; p = 0.059), iliac diameter (7.3 vs 7.1mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7mm3; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71). Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair.

Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68days in the endovascular and 107 ± 79days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28days) and 7days (ranging, 3-18days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.

Comparison of Hemodynamic Changes Associated With Two- Versus Four-Vessel Fenestrated Endovascular Aneurysm Repair Using Patient-specific Computational Flow Modeling

Fenestrated endovascular aneurysm repair (fEVAR) endografts with additional proximal fenestrations are the subject of upcoming pivotal trials in the United States. This study sought to use patient-specific flow simulation (CFS) to assess the differences in hemodynamic effects associated with two-vessel (2v) vs four-vessel (4v) fEVAR after repair of complex aortic aneurysms.

Postoperative and Three-Year Outcomes After Endovascular Repair of Complex Aortic Aneurysms in the Vascular Quality Initiative

Advances in endovascular technology have allowed for minimally invasive repair options for complex aortic aneurysms (cAAAs); however, direct comparisons are limited. Therefore, we compared the postoperative and 3-year outcomes after cAAA repair stratified by endovascular treatment type.

Commentary "Initial Results of Antegrade Laser Fenestrations Using Image Fusion Guidance and Company Manufactured Stent Grafts in Complex Aortic Aneurysm Repair"

Commentary "Initial Results of Antegrade Laser Fenestrations Using Image Fusion Guidance and Company Manufactured Stent Grafts in Complex Aortic Aneurysm Repair"

Single-center Experience With the Femoral-to-brachial Preloaded Delivery System for Fenestrated-branched Endovascular Repair of Complex Aortic Aneurysms

The role of fenestrated-branched endovascular aortic repair (FB-EVAR) in the treatment of complex aortic pathology has evolved rapidly over the last two decades. Much of this is due to the development and selective use of procedural adjuncts, such as low-profile devices, upper extremity access, and preloaded delivery systems (PDS). Our experience with femoral-to-brachial (FTB) PDS has advanced over the years. The aim of this study was to assess technical aspects and outcomes of FB-EVAR using FTB-PDS with two separate configurations.

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study.

We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR). All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9. Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.

Abstract 13545: Patient-Specific Computational Flow Simulation Reveals Differences in Aortic Hemodynamics Between Two versus Four Vessel Fenestrated Endovascular Aneurysm Repair

Objectives: Fenestrated endovascular aneurysm repair (fEVAR) endografts with additional proximal fenestrations are the subject of upcoming pivotal trials in the United States. This study sought to use patient-specific flow simulation (CFS) to assess differences in hemodynamics associated with two (2v) versus four-vessel (4v) fEVAR after repair of complex aortic aneurysms. Methods: Patients from two institutions who underwent 2v fEVAR for juxatrenal, and 4v fEVAR for pararenal aortic aneurysms with the Cook Zenith Fenestrated platform were retrospectively selected. Device diameters were matched between 2v and 4v groups. Finite element volume meshes were created from pre- and post-operative imaging. Pulsatile flow simulations were performed using a non-compressible Navier-Stokes solver with equivalent patient-specific boundary conditions between pre- and post-operative states. Results: Patient-specific CFS was performed on 20 patients (10 2v, 10 4v fEVAR) with a total of 70 target vessels (40 renal, 10 celiac, 10 superior mesenteric (SMA) stents, and 10 SMA scallops). 4v fEVAR was associated with a decrease in SMA peak flow rate (-7.1 vs +1.1%, p=.042) compared to 2v fEVAR. 4v fEVAR was associated with decreased paravisceral aortic wall shear stress (WSS) (-31.3 vs +0.6%, p=.008), whereas SMA WSS was increased (+36.9 vs +15.5%, p=.049) compared to 2v fEVAR. No differences in celiac or renal perfusion or WSS was observed between groups (p=.14-.93). Streamline visualization revealed flow disturbances surrounding flared branch graft protrusions into the aortic lumen which may be associated with changes in SMA perfusion after 4v fEVAR ( Figure ). In conclusion, structural changes in paravisceral aortic geometry following 4v fEVAR may be associated with a decrease in SMA perfusion and large reduction in aortic wall shear stress compared to 2v fEVAR. Patient-specific CFS is useful for studying the unique hemodynamic effects of additional fenestrations.

