Midterm results of laser generated in situ fenestration of the left subclavian artery during thoracic endovascular aneurysm repair.

OBJECTIVE: To analyze the midterm result of in situ fenestration (ISF) of the left subclavian artery (LSA) during thoracic endovascular aneurysm repair (TEVAR). METHODS: In this clinical study, between 2014 and 2016, ISF for LSA revascularization was attempted during TEVAR in 10 patients (7 males; median age, 68 years). An excimer laser, placed from the left brachial artery, was used to create a fenestration and all fenestrations were stented with covered stent grafts. Follow-up included computed tomography scans 1 month postoperatively and annually thereafter. Survival was analyzed according to Kaplan-Meier. RESULTS: Nine of the 10 laser-assisted ISF were successful. No 30-day mortality occurred. One patient had a transient ischemic attacked in the left carotid territory. After a median follow-up of 27 months, all fenestrations were patent. At 1 month, computed tomography follow-up showed nonspecific endoleaks of unknown origin in five of the nine patients. At 27 months follow-up, only two endoleaks remained. One reintervention was done after 24 months owing to a type Ic endoleak from the LSA. Overall TEVAR success, defined as survival with no aneurysm expansion, was eight of nine. One patient showed aneurysm expansion after 14 months. Two deaths occurred (at 33 and 31 months postoperative), one of unknown reason and one aneurysm related. CONCLUSIONS: Laser fenestration might be an option for LSA revascularization during emergent or semiurgent TEVAR and electively in patients with hostile neck anatomy (eg, previous neck radiation, short and adipose necks) that might make a carotid-subclavian bypass difficult. The LSA fenestration has excellent patency and TEVAR success was not affected by nonspecific endoleaks around the LSA.

Is there an age limit for abdominal aortic aneurysm repair?

INTRODUCTION: There is an increasing number of elderly in society and some of them may have an abdominal aortic aneurysm (AAA). The prevalence of AAA in octo- and nonagenarians indicates that this number could be substantial. The question is: is there an age limit for repair? This complex question incorporates ethical, political, economic and medical aspects. To answer part of this question a review of the outcome of elective and emergent AAA repair in those over 80 was done. EVIDENCE ACQUISITION: A literature research was done in the PubMed and Embase databases between 2007 and 2017 for either emergent and/or elective repair of AAA in individuals older than 80 years of age. EVIDENCE SYNTHESIS: Ten of 663 studies were found eligible for the review. Elective AAA repair in individuals more than 80 years shows a very varying outcome with 30-day mortality between 0% and 20.1% and 1-year mortality between 7% and 26%. Length of procedure, hospital stay, and number of major adverse events are also more in those over 80 years of age. In ruptured AAA 30-day mortality is between 29 and 59 % and 1 one year between 45% and 63%. CONCLUSIONS: No definitive answer whether to perform a repair of AAA in the elderly can be given. The decision has to be individualized and will also vary depending on ethical, political, economic factors and type of healthcare system the individual lives in.

Endovascular redo aortic surgery.

Endovascular redo aortic operations are a challenging undertaking. Techniques for treatment date almost as far back as the original open repair itself. Risk factors for failure following aortic repair include larger abdominal aortic aneurysm necks, severe neck angulation, as well as clinical variables such as age, family history, obesity and chronic obstructive pulmonary disease. The armamentarium of endovascular treatments is vast and increasing. Aside from provisional embolization of endoleaks or deferment to open repair conversion, attention should be directed toward obtaining adequate proximal and distal sealing. This can be achieved with Palmaz stents, endoanchors, and extension with fenestrated or branched endovascular repair. Thoracic aortic coverage may be required, and revascularization of the left subclavian artery should be considered. Technical issues such as these, as well as target vessel cannulation and accommodation of the new graft within the previous implanted graft, require experience and careful planning. Distal extension can likewise resolve a failing repair, and this may require the use of internal iliac artery embolization or iliac-branch devices. Redo aortic operations are technically demanding and are carried out with increased risks. Improving technology, such as fusion imaging, should mitigate some of this risk and are recommended.

