Treatment Of Juxtarenal Aortic Aneurysms Research Articles

Early multicentric outcomes of the on-label and CE-marked combination of the Endurant with the Radiant chimney graft for the chimney endovascular aortic repair (EnChEVAR): The LaMuR Registry.

The aim of this study was to evaluate the early results of the CE-marked standardized device combination consisting of Endurant and the Radiant chimney graft (En-ChEVAR) for the treatment of juxtarenal aortic aneurysms. We analyzed multicentric non-industry sponsored case series evaluating the EnChEVAR technique for patients treated between December 2022 and February 2024. Clinical, perioperative procedure-related and radiological data were collected. The primary outcome measure was the freedom of a type Ia gutter-related endoleak at postoperative computed tomography angiography (CTA). Secondary outcome measures included early type Ia endoleak-related reinterventions, target vessel complications including dissection or loss of target vessel, major adverse events, and mortality. Continuous variables were presented as median (interquartile range [IQR]) and categorical variables as count and percentage. Ten patients were included in the present study. Eight (80%) were males, in nine cases a single chimney was implanted, and the other one was a double chimney graft placement. The treated aneurysms had an infrarenal neck length of 3.4 (1.2) mm. The rate of main body oversizing was 30%. The new neck length after chimney graft placement was 18 (3) mm. The median procedural time was 130 (17) mm, contrast medium use was 109 (26) mL, radiation time was 45 (12) min. The technical success was 100%. No type Ia endoleak was detected at the postoperative CTA. There were no target vessel issues. No major adverse events or death were observed. First reported cohort of patients treated with EnChEVAR demonstrated reproducible clinical and procedural outcomes within the 3 vascular centers with total exclusion of the aneurysms, patent renal arteries, and no evidence of gutter-related type IA endoleak. Further evidence with larger sample size of treated patients and longer follow-up are needed.

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.

Reinterventions after physician-modified endovascular grafts for treatment of juxtarenal aortic aneurysms are non-detrimental to long-term survival

ObjectiveReintervention after endovascular aortic aneurysm repair is common. However, their frequency and impact on mortality after physician-modified endografts (PMEGs) is unknown. This study aims to describe reinterventions after PMEG for treatment of juxtarenal aneurysms and their effect on survival. MethodsData from a prospective investigational device exemption clinical trial (Identifier #NCT01538056) from 2011 to 2022 were used. Reinterventions after PMEG were categorized as open or percutaneous and major or minor by Society for Vascular Surgery reporting standards and as high or low magnitude based on physiologic impact. Reinterventions were also categorized by timing, based on whether they occurred within 30 days of PMEG as well as within 1 week of PMEG. Survival was compared between patients who did and did not undergo reintervention and between reintervention subcategories. ResultsA total of 170 patients underwent PMEG, 50 (29%) of whom underwent a total of 91 reinterventions (mean reinterventions/patient, 1.8). Freedom from reintervention was 84% at 1 year and 60% at 5 years. Reinterventions were most often percutaneous (80%), minor (55%), and low magnitude (77%), and the most common reintervention was renal stenting (26%). There were 10 early reinterventions within 1 week of PMEG. Two aortic-related mortalities occurred after reintervention.There were no differences in survival between patients who underwent reintervention and those who did not. However, survival differed based on the timing of reintervention. After adjusted analysis, reintervention within one week of PMEG was associated with an increased risk of mortality both compared with late reintervention (hazard ratio, 11.1; 95% confidence interval, 2.7-46.5) and no reintervention (hazard ratio, 5.2; 95% confidence interval, 1.6-16.8). ConclusionsReinterventions after PMEG were most commonly percutaneous, minor, and low magnitude procedures, and non-detrimental to long-term survival. However, early reinterventions were associated with increased mortality risk. These data suggest that a modest frequency of reinterventions should be expected after PMEG, emphasizing the critical importance of lifelong surveillance.

Reintervention does not affect long-term survival after fenestrated endovascular aneurysm repair.

Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine whether REI affects long-term survival after FEVAR. A single-institution retrospective review of all Cook Zenith fenestrated (ZFEN; Cook Medical, Inc, Bloomington, IN) repairs was performed. Patients with ≥6months of follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized as early (<30days) or late (≥30days), by indication (ie, branch, endoleak, limb related, access related, other), and by target branch or device components. Patients were stratified into REI vs no REI groups and branch REI vs non-branch REI groups. Of 219 consecutive ZFEN repairs from 2012 to 2021, 158 patients met the inclusion criteria. Of these 158 patients, 41 (26%) required a total of 51 REIs (10 early and 41 late) during a mean follow-up of 33.9months. The most common indication for REI was branch-related (31 of 51; 61%), with the renal arteries the most frequently affected (26 of 51; 51%). The only differences found in baseline, aneurysm, and device characteristics were a higher mean Society for Vascular Surgery comorbidity score (9.6 vs 7.9; P= .04) and larger suprarenal neck angle (23.3° vs 17.1°; P= .04) in the no REI group. In contrast, the REI group had a larger mean proximal seal zone diameter (26.3mm vs 25.1mm; P= .03) and device diameter (31.9mm vs 30.0mm; P= .002) compared with the no REI group. Technical success and operative characteristics were similar between the groups, except for a longer mean fluoroscopy time (74.9minutes vs 60.8minutes; P= .01) and longer median length of stay (2 vs 2days; P= .006) for the REI group. Although the rate of early (<30days) major adverse events was greater for the REI group (24.4% vs 6.0%; P= .001), the difference in 30-day mortality was not statistically significant (4.9% vs 0.9%; P= .10). On Kaplan-Meier analysis, freedom from REI at 1 and 5years was 85.7% and 62.6%, respectively, for the overall cohort. No difference was found in the estimated 5-year survival between the REI and no REI groups (62.8% vs 63.5%; log-rank, P= .87) and branch REI and non-branch REI groups (71.8% vs 49.9%; log-rank, P= .16). On multivariate analysis, REI was not an independent predictor for mortality. However, age, Society for Vascular Surgery comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.02-1.12 [P= .007]; HR, 1.10; 95% CI, 1.01-1.18 [P= .02]; HR, 1.05; 95% CI, 1.02-1.08 [P= .003], respectively). After ZFEN, 41 patients (26%) had required a total of 51 REIs, with most occurring ≥30days after the index procedure, and 61% were branch related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. The use of FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs did not influence 5-year postprocedural survival.

Reinterventions After Physician-Modified Endovascular Grafts for Treatment of Juxtarenal Aortic Aneurysms are Nondetrimental to Long-Term Survival

Reintervention after endovascular aortic aneurysm repair is common. However, the frequency and effects of reintervention on mortality after physician-modified endografts (PMEGs) is unknown. In the present study, we have described the reinterventions after PMEG for treatment of juxtarenal aneurysms and their effect on survival.

Reintervention Does Not Increase Long-term Mortality After Fenestrated Endovascular Aneurysm Repair

Fenestrated endovascular aneurysm repair has been is increasingly used in the treatment of juxtarenal aortic aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource usage. We sought to determine whether REIs affect long-term survival after fenestrated endovascular aneurysm repair.

Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms?

Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

Renal Stent Complications and Impact on Renal Function after Standard Fenestrated Endovascular Aneurysm Repair

To report renal outcomes including long-term patency, secondary interventions, and related renal function after fenestrated endovascular aortic repair (fEVAR). Single-center retrospective review of patients undergoing fEVAR between 2012 and 2018 using the Cook ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent-related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease formula. During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4%, and the mean follow-up was 23.3months. Seventeen renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations, and 1 type III endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48months, respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23 (0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs. 55.58mL/min/1.73m2, P=0.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by chronic kidney disease staging compared with baseline (P=0.51). fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent-graft complications.

Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-renal Aortic Aneurysms

Single-center retrospective review between 2008 and 2017 Of 66 patients who underwent fenestrated endovascular aneurysm repair (FEVAR) of juxtarenal abdominal aortic aneurysms, a total of 236 target visceral arteries were treated and 42 patients underwent three or four fenestrations. Technical success was achieved in 99% (65) of cases. There was only one immediate type III endoleak that required renal artery relining and one (1.5%) death. During approximately 4-year follow-up, only 3% (2) of patients experienced sac enlargement for type II endoleaks. FEVAR for juxtarenal abdominal aortic aneurysms is safe and effective after approximately 4-year follow-up even with three- or four-vessel branches.

