Repair Of Juxtarenal Aneurysms Research Articles

Iliac tortuosity increases reinterventions but not adverse outcomes following repair of juxtarenal aneurysms using physician-modified endografts

ObjectiveIncreased angulation of the proximal aortic neck has been associated with complications following endovascular repair of infrarenal aortic aneurysms, including increased incidence of endoleaks, stent migration, secondary interventions, and conversions. However, knowledge on the impact of aortoiliac tortuosity on outcomes following fenestrated repair remains limited. This study aims to quantify the effect of aortoiliac tortuosity on outcomes following fenestrated repair. MethodsA single-center, retrospective review of all patients who underwent a physician-modified endovascular repair for the treatment of juxtarenal aortic aneurysms under a single physician-sponsored investigation device exemption study from 2011 to 2021 was performed. Center luminal lines and geometric distances were obtained using TeraRecon software (San Mateo, CA). A tortuosity index was calculated (tortuosity index = centerline distance/geometric line distance) for each iliac vessel as well as for the infrarenal aorta according to Society for Vascular Surgery reporting standards. Aortic and iliac tortuosity were assessed independently and stratified as low and high. Demographics, comorbidities, anatomic and operative details, and outcomes were compared using univariable and multivariable analysis. ResultsA total of 135 patients were identified. Thirty-eight patients (28%) had high aortic tortuosity, and 55 patients (42%) had high iliac tortuosity. Patients with high tortuosity were older (aortic: 78 vs 76 years; P = .04; iliac: 78 vs 75 years; P = .01) and differed by sex. Twenty-two percent of men and 50% of women had high aortic tortuosity (P = .01). Forty-seven percent of men and 20% of women had high iliac tortuosity (P = .01). There were no differences in comorbidities based on aortic tortuosity, but coronary artery disease (high: 58% vs low: 36%; P = .01) and hypertension (high: 69% vs low: 86%; P = .02) differed based on iliac tortuosity. Aneurysm diameter was larger for patients with high iliac tortuosity (72 mm vs 64 mm; P < .01), and fluoroscopy time was longer for patients with high aortic tortuosity (41 vs 31 minutes; P = .02). When outcomes were assessed, high iliac tortuosity was associated with increased rate of reinterventions (hazard ratio, 2.6; 95% confidence interval, 1.2-6.0) and type 1 or 3 endoleak (hazard ratio, 5.2; 95% confidence interval, 1.7-16); however, all other outcomes were similar. ConclusionsAmong patients treated with physician-modified endovascular repair for juxtarenal aneurysms, iliac tortuosity but not aortic tortuosity, is associated with increased reinterventions and type 1 or type 3 endoleaks. Long-term follow-up is critical for patients with high iliac tortuosity to ensure that high-risk endoleaks are identified and treated early to avoid the risk of rupture.

Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair.

Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.

Long-Term Sac Regression Is Common After Fenestrated Endovascular Repair of Juxtarenal Aneurysms

The frequency of aneurysm sac regression after endovascular repair of abdominal aortic aneurysms has been well described, with failure of regression associated with an increased risk of mortality. In the present study, we have described the long-term sac behavior after fenestrated endovascular repair (FEVAR) for juxtarenal aneurysms.

Evaluating proximal clamp site and intraoperative ischemia time among open repair of juxtarenal aneurysms

BackgroundThe proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly owing to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between the proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. MethodsWe used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004 to 2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (suprarenal), or above the celiac trunk (supraceliac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and 1-year mortality. We used multilevel logistic regressions and Cox proportional hazards models, clustered at the hospital level, to adjust for confounding. ResultsWe identified 3976 patients (median age, 71 years; 70% male; 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (interquartile range [IQR], 5.4-6.8 cm). Proximal clamp sites were above one renal artery (31%), suprarenal (52%), or supraceliac (17%). The rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for 1-year mortality. On adjusted analyses, independent of ischemia time, suprarenal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (adjusted odds ratio [aOR], 1.50; 95% confidence interval; 95% CI, CI, 1.28-1.75), but similar odds for new-onset RRT (aOR, 1.27; 95% CI, 0.79-2.06) and 30-day mortality (aOR, 1.12; 95% CI, 0.79-1.58) and hazards for 1-year mortality (adjusted hazard ratio, 1.12; 95% CI, 0.86-1.45). However, every 10 minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by 7% (IQR, 3%-11%), new-onset RRT by 11% (IQR, 4%-17%), 30-day mortality by 11% (IQR, 6%-17%), and 1-year mortality by 7% (IQR, 2%-13%). Patients with more than 40 minutes of ischemia time had notably higher rates of all four outcomes. ConclusionsSuprarenal clamping relative to clamping above a single renal artery was associated with AKI, but not new-onset RRT or 30-day mortality. However, the intraoperative renal ischemia time was independently associated with all four postoperative outcomes. Although further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.

