Thoracoabdominal Aneurysm Repair Research Articles

Center-level Outcomes Following Elective Fenestrated Endovascular Aortic Aneurysm Repair in the Vascular Quality Initiative Database

Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, post-operative outcomes and 1-year survival following B-FEVAR. Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair (TEVAR)/complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test and mixed effects Cox regression were used to evaluate 1-year survival. A total of 4,302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (Q1=35/1059 (3.3%), Q2=30/1063 (2.8%), Q3=33/1120 (2.9%), and Q4=44/1060 (4.2%), p = 0.308). The high volume group had a higher rate of major complication (Q1=14.9%, Q2=12.8%, Q3=13.3%, and Q4=20.1%, adjusted p < 0.001). Physician modified grafts were more frequently employed in high-volume centers (Q1=4.5%, Q2=18.7%, Q3=11.3%, and Q4=19.2%, p < 0.001) with a decreased incidence of any endoleak noted at the end of the procedure (Q1=34.9%, Q2=32.8%, Q3=30.0%, and Q4=29.0%, p = 0.003). In the multivariable analysis, in-hospital mortality was not associated with center volume comparing very low volume to medium and high volume centers (OR [95% CI] vs Q4: Q1 =1.1 [0.6-1.9], Q2 =0.6 [0.4-1.1], and Q3 =0.9 [0.5-1.5], p all >0.05). No significant difference was found in 1-year survival between center-volume groups. In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Intravascular Iliac Artery Lithotripsy to Facilitate Aortic Endograft Delivery: Midterm Results of a Dual-Center Experience.

To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries. Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed. Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17-36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up. This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results. In this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to "paving and cracking" and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

Parallel intercostal artery stenting and exclusion of symptomatic bucket-handle intercostal patch aneurysm

Intercostal patch aneurysms after open thoracoabdominal aneurysm repair represent a challenging pathology, with highly variable patient anatomy and spinal cord ischemia risk. We present a case of a 51-year-old man with a large symptomatic “bucket-handle” loop graft intercostal patch aneurysm, which was treated with endovascular exclusion with concurrent parallel intercostal stent grafting. This case highlights specialized endovascular techniques to treat intercostal patch aneurysms and the necessity of meticulous operative case planning in both open and endovascular thoracoabdominal aneurysm repair.

Thoracoabdominal aneurysm repair using the Unitary Manifold Device

ObjectiveTo present a single-center prospective study of 126 consecutively treated patients who underwent endovascular repair of a thoracoabdominal aortic aneurysm with the physician-modified, nonanatomic-based Unitary Manifold (UM) device. MethodsData were collected from 126 consecutive all-comer patients treated with the physician-modified, nonanatomic-based UM from 2015 to 2023. Treatment was performed at a single center by a single physician under a Physician Sponsored Investigation Exemption G140207. ResultsThe UM was indicated for repair of all Crawford extents including juxtarenal, pararenal, and short-neck infrarenal aneurysms (<10 mm) in 126 consecutive patients. Patients were not excluded from the study based on presentation, extent of aneurysm or dissection, or history of a spinal cord event. Patients with a thoracoabdominal aortic aneurysm were categorized by Crawford classification: types I and V (3.3%, n = 4), type II (3.3%, n = 4), type III (1%, n = 1), and type IV (93.3%, n = 117). The type IV classification patients were further categorized with 33 (28.2%) true type IV, 68 (58.1%) pararenal or infrarenal, and 16 (13.7%) with dissection. Technical success was 99.2% (n = 125). The most common major adverse event within both 30 days and 365 days of all patients was respiratory failure (11.9%, n = 15, and 13.5%, n = 17, respectively). One patient (0.8%) experienced persistent paraplegia at 365 days. Reintervention for patients at 365 days was 5.6% (n = 7). Of the 444 branches stented, the primary patency rate was remarkably high as only three patients (2.4%) required reintervention due to loss of limb patency within 365 days. Aneurysm enlargement (≥5 mm) occurred in 1.6% (n = 2) patients, and no patients experienced aneurysm rupture. No patients underwent conversion to open repair. The aneurysm-related mortality at 365 days for all patients was 4.0% (n = 5), whereas all-cause mortality was 16.7% (n = 21). Physician-modified endograft device integrity failure was not observed in any patient. ConclusionsThe UM device demonstrated remarkable technical surgical success, treatment success, and device patency rates with very reasonable major adverse events and reintervention rates. This study is the most representative example of the general population in comparison with other studies of off-the-shelf devices, with 126 consecutive all-comer patients with diverse pathologies.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score.

Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs are Associated With Outcomes

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs are Associated With Outcomes

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access.

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.

The Elevator Technique: A New Bailout Maneuver to Achieve Target Vessel Patency During Challenging BEVAR.

The purpose of the study is to describe a new bailout maneuver for use during branched endovascular thoracoabdominal aneurysm repair (BEVAR) while dealing with challenging target vessel cannulation. A 54-year-old woman underwent urgent BEVAR with a low-profile T-branch device to exclude a type 2 thoracoabdominal aneurysm (TAAA). The endovascular procedure was challenging because the left renal artery ostium was covered by the endograft fabric, compounded by diseased target vessels. A novel bailout maneuver is described. After angioplasty of the left renal artery (LRA), the LRA remained precannulated and a low-profile T-branch was implanted. The 3 proximal branches (superior mesenteric artery, inferior mesenteric artery, and the right renal artery) were connected to their respective target vessels swiftly with a steerable sheath from a femoral approach. Access to the left renal artery was not achieved because it was obstructed by the fully deployed endograft. We subsequently stented the LRA over the "pre-positioned buddy wire," using a balloon-expandable covered stent protruding inside the aneurysm lumen. The proximal stent was then flared and lifted upward using an 8.5 Fr steerable sheath, which made cannulation and stenting of the LRA through the side-branch from above finally achievable. The elevator technique described in this article will help achieve technical success in challenging BEVAR cases. We describe in this technical note the "elevator technique" that will complement the "Snare-Ride" and "Balloon Anchoring" techniques over a buddy wire positioned in a target vessel, to provide successful bailout options for challenging TV cannulations during BEVAR.After failed access to the renal artery through the renal branch, a covered stent was implanted in the renal artery over the buddy wire with 10 mm protruding into the aortic lumen. This stent was then flared, prior to advancing a curved steerable sheath into the stent, which shaped it with a superior-facing funneled aortic segment. This maneuver resulted in the renal stent facing its corresponding branch, finally easy to access from the endograft lumen.

A multidisciplinary multistage complete mega aorta replacement and utilization of extracorporeal membrane oxygenation in thoracoabdominal aneurysm repair.

A 49-year-old woman underwent a 11-month multistage complete replacement of a mega aorta. Replacement stages included ascending aorta and arch replacement in conjunction with a frozen elephant trunk thoracic endovascular aortic repair, extension of thoracic endovascular aortic repair to zone 5, and open repair of the thoracoabdominal aneurysm with the use of venoarterial extracorporeal membrane oxygenation for circulatory support. This case illustrates the complexity of repairing a mega aorta, the multidisciplinary care and staging needed for repair, and the use of peripheral venoarterial extracorporeal membrane oxygenation for circulatory perfusion during thoracoabdominal aneurysm repair.

In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms

In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms

Further research is warranted to identify optimal bridging stent and antiplatelet regimens following fenestrated/branched repair of thoracoabdominal aneurysms

Further research is warranted to identify optimal bridging stent and antiplatelet regimens following fenestrated/branched repair of thoracoabdominal aneurysms