Early and Long-term Efficacy of Fenestrated Endografting in the Treatment of Juxta-renal Aortic Aneurysms

Introduction - Juxta-renal aneurysms (j-AAAs) are increasingly repaired by endovascular means with fenestrated endografts (FEVAR) worldwide, however long-term data are presently lacking. Aim of our study was therefore to evaluate late outcome of FEVAR in j-AAAs Methods - Between 2008 and 2017, all consecutive patients undergoing endovascular repair for j-AAAs (neck length ≤5mm) by FEVAR (Cook-Zenith platform) were prospectively collected. Preoperative clinical and morphological features, together with procedural and postoperative data were analyzed. Early endpoints were: technical success (TS: patency of target visceral vessels; TVVs, absence of type I-III endoleak; iliac leg stenosis/occlusion and 24-hour survival), renal function worsening (reduction of baseline GFR ≥30%) and 30-day mortality. Late endpoints were: survival, freedom from re-intervention (FFR), TVV-patency, j-AAA shrinkage (> 5mm) and renal function worsening. Results - During the study period, overall 181 cases underwent FB-EVAR repair. Sixty-six patients with j-AAA (M: 94%; age: 72±6years; ASA 3/4: 79/21%) were enrolled. The mean j-AAA diameter was 58±6mm. Endograft with 1, 2, 3 and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops (3.6±1 TVV/patient). Technical success was achieved in 65 cases (99%). The only failure occurred for a type III endoleak requiring renal artery relining on postoperative day 32. No TVVs were lost. Cardio and pulmonary morbidities were 5% and 6%, respectively. There were no cases of acute splanchnic ischemia. Renal function worsening occurred in 7 cases (10%): 4 returned to baseline within 30-day; 1 required hemodialysis and died within 30-day (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32 months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required re-interventions (sac embolization by trans-limb approach). Freedom from re-interventions at 1, 3 and 5 years was 97%, 93% and 88%, respectively. An asymptomatic celiac trunk occlusion occurred at 36-month in a case with asevere pre-operative stenosis - accommodated by a scallop. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 patients (8%) during follow-up (2 persisted from post-operative period and 3 with new onset). Survival at 1, 3 and 5 years was 92%, 86% and 67%, respectively, with no j-AAA related mortality. At the univariate analysis, COPD (p:.006), BMI >31 (p:.048), preoperative chronic renal failure (p:0.44) and late renal function worsening (p:.050) were risk factors for mortality. COPD was the only independent predictor for mortality at the multivariate analysis (p:.021; OR:5.3; 95%CI, 1.3-21.9) Conclusion - FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with the results of this series, FEVAR could be proposed as the first line treatment for j-AAAs in anatomically fit cases if performed in high volume centers. Long term survival is reduced in the presence of pre-operative COPD. The results of the present series should be taken in consideration when considering alternative open surgery technique in the treatment of J-AAAs

Evolution of Fenestrated Endografting for the Treatment of Juxtarenal Abdominal Aortic Aneurysms over a Nine Year Period

Introduction - Fenestrated endovascular aneurysm repair (FEVAR) is now an established technique for the treatment of juxtarenal aortic aneurysms. We aimed to examine the evolution of this technique in a single centre.

Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-Renal Aortic Aneurysms

The aim of this study was to report early and mid-term outcomes of fenestrated endografting (FEVAR) for juxtarenal aneurysm (J-AAAs). Between 2008 and 2017, all consecutive J-AAAs treated by FEVAR were prospectively collected. Early endpoints were technical success, renal function worsening, and 30-day mortality. Follow-up endpoints were survival, freedom from reinterventions (FFRs), target visceral vessels (TVVs) patency, J-AAAs shrinkage, and renal function worsening. Among 181 cases who underwent FB-EVAR, 66 (36%) were J-AAAs. Endograft with 1, 2, 3, and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops. Technical success was achieved in 65 (99%) cases. The only failure occurred for a type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening occurred in 7 (10%) cases: 4 returned to baseline within 30-day, 1 required hemodialysis and died within 30 days (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required reinterventions. Freedom from reinterventions at 5 years was 88%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24 months in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 (8%) patients during follow-up. Survival at 5 years was 67%, with no j-AAA-related mortality. COPD was the only independent predictor for mortality at the multivariate analysis (P: 0.021; OR: 5.3; 95% CI, 1.3-21.9). FEVAR for J-AAAs is safe and effective at early and mid-term follow-up. According to these results, it could be proposed as the first-line treatment in high-risk patients if anatomically fit. Long-term survival is reduced in the presence of preoperative COPD.

