Fenestrated endovascular repair for juxtarenal aortic pathology

Kristmundsson, Thórarinn; Sonesson, Björn; Malina, Martin; Björses, Katarina; Dias, Nuno; Resch, Timothy

doi:10.1016/j.jvs.2008.10.022

Cited by 84 publications

(61 citation statements)

References 30 publications

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“…Overall and despite these endoleaks, aneurysm diameter remained stable or decreased in 96% of patients, which compares favorably with the findings described after FEVAR (92e97%). 29,31,32 Moreover, when compared with data from Schanzer et al, 33 sac enlargement was less in the current series. It can be argued that this enlargement was related not only to a lower endoleak incidence (32 vs. 23%), but also to aggressive endoleak treatment based on adherence to a stricter follow up protocol.…”

Section: Discussioncontrasting

confidence: 54%

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure

Pecoraro¹,

Veith²,

Puippe³

et al. 2016

Journal of Vascular Surgery

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WHAT THIS PAPER ADDS Long-term follow up of chimney and periscope grafts for the treatment of pararenal and thoraco-abdominal aortic aneurysm is presented. This approach using off the shelf devices has been increasingly reported in recent years and with good results even in emergent settings. This risk factor analysis showed that inadequate branch graft length and chimney and periscope use in small and diseased target arteries contribute to late failure of this technique.Objective: The aim was to report on chimney and periscope grafts (CPGs) and their mid-and longer-term outcomes when they are used to preserve reno-visceral artery (RVA) perfusion in endovascular repair of pararenal (PRAAs) or thoraco-abdominal aortic aneurysm (TAAAs). In addition, factors associated with CPG failure are presented. Limited data exist on the outcomes of CPGs, and mid-and long-term results are generally not reported.Methods: This was a prospective study in a cohort of 100 patients with PRAA (69) or TAAA (31). A total of 224 (mean 2.24 per patient) RVAs were preserved with 136 (61%) chimney and 88 (39%) periscope grafts. CPGs were constructed mainly using self expandable stent grafts. Patients were followed by clinical examination, CTA (82%), and/or duplex (18%). Data were collected until February 2015. Results: CPG immediate technical success was 99% (222/224 branches). Mean follow up was 29 months (range 0e65; SD 17); 59% patients were followed > 2 years, 30% > 3 years, and 16% > 4 years. Post-operatively, CPG occlusion was observed early ( 30 days) in three (1.3%) branches and during follow up in 10 (4.5%). At 36 and 48 months, the estimated primary patency was 93% and 93%. After corrective percutaneous (10) or surgical (3) reinterventions, the estimated secondary patency was 96% and 96%. Thirty day mortality was 2%; at 36 and 48 months the estimated patient survival was 79%. Significant shrinkage (72 [SD 23] vs. 62 [SD 24] mm; p < .001) was observed, with a substantial reduction (>5 mm) in 55 patients, and sac enlargement in four. Incomplete aneurysm sac sealing was treated successfully by a secondary intervention in 15 patients. Conclusions: Self expandable CPGs have proved to be a highly successful and durable treatment for RVA preservation up to 5 years. Incomplete CPG expansion, inadequate length, and CPG use in small and diseased target arteries were risk factors for occlusion. These mid-and longer-term results support CPG use to treat PRAAs or TAAAs in patients unfit for open surgery or fenestrated/branched stent grafts. Ó

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Section: Discussioncontrasting

confidence: 54%

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure

Pecoraro¹,

Veith²,

Puippe³

et al. 2016

Journal of Vascular Surgery

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“…31 A high percentage of endoleaks eventually require redo operations, which puts into question the longevity of the repair. 28,31 Regular CT examinations are required to adjudicate the absence of endoleaks. Not all patients demonstrate shrinkage of the aneurysm sac during follow-up.…”

