Fenestrated and Branched Endografts for Post-Dissection Thoraco-Abdominal Aneurysms: Results of a National Multicentre Study and Literature Review

Intravascular Ultrasound Impact on Endovascular Treatment of Type B Aortic Dissection: A Single-Center Retrospective Study

BACKGROUND

Intravascular ultrasound (IVUS) has numerous applications for the treatment of patients with type B aortic dissections (TBADs). The aim of this study was to analyze the eventual benefits of the use of IVUS in the endovascular treatment of TBAD.

METHODS

Patients who underwent endovascular surgery for TBAD in our department from January 2015 to January 2024 were included in the study. Results for patients who had intraoperative IVUS (group A, 38 patients) were compared with those of patients who had no IVUS (group B, 37 patients). The use of IVUS or not depended on the surgeon's personal choice. Primary outcomes included technical success, defined as correct release into the true lumen, and clinical success. Secondary outcomes were complication rates, reintervention rates, and mortality. The mean follow-up time was 37.5 months (range, 1-108 months).

RESULTS

During the analyzed period, 75 patients were treated for TBAD: 19 patients were treated in the acute phase, 41 in the subacute phase and 15 in the chronic phase. Technical success was achieved in 69 patients (92%), with a technical success rate of 100% in group A and of 83.8% in group B (P < 0.0115). Adjunctive intraoperative procedures were required in 6 cases (8%). No intraoperative or 24-hr deaths were recorded. Perioperative aorta-related complications were recorded in 7 cases, and perioperative aorta-related reinterventions were recorded in 6 cases. A 30-day death was recorded in 2 cases. Thirty-day complications were recorded in 4 cases and reinterventions were needed in 5 cases.

CONCLUSION

The results of our study show the importance of IVUS utilization during endovascular treatment of TBAD, including the accurate positioning of the graft, reduced complication, and reintervention rates.

Use of the Electrified Wire Technique for In Situ Fenestration Creation Within a Branch Bridging Stent

PURPOSE

To present the use of the electrified wire technique as bailout for target vessel (TV) branch preservation after unintended coverage by a bridging stent during branched endovascular repair (bEVAR).

TECHNIQUE

A 73-year-old male, previously treated with thoracic endovascular aortic repair and Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) for type B aortic dissection, presented with a 68 mm type V thoracoabdominal aortic aneurysm. The patient presented an anatomic variation with a common trunk for the superior mesenteric artery (SMA) and celiac artery (CA). After a previously failed open surgical attempt, a triple-branch custom-made device (2 renal branches and 1 for the SMA/CA trunk) was chosen. Endograft deployment and TV catheterization were uneventful, until an unintended coverage of the CA occurred, due to bridging stent unmount. Using the electrified wire technique, an in situ fenestration was created into the CA/SMA trunk covered bridging stent to preserve CA patency. A bare metal stent was used for CA revascularization. Renal arteries were catheterized and bridged as planned. The 6-month computed tomography angiography confirmed TV patency.

CONCLUSION

The electrified wire technique may be used as bailout for in situ fenestration creation in unintended coverage of early TV side-branches.Clinical ImpactAnatomic variations may increase the technical complexity of branched endovascular aortic repair while technical pitfalls related to target vessel preservation may demand the application of bailout techniques. In this case, the electrified wire technique was used to create an in situ fenestration within the bridging stent of a celiac artery (CA) and superior mesenteric artery common trunk (anatomic variation), after bridging stent unmount during advancement and CA unintended coverage.

Overall survival, cause of death and time interval between diagnosis and death after Stanford type B acute aortic dissection (TBAAD)

OBJECTIVES

This study aimed to assess survival rates and the causes of both early and late mortality in patients with Stanford type B acute aortic dissection (TBAAD).

METHODS

A retrospective analysis was conducted on all consecutive patients presenting with TBAAD from 2000 to 2018 at a single tertiary care centre. The primary end-point was early (<3 months) and late (>3 months) survival following TBAAD, with causes of both early and late mortality evaluated.

RESULTS

A total of 274 patients, with a mean age of 64 ± 13 years, were included. Among these, 155 patients (57%) presented with uncomplicated TBAAD, including 52 (19%) identified as high-risk, and 119 patients (43%) had complicated TBAAD. Early aorta-related mortality occurred in 9 patients (3.3%), all within the complicated TBAAD group. The median follow-up period for the entire cohort was 8.5 years [95% confidence interval (CI) 7.6-11.2]. Long-term survival was significantly higher in patients with uncomplicated TBAAD compared to those with complicated TBAAD (P < 0.001). Both complicated and high-risk uncomplicated TBAAD cases required significantly more interventions in the chronic phase (>3 months) compared to uncomplicated TBAAD cases [hazard ratio (HR) 9.8, 95% CI 6.4-15.4, P < 0.001; HR 3.3, 95% CI 2.1-5.1, P < 0.001).

