Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution

Abstract

Objective: Despite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs.Methods: This retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests.Results: Seventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/ sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 6 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 6 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P ¼ .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P ¼ .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P ¼ .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P ¼ .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P ¼ .8 and P ¼ .6). The median follow-up was 12 months (range, 1-32 months).Conclusions: Parallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.

Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels

“… 19 Use of EndoAnchors (Medtronic), endovascular stiches with helical screws, is also suggested to decrease gutter leak. 20 Bannazadeh and colleagues 21 also reported that oversizing should be adjusted by number of chimney grafts. They recommend use of 20% oversizing for the main graft when <2 chimney grafts are used and 30% oversizing for 3 chimney grafts.…”

“…They recommend use of 20% oversizing for the main graft when <2 chimney grafts are used and 30% oversizing for 3 chimney grafts. 21 However, they did not comment on the size of main graft with 4 chimney grafts, which would often be required for TAAA repair. As such, most of the literature regarding chimney grafts is for juxtarenal and pararenal abdominal aortic aneurysm—and there are scarce data available for extensive TAAA.…”

“…This technique can also be combined with parallel/snorkel to minimize the number of branch grafts within the main body graft, as described by Bannazadeh and colleagues. 21 The proximal-most main body stent graft holds the 2 parallel/snorkels to the celiac and superior mesenteric artery, whereas the branches to the renal arteries sit inside the proximal-most graft but outside the distal stent graft that is deployed after all the other stent grafts ( Figure 2 ). They treated 38 suprarenal abdominal aortic aneurysms and TAAAs, reporting that reinterventions due to endoleaks were required in 5 patients (13%) (1 type IA, 1 type IB, 2 type III, and 1 gutter endoleak).…”

“…Outcomes after hybrid chimney/snorkel repairs with more than 10 cases in the series published after 2000 are summarized in Table 2 . 21 , 22 , 23 , 24 , 25 Reported operative mortality varies from 3% to 20%, with low spinal cord injury rate of 0% to 3%. Bowel ischemia was seen in 2% to 3% of cases (except for 3 of 15 [20%] in 1 series, of which 2 were related to ruptured TAAA before repair 23 ).…”

A risk-adjusted and anatomically stratified cohort comparison study of open surgery, endovascular techniques and medical management for juxtarenal aortic aneurysms—the UK COMPlex AneurySm Study (UK-COMPASS): a study protocol

“…A lack of precise and objective information regarding aneurysm neck anatomy, pooling of shortneck aneurysms with aneurysms without a neck as well as aneurysms of the visceral aortic segment and thoracoabdominal aortic aneurysms seriously limits the value of most published evidence. [11][12][13][14] These sources of bias, confounding and heterogeneity, have been consistently recognised as weaknesses in the evidence base by authors of systematic reviews. 15 16 There is therefore a pressing need to generate comparative effectiveness evidence in this area with adequate internal and external validity.…”