Editor's Choice - Early Outcomes of a Novel Off the Shelf Preloaded Inner Branch Endograft for the Treatment of Complex Aortic Pathologies in the ItaliaN Branched Registry of E-nside EnDograft (INBREED)

Performance Analysis of a New Generation Balloon Expandable Covered Stent When used as Bridging Stent-Graft During Inner-Branched Complex Aortic Repair

INTRODUCTION

Target visceral vessels (TVVs) management during complex aortic treatments remains a critical aspect in endoluminal procedures. Bridge stent-graft (BSG) stability is essential for ensuring the effectiveness and safety of these interventions. Aim of this study was to assess the performance of the Viabahn balloon expandable (VBX) when used as BSG in association with Artivion's inner-branched endografts.

METHODS

All patients consecutively treated for complex aortic pathology with Artivion inner-branched devices were prospectively enrolled, and those receiving at least one VBX as BSG were included. Primary outcome included VBX-related technical success, reinterventions and freedom from target vessel instability. Cox-regression analysis was used to identify variables independently associated with TVVs instability.

RESULTS

Fifty-four patients were included in the study cohort. The total number of target visceral arteries bridged with a VBX through an inner branch was 159. VBX-related technical success was 99.4% (158/159). Each stent-graft was successfully delivered and deployed as planned without any intraprocedural endoleak. The VBX-related patency rate was 98% at 30 days (156/159). Three TVVs occlusions were recorded at follow-up, all asymptomatic and not requiring revascularization. A further TVV-related instability event was documented at a four-month follow-up. The mean follow-up was 11.4 ± 9.3 months. Estimates of freedom from TVVs occlusions and instability at 30 months were 96.6 and 96.0%, respectively. Cox-regression found no variables significantly associated with TVVs instability.

CONCLUSION

The VBX stent-graft appears to be a safe and effective bridging option for inner-branched thoracoabdominal aortic repair. Although preliminary results are promising, larger studies with longer follow-up are needed to validate these findings.

Complete Endovascular Repair of Entire Aorta for Extensive Pathologies - A Set of China Strategies

BACKGROUND

Endovascular aortic repair was introduced in China in 1997, with domestically produced devices emerging post-2000. Despite progress, treatment of complex aortic pathologies remains limited, necessitating innovative endovascular solutions.

METHODS

Our center developed 8 off-the-shelf endovascular innovations, including 3 inner branch stent graft systems for aortic arch reconstruction, 2 branched/fenestrated stent grafts for thoracoabdominal and juxtarenal aortic aneurysms, 1 iliac branch device for internal iliac artery preservation, and 2 novel devices-EndoPatch and EndoSeal (Endonom Medtech)-designed to seal distal tears and occlude false lumen in aortic dissections. These advancements integrate technologies such as steerable delivery systems, preloaded navigation aids, and mixed or inner branch configurations to accommodate anatomical variations.

RESULTS

Preliminary clinical applications demonstrated promising technical success rates and acceptable complication profiles. Two devices have been approved by China's National Medical Products Administration for clinical use, while others remain under investigation. Key challenges include anatomical variability, branch vessel patency concerns, and the absence of long-term outcomes for most devices.

CONCLUSION

These innovations establish a comprehensive endovascular strategy for extensive aortic pathologies, addressing critical gaps in China's device landscape. Early outcomes demonstrate the feasibility of standardized off-the-shelf solutions for complex anatomies, though multicenter trials and long-term follow-up remain essential to confirm safety and efficacy.

Branched Endovascular Aneurysm Repair with Inner and Outer Branches: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to assess the clinical outcomes of branched endovascular aneurysm repair (BEVAR) with inner branches (iBEVAR) and inner/outer branches (oBEVAR).

DATA SOURCES

A systematic literature review was performed using the electronic bibliographic databases MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library up to May 2024.

REVIEW METHODS

The review was designed and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies reported death, technical failure, primary target vessel (TV) patency, TV related complications, branch related re-interventions, and spinal cord ischaemia (SCI). Risk of bias was evaluated with the ROBINS-I tool.