CONCLUSIONS

Complicated TBAAD presents the greatest risk for aorta-related mortality and interventions. Patients with high-risk uncomplicated TBAAD are also notable for an increased rate of aorta-related mortality and interventions. Thorough evaluation of clinical and anatomical characteristics is essential for determining the optimal therapeutic approach.

Primary Intra-operative Embolisation During Urgent Parallel Graft Endovascular Repair in Paravisceral Symptomatic Aortic Pseudoaneurysm

Objective

Paravisceral aortic lesions present significant challenges for endovascular treatment. This retrospective analysis of consecutively treated patients from April 2017 to June 2021 aimed to analyse the outcome of primary intra-operative embolisation of aortic complicated pseudoaneurysms and gutter channels during parallel graft (PG) repair of paravisceral symptomatic aortic pseudoaneurysms.

Methods

Patients with symptomatic pseudoaneurysms of the paravisceral aorta treated with PGs using chimney or periscope configurations were included. Thoracic endografts were positioned to exclude the aortic lesions. Coil embolisation of both the lesions and gutter channels was performed after graft deployment and prior to ballooning of the stent grafts. The primary endpoints were technical success (defined as exclusion of the pseudoaneurysm, target visceral vessel [TVV] patency, absence of gutter endoleaks) and clinical success (technical success + resolution of symptoms + absence of major adverse events) at 30 days. Secondary endpoints included overall survival, TVV patency, gutter endoleaks, and freedom from re-interventions during follow up.

Results

Six patients (four women) were treated for pseudoaneurysm rupture (three cases) and symptomatic aortic pseudoaneurysm (three cases) of the paravisceral aorta. The patients' anatomies were unsuitable for off the shelf devices and patients were all deemed to be at prohibitive surgical risk. A total of 15 TVVs were revascularised (comprising three coeliac arteries, five superior mesenteric arteries, and seven renal arteries) using 10 chimney and five periscope PGs. One coeliac artery was occluded. Seventy coils were deployed to embolise both the aortic ruptures and gutter channels. Both technical and clinical success rates were 100%. The median follow up was 17 months (IQR 5, 35), during which time three patients died due to non-aortic related causes. One coeliac artery (6%) was occluded, and no endoleak evidence was found.

Conclusion

Primary intra-operative embolisation during parallel graft endovascular repair of paravisceral symptomatic aortic pseudoaneurysms may be both safe and effective in excluding the pseudoaneurysm when other options are unavailable.

Post-dissection Thoraco-abdominal Aortic Aneurysm Managed by Fenestrated or Branched Endovascular Aortic Repair

OBJECTIVE

Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients.

METHODS

Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis.

RESULTS

Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p = .006) compared with B-EVAR.

CONCLUSION

Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR.

Comparison of open thoracoabdominal repair for chronic aortic dissections and aneurysms

OBJECTIVE

Aortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm.

METHODS

We retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair.

RESULTS

Compared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment.

CONCLUSIONS

Outcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.

Erasing narrow paravisceral true lumen with endoseptostomy to favor adequate expansion of branched endograft during postdissection thoracoabdomimal aortic aneurysm endovascular repair

Narrow paravisceral aortic true lumen in postdissection thoracoabdominal aneurysm, represents a challenging situation when branched endovascular aneurysm repair is required; it may be responsible for intraprocedural technical difficulties, such as inadequate main endograft deployment, difficult vessels catheterization, or long-term branch instability related to compression. We describe the case of a 56-year-old man with post-type B thoracoabdominal aortic aneurysm and a severely narrow true lumen (10 mm) at the paravisceral segment. Endovascular aortic septostomy was performed first, to erase the narrow paravisceral aortic true lumen, and subsequently allow branched endograft adequate expansion and regular vessels catheterization.

Partial Deployment to Save Space for Vessel Cannulation When Treating Complex Aortic Aneurysms with Narrow Paravisceral Lumen Is Also Feasible Using Inner-Branched Pre-Cannulated Endografts