Significant aortic neck dilation occurs after repair of juxtarenal aneurysms with fenestrated endovascular aneurysm repair

ObjectiveAortic neck dilation is a reported mode of failure and can be associated with aneurysm sac expansion after standard endovascular abdominal aortic aneurysm repair (EVAR). Fenestrated EVAR (FEVAR) of the juxtarenal segment increases the seal zone length and is often used to treat this disease progression. However, the frequency and risk factors for neck dilation after FEVAR is unknown. MethodsWe evaluated 124 consecutive FEVARs performed under an investigational device exemption clinical trial for juxtarenal aneurysms (ClinicalTrials.gov identifier, NCT01538056). The aortic diameter at the level of the superior mesenteric artery (SMA; highest fenestration) and lowest renal artery (lowest fenestration) was assessed from computed tomography angiography preoperatively, at 30 days, and annually thereafter. A subgroup analysis was performed to assess aortic neck dilation by the graft type used, degree of oversizing, infrarenal neck length, effective seal zone length, and aortic diameter at the level of the lowest and highest fenestration. Multivariable analysis was then performed to evaluate for predictors of aortic neck dilation. ResultsOf the 124 patients, 56 had complete anatomic detail and follow-up data available for ≥3 years. Those without preoperative or follow-up data available were excluded. The aortic diameter had increased significantly by 3 years at the level of both the SMA (2.4 mm; P < .01) and the lowest renal artery (3.2 mm; P < .01). When those with and without aortic dilation (>3 mm) were compared, only oversizing differed at the level of the SMA (14% vs 19%; P < .01). At the level of the lowest renal artery, the graft diameter differed (30 mm vs 28 mm; P = .02). However, after adjusted analysis, these differences were not significant. Finally, a subgroup analysis was performed to evaluate aortic dilation over time stratified by anatomic factors and should that aortic dilation occurred across differing aneurysm diameters, percentage of oversizing, graft types, and seal zone lengths. ConclusionsAortic neck dilation in the visceral segment can occur after endovascular repair of juxtarenal aneurysms using FEVAR. Further research is warranted to determine how these changes might affect the long-term outcomes.

Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency

ObjectiveAlthough fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. MethodsAll adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons – National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012–2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the “Cook Zenith Fenestrated” endograft. OSR cases were defined as those that required proximal clamp positions “above one renal” or “between SMA & renals.” Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. ResultsThere were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). ConclusionFor patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.

