Implications of renal artery anatomy for endovascular repair using fenestrated, branched, or parallel stent graft techniques

Mendes, Bernardo C.; Oderich, Gustavo S.; Souza, Leonardo Reis de; Banga, Péter; Macedo, Thanila A.; DeMartino, Randall R.; Misra, Sanjay; Gloviczki, Péter

doi:10.1016/j.jvs.2015.11.047

Cited by 44 publications

(35 citation statements)

References 29 publications

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“…According to prior reports, uncovered stents are an independent predictor of stenosis and occlusion. 5,6,18 Patency rates comparing bare-metal stents distal to covered stents vs covered stents alone have nonetheless not been established. The aim of this study was to evaluate whether the use of distal extension stents influences vessel patency.…”

Section: Discussionmentioning

confidence: 99%

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Visceral stent patency after fenestrated endovascular aneurysm repair using bare-metal stent extensions versus covered stents only

Khoury

Timaran

Knowles

et al. 2020

Journal of Vascular Surgery

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Objective: Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to treat complex abdominal aortic aneurysms. Patency of visceral vessels remains high when covered stents are used. The use of distal uncovered stents to prevent kinking has been associated with loss of branch patency. The aim of this study was to evaluate branch-related outcomes of FEVAR using covered stents only vs the use of uncovered stents distal to covered stents. Methods: During a 4-year period, 142 patients underwent FEVAR. Patients with suprarenal, juxtarenal, and type IV thoracoabdominal aneurysms were included. Patients treated with side branch devices were excluded. Covered iCAST (Maquet, Hudson, NH) stents were used as bridging stents in all cases. The primary end point was primary patency, defined as the absence of stenosis or occlusion that required intervention. Secondary end points included secondary patency, branch-related outcomes (kidney injury and gastrointestinal complications), branch instability, and mortality rates. Results: A total of 442 target vessels were incorporated (49 scallops and 393 fenestrations). Uncovered stents were used in 38 (9.6%) visceral vessels. Median follow-up time was 11 (interquartile range, 6-13) months. Overall, visceral vessel primary patency was 91% at 12 and 24 months. The overall primary patency rate was 86% in the distal extension group vs 93% when only covered stents were used at 12 and 24 months (P ¼ .8). Similarly, the rate of branch-related reinterventions at 12 months was 9% and 15% for each group, respectively, and 22% vs 32% at 24 months, respectively (P ¼ .5). Overall, freedom from branch instability was 87% at 12 months and 81% at 24 months. Freedom from branch instability in the distal extension group was 82% at 12 and 24 months vs 89% at 12 months and 81% at 24 months when only covered stents were used (P ¼. 08). Mortality rate at 24 months was 15% for the bare-metal stent extension group vs 14% for the covered stent only group (P ¼ .4). We found no statistical difference in acute kidney injury at any Kidney Disease: Improving Global Outcomes stage (P ¼ 1.0) or gastrointestinal complications (P ¼ 1.0) between the groups. Conclusions: The use of distal uncovered stents to prevent kinks was not associated with decreased early branch patency. The long-term outcomes of bare-metal stents remain to be determined. For now, the use of uncovered stents distal to covered stents may be considered to prevent kinks in complex anatomy.

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Section: Discussionmentioning

confidence: 99%

“…4,5 Most studies report higher patency rates for patients treated with covered stents vs bare-metal stents. 5,6 Bare-metal stents are considered to be associated with loss of visceral branch patency, specifically when they are used for target artery sealing.…”

mentioning

confidence: 99%

Visceral stent patency after fenestrated endovascular aneurysm repair using bare-metal stent extensions versus covered stents only

Khoury

Timaran

Knowles

et al. 2020

Journal of Vascular Surgery

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“…In addition, there was no detected difference in residual sac size secondary to the presence of these leaks. Whereas previous reports have focused on comparing outcomes of fenestrated vs chimney repairs, [19][20][21][22] limited evidence has thus far been published examining those patients receiving a combined approach. A similar report is a six-patient case series published by Touma et al, 23 who described three suprarenal aneurysms and three thoracoabdominal aneurysms treated with physicianmodified fenestrated aortic grafts in combination with chimneys and periscopes.…”