Early experience with a modified preloaded system for fenestrated endovascular aortic repair.

OBJECTIVE: Preloaded endovascular delivery systems expand the anatomic eligibility for complex aortic repair by requiring only one iliac access vessel and providing a stable platform for guiding sheaths into challenging target vessels. This article reports the lessons learned and early clinical outcomes using a modified preloaded delivery system for fenestrated endovascular aneurysm repair (FEVAR) in three aortic centers in Europe. METHODS: From October 2015 to March 2016, consecutive patients presenting with extensive aortic aneurysm treated with a modified preloaded FEVAR were prospectively enrolled from three high volume European aortic centers. The new design is a modification of previous designs of preloaded fenestrated stent grafts and of the p-branch device platform. The technical details of implantation are described and perioperative outcomes, including the learning curve, are collected and reported. RESULTS: All patients (30 patients; 80% men; 70.2 years old) presented for nonurgent repair of either a type Ia endoleak (3/30; 10%), a type I-II-III thoracoabdominal (8/30; 27%), or a type IV thoracoabdominal or pararenal (19/30; 63.%) aneurysm repair of a mean size of 64 ± 13 mm using a custom made device. Primary technical success was achieved in 28 of 30 patients (93%) and assisted primary technical success in 29 of 30 patients (97%). The two technical failures included open conversion to repair a ruptured iliac artery and restenting of a dissected superior mesenteric artery which was recognized hours after the index procedure had finished. The mean procedure time was 277 ± 153 minutes, fluoroscopy time 79 ± 36 minutes, dose area product 112 ± 90 Gy cm2, and contrast volume 87 ± 46 mL. All renal fenestrations were successfully stented without type III endoleak on completion angiogram; the preloaded guiding sheaths were used for 53 of 58 renal arteries (91%). Challenges related to learning to the use of the modified preloaded system were experienced early and had no clinical consequences. Major complications occurred in seven cases (23%), including two perioperative deaths because of stroke and sepsis following primary conversion attributable to iliac rupture. There were no target vessel occlusions or type I/III endoleaks found on postoperative imaging. CONCLUSIONS: Based on early experience, the modified preloaded system can be safely and effectively used during FEVAR, with good technical result and a short period of learning. This device expands treatment to patients with compromised iliac access, thus, additional patients and more follow-up will be required to determine unique risks of operating in this patient population.

On the complexity of screening detected abdominal aortic aneurysms: a retrospective observational multicenter cohort study.

BACKGROUND: Ultrasound screening for abdominal aortic aneurysms (AAA) has been shown to decrease aneurysm related mortality. Likely by providing an opportunity to intervene while the aneurysm is still intact, but possibly also when and the anatomy still relatively uncomplicated which would provide a less complex procedure. Our aim was to retrospectively investigate the complexity of repair for screening-detected AAAs in a cohort of 65-year-old men. METHODS: All screening detected AAA cases that underwent repair between Sept 2010 and June 2014 in the most southern region of Sweden were included. Procedures were classified as either standard or complex. A standard procedure was defined as either standard EVAR (endovascular aneurysm repair) within the manufacturers Instructions For Use (IFU) or open repair with infrarenal clamping followed by a tube graft repair. All other types of procedures were defined as complex. The prevalence rate of AAA, screening compliance, short- and midterm outcome of the operations were reported. RESULTS: From the 35513 men invited to screening, 27 951 (78.7%) attended screening with ultrasound. AAA≥30 mm was found in 561 cases, yielding a prevalence rate of 2.0%. Forty-eight patients underwent AAA repair. A percentage of 43.8% of these were classified as complex procedures. These consisted mostly of branched/fenestrated EVAR or EVAR with simultaneous exclusion of common iliac aneurysm. CONCLUSIONS: Our study confirms contemporary prevalence rates of AAA. Almost half (43.8%) of screening-detected AAA required complex operations, a significant proportion. The complex aneurysms were, on average, larger than the non-complex cases and they were more likely to be cases that required surgery immediately after screening detection. Our data suggests that the nature of AAA is heterogenous, even in the screening-detected group requiring operation. This should spur interest in more studies to investigate this issue.