Collective Consciousness on Complex Aortic Repair: Time to Focus on Data Capture

In this issue of EJVES, Antoniou et al. synthesise the current literature comparing open treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms (TAAs) with endovascular treatment using branched and fenestrated techniques.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Their meta-analysis of >7 000 patients should be commended, particularly given the fact that they only include comparative studies that utilise propensity or regression analyses, thereby limiting bias. They also capture follow up data. The take home messages are clear. Firstly, their analysis does not show a statistically significant difference in early or late survival between patients treated with either technique. Secondly, re-intervention is twice as likely in patients who have had endovascular vs. open repair, but there is a lack of granular data relating to the impact of these re-interventions, including any adverse effect on survival or quality of life. The third, and perhaps most important, message is that the quality of evidence found to inform both of the aforementioned conclusions is poor. The work by Antoniou et al. is a stark reminder of the need to improve the evidence base that guides treatment of complex aortic aneurysms. However, it is important that we do not obsess with the prospective randomised trial as the only acceptable standard of evidence and recognise the value of other study designs. The European Society for Vascular Surgery guidelines recommended fenestrated endografting as the preferred treatment for juxtarenal aneurysms (Class IIa, Level C), despite the lack of randomised trial data.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (757) Google Scholar Antoniou et al. consider a prospective trial randomising open and endovascular juxtarenal aneurysm repair as feasible but, rightly, suggest that TAA are a different proposition without equipoise for randomisation.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Branched/fenestrated techniques allow treatment of significant numbers of patients with TAAs who would otherwise be turned down for open repair. However, detractors point to a risk of overenthusiasm for endovascular techniques and undue influence by manufacturers driving the operators' decisions to offer repair. To address this there is a need to instigate large scale, structured, prospective data collation from centres performing both endovascular and open repair to the same standard and to analyse these using the latest data science tools.3Dey D. Slomka P.J. Leeson P. Comaniciu D. Shrestha S. Sengupta P.P. et al.Artificial intelligence in cardiovascular imaging.J Am Coll Cardiol. 2019; 73: 1317-1335Crossref PubMed Scopus (151) Google Scholar In addition to post-operative survival and durability of repair, data on this scale may inform (1) objective assessment of anatomical characteristics that affect choice of repair modality; (2) the projected life expectancy of the patient, identifying those best served by conservative management; and (3) the relative effect on quality of life and likelihood of functional decline with each type of repair. For now, we must recognise that our life changing treatment decisions are best made in multidisciplinary teams consisting of a critical mass of experts. At a minimum, these teams should offer equal expertise in both open and endovascular repair so as not to limit the choice offered to the patient. They should also include medical colleagues able to give an objective opinion on the patient's physiology to aid decision making. The recent furore over the drafting of the National Institute for Health and Care Excellence aneurysm guidelines should be a wakeup call.4National Institute for Health and Care Excellence. Abdominal Aortic Aneurysm: Diagnosis and Management. NICE guideline NG156. Available at: https://www.nice.org.uk/guidance/ng156 [Accessed 25 November 2020].Google Scholar The time to gather better evidence that informs treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms is now. Editor's Choice – Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched DataEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 2PreviewThe aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. Full-Text PDF

Aortic Neck Dilation After Repair of Juxtarenal Aneurysms With Fenestrated Endovascular Aneurysm Repair

Aortic Neck Dilation After Repair of Juxtarenal Aneurysms With Fenestrated Endovascular Aneurysm Repair

Early and Mid-Term Outcomes of Open Repair, Fenestrated Stent Graft and Chimney Graft in Juxtarenal Abdominal Aortic Aneurysms

Introduction - Juxtarenal abdominal aortic aneurysm (JAAA) is defined as an infrarenal AAA that is adjacent to or involving the lower margin of the renal artery origins1. Recently, promising results have been reported in peer reviewed journals after fenestrated and chimney graft approaches to repair of JAAA2,3. Open repair, fenestrated endovascular aneurysm repair (FEVAR) and chimney endovascular aneurysm repair (Ch-EVAR) are effective methods to treat this condition, but the comparative effectiveness of these treatment modalities is unclear4. Upon completion of a hybrid vascular intervention room at our institution and careful planning and sizing, we started a prospective registry of all JAAA cases performed. Here we present our retrospectively analyzed results, including short and midterm follow-up results in patients with JAAA treated using either endovascular or open repair. Methods - We retrospectively reviewed patients with JAAA (n= 75) who underwent chimney grafts (Ch-EVAR, n = 23), fenestrated stent grafts (FEVAR, n = 20) or open repair (OR, n = 32) between January 2011 and December 2016 at a single institution. Our primary endpoint was peri-operative mortality. Secondary endpoints included renal function impairment, new-onset dialysis, procedural details and postoperative complications. Descriptive statistics are reported as mean ± standard deviation for continuous data and categorical data are presented as number and percentage. Kaplan-Meier analysis was used to estimate freedom from late re-intervention, primary patency of targeted vessel stent grafts and overall survival. Results - There were no statistically significant differences in baseline characteristics among the three groups. Perioperative mortality was not significantly different between groups: 4.3% (1/23) in the Ch-EVAR group, 0% in the FEVAR group and 3.1% (1/32) in the OR group(p = 0.532). Mean follow up time was 36.7 months. There were no statistically significant differences among the three groups in secondary endpoints, except for increased blood loss in the open repair group when compared to the endovascular groups. There were no statistically significant differences in overall survival among groups (p=0.282). Estimated targeted vessel stent patency at 1 and 4 years were 89.5% and 89.5% in the Ch-EVAR group and 93.8% and 93.8% in the FEVAR group, respectively. There were no statistically significant differences in estimated freedom from late re-intervention among groups (82.3% in the Ch-EVAR group, 77.2% in the FEVAR group and 96.4% in the OR group) Conclusion - We were unable to show a ststistically significant difference in outcomes among the treatment options for JAAA repair, which may be due to the size of our series. Nevertheless, our results show that after careful patient selection, we are able to offer our patients good results with fenestrated and chimney graft techniques that are comparable to open surgical procedures, but with a much faster recovery time. All three approaches (Ch-EVAR, FEVAR and open surgery) are effective treatment options for JAAA repair and have comparable short and mid-term outcomes in well-selected patients. Long term follow-up results are needed to determine the optimal management of JAAA. References·Jongkind V, Yeung KK, Akkersdijk GJ, Heidsieck D, Reitsma JB, Tangelder GJ, Wisselink W. Juxtarenal aortic aneurysm repair. J Vasc Surg. 2010;52:760-767·Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ, Prins TR, Bracale UM, van den Dungen JJ. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: An 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39:529-536·Donas KP, Torsello GB, Piccoli G, Pitoulias GA, Torsello GF, Bisdas T, Austermann M, Gasparini D. The protagoras study to evaluate the performance of the endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique. J Vasc Surg. 2016;63:1-7·Katsargyris A, Oikonomou K, Klonaris C, Topel I, Verhoeven EL. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: Are we ready for a paradigm shift? J Endovasc Ther. 2013;20:159-169

Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair

ObjectiveLong-term outcomes after endovascular aneurysm repair (EVAR) are threatened by aortic neck dilation (AND), graft migration, and subsequent endoleak development. The aim of this study was to determine the rate of AND and the occurrence of endoleaks after fenestrated EVAR of juxtarenal aneurysms with physician-modified endovascular grafts (PMEGs). MethodsThe study included 77 patients presenting with asymptomatic and ruptured juxtarenal abdominal aortic aneurysms treated with PMEGs who received radiologic follow-up. Analysis of computed tomography images took place on a three-dimensional workstation (TeraRecon, San Mateo, Calif). Aortic neck diameter was measured before and after EVAR at the lowest patent renal artery outer wall to outer wall. Significant AND was defined as >3-mm increase between baseline and follow-up, and sac regression >5 mm was considered significant. The patient's 1-month initial postoperative computed tomography measurement was considered baseline. The rate of AND was measured by comparing the baseline measurement with measurements at 6 months, 12 months, and annually thereafter up to 4 years. ResultsIn this cohort of patients, 75% were men with a mean age of 74 ± 7.9 years. Median preoperative aneurysm size was 62 (57-73) mm, and median follow-up was 12 (3.5-30) months. Mean endograft oversizing was 17% ± 12.5%, and mean seal zone length was 41 ± 11 mm. At 1-year follow-up, the median aortic neck increase was 1.7 (0-3) mm. Maximum aneurysm size decreased dramatically during the first postoperative year, with significant sac regression in 65% of the patients. Aortic neck diameter at 1 year did correlate positively with the percentage of device oversizing. No other correlations were found. During the 4-year follow-up, there were no cases of type IA endoleaks. ConclusionsAND does not influence outcome after endovascular repair of juxtarenal aneurysms using PMEGs. These midterm results support the applicability of PMEGs in juxtarenal aneurysm repair.

NESVS11. Fenestrated Endovascular Aneurysm Repair Is Associated With Lower Perioperative Morbidity and Mortality Compared with Open Juxtarenal Aneurysm Repair

NESVS11. Fenestrated Endovascular Aneurysm Repair Is Associated With Lower Perioperative Morbidity and Mortality Compared with Open Juxtarenal Aneurysm Repair

Complex endovascular aneurysm repair is associated with higher perioperative mortality but not late mortality compared with infrarenal endovascular aneurysm repair among octogenarians

