Outcomes of iliofemoral conduits during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms.

To describe the technical pitfalls and outcomes of iliofemoral conduits during fenestrated-branched endovascular repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). We retrospectively reviewed the clinical data of 466 consecutive patients enrolled in a previous prospective nonrandomized study to investigate FB-EVAR for CAAAs/TAAAs (2013-2021). Iliofemoral conduits were performed through open surgical technique (temporary or permanent) in patients with patent internal iliac arteries or endovascular technique among those with occluded internal iliac arteries. End points were assessed in patients who had any iliac conduit or no conduits, and in patients who had conduits performed prior or during the index FB-EVAR, including procedural metrics, technical success, and major adverse events (MAE). There were 138 CAAAs, 141 extent IV, and 187 extent I-III TAAAs treated by FB-EVAR with an average of 3.89 ± 0.52 vessels incorporated per patient. Any iliac conduit was required in 35 patients (7.5%), including 24 patients (10.4%) treated between 2013 and 2017 and 11 (4.7%) who had procedures between 2018 and 2021 (P = .019). Nineteen patients had permanent conduits using iliofemoral bypass, 11 had temporary iliac conduits, and 5 had endoconduits. Iliofemoral conduits were necessary in 12% of patients with extent I to III TAAA, in 6% with extent IV TAAA, and in 3% with CAAA (P = .009). The use of iliofemoral conduit was more frequent among women (74% vs 27%; P < .001) and in patients with chronic obstructive pulmonary disease (49% vs 28%; P = .013), peripheral artery disease (31% vs 15%; P = .009), and American Society of Anesthesiologists classification of III or higher (74% vs 51%; P = .009). There were no inadvertent iliac artery disruptions in the entire study. The 30-day mortality and MAE were 1% and 19%, respectively, for all patients. An iliofemoral conduit using retroperitoneal exposure during the index FB-EVAR was associated with longer operative time (322 ± 97 minutes vs 323 ± 110 minutes vs 215 ± 90 minutes; P < .001), higher estimated blood loss (425 ± 620 mL vs 580 ± 1050 mL vs 250 ± 400 mL; P < .001), and rate of red blood transfusion (92% vs 78% vs 32%; P < .001) and lower technical success (83% vs 87% vs 98%; P < .001), but no difference in intraoperative access complications and MAEs, compared with iliofemoral conduits without retroperitoneal exposure during the index FB-EVAR and control patients who had FB-EVAR without iliofemoral conduits, respectively. There were no differences in mortality or in other specific MAE among the three groups. FB-EVAR with selective use of iliofemoral conduits was safe with low mortality and no occurrence of inadvertent iliac artery disruption or conversion. A staged approach is associated with shorter operating time, less blood loss, and lower transfusion requirements in the index procedure.

Dias-Neto M ，Marcondes G ，Tenorio ER ，Barbosa Lima GB ，Baghbani-Oskouei A ，Vacirca A ，Mendes BC ，Saqib N ，Mirza AK ，Oderich GS ... -  《-》

Outcomes of low- and standard-profile fenestrated and branched stent grafts for treatment of complex abdominal and thoracoabdominal aortic aneurysms.