A Systematic Review and Meta-Analysis of Endovascular Juxtarenal Aortic Aneurysm Repair Demonstrates Lower Perioperative Mortality Compared With Open Repair

The objective of this study was to compare outcomes of endovascular versus open repair for the treatment of juxtarenal aortic aneurysms. OVID, MedLine, and Embase were searched for studies from January 2000 to December 2018 that compared endovascular versus open repair of juxtarenal aortic aneurysms. Studies that included patients with pararenal and suprarenal aneurysms were also included. Endovascular interventions included were off instructions for use standard endovascular aneurysm repair (EVAR), parallel grafts, and fenestrated/branched EVAR. Primary outcomes were 30-day mortality, perioperative reinterventions, acute renal failure, permanent dialysis, stroke, and spinal cord ischemia. Secondary outcomes were myocardial infarction, bowel and limb ischemia, length of stay, and long-term survival. Data were pooled and we performed a meta-analysis using random-effects models. There were 20 studies meeting inclusion criteria. Five studies contained duplicated data and therefore only 15 were included for analysis with 5121 patients (1506 endovascular, 3615 open). There were no randomized controlled trials. Endovascular repair patients were older (mean difference, 3.42; 95% confidence interval [CI], 2.54-4.3; P < .00001; I2 = 56%) more likely to be male (odds ratio [OR], 1.33; 95% CI, 1.02-1.73; P = .04; I2 = 33%), have diabetes (OR, 1.24; 95% CI, 1.04-1.50; P = .02; I2 = 0%) coronary artery disease (OR, 1.64; 95% CI, 1.03-2.62; P = .04; I2 = 75%), and chronic kidney disease (OR, 1.52; 95% CI, 1.07-2.15; P = .02; I2 = 50%). Pooled analysis found endovascular repair to be associated with significantly decreased 30-day mortality (OR, 0.50; 95% CI, 0.34-0.74; P = .0006, I2 = 0%). This remained significant when including only fenestrated EVAR (OR, 0.55; 95% CI, 0.36-0.85; P = .007; I2 = 0%). Endovascular repair also had significantly decreased acute renal failure (OR, 0.50; 95% CI, 0.28-0.89; P = .02; I2 = 67%), increased spinal cord ischemia (OR, 3.14; 95% CI, 1.08-9.09; P = .03; I2 = 0%), decreased bowel ischemia (OR, 0.50; 95% CI, 0.24-1.05; P = .07; I2 = 7%), and a length of stay mean difference (−5.99 days; 95% CI, −7.42 to −4.57; P < .00001; I2 = 78%). There were no significant differences in other outcomes, including permanent dialysis and stroke. Eight of nine studies that reported long-term survival (1-7 years of follow-up) found no significant difference between groups (data not pooled). Only 1 study was noted to have improved long-term survival in the open repair group. Pooling data from 15 studies, we found endovascular repair to be associated with lower 30-day mortality, acute renal failure, bowel ischemia, and length of stay, but increased spinal cord ischemia. These data are limited by risk of bias of the included studies. Further long-term studies are needed to determine if these differences persist during long-term follow-up.