The effects of combining fusion imaging, low-frequency pulsed fluoroscopy, and low-concentration contrast agent during endovascular aneurysm repair.

OBJECTIVE: This study evaluated the effects of a combined imaging protocol using low-frequency pulsed fluoroscopy, fusion imaging, and low-concentration iodine contrast for endovascular aneurysm repair (EVAR) of aortic aneurysms of varying complexity. METHODS: The study retrospectively reviewed the data of 103 patients treated between May 2013 and November 2014 with the combined imaging protocol (group A) with low-dose fluoroscopy at 3.75 frames/s, fusion imaging, and iodine contrast of 140 mg iodine/mL. A control group (group B) consisted of 123 consecutive patients who underwent EVAR before the combined imaging protocol was introduced by matching the type of procedure. In group B, low-dose 7.5 frames/s fluoroscopy, no fusion imaging, and 200 mg iodine/mL contrast were used. All patients were reviewed for preoperative, intraoperative, and postoperative variables, with emphasis on intraoperative radiation (dose area product) and iodine exposure, fluoroscopy, and operation times, as well as technical success. Values are presented as median and interquartile range (IQR) when not stated otherwise. RESULTS: Group A included 22 infrarenal EVARs, 17 iliac branch devices, 10 thoracic endovascular aortic repairs, 21 fenestrated EVARs, and 33 thoracoabdominal branched/fenestrated EVARs. Groups A and B were similar in types of procedure, body mass index (P > .05), and intraoperative technical success (92% and 92%, respectively; P > .05). Operation time (230 [IQR, 138-331] minutes vs 235 [IQR, 158-364] minutes) and fluoroscopy time (66 [IQR, 33-101] minutes vs 72 [IQR, 42-102] minutes) were similar in both groups (P > .05), but radiation exposure (19,934 [IQR, 11,340-30,615] µGym(2) vs 32,856 [IQR, 19,562-55,677] µGym(2); P < .0001), contrast volume usage (63 [IQR, 103-145] mL vs 215 [IQR, 166-280] mL; P < .0001), and iodine dose (14.5 [IQR, 8.8-20.4] g iodine vs 43.0 [IQR, 32.2-56.0] g iodine; P < .0001) were lower in group A than in group B. The differences were uniform throughout the different procedure types, with the exception of fenestrated grafts, where radiation exposure was similar between group A and B; however, group A had a much higher involvement of the superior mesenteric artery in the repairs (81% vs 17%; P < .0001) explaining this finding. Fluoroscopic frame rate reduction contributed to a median reduction of the dose area product by 22%. Only four of the group A patients (3.9%) showed a decrease in the glomerular filtration rate ≥30% after EVAR, although 32% of the entire group had at least moderately impaired renal function preoperatively. CONCLUSIONS: Combining low-frequency pulsed fluoroscopy, fusion imaging, low-concentration, and iodine contrast medium during EVAR reduces the exposure to radiation and iodine.

Morphology of Small Abdominal Aortic Aneurysms Should be Considered before Continued Ultrasound Surveillance.

