Tips and techniques for optimal stent graft placement in angulated aneurysm necks

An increasing number of patients with severely angulated abdominal aortic aneurysm (AAA) necks are being treated by endovascular aneurysm repair (EVAR). Optimal preprocedural planning and investigation of the AAA morphology is essential to achieve a successful EVAR in these patients. In this article, we discuss specific problems that can be encountered during preoperative planning in relation to periprocedural stent graft deployment in patients with angulated AAA necks and offer potential solutions for these problems

Total Endovascular Repair of the Aortic Arch:Initial Experience in the Netherlands

Background. We report procedural and early results in the Netherlands of the Relay Branch device (Terumo Aortic, Sunrise, FL) for total endovascular repair of the aortic arch. Methods. Between 2014 and 2018, all consecutive patients who received the Aortic Relay double-branched stent graft in the Netherlands were included in a multicenter, retrospective registry. Results. The Relay Branch device was used in 11 patients to treat saccular (n = 4), fusiform (n = 5), or false aneurysms (n = 2) in the aortic arch. Patients were deemed unfit or extreme high-risk for open (redo) surgery. The brachiocephalic trunk and left common carotid artery were branched using a retrograde approach in all cases. Additional surgical left subclavian artery revascularization was performed in 8 patients. The main device and the branches were successfully introduced, positioned, and deployed with complete exclusion of the aortic pathology in all patients (100% technical success). There was no retrograde type A dissection or conversion to open surgery. Two procedure-related deaths occurred, both caused by perioperative or postoperative strokes. There were 2 minor strokes with full recovery. One patient recovered from transient paraplegia after spinal fluid drainage. No permanent paraplegia was observed. Follow-up imaging showed persistent adequate exclusion of aortic arch pathology. Mean follow-up was 17 months (range, 3-42 months). Conclusions. Total endovascular aortic arch repair using the Relay Branch device is technically feasible and effective in excluding aortic arch pathology. The observed stroke rate in the initial experience, however, was considerable. Although appealing, this new less-invasive technique should be carefully introduced and its progress thoroughly evaluated. (C) 2020 by The Society of Thoracic Surgeon

Variation in Surgical Treatment of Abdominal Aortic Aneurysms With Small Aortic Diameters in the Netherlands

Objective: To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. Background: Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. Methods: All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage. Results: In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation. Conclusions: Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage

Utilizing numerical simulations to prevent stent graft kinking during thoracic endovascular aortic repair

Numerical simulations of thoracic endovascular aortic repair (TEVAR) may be implemented in the preoperative workflow if credible and reliable. We present the application of a TEVAR simulation methodology to an 82-year-old woman with a penetrating atherosclerotic ulcer in the left hemiarch, that underwent a left common carotid artery to left subclavian artery bypass and consequent TEVAR in zone 2. During the intervention, kinking of the distal thoracic stent graft occurred and the simulation was able to reproduce this event. This report highlights the potential and reliability of TEVAR simulations to predict perioperative adverse events and short-term postoperative technical results. (J Vasc Surg Cases Innov Tech 2023;9:101269.

Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms

PURPOSE: Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. METHODS: All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. RESULTS: The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8). CONCLUSION: Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.publishersversionepub_ahead_of_prin

Multicenter experience of upper extremity access in complex endovascular aortic aneurysm repair

Purpose: Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites, and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR). Methods: In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received UEA during complex EVAR were included. The primary outcome was a composite end point of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions, and incidence of ischemic cerebrovascular events. Results: A total of 417 patients underwent 437 UEA for 303 fenestrated/branched EVARs and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. A total of 413 approaches were performed surgically and 24 percutaneously. Distal brachial access (DBA) was used in 89 cases, medial brachial access (MBA) in 149, proximal brachial access (PBA) in 140, and axillary access (AA) in 59 cases. No significant differences regarding the composite end point of access complications were seen (DBA: 11.3% vs MBA: 6.7% vs PBA: 13.6% vs AA: 10.2%; P =.29). Postoperative neuropathy occurred most after PBA (DBA: 1.1% vs MBA: 1.3% vs PBA: 9.3% vs AA: 5.1%; P =.003). There were no differences in cerebrovascular complications between access sides (right: 5.9% vs left: 4.1% vs bilateral: 5%; P =.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs 6.8%; P =.002). In multivariate analysis, the risk for access complications after an open approach was decreased by male sex (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.10-0.72; P =.009), whereas an increase in age per year (OR: 1.08; 95% CI: 1.004-1.179; P =.039) and diabetes mellitus type 2 (OR: 3.70; 95% CI: 1.20-11.41; P =.023) increased the risk. Conclusions: Between the four access localizations, there were no differences in overall access complications. Female sex, diabetes mellitus type 2, and aging increased the risk for access complications after a surgical approach. Furthermore, a percutaneous UEA resulted in higher complication rates than a surgical approach

Endovascular treatment of a patient with an aneurysm of the proper hepatic artery and a duodenal fistula

Aneurysms of the proper hepatic artery comprise a rare but potentially dangerous entity for which treatment is performed both surgically and endovascularly. Covered stents are generally used for endovascular treatment of such aneurysms. When the aneurysm is contaminated due to an enteric fistula, however, use of a covered stent is considered inappropriate. This case report describes the endovascular repair of a proper hepatic artery aneurysm using overlapping bare metal stents after the patient was surgically treated for duodenal hemorrhage

ENDOVASCULAR ANEURYSM REPAIR IN WIDE INFRARENAL NECKS - INCREASED RISK OF COMPLICATIONS?

EVAR has become the predominant repair technique for abdominal aortic aneurysm. Long-term clinical success relies greatly upon a long-lasting proximal seal. EVAR has achieved good outcomes on the short-term in patients with hostile neck features such as large proximal necks. However, the long-term outcomes in these patients is greatly unknown. In this article, the authors perform a literature review in order to assess the clinical impact of wide proximal neck on mid to long-term outcomes following EVAR

Proximal aortic perforation after endovascular repair of a type B dissection in a patient with Marfan syndrome

Several successful cases of endovascular treatment of type B dissections in patients with Marfan syndrome have been reported. In our patient with Marfan syndrome, a type B dissection was successfully treated endovascularly. Three weeks after this procedure, a computed tomographic angiography (CTA) revealed a perforation of the aortic wall distal to the left subclavian artery by a bare strut of the stent graft. A second stent graft was placed to treat this complication. In patients with Marfan syndrome, complications might be prevented by using stent grafts specifically developed to treat dissections. However, specific complications, eg, perforation, must be taken into account and patients have to be followed attentively