The removal of all proximal aneurysmal aortic tissue does not affect anastomotic degeneration after open juxtarenal aortic aneurysm repair

ObjectiveFor the open treatment of juxtarenal aortic aneurysms (JRAAs), some argue for the removal of all proximal aneurysmal aortic tissue to prevent future degeneration, whereas others deem it unnecessary. This study sought to compare perioperative and long-term outcomes of two different approaches to treatment of JRAAs. MethodsPatients who underwent open JRAA repair from 2007 to 2015 at our institution were reviewed and stratified by operative technique: plication of the aneurysm cuff with graft sewn up to the renal arteries (PLI) vs a beveled anastomosis with left renal artery bypass (LRB). Patients who underwent additional mesenteric bypasses were excluded. Primary outcomes included death, anastomotic degeneration, and decline in renal function. Univariate and Kaplan-Meier analyses were performed. ResultsThere were 199 patients identified, 56% PLI (n = 112) and 44% LRB (n = 87). The majority were male (68%), white (89%), and smokers (58%). Mean age was 71.5 ± 8.5 years. LRB patients were more likely to have chronic kidney disease (29% vs 13%; P = .01) and larger juxtarenal diameters (median, 25 mm vs 28 mm; P = .001). LRB patients had longer postoperative length of stay (median, 8 days vs 7 days; P = .003) and longer operative times (median, 4.7 hours vs 3.7 hours; P < .001). Overall 30-day mortality was 2% (n = 4), with no difference between cohorts. There were no differences in perioperative complications except for the development of acute kidney injury, which was more common in LRB patients (47% vs 23%; P < .001). During 3-year follow-up, there was no difference in anastomotic aneurysmal degeneration or sac growth. In the long term, LRB patients were more likely to develop an occluded left renal artery (20% vs 0%; P = .004) and right renal artery stenosis (29% vs 3%; P = .002). However, neither group was more likely to have a decline in renal function (PLI, 23%; LRB, 25%; P = .84). There was no difference in 5-year mortality (P = .72). ConclusionsThe more complex technique involving LRB was not protective against long-term anastomotic degeneration, decline in renal function, or mortality. In addition, LRB led to longer length of stay and operative times, with increased risk of perioperative acute kidney injury. In an era when fewer open aortic repairs are being performed, it is reasonable to consider the PLI technique in the treatment of JRAAs, particularly in patients with baseline chronic kidney disease.

CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms

Purpose: To evaluate chimney stent-graft position and morphological changes of the aneurysm sac as visualized by postoperative computed tomography angiography (CTA) over a minimum 24-month follow-up period. Materials and Methods: Twenty-one patients (mean age 75.7±8.6 years; 20 men) with juxtarenal aortic aneurysms who underwent successful chimney endovascular aneurysm repair (ch-EVAR) with the Endurant stent-graft and had 2 postoperative CTAs separated by at least 24 months were included in the study. CTA-based measurements of aortic stent-graft migration, target vessel angle, and chimney angle were compared between the serial scans. Results: During a mean follow-up of 34.9 months (range 24–69.2), the mean migration of the aortic stent-grafts was under 5 mm (2.76±2.4 mm). The average migration distance per year was 1.15 mm. The aneurysm diameter reduced a mean 3.25 mm (p=0.048). The right renal artery angle moved significantly upward 6.72° (p=0.025), while the right renal chimney stent-graft moved significantly downward 7.83° (p=0.042). The left renal artery angle also moved upward 1.87° (p=0.388) and the corresponding chimney moved downward 5.68° (p=0.133). During the study period, no type I/III endoleak or chimney occlusion was observed. Conclusion: Midterm morphometric assessment of ch-EVAR using CTA showed significant aneurysm sac shrinkage and a stable 3-year position of the abdominal devices, with the mean downward migration of the aortic stent-graft being <5 mm in the majority of cases. The chimney grafts seem to be prone to take an oblique rather than parallel configuration during follow-up. However, there was no relevant clinical consequence related to this phenomenon.