BACKGROUND: To evaluate abdominal aortic aneurysm (AAA) morphology in a cohort of patients presenting with ruptured AAA (rAAA) and to explore if aneurysms with diameters below the recommended threshold for elective repair (<55 mm) have some distinctive morphological characteristics. METHODS: All patients diagnosed with rAAA using computed tomography (CT) scans between January 2006 and June 2013 were eligible for this study. Where CT scans of acceptable quality were available, images were reconstructed in a dedicated three-dimensional vascular workstation for evaluation of aneurysm diameters and morphology. All morphological characteristics were defined according to the reporting standards for endovascular aortic aneurysm repair. Additionally, fusiform AAAs were defined as aneurysms involving the whole circumference of the aortic wall and saccular AAAs as spherical aneurysms involving only a portion of the aortic circumference. RESULTS: A total of 248 patients were identified. Of those, 83% (n = 206) had high-quality CT scans available and were included in the study. Patients were on average 75 years old and 85% were men. Mean aneurysm diameter was 76 ± 14 mm and 95% (n = 197) had fusiform morphology. Six percent (n = 12) were <55 mm and those included all saccular aneurysms in women (n = 3) and 22% of saccular aneurysms in men (n = 2). The remaining saccular aneurysms (n = 4) were small with a maximal diameter of 56 mm. Aneurysms <55 mm had less angulated proximal necks than their larger counterparts (P < 0.01). No other morphological differences were found between the groups. CONCLUSIONS: Ruptured aneurysms are often large and the ≥55 mm threshold for elective repair is probably appropriate. However, approximately 6% of rAAAs are <55 mm, with a significant portion being saccular, especially in women. Morphological assessment of AAAs with CT scans should be considered in small aneurysms (40-55 mm), particularly in women, to exclude saccular morphology before continued ultrasound surveillance.

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS.

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and expert's opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

Chimney grafts preserve visceral flow and allow safe stenting of juxtarenal aortic occlusion.

OBJECTIVE: Chimney grafts have proven useful for urgent endovascular repair of juxtarenal aortic aneurysms. Stenting of juxtarenal aortic occlusive disease is not routinely advocated due to the risk of visceral artery obstruction. We report on the potential applicability of chimney grafts in 10 patients with juxtarenal aortic stenosis or occlusion. To our best knowledge, chimney grafts have not been applied previously in this challenging setting. METHODS: Ten high-risk female patients (mean age, 68 years) with severe stenosis or occlusion of the aorta at the level of the visceral arteries were offered stenting. "Chimney" stents or stent grafts (20-40 mm long) were implanted from a brachial approach into visceral arteries that needed to be covered by the aortic stent. The chimney stents were then temporarily obstructed by balloon catheters to prevent visceral embolization until the aortic stent or stent graft was deployed. RESULTS: All procedures were technically successful, and patency was obtained in all visceral arteries and the aorta without distal embolization. One patient died after 9 days of acute heart failure. The nine surviving patients presented no complications, and all stented vessels remained patent at up to 6 years. Another patient died after 5.5 years due to lung cancer. All three patients with renal impairment have improved renal function, and a reduction in antihypertensive medication has been possible. CONCLUSIONS: Chimney grafts may allow stenting of juxtarenal aortic occlusive disease by protecting the patency of visceral arteries. Further evaluation with more patients and longer follow-up is required.

New temporary internal introducer shunt for brain perfusion during total endovascular arch replacement with in situ fenestration technique.

Complete endovascular arch replacement by in situ fenestration technique requires maintenance of cerebral perfusion during the fenestration procedure by an extracorporeal femoral-carotid bypass. The bypass has the disadvantages of being invasive, requiring a pump, and shunting blood extracorporeally. This report describes bench testing and an in vivo experimental animal setup with an endovascular, temporary introducer shunt. This technique represents an adjunctive step toward a complete endovascular repair for the aortic arch.

Endovascular total aortic arch replacement by in situ stent graft fenestration technique.

Open surgical total aortic arch replacement is a demanding procedure which carries a substantial morbidity and mortality. A less invasive endovascular option is endovascular stent grafting using in situ fenestrations. After thoracic stent graft deployment in the arch, fenestrations are made for the major arch vessels. During this procedure, antegrade cerebral perfusion is maintained using a temporary bypass from the left femoral artery to both carotids perfusing both the anterior and posterior cerebral circulation. The endovascular technique and devices used are herein described.