Renal Artery Reimplantation Versus Bypass in Elective Open Aneurysm Repair

Complex open abdominal aortic aneurysm (AAA) repair often necessitates revascularization of renal arteries by either renal artery reimplantation or bypass. This study aims to evaluate the perioperative and short term outcomes between these two strategies of renal artery revascularization. We performed a retrospective review of patients who underwent open AAA repair from 2004-2020 at our own institution. Patients who underwent elective suprarenal, juxtarenal, or type 4 thoracoabdominal aneurysm repair were identified using current procedural terminology (CPT) codes as well as a retrospectively maintained database of AAA patients. Patients who had symptomatic aneurysm or significant renal artery stenosis prior to AAA repair were excluded. Patient demographics, intraoperative conditions, renal function, bypass patency and perioperative and postoperative outcome at 30 days and 1 year were compared. 143 patients underwent either renal artery reimplantation (n=86) or bypass (n=57) during this time period. The mean age was 69.7 years and 76.2% of the patients were male. Median preoperative creatinine was 1.2 mg/dL for the renal bypass group vs 1.06 mg/dL for reimplantation (P=0.088). Both groups had similar median preoperative glomerular filtration rate (GFR) of >60 mL/min (P=0.13). Bypass and reimplantation groups had similar perioperative complications including acute kidney injury (51.8% vs 49.4% P=0.78), inpatient dialysis (3.6% vs 1.2% P=0.56), myocardial infarction (1.8% vs 2.4% P=0.99), and death (3.5% vs 4.7% P=0.99), respectively. During the 30 day follow-up period, renal artery stenosis was identified in 9.8% of bypasses and 6.7% of reimplantations (P=0.71). 6.1% of patients in the bypass group had renal failure requiring dialysis (both acute and permanent) compared to 1.3% in reimplantation group (P=0.3). For those who had 1 year follow up, the reimplantation group had higher new incidence of renal artery stenosis compared to bypass group (6 vs. 0 p=0.16). Given that there is no significant difference in outcomes between renal artery reimplantation and bypass within 30 days or at 1 year follow-up, both bypass and re-implantation are acceptable means for renal artery revascularization during elective AAA repair.

New Preloaded System for Renal and Visceral Arteries in Fenestrated Endografting.

The New Preloaded System (NPS) for renal/visceral arteries (TVVs) is an emerging technology in fenestrated endografting (FEVAR) that allows TVVs cannulation and stenting through the same access of the endograft main body. However, only few preliminary experiences are currently available in the literature. The aim of this study is to report the outcomes of NPS-FEVAR in juxta/para-renal (J/P-AAAs) and thoracoabdominal (TAAAs) aneurysms repair. This is a prospective (NCT05224219), single-center/observational study of patients submitted to NPS-FEVAR for J/PAAAs and TAAAs between 2019 and 2022 (July). Definitions and outcomes were evaluated according to the current SVS-reporting standard. Technical success (TS) and TS preloaded related, spinal cord ischemia (SCI), and 30-day mortality were assessed as early endpoints. Survival, freedom from reinterventions (FFRs), and freedom from TTVs-instability (FFTVVs-instability) were analyzed during follow-up. Among 157 F/B-EVAR cases, 74 (47%) NPS-FEVAR were planned and enrolled in the study [48 (65%) J/P-AAAs; 26 (35%) TAAAs]. The main indication for NPS-FEVAR was the presence of a hostile iliac axis (54%-73%) or the necessity of expeditious pelvic/lower-limb reperfusion for SCI prevention in TAAAs (20%-27%). Overall, 292 TVVs were accommodated by 289 fenestrations and 3 branches; 188 of 289 (65%) fenestrations were preloaded. NPS-FEVAR configuration was from "below" and "from below to above" in 28 (38%) and 46 (62%) cases, respectively. TS and TS preloaded system-related was 96% (71/74) and 99% (73/74), respectively. Target visceral vessels patency at the completion angiography was 99% (290/292). Failures were 2 renal arteries loss and 1 massive bleeding from a percutaneous closure system breakage. The latter patient developed postoperative multiorgans failure and died on the fifth postoperative day, causing only 30-day/in-hospital mortality (1.3%). One (1.3%) patient with a JAAA and preoperative bilateral occlusion of the hypogastric arteries suffered SCI. The median follow-up was 14 (IQR: 8) months. The estimated 3-year survival was 91% with no aneurysm-related mortality during follow-up. The estimated 3-year FFR and FFTVVs-instability were 85 and 92%, respectively. New preloaded system FEVAR is a safe and effective option in the treatment of J/PAAAs and TAAAs in the presence of hostile iliac access or to guarantee an expeditious pelvic/lower limb reperfusion, leading to satisfactory results in terms of TS, early and mid-term clinical outcomes. New preloaded system for fenestrated and branched endografting allows to increase the feasibility of the advanced endovascular aortic repair in challenging iliac access, thoracoabdominal aneurysm repair and reduce difficulties in target visceral vessels cannulation.

Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms

ObjectiveSpinal cord ischemia (SCI) is a devastating complication after thoracoabdominal aortic aneurysm (TAAA) repair. The benefit of prophylactic cerebrospinal fluid drainage (pCSFD) to prevent SCI is still under investigation. The aim of this study was to evaluate the SCI rate and the impact of pCSFD following complex endovascular repair (fenestrated or branched endovascular repair [F/BEVAR]) for type I to IV TAAA. MethodsThe STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A single-center retrospective study was conducted, including all consecutive patients, managed for TAAA type I to IV using F/BEVAR, between January 1, 2018, and November 1, 2022, for degenerative and post-dissection aneurysms. Patients with juxta- or pararenal aneurysms were excluded, as well as cases managed urgently for aortic rupture or acute dissection. After 2020, pCSFD in type I to III TAAAs was abandoned and replaced by therapeutic CSFD (tCSFD), performed only in patients presenting SCI. The primary outcome was the perioperative SCI rate for the entire cohort and the role of pCSFD for type I to III TAAAs. ResultsIn total, 198 patients were included (mean age, 71.1±3.4 years; 81.8% males), including 50.5% with type I to III TAAA. The primary technical success was 94.9%. The perioperative mortality was 2.5%. and the major adverse cardiovascular event (MACE) rate was 10.6%; 4.5% presented SCI of any type (2.5% paraplegia). When comparing the SCI group with the remaining cohort, patients with SCI presented higher MACE (66.7% vs 7.9%; P < .001) rate and longer intensive care unit stay (3.5 vs 1 day; P = .002). Following type I to III repair, similar SCI, paraplegia, and paraplegia with no recovery rates were reported in the pCSFD and tCSFD groups (7.3% vs 5.1%; P = .66; 4.8% vs 3.3%; P = .72; and 2% vs 0%; P = .37). ConclusionsThe incidence of SCI after TAAA I to IV endovascular repair was low. SCI was associated with significantly increased MACE and intensive care unit stay. The prophylactic use of CSFD in type I to III TAAAs was not associated with lower SCI rates and may not be justified routinely.

Usefulness of the H-Reflex for Intraoperative Monitoring of Thoracoabdominal Aneurysms.

Intraoperative neurophysiologic monitoring in thoracoabdominal aneurysms (TAAA) is essential to avoid intraoperative spinal cord injury). Motor and somatosensory evoked potentials may be considered intraoperative tools for detecting spinal cord injury. H-reflex is a well-known neurophysiologic technique to evaluate L5-S1 root. Current evidence supports the observation that H-reflex changes may occur with spinal cord damage as high as the cervical level. This study aimed to evaluate the usefulness of the H-reflex in these surgeries. The use of intraoperative H-reflex in TAAA monitoring was evaluated in 12 patients undergoing open or endovascular repair of TAAA for a period of four years (2016-2020) using somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) and bilateral H-reflex. Six neurophysiologic alarms were recorded in five of the 12 patients. Summarizing the neurophysiologic changes of our series, we considered a peripheral change when we detected a unilateral loss of SSEPs, TcMEPs, and H-reflex. Instead, we assumed a central change when we detected a unilateral or bilateral loss of TcMEPs and H-reflex with normal SSEPs, which we considered a sign of spinal cord ischemia. Interestingly H-reflex always changed significantly in combination with TcMEPs in the same fashion. According to our series, H-reflex can detect intraoperative changes with the same sensitivity as TcMEPs in TAAA surgeries. With the support of other techniques, it can be useful to localize the origin of the lesion (peripheral or central spinal cord), to help in surgical decision-making to avoid postoperative neurologic damage. Based on our results, we recommend the systematic use of H-reflex in TAAA surgeries.

