Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair

Purpose Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. Technique The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. Conclusion Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels

Outcomes of fenestrated/branched endografting in post-dissection thoracoabdominal aortic aneurysms

Objectives: Fenestrated/branched thoracic endovascular repair (F/Br-TEVAR) is increasingly applied for atherosclerotic thoracoabdominal aortic aneurysm (TAAA); however use in post-dissection TAAAs is still very limited. Experience with F/Br-TEVAR in the treatment of post-dissection TAAA is presented. Methods: Data were analysed from prospectively maintained databases including all patients with post-dissection TAAAs that underwent F/Br-TEVAR within the period January 2010 to July 2013 in two vascular institutions. Evaluated outcomes included initial technical success, operative mortality and morbidity, late survival, endoleak, aneurysm diameter regression, renal function and reintervention during follow-up (FU). Results: A total of 31 patients (25 male, mean age 65 ± 11.4 years) were treated. Technical success was 93.5% and 30-day mortality 9.6%. Temporary spinal cord ischaemia occurred in four (12.6%) patients, with no case of permanent paraplegia. Mean FU was 17.0 ± 10 months. There were seven late deaths, all aneurysm unrelated. Estimated overall survival rates were 83.9 ± 6.7, 76.4 ± 7.9 and 71.6 ± 8.7% at 6, 12, and 18 months, respectively. Impairment of renal function occurred in two (6.4%) patients. Endoleaks were diagnosed in 12 patients during FU, including six type IB endoleaks and six type II endoleaks. Reintervention was required in seven (22.5%) patients. Mean aneurysm sac regression was 9.3 ± 8.7 mm, with a false lumen thrombosis rate of 66.7% and 88.2% for patients with a FU longer than 6 and 12 months respectively. Conclusion: F/Br-EVAR is feasible for patients with a post-dissection TAAA. Although associated with additional technical challenges, and a significant need for reintervention, it leads to favorable aneurysm morphologic changes, and may play a more prominent role in the future for this type of pathology if long-term results confirm the good initial outcome

The Ongoing Evolution of Abdominal Aortic Surgery

Abdominal aortic surgery has witnessed significant paradigm shifts in recent years with the introduction of structured screening programs, as well as the evolution of endovascular aortic aneurysm repair (EVAR), which has allowed physicians to promptly identify and successfully treat an increasing number of patients, even including those previously considered unfit for open repair [...

Graft complexity-related outcomes of fenestrated endografting for abdominal aortic aneurysms

PURPOSE: To report the outcomes of fenestrated endovascular aneurysm repair (FEVAR) and compare early and midterm results in relation to stent-graft complexity. METHODS: Between August 2006 and December 2014, 141 consecutive patients (mean age 72±7.6 years, range 50-89; 120 men) were treated electively with FEVAR for short-neck, juxtarenal, or suprarenal aortic aneurysms. Forty-five patients treated with stent-grafts featuring renal-only fenestrations were assigned to group A, while 96 patients receiving additional fenestrations for the superior mesenteric and/or celiac arteries were assigned to group B. Technical success, operative mortality and morbidity, target vessel patency, endoleak, reintervention, and survival were compared between the groups. Survival, target vessel stent patency, and reintervention during follow-up were estimated by Kaplan-Meier analysis; the estimates are presented with the 95% confidence interval (CI). RESULTS: Technical success was achieved in 135 (95.7%) patients. Overall 30-day operative mortality was 3.5% (5/141). Perioperative complications occurred in 16 (12.1%) patients. Mean follow-up was 33±23 months. Overall estimated survival was 85.1% (95% CI 79.1% to 91.1%) at 1 year and 75.8% (95% CI 68.2% to 83.5%) at 3 years. Freedom from reintervention was 90.6% (95% CI 85.6% to 95.6%) at 1 year and 79.2% (95% CI 71% to 87.5%) at 3 years. There was no statistically significant difference between the groups in terms of perioperative mortality or morbidity, endoleak, survival, target vessel patency, or reintervention. CONCLUSION: The use of FEVAR for juxta- and suprarenal aneurysms is associated with low 30-day mortality/morbidity and high midterm efficacy. So far, perioperative and midterm results are not affected by the use of more complex fenestrated designs

Persistent Sciatic Artery Aneurysm as a Rare Cause of Acute Lower Limb Ischemia

Purpose: Kissing stent angioplasty is an established endovascular treatment strategy for stenosis at the aortic bifurcation but not without its detractors. This study aimed to analyze the outcomes of kissing stents with regard to stent occlusion and complications in which an asymptomatic limb was treated. Materials and Methods : A total of 106 patients undergoing aortic bifurcation intervention from January 2015 to November 2020 were retrospectively reviewed. Only patients with at least one common iliac artery (CIA) ostium and undergoing bilateral CIA intervention were included in the study. Results : Patients were followed up for a median period of 26 months (interquartile range, 21-51 months). The TransAtlantic InterSociety Consensus (TASC)-II classification of lesions was as follows: A, 49%; B, 41%; C, 6%; and D, 5%. The treatment indication was limited to one side in 53% of patients. Technical and procedural success rates were 99% and 90%, respectively. Ischemic events in an asymptomatic limb occurred in 6% of cases, 3% due to late stent thrombosis >30 days, and 3% due to progression of downstream infrainguinal disease. Primary and secondary patency rates at 1, 3, and 5 years were 98%, 87%, and 85%, and 99%, 94%, and 94%, respectively. Periprocedural mortality developed in two patients with no amputation. Conclusion : Kissing stent deployment is a safe and effective strategy for the treatment of aortoiliac bifurcation disease. Unfavorable outcomes due to stenting in the asymptomatic iliac artery are very rare. Long-term surveillance is necessary due to the risk of late thrombosis or downstream disease progression

Indikationen für den Einsatz von Endoanchors: State of the Art

Complications during follow-up - including loss of seal and graft migration with endoleakage - are the Achilles heel of endovascular abdominal and thoracic aneurysm repair (EVAR and TEVAR, respectively). At the level of the proximal and distal landing zones, the characteristics of aortic anatomy include length and shape, thrombus, calcification, kinking and progressive dilatation, and these may impact the long-term durability of endovascular repair. Endoanchors have been shown to mimic the stability of a hand sewn aortic anastomosis. This report gives an overview of current literature on the use of endoanchors in EVAR and TEVAR. Indications for use include primary implantation to secure the proximal or distal landing zone, in case of unfavourable anatomy or intraoperative type I endoleak/suboptimal apposition to the aortic wall, as well as secondary use for the treatment of type I endoleaks and stent-graft migration often in conjunction with a proximal or distal extension of the stent-graft. To conclude the report, we analysed perioperative results of the first 100 patients treated with TEVAR/EVAR and endoanchors - primarily or secondarily - during re-interventions in our department. From March 2011 to November 2015, 100 patients (85 men, 15 women; mean age 70 +/- 9.7 years) were treated. 82 applications were carried out in the abdominal and 18 in the thoracic aorta. The implantation was performed during the primary EVAR/TEVAR procedure in 80 cases (group A); 20 patients were treated secondarily (group B). Technical success was 100%. Clinical success was 98%. No endoanchors were lost. Perioperative mortality was 4% and morbidity 7%. During 30-day follow-up, endoleaks were found in 8/96 surviving patients. 7/8 patients had type II endoleaks, and one patient with secondary proximal extension of the thoracic stent-graft had a persistent type I endoleak