Fenestrated endovascular repair of complex aortic aneurysms.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) provides an endovascular solution for patients with large abdominal aortic aneurysms and challenging neck anatomy in addition to repair of endoleaks and pseudoaneurysms. This article reports the midterm outcomes of FEVAR from a single-tertiary referral centre in Ireland. METHODS: From 2006 to 2012, nine consecutive asymptomatic patients with neck anatomy unfavourable for standard EVAR underwent endovascular repair with a customised fenestrated Zenith stent graft. An additional three patients had fenestrated grafts for repair of pseudoaneurysms (n = 2) following open AAA repair and a type I endoleak (n = 1). All patients were prospectively enrolled in a computerised database. Outcomes including mortality, morbidity, renal function, target vessel patency, endoleak and reintervention were analysed. FINDINGS: The mean age and aneurysm size in the primary repair group were 74 years (65-84 years) and 6 cm (5-8.3 cm), respectively, and in the secondary repair group, the mean age was 66 years (61-75 years). No procedures required open conversion, and no visceral arteries were lost. On completion angiography, two patients in group 1 had a type I endoleak and one had a type III endoleak. There were no endoleaks in the secondary repair group. Follow-up ranged from 30 days to 6 years. There was one death within 30 days (8 %) and two deaths at 3 years from non-aneurysm-related causes. Six patients required secondary interventions. Three patients had a transient post-operative creatinine rise of >30 %. CONCLUSION: Our study supports FEVAR as a feasible and effective therapy in the management of patients with complex aortic aneurysms.

Endovascular repair of thoracoabdominal aortic aneurysm (TAAA): early experience.

BACKGROUND: Repair of thoracoabdominal aortic aneurysms (TAAA) represents a considerable technical challenge. Since its first description in 1955, open repair of TAAA has been considered the gold standard of repair. Despite improvements in surgical techniques, spinal cord protection and post-operative critical care support, patients who undergo open repair are faced with a mortality rate of 5-35 %. We report the first Irish experience of endovascular management of TAAAs. RESULTS: To date five patients have undergone endovascular repair; four had hybrid repair and one a fenestrated graft. The mean age of the patients was 66.8 ± 3.4 and the mean aneurysm diameter was 6.74 ± 0.6 cm. All patients were ASA III. Two-stage hybrid repair was associated with an increased risk of complications, prolonged intensive care unit and overall hospital stay. One patient died in the perioperative period due to rupture of their aneurysm between the two stages of their hybrid repair. CONCLUSION: The role of endovascular techniques in the treatment of TAAA continues to evolve. Hybrid and complete endovascular repairs do not replace conventional repair, but provide an alternative for high-risk patients who might otherwise be denied treatment.

Measurement and optimization of patient radiation doses in endovascular aneurysm repair.

The study assessed radiation exposure during EVAR. Two types of patient dose were estimated: effective dose (ED), which allows estimation of radiation risk to the EVAR patient population; and Peak Skin Dose (PSD), which allows us assess the potential for an individual patient to receive a radiation skin injury. An ancillary aim was to examine dose optimization in EVAR procedures. Based on 111 EVAR cases we estimated average ED as 12.4 mSv. Cumulative patient dose in our centre was lower than other studies because the follow up of EVAR patients is based on ultrasound rather than CT. PSD calculated using a published conversion formula closely matched measurements with calibrated gafchromic film. 99% of patients had an estimated PSD of < 2Gy. Results indicate that skin injuries are possible, but very unlikely in EVAR procedures at our centre. EVAR is a high dose procedure and emphasis on dose optimisation is important. We broke the EVAR procedure into 15 steps and, in a phantom study, showed how skin dose changes as procedure steps are varied. The resulting dose matrix has the potential to be used as an educational tool to promote dose optimization.

Hybrid repair of a symptomatic thoracic intra-mural haematoma.

INTRODUCTION: The repair of thoracic aortic pathology by open techniques is associated with high morbidity and mortality. METHODS: We describe the first case of hybrid thoracic aortic repair performed in Ireland for a symptomatic thoracic intramural haematoma. CONCLUSION: Hybrid repair with extra-anatomical aortic visceral revascularisation and subsequent thoracic endograft exclusion offers an attractive alternative method of repair for thoracic aortic pathology.

Hybrid repair of thoracic aortic arch aneurysm.

INTRODUCTION: Aortic arch pathology requiring surgery most often affects elderly patients with multiple co-morbidities and represents a significant challenge to both patient and surgeon. MATERIALS AND METHODS: This case report describes the repair of an 8.2 cm aortic arch aneurysm arising at the origin of the left subclavian artery using a combined endovascular and open surgical approach. CONCLUSION: Hybrid techniques allow for the treatment of pathology that would otherwise not be amenable to surgery.

Endovascular management of thoracic aortic pathology.

BACKGROUND: Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date. METHODS: A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted. FINDINGS AND CONCLUSIONS: The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.