Single Centre Experience with Anaconda Custom-made Fenestrated Stent Graft in the Endovascular Repair of the Juxtarenal Aneurysms

Aim: The fenestrated Anaconda custom-made stent graft is one of the recently widely accepted fenestrated devices for managing complex juxta- and pararenal aortic pathology. This study showed its feasibility for treatment of challenging juxtarenal anatomy of the abdominal aorta. Methods: Over the period of 12 months, 9 patients with juxtarenal aortic aneurysm underwent fenestrated stent graft implantation in our institution. The graft fenestrations were customized on the basis of computerized tomography (CT-Angiography; CTA). Selected visceral ostia were protected with covered balloon-expandable stents after partial stent graft deployment. The perioperative and short term data were collected prospectively. Results: The mean aneurysm diameter was 58.4 mm (range 46-73 mm). The mean infrarenal neck length was 3.5 mm (range 0-7 mm), no patient had a severe (&gt;60°) angulation of proximal neck. 18 fenestration for renal arteries, 1 for SMA and 3 for coeliac´s were treated with Advanta V12 covered stent. All the target vessels were cannulated successfully through fenestrations and all the stent grafts were successfully deployed in patients with no technical issue in the release mechanism. All the patients have undergone 6 month follow-up, no aneurysm related or aneurysm-unrelated deaths were reported. On the CTA scan, 3 of the patients had a weak type IIb endoleak; no type I or Type III endoleak was demonstrated. All target vessels were open without an instance of branch-stent stenosis/occlusion. No reintervention was needed. Conclusion: The usage of custom-made Anaconda fenestrated stent graft for endovascular treatment of juxtarenal aortic aneurysms is feasible with acceptable intermediate-term results.

Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms

ObjectiveThe objective of this study was to compare surgical risk and early and late mortality of patients treated for anatomically classified juxtarenal aortic aneurysms (JRAs) by fenestrated endovascular aneurysm repair (F-EVAR) or open surgical repair (OSR) during a period when the two treatments were available and to validate an institutional algorithm for JRA repair. MethodsWe retrospectively included all patients treated electively in our center between January 2005 and December 2015 for JRAs classified into three anatomic categories, excluding suprarenal aneurysms. Lee score and American Society of Anesthesiologists (ASA) class evaluated preoperative surgical risk. We compared clinical and radiologic parameters between the patients treated by F-EVAR and those treated by OSR. The primary study end point was 30-day mortality. We also compared 5-year survival. ResultsFrom 2005 to 2015, there were 191 patients separated into two groups, one treated by OSR (n = 134; mean age, 69 years) and the other treated by F-EVAR (n = 57; mean age, 74 years). Patients of the F-EVAR group were significantly older (P = .001). Intensive care unit length of stay was significantly higher in the OSR group (3.4 days vs 1.5 days; P = .01). Surgical risk was significantly higher in the F-EVAR group as measured by Lee score ≥2 (OSR, 8.9 %; F-EVAR, 21%; P = .02) and ASA class 3 and class 4 (OSR, 32.8%; F-EVAR, 73.6%; P = .001), whereas 30-day postoperative mortality was not significantly different (OSR, 1.5%; F-EVAR, 0%; P = .394). The 5-year survival was not significantly different in the two groups (OSR, 82.1%; F-EVAR, 69.2%). ConclusionsIn this study, despite a higher surgical risk by Lee score and higher ASA class in the group of patients treated by F-EVAR, postoperative mortality was not significantly different between these groups. In our opinion, F-EVAR and OSR of JRA are complementary.

Open Repair for Juxtarenal Aortic Aneurysm: Short and Long-term Results

The recent technological evolution has also allowed for the treatment of juxtarenal aortic aneurysm (JAA) with an endovascular technique, but short- and long-term results must be compared with the results of open treatment, which is the gold standard. In this study, we analyzed the short- and long-term results of open surgical treatment (open repair) in patients with JAA in our series. From January 2006 to December 2016, 155 patients were treated for JAA with open repair; the data were analyzed retrospectively. The mean age was 71.17years (standard deviation [SD] 7.1), and mean size of aneurysm was 6.15cm (SD 1.1). The ASA classes 2, 3, and 4 were 20%, 74% and 6%, respectively. Follow-up included clinical visit and abdominal aorta Duplex scan after 1 and 6 months and annually. The mean follow-up interval was 48.6 (SD 32.4) months. The mean surgical time was 256min (SD 69), the mean stay in the intensive care unit was 1.6days (SD 1.2), and the mean total hospital stay was 10.2days (SD 4.3). Aortic cross-clamping was usually suprarenal (110, 71%); in 39 (25%), the aortic clamping was between the renal arteries, and 6 patients (4%) required a supraceliac cross-clamping. The mean renal ischemia time due to aortic clamping was 17min (SD 3.5). In 32 patients (21%), the left renal vein was sectioned for performing proximal aortic anastomosis and then reconstructed. Twelve patients (8%) required a renal revascularization, and in 49 patients (32%), an hypogastric bypass was performed. The 30-day mortality rate was 0.6%, and only 1 patient died in the postoperative due to intestinal infarction. The postoperative morbidities occurred in 15 cases (10%). Six patients had dehiscence of the laparotomy without the involvement of the muscle, 4 patients had an asymptomatic small increase of the troponin, and in 3 patients, there was an increase in creatinine >1.8mg/dL. No dialysis was performed. Two patients had peripheral embolism in the lower limbs. Twenty-six patients (15%) died in the follow-up, but causes have never been related to aortic disease. Open repair of JAA is still safe, effective, and durable also in the long-term period and even in patients with multiple cardiovascular risk factors.