We compared the outcomes of fenestrated-branched (FB) endovascular abdominal aortic aneurysm repair (EVAR) using low-profile (LP) and standard-profile (SP) stent grafts for the treatment of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). We reviewed the clinical data of 466 consecutive patients (70% male; mean age, 74 ± 8 years) enrolled in a prospective nonrandomized study to investigate FB-EVAR for the treatment of CAAAs and TAAAs (2013-2021). The endpoints compared between the patients treated with LP (18F-20F) and SP (20F-22F) devices included procedural metrics, access-related complications, major adverse events (MAE), patient survival, freedom from secondary intervention, thromboembolic events, stent graft integrity issues, aneurysm sac enlargement, and the rate of sac shrinkage. Of the 466 aneurysms treated by FB-EVAR, 138 were CAAAs and 141 were extent IV and 187 extent I to III TAAAs, with a mean number of 3.9 ± 0.5 vessels stented per patient. LP devices had been used in 239 patients (51%) and SP devices in 227 patients (49%). LP devices had been used more frequently for chronic dissections (12% vs 7%; P = .041) and with preloaded systems (77% vs 65%; P = .005) and bilateral percutaneous femoral access (83% vs 74%; P = .020) and less frequently with upper extremity access (67% vs 88%; P < .001) and iliac conduits (2% vs 6%; P = .020). The patients treated using LP devices had experienced similar technical success (96% vs 97%; P = .527), with a shorter total operating time (225 ± 81 minutes vs 243 ± 78 minutes; P = .018), lower radiation exposure (median, 0.93 Gy; interquartile range [IQR], 0.94; vs median, 1.01 Gy; IQR, 0.91 Gy; P < .001), and less use of contrast (median, 135 mL; IQR, 68 mL; vs median, 144 mL; IQR, 80 mL; P = .008). No differences were found in the rates of iliofemoral access complications between the LP and SP device groups (1.3% vs 3.5%; P = .107). At 30 days, 5 patients had died (1%) and MAEs had occurred in 89 patients (19%), with no differences between the two groups. The mean follow-up was 28 months (95% confidence interval, 25-30 months). At 4 years, the patients treated with LP devices had had similar freedom from all-cause mortality (69% ± 6% vs 68% ± 4%; P = .199), freedom from aortic-related mortality (97% ± 1% vs 98% ± 1%; P = .488), freedom from any secondary intervention (65% ± 6% vs 70% ± 4%; P = .433), freedom from thromboembolic events (98% ± 1% vs 99% ± 1%; P = .364) and aneurysm sac enlargement (93% ± 3% vs 91% ± 3%; P = .293). However, the LP group had had less freedom from any integrity-related issues (92% ± 5% vs 100%; P < .001). The cumulative risk of sac shrinkage was greater for patients treated with LP devices (adjusted hazard ratio, 2.040; 95% confidence interval, 1.516-2.744; P < .001). FB-EVAR was performed with low rates of mortality and MAEs, irrespective of the device profile. However, the procedures performed with LP devices had had less need for iliac conduits and had had better procedural metrics. The use of LP devices resulted in higher rates of sac shrinkage. However, the results on stent graft integrity require future investigation.

Dias-Neto M ，Tenorio ER ，Lima GBB ，Baghbani-Oskouei A ，Saqib N ，Mendes BC ，Mirza AK ，Oderich GS ... -  《-》

Outcomes of fenestrated-branched endovascular aortic repair in patients with or without prior history of abdominal endovascular or open surgical repair.

The aim of this study was to compare outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) in patients with or without prior history of abdominal open surgical (OSR) or endovascular aortic repair (EVAR). The clinical data of consecutive patients enrolled in a prospective, non-randomized study to evaluate FB-EVAR for treatment of CAAAs and TAAAs was reviewed. Clinical outcomes were analyzed in patients with no previous aortic repair (Controls), prior EVAR (Group 1), and prior abdominal OSR (Group 2), including 30-day mortality and major adverse events (MAEs), patient survival and freedom from aortic-related mortality (ARM), secondary interventions, any type II endoleak, sac enlargement (≥5 mm), and new-onset permanent dialysis. There were 506 patients (69% male; mean age, 72 ± 9 years) treated by FB-EVAR, including 380 controls, 54 patients in Group 1 (EVAR), and 72 patients in Group 2 (abdominal OSR). FB-EVAR was performed on average 7 ± 4 and 12 ± 6 years after the index EVAR and abdominal OSR, respectively (P < .001). All three groups had similar clinical characteristics, except for less coronary artery disease in controls and more TAAAs and branch stent graft designs in Group 2 (P < .05). Aneurysm extent was CAAA in 144 patients (28%) and TAAA in 362 patients (72%). Overall technical success, mortality, and MAE rate were 96%, 1%, and 14%, respectively, with no difference between groups. Mean follow up was 30 ± 21 months. Patient survival was significantly lower in Group 2 (P = .03), but there was no difference in freedom from ARM and secondary interventions at 5 years between groups. Group 1 patients had lower freedom from any type II endoleak (P = .02) and sac enlargement (P < .001), whereas Group 2 patients had lower freedom from new-onset permanent dialysis (P = .03). FB-EVAR was performed with high technical success, low mortality, and similar risk of MAEs, regardless of prior history of abdominal aortic repair. Patient survival was significantly lower in patients who had previous abdominal OSR, but freedom from ARM and secondary interventions were similar among groups. Patients with prior EVAR had lower freedom from type II endoleak and sac enlargement. Patients with prior OSR had lower freedom from new-onset dialysis.