ObjectiveAs our collective experience with complex endovascular aneurysm repair (EVAR) has grown, an increasing number of older patients are being offered endovascular repair of juxtarenal aneurysms. Outcomes after complex EVAR in this older subpopulation are not well-described. We sought to specifically evaluate clinical outcomes after complex EVAR compared with infrarenal EVAR in a cohort of octogenarians. MethodsA single-center retrospective review was conducted using a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients 80 years of age or older were included. Patients in the complex EVAR group were treated with either snorkel/chimney or fenestrated techniques, whereas infrarenal EVAR consisted of aneurysm repair without renal or visceral involvement. Relevant demographic, anatomic, and device variables, and clinical outcomes were collected. ResultsThere were 103 patients (68 infrarenal, 35 complex) treated within the study period with a mean follow-up of 21 months. A total of 75 branch grafts were placed (59 renal, 11 celiac, 5 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients undergoing complex EVAR were more likely to be male (82.8% vs 60.2%; P = .02) and have a higher prevalence of renal insufficiency (71.4% vs 44.2%; P = .008). The 30-day mortality was significantly greater in patients treated with complex EVAR (8.6% vs 0%; P = .03). There were no differences in major adverse events (P = .795) or late reintervention (P = .232) between groups. Interestingly, sac growth of more than 10 mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.8%; P = .039). However, both type IA (5.7% infrarenal; 4.9% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at latest follow-up (P = .322). Multivariable Cox modeling demonstrated that AAAs greater than 75 mm in diameter (hazard ratio; 4.9; 95% confidence interval, 4.6-48.2) and renal insufficiency (hazard ratio, 3.71; 95% confidence interval, 1.17-11.6) were the only independent risk factors of late death. ConclusionsComplex EVAR is associated with greater perioperative mortality compared with infrarenal EVAR among octogenarians. However, late outcomes, including the need for reintervention and all-cause mortality, are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular treatment to older patients.

Fenestrated and Branched Endografts

Multiple clinical trials have established the safety and efficacy of endovascular aortic aneurysm repair, which has resulted in a major paradigm shift from open to endovascular repair for the treatment of most aortic aneurysms. However, juxtarenal aneurysms (JRAAs) and more complex aneurysms involving the visceral aorta pose a significant challenge to the goals of fixation and seal using standard infrarenal devices. The need for branch vessel preservation and the individual variability of their origins from the aorta add significant complexity to the design, manufacturing, and implantation of endovascular grafts. To address these limitations, fenestrated and branched endografts have been developed that allow fixation and seal above the renal or visceral vessels but maintain perfusion to these branches by aligning fenestrations in the endograft fabric to the origins of these vessels or, in the case of thoracoabdominal aneurysms, providing branches. This review discusses fenestrated and branched endografts, as well as their complications and outcomes. Figures show definitions and examples of complex abdominal aortic aneurysm (AAA), features of the Zenith Fenestrated AAA Endovascular Graft, and features of the Cook Zenith P-branch device, an off-the-shelf fenestrated device under investigation for endovascular repair of JRAA. Tables list Zenith Fenestrated AAA Endovascular Graft indications for use and device components, graft and vessel-sized diameters for fenestrated devices, accessories for fenestrated endovascular repair, and results of reports dealing with fenestrated and branched endografts for juxtarenal and suprarenal AAA. This review contains 12 highly rendered figures, 5 tables, and 53 references. Key words: abdominal aortic aneurysm, branched endograft, complex abdominal aortic aneurysm, endovascular aortic aneurysm repair, fenestrated endograft, juxtarenal aneurysms, suprarenal abdominal aortic aneurysm

Complex EVAR Is Associated With Higher Perioperative Mortality but Not Late-Mortality Compared to Infrarenal EVAR Amongst Octogenarians

An increasing number of elderly patients are being offered endovascular repair of juxtarenal aneurysms. We sought to evaluate outcomes after complex endovascular aneurysm repair (EVAR) compared to infrarenal EVAR in a cohort of octogenarians. A single-center retrospective review was conducted with a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients aged ≥80 years were included. The complex EVAR group was treated with snorkel (Sn-EVAR) or fenestrated (F-EVAR) techniques, whereas infrarenal EVAR consisted of aneurysm repair without renovisceral involvement. Relevant demographic, anatomic/device variables, and clinical outcomes were collected. A total of 105 patients (69 infrarenal, 36 complex) were treated within the study period with a mean follow-up of 22 months. A total of 79 branch grafts were placed (61 renal, 11 celiac, 7 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients with complex EVAR were more likely to be male (83.3% vs 61.1%; P = .019) and have a higher prevalence of renal insufficiency (72.2% vs 44.5%; P = .008). Thirty-day mortality was significantly more common in patients treated with complex EVAR (11.1% vs 0%; P = .012). There were no significant differences in major adverse events (P = .795) or late reintervention (P = .232) between groups. Interestingly, sac growth >10 mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.9%; P = .039). However, both type Ia (5.7% infrarenal; 5.0% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at the latest follow-up (P = .256; Fig). Multivariate Cox modeling demonstrated that AAAs >75 mm in diameter (hazard ratio, 5.1; 95% confidence interval, 1.8-13.9), and renal insufficiency (hazard ratio, 4.45; 95% confidence interval, 1.27-15.6) were the only independent risk factors of late death. Complex EVAR is associated with higher perioperative mortality compared to infrarenal EVAR amongst octogenarians. However, late outcomes are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular therapy to older patients.

