“…15 These devices avoid the time delay needed for custom-made stent-grafts, which can reduce the adverse events during waiting time and allow for expedite treatment or non-elective cases. 16 Although there is some variations in design between manufacturer, most apply the concept of four down-going cuffs or branches, which are intended for the CT, SMA, and renal arteries. Intentional occlusion of one or more DB in patients with less than four TVs may be needed to accommodate variations in renal and mesenteric anatomy and has been previously reported using an accepted approach that entails stenting of the DB itself followed by its occlusion using the standard Amplatzer Vascular Plug (AVP).…”
Section: Discussionmentioning
confidence: 99%
“…15 These devices avoid the time delay needed for custom-made stent-grafts, which can reduce the adverse events during waiting time and allow for expedite treatment or non-elective cases. 16 Although there is some variations in design between manufacturer, most apply the concept of four down-going cuffs or branches, which are intended for the CT, SMA, and renal arteries.Figure 2.CTA at 36 months with 3D volume-rendering A, and transversal view reconstructions B, showing patency of visceral branches and sustained occlusion of renal branches by the microvascular plugs.…”
Purpose To demonstrate the feasibility and outcomes of using the microvascular plug (MVP) for intentional occlusion of directional branches (DB) during complex endovascular aortic procedures. Case Report Two patients were treated with the off-the-shelf four-branched Zenith t-Branch thoracoabdominal stent-graft (Cook Medical, Bloomington, Ind). In both cases, the renal arteries (on one side in patient #1 and on both sides in patient #2, respectively) were occluded at time of index intervention. Preoperative planning included the intentional occlusion of each DB with one 7Q-MVP. Technical success was achieved in all cases and maintained at mid-term follow-up (12 months and 36 months, respectively). Conclusions Use of the MVP appears to be feasible and effective for intentional occlusion of DB during complex endovascular aortic repair. This novel and simple technique may present some unique technical advantages, allowing precise placement of the device while avoiding extension using a bridging stent and DB cannulation with larger sheaths.
“…15 These devices avoid the time delay needed for custom-made stent-grafts, which can reduce the adverse events during waiting time and allow for expedite treatment or non-elective cases. 16 Although there is some variations in design between manufacturer, most apply the concept of four down-going cuffs or branches, which are intended for the CT, SMA, and renal arteries. Intentional occlusion of one or more DB in patients with less than four TVs may be needed to accommodate variations in renal and mesenteric anatomy and has been previously reported using an accepted approach that entails stenting of the DB itself followed by its occlusion using the standard Amplatzer Vascular Plug (AVP).…”
Section: Discussionmentioning
confidence: 99%
“…15 These devices avoid the time delay needed for custom-made stent-grafts, which can reduce the adverse events during waiting time and allow for expedite treatment or non-elective cases. 16 Although there is some variations in design between manufacturer, most apply the concept of four down-going cuffs or branches, which are intended for the CT, SMA, and renal arteries.Figure 2.CTA at 36 months with 3D volume-rendering A, and transversal view reconstructions B, showing patency of visceral branches and sustained occlusion of renal branches by the microvascular plugs.…”
Purpose To demonstrate the feasibility and outcomes of using the microvascular plug (MVP) for intentional occlusion of directional branches (DB) during complex endovascular aortic procedures. Case Report Two patients were treated with the off-the-shelf four-branched Zenith t-Branch thoracoabdominal stent-graft (Cook Medical, Bloomington, Ind). In both cases, the renal arteries (on one side in patient #1 and on both sides in patient #2, respectively) were occluded at time of index intervention. Preoperative planning included the intentional occlusion of each DB with one 7Q-MVP. Technical success was achieved in all cases and maintained at mid-term follow-up (12 months and 36 months, respectively). Conclusions Use of the MVP appears to be feasible and effective for intentional occlusion of DB during complex endovascular aortic repair. This novel and simple technique may present some unique technical advantages, allowing precise placement of the device while avoiding extension using a bridging stent and DB cannulation with larger sheaths.
“…During the waiting time, there is an inherent risk of both aneurysm rupture and patient decline from other medical conditions (heart or renal failure episodes). This may lead to postponement or cancellation of the planned procedure, with a considerable expense in the case of custom-made devices [ 97 ]. Recent evidence has shown that this delay will ultimately lead to the cancellation of the surgical procedure up to 3% of the time [ 98 ].…”
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
“…In some patients, anatomical specificities disable the use of off-the-shelf devices but require the use of custom-made devices (CMDs) tailored to the specific anatomy. However, the production time of such CMDs can take an average of 15 weeks [1]. Thus, to manage complex aortic pathologies requiring urgent or emergent endovascular treatment, off-the-shelf devices [2], parallel grafts [3], in situ fenestrations [4,5] and physician-modified endografts (PMEGs) [6,7] can be used [8].…”
Background: We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation. Materials and methods: The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration. Results: Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010–1090) compared to 760 s (IQR:685–784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8–27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3–20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm. Conclusion: Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.
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