Removal of All Proximal Aneurysmal Aorta Is Unnecessary in the Open Treatment of Juxtarenal Aortic Aneurysms

Removal of All Proximal Aneurysmal Aorta Is Unnecessary in the Open Treatment of Juxtarenal Aortic Aneurysms

Midterm results from a physician-sponsored investigational device exemption clinical trial evaluating physician-modified endovascular grafts for the treatment of juxtarenal aortic aneurysms

ObjectiveThe objective of this study was to report midterm results of an ongoing physician-sponsored investigational device exemption pivotal clinical trial using physician-modified endovascular grafts (PMEGs) for treatment of patients with juxtarenal aortic aneurysms who are deemed unfit for open repair. MethodsData from a nonrandomized, prospective, consecutively enrolling investigational device exemption clinical trial were used. Data collection began on April 1, 2011, and data lock occurred on May 31, 2015, with outcomes analysis through December 31, 2015. Primary safety and efficacy end points were used to measure treatment success. The primary safety end point was defined as the proportion of subjects who experienced a major adverse event within 30 days of the procedure. The primary efficacy end point was the proportion of subjects who achieved treatment success. Treatment success required the following at 12 months: technical success, defined as successful delivery and deployment of a PMEG with preservation of those branch vessels intended to be preserved; and freedom from type I and III endoleak, stent graft migration >10 mm, aortic aneurysm sack enlargement >5 mm, and aortic aneurysm rupture or open conversion. ResultsDuring the 50-month study period, 64 patients were enrolled; 60 began the implant procedure and 59 received the PMEG implant. Aneurysm anatomy, operative details, and lengths of stay were recorded and included aneurysm diameter (mean, 65.9 mm; range, 49-104 mm), proximal seal zone length (mean, 40.8 mm; range, 18.9-72.2 mm), graft manufacture time (mean, 55.1 minutes), procedure time (mean, 156.8 minutes), fluoroscopy time (mean, 39.6 minutes), contrast material use (mean, 75.3 mL), estimated blood loss (mean, 213 mL), and length of hospital stay (mean, 4.1 days) with intensive care unit length of stay (mean, 2.2 days). There were 145 fenestrations made for 110 renal arteries and 38 superior mesenteric arteries (SMAs). One patient had an SMA stent placed before the procedure for severe stenosis, and one subject had the SMA stented during the procedure. Renal arteries were stented whenever possible (93%). There were 102 stented renal arteries in 58 patients. There were no open conversions or explantations. Thirty-day mortality was 5.1% (3/59). There were zero type Ia, one type Ib, and two type III endoleaks during follow-up treated with successful reintervention. The overall rate of major adverse events at 30 days was 11.9%. The primary efficacy end points were achieved in 94.1% of patients. ConclusionsThese midterm results are favorable and verify our early report that endovascular repair with PMEG is safe and effective for managing patients with juxtarenal aortic aneurysms. PMEG has exceptional midterm rates of morbidity, mortality, and endoleak and may outperform standard endovascular aneurysm repair with favorable anatomy. In patients who are poor open surgical candidates who present with symptomatic or ruptured juxtarenal aortic aneurysms, PMEG continues to be an extremely appealing option as reliable off-the-shelf solutions are not widely available. Preoperative planning remains the key ingredient for success with use of these techniques.