Use of the Zenith Fenestrated platform to rescue failing endovascular and open aortic reconstructions is safe and technically feasible

Wang, S. Keisin; Drucker, Natalie A.; Sawchuk, Alan P.; Lemmon, Gary W.; Dalsing, Michael C.; Motaganahalli, Raghu L.; Murphy, Michael P.; Fajardo, Andres

doi:10.1016/j.jvs.2018.01.038

Cited by 29 publications

(18 citation statements)

References 19 publications

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“…Two celiac arteries were lost during cannulation but both remained asymptomatic (Falkensammer et al, 2017). Our technical success rate of 95%, target vessels incorporation of 97.3%, early (in hospital) and late reintervention rate of 15.5% and 5.3%, respectively, longterm target primary vessel patency of 98.6% and primary assisted patency rate of 100% compares favorably to results from these series (Katsargyris et al, 2013;Falkensammer et al, 2017;Martin et al, 2014;Wang et al, 2018). The single death in our series occurred in a patient treated for a rupture.…”

Section: Discussionsupporting

confidence: 63%

“…In the Cleveland clinic series, treatment failure was attributed to type IA endoleak in 70.4% of patients, stent migration in 33.3% and neck degeneration in 14.8% with some patients having a combination of these factors (Falkensammer et al, 2017). Wang et al attributed treatment failure in a series of 12 patients to neck enlargement after open repair in 6, type IA endoleak in 5 and neck enlargement in 1 patient post EVAR (Wang et al, 2018). In our series, type IA endoleak was observed in 94.7% of patients with stent graft migration accounting for 47.4% of primary treatment failure, disease progression for 26.3% and short neck for 15.8%.…”

Section: Discussionmentioning

confidence: 99%

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Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

et al. 2019

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Background: Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/ branched endografts (f/b-EVAR). Methods: A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/ b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates. Results: During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively. Conclusion: Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

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Section: Discussionsupporting

confidence: 63%

Section: Discussionmentioning

confidence: 99%

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

et al. 2019

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“…As the risk of rupture secondary to type II endoleak is an area of ongoing debate, this is only performed in patients with aneurysm sac expansion and only after embolization has been attempted. The advent of newer endovascular devices, including fenestrated and branched endografts and fixation anchors, has reduced the need for open conversion for type IA endoleak [22][23][24] . However, we have also treated some type IA endoleaks by external banding of the aneurysm neck.…”

Section: Discussionmentioning

confidence: 99%

Increasing use of open conversion for late complications after endovascular aortic aneurysm repair

Mohapatra

Robinson

Malak

et al. 2019

Journal of Vascular Surgery

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Objectives: Open procedures are often required for late complications after endovascular abdominal aortic aneurysm repair (EVAR). Our aim is to describe the indications for open interventions and their post-operative outcomes, and to specifically examine our experience with limited conversions in which problematic endoleaks are targeted without endograft explantation. Methods: We reviewed patients from 2002-2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, pre-operative imaging, procedural details, and post-operative outcomes were reviewed. The primary endpoint was 30-day mortality. Results: 102 patients underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016. 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (OR 6.70, 95% CI 1.75-25.60, P = .005), endograft infection (OR 8.48, 95% CI 1.99-36.20, P = .004), and use of a supraceliac clamp (OR 4.80, 95% CI 1.47-15.66, P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common post-operative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation while 28 had a graft-preserving (GP) intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). Over 3.0 ± 3.5 years of follow-up, there was one re-intervention after endograft explantation (for rupture secondary to type IB endoleak) and

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“…1,2 In patients where this is unsuccessful, an open repair or fenestrated endovascular aneurysm repair (FEVAR) is considered. 3 A fenestrated repair in these patients can be technically challenging, with difficulties catheterizing the target vessels frequently encountered. We describe the case of successful retrograde catheterization of the target vessels, where routine antegrade cannulation methods have failed.…”

Section: Introductionmentioning

confidence: 99%

Retrograde Catheterization of the Superior Mesenteric Artery and Celiac Axis as a Bailout Technique in a Complex FEVAR

Pineda

Pathmarajah

Sieunarine

2021

Vasc Endovascular Surg

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Introduction: A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed. Report: In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak. Discussion: Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.

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Use of the Zenith Fenestrated platform to rescue failing endovascular and open aortic reconstructions is safe and technically feasible

Abstract: FEVAR with the ZFEN platform of failed and failing aortic reconstructions due to disease progression is safe and feasible without increased morbidity and mortality in select patients. These preliminary results support the inclusion of ZFEN as a treatment option for aortic reintervention.

Cited by 29 publications

References 19 publications

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Increasing use of open conversion for late complications after endovascular aortic aneurysm repair

Retrograde Catheterization of the Superior Mesenteric Artery and Celiac Axis as a Bailout Technique in a Complex FEVAR

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