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Outcomes Following Urgent Fenestrated-Branched Endovascular Repair for Pararenal and Thoracoabdominal Aortic Aneurysms

      Background

      To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients who are considered high-risk for open repair.

      Methods

      A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and 1 year aortic related outcomes.

      Results

      Thirty-two patients (23 male, mean age, 74 ± 9 years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and 18 patients underwent urgent repair for symptomatic, mycotic, or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and 8 patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%), and 2 double-wide scallops (2%). A 30-day mortality was 6%, with 1 patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. Mortality and major adverse events MAEs otherwise occurred in 16 patients (50%), including minor stroke in 3 patients, transient paraparesis and heart failure in 1 patient each, and early return to the operating room in 6 patients. Mean follow-up was 24 ± 22 months. At 1-year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70% ± 8%, 94% ± 3 and 83% ± 7, respectively.

      Conclusions

      Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow-up is needed to assess the durability of repair and device-related complications.
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      References

        • Greenhalgh R.M.
        • Brown L.C.
        • Powell J.T.
        • et al.
        Endovascular versus open repair of abdominal aortic aneurysm.
        N Engl J Med. 2010; 362: 1863-1871
        • De Bruin J.L.
        • Baas A.F.
        • Buth J.
        • et al.
        Long-term outcome of open or endovascular repair of abdominal aortic aneurysm.
        N Engl J Med. 2010; 362: 1881-1889
        • Lederle F.A.
        • Freischlag J.A.
        • Kyriakides T.C.
        • et al.
        Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.
        JAMA. 2009; 302: 1535-1542
        • Oderich G.S.
        • Ribeiro M.S.
        • Sandri G.A.
        • et al.
        Evolution from physician-modified to company-manufactured fenestrated-branched endografts to treat pararenal and thoracoabdominal aortic aneurysms.
        J Vasc Surg. 2019; 70: 31-42.e7
        • Juszczak M.T.
        • Vezzosi M.
        • Khan M.
        • et al.
        Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts.
        J Vasc Surg. 2019; 72: 435-444
        • Scali S.T.
        • Waterman A.
        • Feezor R.J.
        • et al.
        Treatment of acute visceral aortic pathology with fenestrated/branched endovascular repair in high-surgical-risk patients.
        J Vasc Surg. 2013; 58: 56-65.e1
        • Georgiadis G.S.
        • van Herwaarden J.A.
        • Antoniou G.A.
        • et al.
        Systematic Review of off-the-shelf or physician-modified fenestrated and branched endografts.
        J Endovasc Ther. 2016; 23: 98-109
        • Starnes B.W.
        Physician-modified endovascular grafts for the treatment of elective, symptomatic, or ruptured juxtarenal aortic aneurysms.
        J Vasc Surg. 2012; 56: 601-607
        • Johnston K.W.
        • Rutherford R.B.
        • Tilson M.D.
        • et al.
        Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc Committee on reporting standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery.
        J Vasc Surg. 1991; 13: 452-458
        • Chaikof E.L.
        • Blankensteijn J.D.
        • Harris P.L.
        • et al.
        Reporting standards for endovascular aortic aneurysm repair.
        J Vasc Surg. 2002; 35: 1048-1060
        • Oderich G.S.
        Diameter-reducing wire to facilitate deployment of a modified Zenith fenestrated stent graft.
        Ann Vasc Surg. 2010; 24: 980-984
        • Oderich G.S.
        Technique of adding a diameter-reducing wire to the modified TX2 fenestrated stent graft.
        Vascular. 2010; 18: 350-355
        • Oderich G.S.
        • Fatima J.
        • Gloviczki P.
        Stent graft modification with mini-cuff reinforced fenestrations for urgent repair of thoracoabdominal aortic aneurysms.
        J Vasc Surg. 2011; 54: 1522-1526
        • Oderich G.S.
        • Mendes B.C.
        • Correa M.P.
        Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm using a physician-modified branched stent graft.
        J Vasc Surg. 2014; 59: 1168-1173
        • Oderich G.S.
        • Ricotta 2nd, J.J.
        Modified fenestrated stent grafts: device design, modifications, implantation, and current applications.
        Perspect Vasc Surg Endovasc Ther. 2009; 21: 157-167
        • Le Houérou T.
        • Fabre D.
        • Alonso C.G.
        • et al.
        In situ antegrade laser fenestrations during endovascular aortic repair.
        Eur J Vasc Endovasc Surg. 2018; 56: 356-362
        • Oderich G.S.
        • Forbes T.L.
        • Chaer R.
        • et al.
        Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries.
        J Vasc Surg. 2020; 73: 4S-52S
        • Starnes B.W.
        • Heneghan R.E.
        • Tatum B.
        Midterm results from a physician-sponsored investigational device exemption clinical trial evaluating physician-modified endovascular grafts for the treatment of juxtarenal aortic aneurysms.
        J Vasc Surg. 2017; 65: 294-302
        • Starnes B.W.
        • Tatum B.
        Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts.
        J Vasc Surg. 2013; 58: 311-317
        • Sweet M.P.
        • Starnes B.W.
        • Tatum B.
        Endovascular treatment of thoracoabdominal aortic aneurysm using physician-modified endografts.
        J Vasc Surg. 2015; 62: 1160-1167
        • Han S.M.
        • Tenorio E.R.
        • Mirza A.K.
        • et al.
        Low-profile Zenith Alpha™ thoracic stent graft modification using preloaded wires for urgent repair of thoracoabdominal and pararenal abdominal aortic aneurysms.
        Ann Vasc Surg. 2020; 67: 14-25
        • Taneva G.T.
        • Criado F.J.
        • Torsello G.
        • et al.
        Results of chimney endovascular aneurysm repair as used in the PERICLES Registry to treat patients with suprarenal aortic pathologies.
        J Vasc Surg. 2020; 71: 1521-1527.e1
        • Donas K.P.
        • Lee J.T.
        • Lachat M.
        • et al.
        Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry.
        Ann Surg. 2015; 262 (discussion 552-3): 546-553
        • Mougin J.
        • Oderich G.S.
        • Multon S.
        • et al.
        Urgent repair of postdissection thoracoabdominal aortic aneurysms using branched endografts.
        J Endovasc Ther. 2020; 27: 929-935
        • Schaffer J.M.
        • Lingala B.
        • Fischbein M.P.
        • et al.
        Midterm outcomes of open descending thoracic aortic repair in more than 5,000 medicare patients.
        Ann Thorac Surg. 2015; 100 (discussion 2094): 2087-2094
        • Tenorio E.R.
        • Eagleton M.J.
        • Kärkkäinen J.M.
        • et al.
        Prevention of spinal cord injury during endovascular thoracoabdominal repair.
        J Cardiovasc Surg (Torino). 2019; 60: 54-65
        • Gallis K.
        • Kasprzak P.M.
        • Cucuruz B.
        • et al.
        Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm.
        J Vasc Surg. 2017; 65: 1577-1583
        • Griepp E.B.
        • Di Luozzo G.
        • Schray D.
        • et al.
        The anatomy of the spinal cord collateral circulation.
        Ann Cardiothorac Surg. 2012; 1: 350-357
        • Kärkkäinen J.M.
        • Cirillo-Penn N.C.
        • Sen I.
        • et al.
        Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair.
        J Vasc Surg. 2020; 71: 1109-1118