Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
Abdominal aortic aneurysms that are unsuitable for a standard endovascular repair (EVAR) could be considered for fenestrated endovascular repair (f-EVAR). The aim of this study was to conduct a risk-adjusted retrospective concurrent cohort comparison of f-EVAR and open repair for such aneurysms.
All patients who underwent repair of an abdominal aortic aneurysm that was unsuitable for a standard EVAR due to inadequate neck within one institution between January 2006 and December 2010 were identified. Case notes were retrieved for clinical data, Vascular Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (V-POSSUM) score, and aneurysm morphology. Computed tomography scans were reviewed to establish aneurysm morphology.
A total of 107 patients were identified. The open surgery cohort included 54 patients (35 men) who were a median age of 72 years (interquartile range [IQR], 9.5; range, 60-86 years). The aortic cross-clamp was infrarenal in 20 patients, suprarenal or above in 21, and inter-renal in eight. Postoperatively, 63 major complications were noted in 30 patients, nine of whom required 16 reinterventions. Cumulative hospital stay of the cohort was 1170 days (median, 12; IQR, 13; range, 1-205 days) of which 234 days (median, 28; IQR, 36; range, 1-77 days) were in the intensive therapy unit (ITU). Perioperative mortality was 9.2% (n = 5), exactly as estimated by V-POSSUM. The f-EVAR cohort included 53 patients (47 men) who were a median age of 76 years (IQR, 11.50; range, 55-87 years). Two fenestrations and one scallop was the most frequent configuration (n = 31). Postoperatively, 37 major complications were noted in 18 patients, six requiring reintervention. Hospital stay was 559 days (median, 7; IQR, 4.5; range, 4-64 days), of which 31 days (median, 4; IQR, 10.5; range, 1-15 days) were in the ITU. Two patients died perioperatively (3.7%), resulting in an observed crude absolute risk reduction of 5.5% compared with open repair. The V-POSSUM estimated perioperative death in five patients (9.4%) in the f-EVAR cohort. In a hypothetic scenario of the f-EVAR cohort undergoing open repair, V-POSSUM estimated seven deaths (13.2%), resulting in an estimated risk-adjusted absolute risk reduction due to f-EVAR of 9.5%.
In this group of patients, f-EVAR reduced mortality and morbidity substantially compared with open repair and also reduced total hospital stay and ITU utilization.
Canavati R
，Millen A
，Brennan J
，Fisher RK
，McWilliams RG
，Naik JB
，Vallabhaneni SR
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Dutch experience with the fenestrated Anaconda endograft for short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair.
In the past decennium, the management of short-neck infrarenal and juxtarenal aortic aneurysms with fenestrated endovascular aneurysm repair (FEVAR) has been shown to be successful, with good early and midterm results. Recently, a new fenestrated device, the fenestrated Anaconda (Vascutek, Renfrewshire, Scotland), was introduced. The aim of this study was to present the current Dutch experience with this device.
A prospectively held database of patients treated with the fenestrated Anaconda endograft was analyzed. Decision to treat was based on current international guidelines. Indications for FEVAR included an abdominal aortic aneurysm (AAA) with unsuitable neck anatomy for EVAR. Planning was performed on computed tomography angiography images using a three-dimensional workstation.
Between May 2011 and September 2013, 25 patients were treated in eight institutions for juxtarenal (n = 23) and short-neck AAA (n = 2). Median AAA size was 61 mm (59-68.5 mm). All procedures except one were performed with bifurcated devices. A total of 56 fenestrations were incorporated, and 53 (94.6%) were successfully cannulated and stented. One patient died of bowel ischemia caused by occlusion of the superior mesenteric artery. On completion angiography, three type I endoleaks and seven type II endoleaks were observed. At 1 month of follow-up, all endoleaks had spontaneously resolved. Median follow-up was 11 months (range, 1-29 months). There were no aneurysm ruptures or aneurysm-related deaths and no reinterventions to date. Primary patency at 1 month of cannulated and stented target vessels was 96%.
Initial and short-term results of FEVAR using the fenestrated Anaconda endograft are promising, with acceptable technical success and short-term complication rates. Growing experience and long-term results are needed to support these findings.
Dijkstra ML
，Tielliu IF
，Meerwaldt R
，Pierie M
，van Brussel J
，Schurink GW
，Lardenoye JW
，Zeebregts CJ
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An analysis of variables affecting aortic neck length with implications for fenestrated endovascular repair of abdominal aortic aneurysm.