In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms

ObjectiveTo compare costs and effectiveness of elective open (OR) vs fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAAs) in a high-volume center. MethodsThis single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger health technology assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. End points were clinical success, major adverse events (MAEs), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value and incremental cost-effectiveness ratio were calculated, considering the absence of MAEs as a measure of effectiveness. ResultsPropensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, P = .048; 60% vs 17%, P < .001; 10% vs 3%, P = .045; 91% vs 18%, P < .001; 16% vs 6%, P = .024; 27% vs 6%, P < .001, respectively). Access complication rate (6% vs 27%; P < .001) was higher in the ER group. Intensive care unit stay was longer (P < .001) for OR, and ER patients were discharged home more frequently (3% vs 94%; P < .001). No differences in midterm end points were observed at 2 years. Despite ER reducing all the hospital cost items (−42% to −88%, P < .001), the higher expenses (P < .001) of the endovascular devices increased the overall cost of ER by 80%. Cost-effectiveness value for ER was favorable to OR (56,365 vs 64,903 €/patient) with an incremental cost-effectiveness ratio of 48,409 € per MAE saved. ConclusionsER of TAAA reduces perioperative mortality and morbidity compared with OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER was found to be more cost-effective in preventing MAEs.

Aneurysm extent-based mortality differences in complex endovascular repair of thoracoabdominal aneurysms in the Vascular Quality Initiative and the United States Aortic Research Consortium

BackgroundEndovascular management of thoracoabdominal aneurysms (TAAA) is becoming more common. Technological advances including custom devices under the Physician-Sponsored Investigational Device Exemption (PS-IDE), physician-modified endografts (PMEG), and parallel stenting techniques have expanded the extent of disease that is amenable to endovascular treatment. Patients within the PS-IDE studies are a highly selected group of patients, whereas patients treated with PMEG as captured within the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) represent a real-world experience. Research within both the SVS VQI on PMEG and the US Aortic Research Consortium (US-ARC) has demonstrated a relationship between extent of aneurysmal disease and mortality after complex endovascular TAAA repair, but no direct comparison of these cohorts has been conducted. In this study, we sought to compare outcomes of custom PS-IDE devices with off-label uses of commercially available devices for the endovascular management of TAAAs. MethodsA retrospective review of patients presenting for elective endovascular TAAA repair for asymptomatic disease between 2011 and 2019 was conducted within both the SVS VQI registry and the US-ARC. Patients within the SVS VQI registry were treated with either PMEG or with parallel stenting techniques. Patients within the US-ARC were treated with PS-IDE custom devices. The extent of aneurysm disease was defined by the deployment zones documented for the devices entered in the registry using Crawford extents I to V. Primary outcomes were 30-day and 1-year mortality rates. ResultsA total of 3212 patients were included in the study: 1571 PMEG/parallel stenting within the VQI registry and 1641 with PS-IDE within the US-ARC database. The majority of patients presented with extent IV aneurysms (n = 1827 [57%]), with extent IV aneurysms being slightly more prevalent within the US-ARC cohort. Maximal aneurysm diameter within each extent did not vary between the US-ARC and VQI cohorts. Across all patients, the 30-day mortality was 4.4% and the 1-year mortality was 12.2%. Unadjusted mortality at 30-days was 6.7% within the VQI, and 2.2% in the US-ARC (P < .001). The unadjusted 1-year mortality was 14.3% within the VQI and 10.2% within the US-ARC (P < .001). When adjusted for aneurysm extent, similar differences in 30-day and 1-year survivals were identified. ConclusionsPatients treated in PS-IDE studies had better 30-day and 1-year survival rates compared with those treated with a similar extent of disease using off-label approaches in a real-world registry. These differences are complex and likely associated with a number of factors, including arterial anatomy, patient comorbidities, device construct, and volume outcomes, as well as complex and unmeasurable surgeon- and patient-specific factors.