Section: Type I and Type Iii Endoleaksmentioning

confidence: 99%

“…Some designs are without fenestrations but with branches (pre-attached limbs or cuffs) targeted for the visceral aortic vessels, suitable for the endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs). At least for short-necked and juxtarenal aortic aneurysms (JRAs), fenestrated stent-grafting technology has been shown to be feasible, [12][13][14][15][16][17][18][19][20] with published results of highvolume experienced single centers [21][22][23][24][25][26][27][28][29][30][31] and a few recent multicenter trials 32,33 sharing remarkable short-and midterm results, with the durability of the technique being satisfactory (technical success > 95%, low mortality rates averaging 1-2% and low rates of mid-term branch vessel occlusion averaging 4-9%). [25][26][27][28][29]34 Other imaginative procedures have also been developed or modified to allow for the segmental or complete coverage of the aorta in the region of vital branches, including the 'chimney', 'snorkel', 'periscope' [35][36][37] and combined endovascular exclusion and extra-anatomic mesenteric/renal bypasses (hybrid visceral revascularization).…”

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confidence: 99%

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

et al. 2016

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The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).

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“…That demanded more endovascular skills and the side branches were not always possible to catheterize from the fenestrations. The fenestration technique was soon adopted by several centers (Kristmundsson et al 2009, 2013, Oderich et al 2014, Grimme et al 2014 showing fully acceptable results. In the summarizing table below (Table I), the increasing experience is showing promising results, and this new technique has mainly replaced open surgery for juxta-renal aneurysms.…”

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confidence: 99%

Impact of Renal Chimney Grafts on Anatomical Suitability for Endovascular Repair in Ruptured Abdominal Aortic Aneurysm

et al. 2015

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Introduction: Open repair of the aorta carries a high risk for morbidity and mortality especially in the elderly population and in patients unfit for major surgery. Endovascular aortic repair is safe, durable and effective when there is adequate proximal and distal sealing zone for the aortic stent graft. Fenestrated and branched stent grafts have made the repair possible for complex but elective cases that do not have an adequate sealing zone. Urgent complex cases and patients with midaortic occlusive diseases do not have any therapeutic alternative if they are not fit for open repair. Chimney graft technique fills this gap and allows the sealing zones for aortic stent graft to be extended as required. The aim of the present thesis is to study the applicability, safety and durability of CG technique in urgent cases with complex lesions in the thoracic and abdominal aorta including the midaortic occlusive diseases. Patients and Methods: All patients who received CG were treated urgently or semi-urgently. The majority of the treated aortic lesions were aneurysms, dissections, pseudoaneurysms, infection, and accidental overstented vital aortic side branches. The median age of all patients was 75 years (IQR, 69-78), of them 32% were female except for the first study where all ten patients were female with midaortic occlusive diseases. The second study evaluated the mid to long-term efficacy and durability of the CG technique in 29 patients with urgent and complex lesions of the thoracic aorta. The third study examined the long-term results of CG in preserving the visceral flow of 51 patients with urgent complex aortic lesions. The fourth study evaluated the CTA images of 206 patients with ruptured abdominal aortic aneurysm. The study measured the applicability of CG in patients for whom standard EVAR was contraindicated because of a short aneurysmal neck. Results:The results showed that CG is applicable and safe for midaortic occlusive diseases with high technical success and patency rate without major adverse effect. The treated patients with thoracic aortic lesions had 14% 30-day mortality, 21% type I endoleak, 7% CG-related mortality, 98% secondary patency and 68% of the aortic lesions shrank significantly. Visceral CG had a 10% 30-day mortality, 6% CG-related mortality, 12% type I endoleak, 93% secondary patency and 63% of the aortic lesions shrank significantly. Twenty-two patients had one renal arteriy sacrificed, 57% of these required permanent renal dialysis. The fourth study proved that CG technique increased the overall suitability for endovascular repair from 34% to 40-46%. Conclusions: Chimney graft seems effective and safe for treating midaortic occlusive diseases in patients unfit for open surgery. The early and mid to long-term results of the CG technique for urgent and complex lesions of the thoracic and abdominal aorta in high-risk patients are promising with a low early mortality, acceptable rate of type I endoleaks and long durability of the CGs, which may justify a broader applicability of this ...

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Fenestrated endovascular repair for juxtarenal aortic pathology

Abstract: Despite complex anatomy or severe comorbidities in these patients f-EVAR has acceptable short- and midterm results in this series which includes a learning curve and offers a valid treatment alternative to patients unsuitable for standard EVAR or open repair.

Cited by 84 publications

References 30 publications

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

Impact of Renal Chimney Grafts on Anatomical Suitability for Endovascular Repair in Ruptured Abdominal Aortic Aneurysm

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