Introduction: The aim of this paper is to propose a sequential deployment technique for the E-nside off-the-shelf endograft that could potentially enhance target visceral vessel (TVV) cannulation and overstenting in narrow aortic anatomies. Methods: All data regarding patients consecutively treated in two aortic centers with the E-nside graft employing the partial deployment technique were included in the study cohort and analyzed. To execute the procedure with partial endograft deployment, the device should be prepared before insertion by advancing, under fluoroscopy, all four dedicated 400 cm long 0.018″ non-hydrophilic guidewires until their proximal ends reach the cranial graft's edge. Anticipating this guidewire placement prevents the inability to do so once the endograft is partially released, avoiding potentially increased friction inside the constricted pre-loaded microchannels. The endograft is then advanced and deployed in the standard fashion, stopping just after the inner branch outlets are fully expanded. Tip capture is released, and the proximal end of the device is opened. Visceral vessel bridging is completed from an upper access in the desired sequence, and the graft is fully released after revascularizing one or more arteries. Preventing the distal edge of the graft from fully expanding improves visceral vessel cannulation and bridging component advancement, especially when dealing with restricted lumina. Results: A total of 26 patients were treated during the period December 2019-March 2024 with the described approach. Procedure was performed in urgent settings in 14/26 cases. The available lumen was narrower than 24 mm at the origin of at least one target vessel in 11 out of 26 cases performed (42.3%). Technical success was obtained in 24 out of 26 cases (92.3%), with failures being due to TVVs loss. No intraoperative death or surgical conversion was recorded, and no early reintervention was needed in the perioperative period. Clinical success at 30 days was therefore 80.7%. Conclusions: The described technique could be considered effective in saving space outside of the graft, allowing for safe navigation and target vessel cannulation in narrow visceral aortas, similar to what has already been reported for outer-branched endografts.

Pre-emptive False Lumen Embolization to Prevent Persistent Type II Endoleak in Fenestrated-Branched Endovascular Repair of Post-Dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

The purpose was to describe a technique to promote false lumen (FL) thrombosis in post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) managed by fenestrated/branched endografting (F/B-EVAR).

TECHNIQUE

A 5/6Fr-90 cm length sheath is advanced from the true lumen (TL) to FL through the most distal entry tear of the infrarenal aorta or iliac arteries. It is parked in the most cranial portion of the FL in the thoracic aorta. Aortic endografts are deployed in the TL excluding all the para-visceral/distal entry tears and target visceral vessels bridging stenting is performed. A selective FL angiography is performed through the 5/6Fr sheath to detect the origin of all segmentary arteries. Embolization of FL is performed from above to below by M-reye pushable coils, obtaining the packaging of FL. After completion angiography, the 5/6Fr sheath is retrieved in external iliac artery and molding ballooning of the distal segment of the aortic/iliac endograft is performed. Between 2019 and 2023, this technique was applied in 11cases with a median number of 73 (interquartile range [IQR=12) coils. Out of 8 (72%) patients with available radiological follow-up at 1 year, 7 exhibited complete FL thrombosis.

CONCLUSIONS

The FL coiling in PD-TAAAs managed by F/B-EVAR is feasible, safe, and effective to promote the complete FL thrombosis.

CLINICAL IMPACT

Preemptive false lumen embolization is a feasible, safe, and effective technique for preventing persistent type II endoleaks after fenestrated-branched endovascular repair of post-dissection thoracoabdominal aortic aneurysms. This technique may be routinely recommended to promote FL thrombosis and aortic remodeling after FB-EVAR in PD-TAAAs, thereby reducing the incidence of reinterventions during follow-up.

A Systematic Review and an Updated Meta-Analysis of Fenestrated/Branched Endovascular Aortic Repair of Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms

The objective of this study is to present the current outcomes of fenestrated/branched endovascular repair (F/BEVAR) for post-dissection thoracoabdominal aortic aneurysms (PDTAAAs). A systematic review of the literature according to PRISMA guidelines up to October 2023 was conducted (protocol CRD42023473403). Studies were included if ≥10 patients were reported and at least one of the major outcomes was stated. A total of 10 studies with 585 patients overall were included. The pooled estimate for technical success was 94.3% (95% CI 91.4% to 96.2%). Permanent paraplegia developed with a pooled rate of 2.5% (95% CI 1.5% to 4.3%), whereas a cerebrovascular event developed with a pooled rate of 1.6% (95% CI 0.8% to 3.0%). An acute renal function impairment requiring new-onset dialysis occurred with a pooled rate of 2.0% (95% CI 1.0% to 3.8%). Postoperative respiratory failure was observed with a pooled estimate of 5.5% (95% CI 3.8% to 8.1%). The pooled estimate for 12-month overall survival was 90% (95% CI 85% to 93.5%), and the pooled estimates for 24-month and 36-month survival were 87.8% (95% CI 80.9% to 92.5%) and 85.5% (95% CI 76.5% to 91.5%), respectively. Freedom from reintervention was estimated at 83.9% (95% CI 75.9% to 89.6%) for 12 months, 82.8% (95% CI 68.7% to 91.4%) for 24 months and 76.1% (95% CI 60.6% to 86.8%) for 36 months. According to the present findings, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results.

Superior mesenteric artery-related outcomes in fenestrated/branched endografting for complex aortic aneurysms

Aim

Early/follow-up durability of superior mesenteric artery (SMA) stent-grafts is crucial after fenestrated/branched endografting (FB-EVAR) in complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). The study aimed to report early/midterm outcomes of SMA incorporated during FB-EVAR procedures.