Endovascular Treatment of Chronic Aneurysmal Aortic Dissection: In Search of Effective Repairs

Management of aneurysms in the setting of chronic Type B aortic dissections still represents one area that leaves much to be desired. As the authors and others have pointed out, 20–50% of dissection patients will have aneurysmal degeneration with up to 40% of medically managed patients requiring an intervention and two-thirds of those due to aneurysmal degeneration. 1 Durham C.A. Aranson N.J. Ergul E.A. et al. Aneurysmal degeneration of the thoracoabdominal aorta after medical management of type B aortic dissection. J Vasc Surg. 2015; 62: 900-906 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Traditional open surgery is not an easy feat for both the patient and operator with high complication rates. 2 Conrad M.F. Crawford R.S. Davison J.K. et al. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007; 83: S856-S861 Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar Much effort has been spent searching for an acceptable endovascular solution to this problem but these suffer from both a lack of the necessary technology and the technically demanding nature of the case. Many of the challenges to endovascular treatment stem from the dual lumens, multiple entry points, lack of distal seal zones, and difficult access and angles to the visceral vessels. 3 Kuzniar M.K. Wanhainen A. Tegler G. et al. Endovascular treatment of chronic aortic dissection with fenestrated and branched stent grafts. J Vasc Surg. 2021; 73: 1573-1582 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Treatment of thoracoabdominal aortic aneurysmal degeneration following aortic dissections at a single surgical center using a physician-assembled branched endovascular stent graftAnnals of Vascular SurgeryPreviewAneurysmal degeneration of aortic dissection portends significant morbidity and mortality consequences in the subacute and chronic phases of aortic dissection. This paper describes the use of a multi-branched stent graft system for the treatment of thoracoabdominal aneurysmal degeneration of dissections with visceral segment involvement and reports upon the 30-day and one-year outcomes for the first 18 patients treated with this design configuration. Full-Text PDF

Monocentric Evaluation of Physician-Modified Fenestrations or Parallel Endografts for Complex Aortic Diseases.

This study aimed to investigate the demographic and anatomic characteristics, as well as perioperative and follow-up results of fenestration and parallel techniques for the endovascular repair of complex aortic diseases. A retrospective study was conducted on 67 consecutive patients underwent endovascular treatment for complex aortic diseases including abdominal aortic aneurysm (AAA), thoracoabdominal aneurysm (TAAA), aortic dissection, or prior endovascular repair with either fenestrated and parallel endovascular aortic repair (f-EVAR or ch-EVAR) at a single institute from 2013 to 2021. Choices of intervention were made by the disease' emergency, patients' general condition, the anatomic characteristics, as well as following the recommendation from the devices' guidelines. Patients' clinical demographics, aortic disease characteristics, perioperative details, and disease courses were discussed. Short- and mid-term follow-up results were obtained and analyzed. Endpoints were aneurysm-related and unrelated mortality, branch instability, and renal function deterioration. Totally, 34 and 27 patients received f-EVAR and ch-EVAR, while 6 patients received a combination of both. Fenestrated endovascular aortic repair was conducted mainly in AAA affecting visceral branches and TAAA, whereas ch-EVAR was normally utilized for infrarenal AAA. Regarding the average number of reconstructed arteries per patient, there was a significant difference among f-EVAR, ch-EVAR, and the combination group (mean = 2.3 ± 0.9, 1.4 ± 0.6, 3.5 ± 0.5, p<0.001). Primary technical success was achieved in 28 (82.4%), 22 (81.5%), and 3 (50.0%) patients for each group. Besides operational time (5.77 ± 2.58, 4.47 ± 1.44, p=0.033), no significant difference was observed for blood transfusion, intensive care unit (ICU) or hospital stay, blood creatinine level, 30-day complications, or follow-up complications between patients undergoing f-EVAR or ch-EVAR. Patients receiving combination of both techniques had a higher rate of blood transfusion (p=0.044), longer operational time (p=0.008) or hospital stay (p=0.017), as well as more stent occlusion (p=0.001), endoleak (p=0.004) at short-term and a higher rate of endoleak (p=0.023) at mid-term follow-up. In conclusion, this study demonstrated that f-EVAR and ch-EVAR techniques had acceptable perioperative and follow-up results and should be considered viable alternatives when encountering complex aortic diseases. This study sought to investigate the baseline and pathological characteristics, as well as perioperative and follow-up results of f-EVAR and ch-EVAR at a single Chinese institution. F-EVAR (mostly physician-modified f-EVAR) was applied in patients with a wide range of etiologies and disease types, while ch-EVAR was preferred for AAA in older patients with an average higher ASA grade. Our experience suggested acceptable safety and efficacy both for techniques, and no significant difference was observed between the two groups regarding any short or mid-term adverse events.