Effects of Mentorship on Graduating Vascular Surgery Trainees

Mentorship within surgery, particularly vascular surgery, has not been extensively evaluated. This study sought to examine mentorship experiences in graduating vascular trainees (VTs). An anonymous electronic survey examining current mentor relationships, ideal characteristics, academic productivity, and operative comfort level was emailed to all US graduating 2015 (n=141) and 2016 (n=144) VTs during their last year of training. A parallel survey was emailed to program/associate program directors (PDs) of all US vascular training programs (n=169). Surveys were completed by 65 (38%) PDs and 62 (22%) VTs. Forty-three (69%) VTs identified a mentor with no difference in frequency of having a mentor noted among gender, type of training (fellowship/residency), or geographical region. The majority (41/43, 95%) recognized a vascular surgeon as their mentor; the mentor was assigned to 10 of 43 (23%) trainees and was their PD to 9 of 43 (21%). Ideal mentor characteristics, identified by VTs using 4-point Likert scales, were approachability, supportiveness, and accessibility (3.94, 3.76, and 3.74, respectively), while those of a good mentee were enthusiasm, ethical work, and commitment (3.79, 3.69, and 3.45, respectively). Trainees scored accessibility, approachability, compassion, and same gender significantly higher than PDs as characteristics of ideal mentors (P<0.05). The majority of PDs thought mentorship increased access to research opportunities, professional networking, and job opportunities, but not operative skill (90%, 95%, 65%, and 18%, respectively). There was no difference between trainees with mentors and those without in terms of reported academic productivity or operative comfort level. Vascular fellows reported higher comfort than residents in open abdominal aortic aneurysm repair (3.32 vs. 2.73, P=0.006), juxtarenal aneurysm repair (2.8 vs. 2.1, P=0.02), and aorto-mesenteric bypass (2.57 vs. 1.93, P=0.03), and neither group was comfortable performing carotid stenting or fenestrated endovascular aneurysm repairs. There is no difference in academic productivity or case comfort level between surgical trainees with mentors and those without. Possible benefits identified by PDs and trainees include professional networking and increased research and job opportunities. Mentors should be approachable, accessible, supportive, and ethical, while mentees should be enthusiastic, ethical, committed, and approachable. Vascular fellows feel more comfortable with open vascular operations than residents, and nether group feels comfortable with complex endovascular cases. More research is warranted.

