Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair – A Systematic Review

Nordon, Ian M.; Hinchliffe, Robert J.; Holt, Peter; Loftus, Ian; Thompson, Matt

doi:10.1016/j.ejvs.2009.02.012

Cited by 156 publications

(127 citation statements)

References 38 publications

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

et al. 2016

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“…2). Initial experiences with these devices have shown that total endovascular repair is effective and may reduce morbidity rates in patients with arch, thoracoabdominal, pararenal and juxtarenal aneurysms [14][15][16][17][18][19][20][21]. Treatment of chronic type B aortic dissection with the use of fenestrated devices has also been reported with good preliminary results [22,23].…”

Section: Fenestrated and Branched Stent Graftsmentioning

confidence: 99%

“…The patients appear to be at higher risk of failure within the first postoperative year, with a plateau in subsequent follow-up. Secondary intervention rates range between 10 and 20 % are noted in these studies [14].…”

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confidence: 99%

Endovascular Repair of Complex Aortic Pathology

et al. 2013

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Aortic aneurysms are classified as complex based on their extent and involvement of side branches. Complex aortic aneurysms include arch, thoracoabdominal, juxtarenal and suprarenal aortic aneurysms. Open surgical repair carries high morbidity and mortality beyond large tertiary care centers. During the last decade, numerous technological advances have allowed incorporation of side branches using hybrid and total endovascular techniques. Fenestrated and branched endografts have been widely applied to treat patients with complex aneurysm anatomy. Newer stent graft designs are currently under clinical investigation offering an off-the-shelf alternative to custom-made stent grafts for patients with complex aortic aneurysms. Alternatively, a number of endovascular techniques have been described including chimney, snorkel, periscope and sandwich stent grafts. This article summarizes the current status of hybrid and total endovascular techniques to repair of thoracoabdominal, juxtarenal and suprarenal aortic aneurysms.

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“…However, none of them found any RCTs or any comparative studies to answer this question. A systematic review by Nordon et al 51 reported that non-RCTs were identified and they included eight cohort studies reporting 368 fEVAR cases and 12 cohort studies reporting 1164 OSRs of JRAAs. One systematic review by Cross et al 52 identified 11 fEVAR studies describing 660 procedures with no comparison.…”

Section: Chapter 7 Discussionmentioning

confidence: 99%

The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis

Armstrong

Burgers

Deshpande

et al. 2014

Health Technology Assessment

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BackgroundPatients with large abdominal aortic aneurysms (AAAs) are usually offered reparative treatment given the high mortality risk. There is uncertainty about how to treat juxtarenal AAAs (JRAAAs) or thoracoabdominal aortic aneurysms (TAAAs). Endovascular repair of an abdominal aortic aneurysm (EVAR) is often seen as safer and easier than open surgical repair (OSR). However, endovascular treatment of JRAAAs or TAAAs requires specially manufactured stent grafts, with openings to allow blood to reach branches of the aorta. Commissioners are receiving increasing requests for fenestrated EVAR (fEVAR) and branched EVAR (bEVAR), but it is unclear whether or not the extra cost of fEVAR or bEVAR is justified by advantages for patients.Objective(s)To assess the clinical effectiveness, safety and cost-effectiveness of fEVAR and bEVAR in comparison with conventional treatment (i.e. no surgery) or OSR for two populations: JRAAAs and TAAAs.Data sourcesResources were searched from inception to October 2013, including MEDLINE (OvidSP), EMBASE (OvidSP) and the Cochrane Central Register of Controlled Trials (Wiley) and, additionally, for cost-effectiveness, NHS Economic Evaluation Database (NHS EED; Wiley) and EconLit (EBSCOhost). Conference abstracts were also searched.Review methodsStudies were included based on an intervention of either fEVAR or bEVAR and a comparator of either OSR or no surgery. For clinical effectiveness, observational studies were excluded only if they were not comparative, i.e. explicitly selected on the basis of prognosis.ResultsFor clinical effectiveness, searches retrieved 5253 records before deduplication. Owing to overlap between the databases, 1985 duplicate records were removed. Of the remaining 3268 records, based on titles and abstracts, 3244 records were excluded, leaving 24 publications to be ordered. All 24 studies were excluded as none of them satisfied the inclusion criteria. Sixteen studies were excluded on study design, six on intervention and two on comparator. Five out of 16 studies excluded on study design reported a comparison. However, all of the studies acknowledged that they had groups that were not comparable at baseline given that they had selectively assigned younger, fitter patients to OSR. Therefore, these studies were considered ‘non-comparative’. For cost-effectiveness, searches identified 104 references before deduplication. Owing to overlap between the databases, 34 duplicate records were removed. Of the remaining 70 records, seven were included for the full assessment based on initial screening. After a full-text review, no studies were included. Because of the lack of clinical effectiveness evidence and difficulty in estimating costs given the rapidly changing and variable technology, a cost-effectiveness analysis (CEA) was not performed. Instead a detailed description of modelling methods was provided.ConclusionsDespite a thorough search, no studies could be found that met the inclusion criteria. All studies that compared either fEVAR or bEVAR with either OSR or no surgery explicitly selected patients based on prognosis, i.e. essentially the populations for each comparator were not the same. Despite not being able to conduct a CEA, we have provided detailed methods for the conduct if data becomes available.Future workWe recommend at least one clinical trial to provide an unbiased estimate of effect for fEVAR/bEVAR compared with OSR or no surgery. This trial should also collect data for a CEA.Study registrationThis study is registered as PROSPERO CRD42013006051.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair – A Systematic Review

Cited by 156 publications

References 38 publications

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

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

Endovascular Repair of Complex Aortic Pathology

The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis

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