Urinary neprilysin - Another marker to predict postoperative acute kidney injury.

Dear Editor, Perioperative acute kidney injury (AKI) is a serious complication which is multifactorial, which leads to increased hospital and intensive care unit stay, possibility of chronic kidney disease and hemodialysis, increased cost of treatment, significant morbidity, and mortality. Neprilysin or neutral endopeptidase (NEP) is a single-pass membrane glycoprotein with zinc-dependent endopeptidase activity and a short cytosolic tail. NEP is found predominantly within the kidneys, gastrointestinal tract, liver, male genital organs, lungs, adipose tissue, brain, and heart. The renal brush border of proximal tubule on the luminal side is rich in membrane-bound NEP. NEP is involved in the degradation of both atrial and B-type natriuretic peptides, adrenomedullin, endothelin-1 and angiotensin II, and also nonvasoactive peptides, such as glucagon, glucagon-like peptide, enkephalins, and somatostatin. Circulating NEP estimation in serum has been used as a biomarker in acute and chronic heart failure patients for predicting cardiovascular death and time-to-first admission for an acute event.[1] The prospective comparison of angiotensin receptor neprilysin inhibitor with angiotensin-converting enzyme (ACE) inhibitor (ACEi) to determine impact on global mortality and morbidity in heart failure (PARADIGM-HF) study reported significant clinical benefits with the combination of an angiotensin receptor blocker valsartan with a neprilysin inhibitor sacubitril over ACEi in heart failure with reduced ejection fraction.[2] However, trends of serum NEP could never correlate NT-pro-BNP and even clinically. In AKI, NEP is flushed out from the kidneys due to shedding of the tubular brush border and thus is available for estimation in the urine as a marker. Bernardi et al.[3] conducted a prospective, observational cohort study involving 96 patients undergoing elective cardiac surgeries with cardiopulmonary bypass. They estimated urinary neprilysin levels in the immediate postoperative period and on day 1. The authors concluded that estimation of urinary neprilysin levels after cardiac surgeries has comparable discriminatory power to presently studied AKI biomarkers and has potential as a biomarker for the early detection of AKI after cardiac surgery. Pajenda et al.[4] analyzed urinary neprilysin levels of 90 critically ill patients admitted to intensive or intermediate care unit over 2–5 days. On analysis, they found that NEP levels who suffered AKI according to the KDIGO (Kidney Disease Improving Global Outcomes) criteria were significantly elevated in comparison to healthy controls. In a comparative study performed by Gutta et al.[5] between 20 nondiabetics and 40 diabetic patients, authors compared urinary ACE2, NEP, disintegrin and metalloproteinase 17 (ADAM17) between two groups. The authors concluded that urinary ACE2 and NEP can be used as early biomarkers to predict the incidence or progression of chronic kidney disease at early stages among individuals with type 2 diabetes. The normal values of urinary neprilysin derived from recent studies are in the range of 0.5–1 ng/mL. To conclude, urinary NEP needs to be validated with adequately powered randomized controlled studies in various postoperative scenarios like thoraco-abdominal aneurysm repair, major laparotomies including cytoreductive surgeries and heated intraperitoneal chemotherapy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.