A major factor in the selection of patients for endovascular aneurysm repair (EVAR) is the character of the aortic neck, and studies suggest that many patients are treated outside of the instructions for use (IFU) criteria. By analyzing aortic neck morphology, we hope to identify factors that may influence decision making about the use of fenestrated endografts as an alternative to extending the neck limitations of traditional endografts.
A retrospective analysis was completed on 111 patients who underwent computed tomography angiography (CTA) scans between May 1, 2009 and January 3, 2011 for the evaluation of abdominal aortic aneurysm (AAA). Individual characteristics of neck and aneurysm morphology were analyzed to establish whether certain factors determined suitability for EVAR with traditional nonfenestrated endografts. In considering augmented neck lengths (ANL), anatomic measurements of distance from the start of aortic dilatation to the lowest renal artery (LRA) and highest renal artery (HRA) were analyzed. Measurements were analyzed using Stata software (version 11.2; StataCorp, College Station, TX).
There were 86 men and 25 women in the patient population, with an average age of 72.9 years. In 46 patients, the proximal neck length was <15 mm, with 26 patients having neck lengths <10 mm. There was a negative relationship between AAA maximum diameter and proximal neck length (rs = -0.2237; P = 0.018), indicating that as aneurysm size increases, proximal neck length decreases. There was a significant correlation between proximal neck length and proximal neck diameter (rs = -0.2585; P = 0.006) and between proximal neck length and angle (rs = -0.2355; P = 0.013), and between proximal neck diameter and right iliac maximum diameter (rs = 0.2329; P = 0.014). Using fenestration to place an endograft above the LRA would create an ANL of >15 mm in 20 of 40 patients with aortic necks deemed too short to be eligible for EVAR using conventional infrarenal graft positioning. Extending the graft above the HRA would create an ANL of >15 mm in 36 of 40 patients.
In this study, 41% of patients presented with neck lengths outside that of the traditional IFU for most aortic endografts. While there was wide variation from patient to patient, there was a general correlation between increasing AAA size and aneurysms that have shorter, wider, and more angulated proximal necks. Fenestration of even 1 renal artery could substantially increase the ANL. Additional study is warranted to determine if an increase in ANL in patients with otherwise short necks will positively impact long-term EVAR outcomes.
Stark M
，Suresh A
，Alexander J
，Cragg A
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Changes in Aortoiliac Anatomy After Elective Treatment of Infrarenal Abdominal Aortic Aneurysms with a Sac Anchoring Endoprosthesis.
Endovascular aortic sealing (EVAS) with the Nellix endosystem (Endologix, Irvine, CA, USA) is a new concept to treat infrarenal abdominal aortic aneurysms (AAAs). By sealing the aneurysm, potential endoleaks may be avoided. Early results of EVAS are good, but no data have been published regarding peri-procedural changes in aortoiliac anatomy. In this study, 27 consecutive patients who underwent elective EVAS repair of an AAA were reviewed.
Specific AAA (diameter, length from renal arteries to aortic bifurcation, supra- and infrarenal neck angulation, AAA volume, thrombus volume, and flow lumen volume), and iliac artery characteristics (length, angulation, location of most severe angulation with reference to the origin of the common iliac artery) were determined from pre- and post-procedural reconstructed computed tomography angiograms.
No type I or II endoleaks were seen at 30 day follow up. Total AAA volume, suprarenal and infrarenal angulation, as well as aortic neck diameter did not change significantly post-EVAS. AAA flow lumen increased significantly (mean difference -4.4 mL, 95% CI 2.0 to -8.6 mL) and AAA thrombus volume decreased (mean difference 3.2 mL, 95% CI 2.0 to -1.1 mL). AAA length (125.7 mm vs. 123.1 mm), left common iliac artery length (57.6 mm vs. 55.3 mm), and right and left maximum iliac artery angulation (right 37.4° vs. 32.2°; left: 43.9° vs. 38.4°) were reduced significantly and the location of maximum angulation was further from the iliac artery origin post-EVAS, suggesting slight straightening of the aortoiliac anatomy.
Most aortoiliac anatomic characteristics remained unchanged post-EVAS. Filling of the endobags to a pressure of 180 mmHg may lead to lost thrombus volume in some patients, probably because liquid is squeezed into lumbar or the inferior mesenteric artery. The absolute differences in pre- and post-EVAS aortoiliac lengths were small, so pre-operative sizing is accurate for determining stent length.
Boersen JT
，Schuurmann RC
，Slump CH
，van den Heuvel DA
，Reijnen MM
，ter Mors TG
，Vahl AC
，de Vries JP
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