Section: Discussionmentioning

confidence: 99%

Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair

Wang

Drucker

Dalsing

et al. 2018

Journal of Vascular Surgery

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Objective: Visceral artery chimneys have been employed as an adjunct to endovascular aneurysm repair (EVAR) to treat short-neck infrarenal and juxtarenal aortic aneurysms for more than two decades. With the widespread introduction of fenestrated endovascular aneurysm repair by the Food and Drug Administration-approved Zenith Fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) to the United States in 2012, clinicians gained the ability to apply the chimney technique to these custom devices for difficult anatomy. The purpose of this report was to demonstrate feasibility and to provide evidence on the performance of chimneys for the treatment of complex juxtarenal aneurysms that could not be adequately treated with ZFEN alone.Methods: A retrospective analysis was performed of a prospectively maintained institutional ZFEN database capturing 110 fenestrated endovascular aneurysm repairs from October 2012 to January 2018 to identify patients undergoing a concomitant visceral artery chimney. All patients with <12 months of follow-up were excluded from further analysis. Demographic, anatomic, intraoperative, perioperative, and follow-up characteristics were tabulated and analyzed.Results: Six patients met criteria and were included in this investigation. They were universally male with a mean age of 76.2 years at the time of ZFEN/chimney. Chimneys were placed in a total of six visceral arteries (n ¼ 1 per patient) consisting of three renal arteries, two celiac arteries, and one accessory renal artery. Mean estimated blood loss and operative time were 283 mL and 298 minutes, respectively. Technical success was achieved in all cases. Two small type IA "gutter" endoleaks were detected early; both spontaneously resolved on follow-up. We observed no instances of chimney migration, stenosis, or thrombosis perioperatively or on follow-up. Two reinterventions were performed in these six patients; these consisted of a repeated renal stent for ostial stenosis at a main body fenestration and a common femoral artery endarterectomy and patch angioplasty for an access-related common femoral artery occlusion.Conclusions: Use of ZFEN in conjunction with a singular chimney is safe, feasible, and durable in patients with difficult anatomy who do not meet instructions for use as demonstrated in this limited series. (J Vasc Surg 2018;68:1688-95.)

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“…The problems most likely to occur during EVAR for AAA with ARA are renal infarction caused by ARA obstruction and type II endoleaks from ARA blood flow. As ARA coverage has been reported to increase risk of renal infarction, with reported rates ranging from 0 to 84%, ARA reconstruction procedures have been devised using fenestrated stentgrafts, branched stentgrafts, or debranching [7–9]. Yet some believe that the reconstruction of ARA is unnecessary since it offers no significant benefit in terms of eGFR or blood pressure control [3–6].…”

Section: Discussionmentioning

confidence: 99%

Prophylactic accessory renal artery coil embolization for prevention of type II endoleak following endovascular aneurysm repair: a case report

et al. 2017

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BackgroundPrior reports indicate that intentional coverage of the accessory renal arteries (ARAs) with a diameter larger than 3 mm during endovascular aneurysm repair (EVAR) increases risk of additional treatment for type II endoleak. Here, we report a case of prophylactic coil embolization for a 4 mm ARA originating from an abdominal aortic aneurysm.Case presentationA 76-year-old woman was admitted to our hospital after noticing an abdominal pulsatile mass. Computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 mm. Preoperative CT scan showed a right ARA, 4 mm in diameter, which was considered likely to lead to type II endoleak following EVAR. ARA coil embolization was performed at the time of EVAR. We observed no endoleaks and no infarct of the inferior pole of the right kidney on completion angiography. The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative level (56.7 ml/min). After EVAR, blood pressure was under control, and no additional anti-hypertensive medicines were required. Postoperative enhanced CT image showed that the distal portion of the ARA was well perfused without type II endoleak from ARA.ConclusionsProphylactic coil embolization for a large ARA originating from an abdominal aortic aneurysm appears to be safe and effective in preventing type II endoleak following EVAR.

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Implications of renal artery anatomy for endovascular repair using fenestrated, branched, or parallel stent graft techniques

Cited by 44 publications

References 29 publications

Visceral stent patency after fenestrated endovascular aneurysm repair using bare-metal stent extensions versus covered stents only

Visceral stent patency after fenestrated endovascular aneurysm repair using bare-metal stent extensions versus covered stents only

Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair

Prophylactic accessory renal artery coil embolization for prevention of type II endoleak following endovascular aneurysm repair: a case report

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