Outcomes of off-the-shelf multibranched stent grafts with intentional occlusion of directional branches using endovascular plugs during endovascular repair of complex aortic aneurysms

ObjectiveTo evaluate the technique and outcomes of intentional occlusion of directional branches (DBs) using endovascular plugs during branched endovascular aortic repair using off-the-shelf Zenith t-Branch thoracoabdominal (TAAA) stent grafts. MethodsWe reviewed the clinical data and outcomes of all consecutive patients treated by branched endovascular aortic repair using off-the-shelf Zenith t-Branch TAAA stent-graft (Cook Medical, Bloomington, Ind) in seven academic centers from 2013 to 2019. All patients had at least one DB intentionally occluded using extension of the branch with balloon or self-expandable covered stent, followed by placement of endovascular plugs. Intentional occlusion was indicated in patients with variations in the normal four-vessel renal-mesenteric anatomy, pre-existing dialysis, or in those who failed catheterization of a target vessel. End points were 30-day/in-hospital mortality, major adverse events, secondary interventions, target artery (TA) patency, TA instability, and patient survival. ResultsThere were 100 patients, 65 male and 35 female, with median age of 71 years (interquartile range [IQR], 66-75 years). Of these, 31 patients (31%) had urgent/emergent operations for symptomatic/contained ruptured aneurysms. The median aneurysm diameter was 72 mm (IQR, 61-85 mm). A total of 290 renal-mesenteric arteries were incorporated with a median of three (IQR, 3-3) vessels/patient. Indications for DB occlusion were less than four suitable renal-mesenteric targets in 84 patients or pre-existing dialysis and inability to catheterize a target vessel in eight patients each. There were 110 DBs occluded by vascular plugs, including 48 celiac axis, one superior mesenteric artery, and 61 renal DBs. Thirty-day/in-hospital mortality was 10%, including 9% for elective and 13% for urgent/emergent procedures. Major adverse events occurred in 44 patients (44%), including acute kidney injury in 19 patients (19%), estimated blood loss >1 L in 12 patients (12%), respiratory failure and new onset dialysis in six patients (6%) each, bowel ischemia in five patients (5%), and myocardial infarction and paraplegia in two patients (2%) each. The median follow-up was 5 months (range, 1-13 months). Eighteen patients (18%) required secondary interventions, none for problems related to the occluded DB. There were no endoleaks related to the occluded DB. At 2 years, primary and secondary patency and freedom from TA instability were 93% ± 3%, 97% ± 2%, and 91% ± 4%, respectively. Freedom from secondary interventions and patient survival were 75% ± 6% and 63% ± 7%, respectively. ConclusionsIntentional occlusion of DBs using endovascular plugs allows versatile use of a four-vessel off-the-shelf multi-branched TAAA stent graft in patients with variations in the normal renal and mesenteric anatomy or when technical difficulties prevent successful target vessel stenting. There were no endoleaks or secondary interventions associated with the occluded DB.

Efficacy of Cold Renal Perfusion Protection for Open Complex Aortic Aneurysm Repair: A Meta-Analysis

Open surgical repair of complex aortic aneurysms has been associated with a risk of acute kidney injury, leading to significant morbidity and mortality. Cold renal perfusion (CRP) with 4°C crystalloid fluids during open repair is a method to reduce renal injury during repair. A meta-analysis assessing CRP for open repair of complex aortic aneurysms was performed. Complex aneurysms were defined as those requiring at least a suprarenal clamp site and included juxtarenal, suprarenal, and thoracoabdominal aortic aneurysms.

Renovisceral Stents in Complex Aortic Grafts: Assessing Endoleaks, Patency, and Reintervention

Endovascular techniques for complex aortic aneurysm repair include fenestrated endovascular aortic repair, branched aortic grafts, and parallel stent-grafts. These require durable stent-grafts to maintain renovisceral perfusion and limit endoleak and gutter leaks, specifically the occurrence of type Ic endoleaks between stent-graft and distal target vessel attachment and the occurrence of type IIIc endoleaks between renovisceral stent placement and fenestration of the main aortic graft. Others have anecdotally reported an increase in type IIIc endoleaks with VBX stents (W.

Innovative approaches and new endograft designs to perform complex endovascular thoracoabdominal aortic aneurysm repair

I would like to congratulate and thank Said Abisi et al1 for their thorough description of a new endograft design for the endovascular repair of complex aortic aneurysms, its possible indications, and their early experience in its use. They are further to be commended for the reported technical and clinical results, which are certainly impressive and reflect clinical practice in a very experienced high-volume aortic center.

Initial Results of Antegrade Laser Fenestrations Using Image Fusion Guidance and Company Manufactured Stent Grafts in Complex Aortic Aneurysm Repair

The aim was to describe initial outcomes of physician modified stent grafts using antegrade laser fenestrations and image fusion guidance (LEVAR) and company manufactured custom made (CM) stent grafts for the treatment of complex abdominal aortic aneurysms (CAAAs), thoraco-abdominal aortic aneurysms (TAAAs) and type I endoleaks (T1ELs).