Vacirca A ，Wong J ，Baghbani-Oskouei A ，Tenorio ER ，Huang Y ，Mirza A ，Saqib N ，Sulzer T ，Mesnard T ，Mendes BC ，Oderich GS ... -  《-》

Impact of previous open aortic repair on the outcome of thoracoabdominal fenestrated and branched endografts.

Thoracoabdominal aortic aneurysms (TAAAs) after previous aortic open surgical repair (OSR) are challenging clinical scenarios. Redo-OSR is technically demanding, and standard endovascular repair is unavailable due to visceral vessel involvement. Fenestrated and branched endografts (FB-EVAR) are effective options to treat TAAAs in high surgical risk patients but dedicated studies on the FB-EVAR outcomes in patients with TAAAs with previous OSR are not available. The aim of the study was to evaluate the impact of previous OSR on TAAAs FB-EVAR outcomes. Between 2010 and 2016, all TAAAs undergoing FB-EVAR were prospectively evaluated, retrospectively categorized in two groups, and then compared: group A-primary TAAAs and group B-TAAAs after previous OSR (abdominal, thoracic, or thoracoabdominal aneurysm). Early end points were technical success (absence of type I-III endoleak, target visceral vessel loss, conversion to OSR, intraoperative mortality), spinal cord ischemia (SCI), and 30-day mortality. Follow-up end points were survival, target visceral vessel patency, and freedom from reinterventions. Sixty-two patients (male: 74%; age: 72 ± 7 years) with 1 (1%) extent I, 14 (23%) extent II, 24 (39%) extent III, and 23 (37%) extent IV TAAA underwent FB-EVAR. The mean TAAA diameter and total target visceral vessels were 65 ± 13 mm and 226, respectively. Ninety branches and 136 fenestrations were planned. Thirty cases (48%) were clustered in group A and 32 (52%) in group B. Patients in group A and group B had similar preoperative clinical and morphologic characteristics, except for female sex (group A: 40% vs group B: 13%; P = .02). Technical success was 92% (group A: 90% vs group B: 94%; P = .6), SCI 5% (group A: 10% vs group B: 0%; P = .1) and 30-day mortality 5% (group A: 10% vs group B: 0%; P = .1). The mean follow-up was 17 ± 11 months with a total survival of 86%, 80%, and 60% at 6, 12, and 24 months, respectively and no differences in the two groups (group A: 83%, 83%, and 67% vs group B: 88%, 78%, and 55% respectively; P = .96). There was no late TAAA-related mortality. Target visceral vessel patency was 91%, 91%, and 91% at 6, 12, and 24 months, respectively (group A: 87%, 87%, and 87% vs group B: 95%, 95%, and 95%; P = .25). Freedom from reinterventions was 90%, 87%, and 87%, at 6, 12, and 24 months, respectively, and it was significantly lower in group A compared with group B (group A: 83%, 76%, and 76% vs group B: 96%, 96%, and 96% respectively; P = .002). Previous open surgery repair does not significantly affect the early outcomes of FB-EVAR in TAAA, with encouraging results in terms of technical success, SCI, mortality, and lower reinterventions rate at midterm follow-up.