Methods

FB-EVAR procedures performed between 2016 and 2021 in a single institution were reviewed. Anatomical SMA characteristics were analyzed. The SMA configuration was classified into three types according to the angle between the SMA main trunk and the aorta: (A) perpendicular, (B) downward, and (C) upward. SMA-related technical success (SMA-TS: cannulation and stenting, patency at completion angiography without endoleak, stenosis/kinking, dissection, bleeding, and 24-h mortality) and SMA-adverse events (SMA-AEs: one among bowel ischemia, stenosis, occlusion, endoleak, reinterventions, or SMA-related mortality) were assessed.

Results

Two hundred FB-EVAR procedures with SMA as the target artery were performed. The indication for FB-EVAR was CAAAs and TAAAs in 99 (49%) and 101 (51%) cases, respectively. The SMA configuration was A, B, and C in 132 (66%), 63 (31%), and 5 (3%) cases, respectively. SMA was incorporated with fenestrations and branches in 131 (66%) and 69 (34%) cases, respectively. Directional branch (P < .001), aortic diameter ≥35 mm at the SMA level (P < .001), and ≥2 SMA bridging stent-grafts (P = .001) were more frequent in TAAAs. Relining of the SMA stent-graft with a bare metal stent was necessary in 41 (21%) cases to correct an acute angle between the stent-graft and native artery (39), stent-graft stenosis (1), or SMA dissection (1). Relining was associated with type A or C SMA configuration (OR: 17; 95% CI: 1.8-157.3; P = .01). SMA-TS was achieved in all cases. Overall, 15 (7.5%) patients had SMA-AEs [early: 9 (60%), follow-up: 6 (40%)] due to stenosis (2), endoleak (8), and bowel ischemia (5). Aortic diameter ≥35 mm at the SMA level was an independent risk factor for SMA-AEs (OR: 4; 95% CI: 1.4-13.8; P = .01). Fourteen (7%) patients died during hospitalization with 10 (5%) events within the 30-postoperative day. Emergency cases (OR: 33; 95% CI: 5.7-191.3; P = .001), peripheral arterial occlusive disease (OR: 14; 95% CI: 2.3-88.8; P = .004), and bowel ischemia (OR: 41; 95% CI: 1.9-87.9; P = .01) were risk factors for 30-day/in-hospital mortality. The mean follow-up was 32 ± 24 months; estimated 3-year survival was 81%, with no case of late SMA-related mortality or occlusion. The estimated 3-year freedom from overall and SMA-related reinterventions was 74% and 95%, respectively.

Conclusion

SMA orientation determines the necessity of stent-graft relining. Aortic diameter ≥35 mm at the SMA level is a predictor of SMA-AEs. Nevertheless, SMA-related outcomes of FB-EVAR are satisfactory, with excellent technical success and promising clinical outcomes during the follow-up.

Clinical effect of endovascular repair of complex aortic lesions using optimized Octopus surgery

Objective: Complex aortic lesions, especially those involving branches of the visceral artery, remain a challenge to treat. A single-center study using the Octopus technique to evaluate the safety and short-term effects of endovascular repair of complex aortic lesions was reported and documented. Methods: The data of six cases who underwent optimized Octopus surgery in our center from August 2020 to February 2022 were analyzed retrospectively. The choice of operation scheme, operation time, operation complications, and follow-up data were analyzed among them. Results: The average age of the six patients undergoing optimized Octopus surgery was 55.1 ± 17.2 years. Two cases were diagnosed as pararenal aortic aneurysms; four cases were aortic dissection involving the visceral artery. All cases achieved technical success; all visceral arteries were reconstructed as planned. A total of 17 visceral arteries were planned to be reconstructed; five celiac arteries were embolized. Three cases of gutter endoleak were found during the operation without embolization but with follow-up observation. There were two cases of slight damage to renal function and two cases of perioperative death. Other complications, such as intestinal ischemia and spinal cord ischemia, did not occur. Follow-up ranged from 6 months to 30 months. One patient died of gastrointestinal bleeding 6 months after the operation. At the 6 months follow-up, computed tomographic angiography showed that all internal leaks had disappeared. The patency rate of the visceral artery was 100%, and no complications, such as stent displacement and occlusion, occurred during the follow-up period. Conclusion: With fenestrated and branched stent grafts technology not widely available, and off label use not a viable option, Octopus technology for treating complex aortic lesions should be considered. The Octopus technique is an up-and-coming surgical method, but we should recognize its operation difficulty, operation-related complications, and long-term prognosis. We should pay attention to and continue to optimize Octopus technology.

Acute aortic dissection

Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.