Chimney versus fenestrated endovascular aortic repair for juxta-renal aneurysms

Anatomical constrains, high price and manufacturing delay restrict fenestrated (F)-endovascular aortic repair (EVAR) to elective patients in specialized centers. Chimney graft (CG)-EVAR offers an alternative but uncertainties remain over target vessel's patency and type Ia endoleaks (ELs). We reviewed the literature reporting F-EVAR and CG-EVAR for juxta-renal aneurysms between January 2005 and July 2016. Fifteen studies on F-EVAR, 8 on CG-EVAR and 5 on both techniques were included; 1748 F-EVAR patients (3993 target vessels) vs. 757 (1158 target vessels, 13% symptomatic and 7% ruptured). F-EVAR patients suffered from significantly less comorbidities, technical success was lower (94% vs. 99%; P<0.0001) but with more reconstructed vessels/patient (2.2±0.4 vs. 1.5±0.3; P<0.0001) and 30-day mortality was lower (2% vs. 4%, P=0.02). There were more re-interventions after F-EVAR (20% vs. 8%; P<0.0001); mainly EL (44% vs. 25%) and target vessels related (36% vs. 32%); less type I ELs (1% vs. 6%; P=0.002) but more type III (2% vs. 0%; P<0.0001). The rates of chronic kidney disease (9% vs. 15%; P=0.0002) and dialysis (1% vs. 3%; P=0.007) were lower after F-EVAR, with less target vessel's occlusions (3% vs. 6%; P<0.0001). The meta-analysis on 5 comparative studies supported F-EVAR in terms of 30-day mortality (OR 0.94 [0.25, 3.55]), target vessel's occlusions (OR 2.40 [0.95, 6.06]) and type I EL (OR 0.62 [0.10, 3.93]); and CG-EVAR in terms of technical success (OR 3.28 [0.67, 15.93], type II (OR 1.25 [0.48, 3.28]) and III ELs (OR 1.62 [0.29, 8.94]) and re-intervention (OR 1.77 [0.89, 3.52]) without a significant difference. Current evidence does not support CG-EVAR's widespread use in all elective patients but CG-EVAR seems justified in symptomatic patients, as bailout, or in elective patients who are poor candidates for open repair and F-EVAR.

Renal Outcome After Open Surgery and Fenestrated Endovascular Aneurysm Repair of Juxta-renal Aneurysms

function. 1 New onset of renal insufficiency was detected in 26.5% of the open surgery group and 8.5% of the endovascular group, which was persistent in 11.8% and 5.7%, respectively.Three per cent of the patients in each group required dialysis in the longer term.The rate of renal failure after open repair and after FEVAR in a recent systematic review were 13.9% and 11.4%, respectively, with no difference in the rate of permanent dialysis between the groups (2.8% and 1.9%, respectively). 2 In a propensity-matched comparison, the rates of perioperative renal insufficiency were 2.7% after open repair and 7.1% after FEVAR (p ¼ .1); the FEVAR group were initially considered to be high risk for open surgery. 3 Despite the transient nature of postoperative renal dysfunction, in most cases it remains a significant predictor of mortality in these patients. Serum creatinine is the most commonly reported marker of renal function, but estimated glomerular filtration rate (eGFR) can offer greater functional sensitivity. 4 Renal volume has been assessed in various urological studies as a predictor of graft function in living donor renal transplantation. It can be calculated from computed tomography (CT) data and has been shown in the context of endovascular aneurysm repair to be an early marker of renal dysfunction and to correlate well with eGFR. 5 Renal impairment in FEVAR is related to the nephrotoxicity of the contrast medium, micro- and macro-embolisation into the renal arteries during device manipulation in the aorta, and the inflammatory response associated with the procedure. Carbon dioxide has been used as a contrast medium in patients with renal failure, but it is associated with a high complication rate including right heart strain and fatal nonocclusive mesenteric ischaemia. 6 The repositionability of the Cook and Anaconda stent-grafts is intended to allow better alignment between the device and the renal artery ostia but it may also cause embolisation of athero-embolic material into the renal arteries. Other endovascular considerations include the design of the bridging stents, the amount of flaring of the proximal end, and the anatomy of the renal artery. Aortic cross-clamping during open surgical repair results in renal hypoperfusion and every additional 5 minutes of renal ischaemia time has been shown to double the risk of postoperative renal dysfunction. 7 Clamp placement above both renal arteries, and manipulation of the aorta and renal arteries results in embolisation of material and this effect is compounded by ischaemia-reperfusion injury. Division of the left renal vein increases the risk of renal dysfunction by six times. 7 Perfusion of the renal arteries with cold crystalloid solution may preserve renal function during thoracoabdominal aneurysm repair but is not widely used in juxtarenal aneurysm repair. Imaging surveillance is mandatory after FEVAR but repeated CT angiography exposes the patient to nephrotoxic iodinated contrast agent. Studies investigating the effect of different CT contrast agents on renal kinetics and renal oxygenation have shown that low osmolar compared with iso-osmolar contrast agents have a superior profile regarding rapid excretion, short-term renal exposure, and renal oxygenation. 8 Surveillance is currently changing from repeated CT angiography to immediate post-EVAR cone-beam CT in the hybrid room with ultrasound performed prior to hospital discharge. 9 CT angiograms are then performed at years 1 and 3 in the presence of good renal function with ultrasound performed annually. Ultrasound provides a hemodynamic evaluation of the bridging stents and target vessels, and the CT images are used to verify device integrity and positioning. Contrast-enhanced ultrasound has been shown to be as accurate as CT scan in detecting endoleaks and in assessing both target vessel patency and aortic diameter after fenestrated endovascular repair. 10 Future work should be directed towards investigation of potential biomarkers to predict risk, prognosis, and therapeutic response in patients with acute kidney injury. Renal impairment should be assessed with eGFR, which is a sensitive and reliable measure of renal function. Definite evidence of a difference between open surgical repair and FEVAR would require a randomised controlled trial and long term followup of 5e10 years.

Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms

The practice of using fenestrated endografts to treat juxtarenal and group IV thoracoabdominal aortic aneurysms (TAAAs) has become more accepted, but long-term outcomes are still unknown. We report long-term survival, complications, and branch-related outcomes from a single-center experience. The study included consecutive patients enrolled prospectively into a physician-sponsored investigational device exemption classified as undergoing group IV TAAA or juxtarenal aneurysm repair by the treating surgeon using fenestrated endografts. Device morphology was used to subclassify this group of patients. Long-term survival and a composite outcome of secondary intervention, branch occlusion, stent migration, endoleak, aneurysm growth, or spinal cord injury were calculated. Descriptive analysis of branch-related outcomes and need for any reintervention was performed. Univariate and multivariate analysis of mortality and the composite outcome was performed to determine associative risks. Long-term survival for patients with juxtarenal and group IV TAAA aneurysms treated with fenestrated stent grafts was 20% at 8 years. Multivariate analysis showed long-term survival for this patient population was negatively associated with increasing age, congestive heart failure, cancer, and previous aneurysm repair. The risk of spinal cord ischemia (SCI) in this group was 1.2% and of aortic-related mortality was 2%. The risk of a spinal event increased with coverage above the celiac artery (52 mm of coverage above the celiac artery in patients with SCI vs 33 mm without SCI; P = .099). More complex device configurations were more likely to require an increased rate of reinterventions, and patients with celiac fenestrations were more likely to experience celiac occlusion over time (3.5% vs 0.5%; P = .019). However, less complex designs were complicated by an increased risk of type I endoleak over time (10.4% for renal fenestrations only vs 1.9% for others; P < .01). As experience evolved, there was a trend to increase the number of fenestrations in devices treating the same anatomy. The use of fenestrated devices to treat juxtarenal and group IV TAAA is safe and effective in long-term follow-up. Mortality in this patient population is largely not aortic-related. Devices designed for fenestrated repair of juxtarenal and group IV thoracoabdominal aneurysms within a physician sponsored investigational device exemption have changed over time. Further research is needed to determine the best configuration to treat aneurysms requiring coverage proximal to the celiac artery.

Elective endovascular aortic repair conversion for type Ia endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair

Type Ia endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to outcomes of elective OSC for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair (OJAR) to determine if these concerns are warranted. From 2000 to 2012, 54 patients underwent EVAR OSC at median time of 27 months (interquartile range, 9-55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]). Because many OSCs are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective OJAR cohort matched by anatomy and comorbidities. Primary end points were 30-day and 1-year mortality. Secondary end points included early complications, cross-clamp time, procedure time, blood loss, and length of stay. Demographic and comorbidity data in the OSC and OJAR groups did not differ, with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a nontube graft repair (OSC, n = 20 [80%] vs OJAR, n = 6 [24%]; P = .0002), required longer procedure times (P = .03), and received more plasma transfusions (P = .03). The 30-day mortality was 4% in both groups (observed difference in rates, 0%; 95% confidence interval for difference in mortality rates, -14.0% to 14.0%; P = 1). A similar rate of major complications occurred (OSC, n = 9 [36%] vs OJAR, n = 8 [32%]; P = 1). One-year survival was 83% in OSC and 91% in OJAR (observed difference, 7%; 95% confidence interval, -15% to 29%; P = .65). Despite many advances in EVAR technology, the need for OSC persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.

EVAR Conversion for Type 1a Endoleak is not associated with Increased Morbidity or Mortality Compared with Primary Juxtarenal Aneurysm Repair

Objectives Type 1a endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to determine outcomes of elective open conversion for type 1a endoleak and compare them to elective primary open juxtarenal aortic repair (OJAR) to determine if these concerns are warranted.