A Single Center Review of a Total Transfemoral Approach to Upper Extremity Access in Branched and Fenestrated Physician Modified Endografts.

BACKGROUND: Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches. METHODS: Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes. RESULTS: Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke. CONCLUSIONS: This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators

Prophylactic Perigraft Arterial Sac Embolization During EVAR: Minimizing Type II Endoleaks and Improving Sac Regression

BackgroundType II endoleaks (ELII) are the most common complication following endovascular aneurysm repair (EVAR). Persistent ELII require continual surveillance and have been shown to increase the risk of Type I and III endoleaks, sac growth, need for intervention, conversion to open or even rupture, directly or indirectly. These are often difficult to treat following EVAR, and there are limited data regarding the effectiveness of prophylactic treatment of ELII. The aim of this study is to report the midterm outcomes of prophylactic perigraft arterial sac embolization (pPASE) performed in patients undergoing EVAR.MethodsThis is a comparison of 2 elective cohorts of those undergoing EVAR using the Ovation stent graft with and without prophylactic branch vessel and sac embolization. Patients who underwent pPASE at our institution had their data collected in a prospective, institutional review board-approved database. These were compared against the core lab-adjudicated data from the Ovation Investigational Device Exemption trial. Prophylactic PASE was performed at the time of EVAR with thrombin, contrast, and Gelfoam if the lumbar or mesenteric arteries were patent. Endpoints included freedom from ELII, reintervention, sac growth, all-cause mortality, and aneurysm-related mortality.ResultsThirty-six patients (13.1%) underwent pPASE, while 238 patients (86.9%) had standard EVAR. Median follow-up was 56 months (33-60 months). The 4-year freedom from ELII estimates were 84% for the pPASE versus 50.7% for the standard EVAR group (P = 0.0002). All aneurysms in the pPASE group remained stable in size or demonstrated regression, whereas aneurysm sac expansion was seen in 10.9% of the standard EVAR group, P = 0.03. At 4 years, mean AAA diameter decreased by 11 mm (95% CI 8-15) in the pPASE group versus 5 mm (95% CI 4-6) for the standard EVAR group, P = 0.0005. There were no differences in the 4-year freedom from all-cause mortality and aneurysm-related mortality. However, the difference in reintervention for ELII trended toward significance (0.0% vs. 10.7%, P = 0.1). On multivariable analysis, pPASE was associated with a 76% reduction in ELII [(95% CI): 0.24 (0.08-0.65), P = 0.005].ConclusionsThese results suggest that pPASE in those undergoing EVAR is safe and effective in the prevention of ELII and significantly improves sac regression over standard EVAR while minimizing the need for reintervention

Diagnosis and relining techniques for delayed type IIIB endoleaks with the second-generation AFX endograft

Type IIIB endoleaks resulting from endograft fabric tear are an uncommon but serious late complication of endovascular aortic aneurysm repair. The Strata fabric used in the earlier generation AFX endograft (updated to Duraply in October 2014) has been associated with an increased frequency of these events. Herein we report on two patients exhibiting delayed type IIIB endoleaks after AFX device insertion to treat an abdominal aortic aneurysm and discuss optimal relining techniques. Keywords: Type III endoleak, EVAR relining, AFX endograf

Upper Extremity Access Has Worse Outcomes in F/BEVAR using the VQI Dataset

ObjectivePhysician modified endografts (PMEG) and custom manufactured devices (CMD) use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity access from a transfemoral approach. Single institution studies have demonstrated increased risks of access site complications and stroke when upper extremity access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed upper extremity (UEM) access.MethodsThis study is an analysis of the Vascular Quality Initiate for all patients who underwent F/BEVAR from 2014-2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction and perioperative death. Secondary outcomes included access site hematoma, occlusion, or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed.Results3146 patients underwent a F/BEVAR; 2309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 versus 297 minutes, p<0.001) and fluoroscopy time (62 versus 80 minutes, p<0.001) in the TTF group and no difference in technical success between groups (96% versus 97%, p=0.159). Finally, there was a decrease in access site hematoma 2.54% versus 4.31% (p=0.013), access site occlusion 0.61% versus 1.91% (p=0.001) and extremity embolization 2.17% versus 3.58% (p=0.026) in the TTF versus UEM group.ConclusionThis study using VQI data demonstrates that patients who undergo a F/BEVAR utilizing UEM access have an increased risk of perioperative MI, death and stroke compared to TTF access