Gallitto E ，Faggioli G ，Mascoli C ，Pini R ，Ancetti S ，Vacirca A ，Stella A ，Gargiulo M ... -  《-》

Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair.

Fenestrated and branched endovascular aneurysm repair (FB-EVAR) is a valid option to treat juxtarenal and pararenal abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Because successful deployment depends on complex maneuvers, hostile iliac artery anatomy (HIA) can prejudice the FB-EVAR outcome. The aim of the study was to evaluate the impact of HIA on FB-EVAR outcome. Between 2010 and 2015, all patients undergoing FB-EVAR were prospectively categorized according to iliac anatomy (friendly iliac artery anatomy [FIA] or HIA). HIA was defined as the presence of one of the following: severe (>90-degree) iliac angle, extensive (>50%) iliac circumferential calcification, hemodynamic iliac stenosis or obstruction, external iliac artery diameter <7 mm, or previous aortoiliac/femoral graft. Early end points were technical success (absence of type I or type III endoleak, target visceral vessel [TVV] loss, conversion to open repair), intraoperative adjunctive maneuvers (IAMs; iliac percutaneous transluminal angioplasty/stenting, surgical iliac conduit, intra-aortic graft rotations, several attempts of TVV cannulation), intraoperative technical problems (iliac rupture, significant endograft twisting, difficult TVV cannulations, TVV injuries, TVV loss), and 30-day mortality. Follow-up end points were survival, TVV patency, and freedom from reintervention. Ninety-four patients (male, 87%; age, 73 ± 6 years) with 59 (63%) juxtarenal and pararenal abdominal aortic aneurysms and 35 (37%) thoracoabdominal aortic aneurysms underwent FB-EVAR, for a total of 324 TVVs; 60 (64%) patients had HIA and 34 (36%) had FIA. Patients with HIA and FIA had similar preoperative clinical characteristics, except for coronary artery disease, peripheral artery occlusive disease, and American Society of Anesthesiologists class 4 (47% vs 24% [P = .03], 12% vs 0% [P = .04], and 28% vs 9% [P = .03], respectively). Technical success was 96% (HIA, 97%; FIA, 95%; P = .6). In HIA, adjunctive iliac procedures were performed in 32 cases (surgical conduit, 14 [15%]; percutaneous transluminal angioplasty/stenting, 27 [29%]). Endograft twisting and difficult TVV cannulation occurred in 13 (14%) and 33 (35%) cases, respectively (HIA 18% vs FIA 15% [P = .09]; HIA 28% vs FIA 21% [P = .03]). TVV cannulation failed in nine cases and injury occurred in five (TVV patency rate, 97.8%; HIA 94.7% vs FIA 98.3%; P = .3). One (1%) iliac rupture occurred in HIA, needing surgical repair. Overall, 44 (47%; HIA 55% vs FIA 25%; P = .03) IAMs were necessary. Perioperative mortality was 4% (HIA 3% vs FIA 5%; P = .9). At multivariate analysis, predictors of IAMs were external iliac diameter <7 mm (odds ratio [OR], 12.5; 95% confidence interval [CI], 2.2-71.4; P = .004) and extensive iliac calcifications (OR, 8.3; 95% CI, 1.4-50.0; P = .02). The mean follow-up was 24 ± 17 months, with an overall survival of 87% and 71% at 1 year and 3 years, respectively, significantly lower in HIA compared with FIA (at 3 years, HIA 60% vs FIA 92%; P = .02). On multivariate analysis, HIA was a significant predictor of late mortality (OR, 3.6; 95% CI, 1.1-13.2; P = .04). Freedom from reintervention (87%) and 3-year TVV patency (92%) were similar in the two groups. HIA does not significantly affect the early outcome of FB-EVAR. However, in patients with HIA, procedures are technically more demanding and late mortality is increased. Iliac characteristics should be taken into account to correctly stratify the surgical risk in FB-EVAR.

Gallitto E ，Gargiulo M ，Faggioli G ，Pini R ，Mascoli C ，Freyrie A ，Ancetti S ，Stella A ... -  《-》