RESULTS

Twenty seven observational studies reporting a total of 1 780 patients treated with BEVAR and 6 633 TVs were included. Three hundred and eightysix patients (84.3%) were treated electively with iBEVAR and 72 (15.6%) urgently vs. 845 (63.2%) and 491 (36.7%) with oBEVAR, respectively. The pooled estimate of 30 day death was 4.9% (95% confidence interval [CI] 2.9 - 8.2%) for iBEVAR and 7.6% (95% CI 4.9 - 11.7%) for oBEVAR. Overall mortality rates were 13.8% (95% CI 9.7 - 19.1%) for iBEVAR vs. 15.4% (95% CI 10.6 - 21.9%) for oBEVAR. The rate of SCI was 6.5% (95% CI 4.2 - 10.0%) in iBEVAR compared with 12.9% (95% CI 9.6 - 17.1%) in oBEVAR. Primary TV patency was similar between iBEVAR (97.3%, 95% CI 94.8 - 98.6%) and oBEVAR (97.6%, 95% CI 95.3 - 98.7%). TV related complication rates were 2.9% (95% CI 2.0 - 4.1%) for iBEVAR vs. 3.9% (95% CI 2.7 - 5.6%) for oBEVAR. Technical failure rates were 4.1% (95% CI 2.4 - 6.9%) for iBEVAR vs. 5.7% (95% CI 3.5 - 9.1%) for oBEVAR. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty was low or very low for all outcomes.

CONCLUSION

BEVAR with inner and inner/outer branches has been used in elective and urgent cases, as well as across a variety of anatomies, with both designs demonstrating satisfactory clinical outcomes.

The E-nside, multi-inner branch-based off-the-shelf stent graft for the treatment of thoracoabdominal aortic aneurysms

INTRODUCTION

Endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) has changed treatment paradigm over the past decades. However for urgent cases, there are not many options available. The E-nside (Artivion, Georgia, U.S.A.) endograft is one of the three off-the-shelf-aortic endografts available on the market. Its unique design with four inner branches and other special features offer more versatility, so more patients could be minimally invasively treated.

AREAS COVERED

We present a descriptive review based on market analysis on the available devices and a PubMed literature research on the E-nside endograft. The aim of this article is to present its unique structure, deployment method, and cannulation methods and discuss its applicability, indications, associated concerns and an overview of the available alternative devices.

EXPERT OPINION

The implantation of the E-nside endograft is a promising technique for treating not only TAAAs but also complex abdominal aortic aneurysm. Unlike FEVAR or BEVAR, which require precise planning and have the disadvantage of long manufacturing time. We think that with the off-the-shelf feature from E-nside endograft this can be obviated, and through its flexible planning along with its simple use, more patients could benefit and so favorable results can be achieve.

Target Vessel Cannulation with a Transfemoral Retrograde Approach Equals Antegrade Approach from the Upper Extremity in Complex Aortic Treatment with Off the Shelf Inner Branched Endografts in the ItaliaN Branched Registry of E-nside EnDograft (INBREED)

OBJECTIVE

The aim of this study was to assess the results of an off the shelf inner branched thoraco-abdominal endograft for treating aortic pathologies, with a specific focus on comparing outcomes between antegrade and retrograde approaches for target vessel (TV) cannulation.

METHODS

This was a national, physician initiated, multicentre, observational study. Data from a registry on patients treated with the E-nside endograft were gathered prospectively. Patients were divided into two groups based on the type of endovascular approach for TV cannulation. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

From September 2020 to February 2024, 166 procedures were collected, of which 128 (77.1%) used an antegrade upper extremity approach to TV cannulation, while 38 (22.9%) employed a retrograde femoral approach. There were no statistically significant differences in terms of bridging stent choice (balloon expandable only, 69.4% vs. 73.7%; self expandable only, 12.9% vs. 7.9%; mixed configurations, 17.7% vs. 18.4%; p = .68). The mean operation time ± standard deviation was longer for the retrograde approach (282 ± 90 minutes vs. 313 ± 155 minutes; p = .006), but fluoroscopy time, dose area product, and the volume of contrast injected were similar. Six cases of post-operative stroke were reported in the antegrade group (4.7% vs. 0%; p = .17). The 30 day TV related technical success was 94.5% and 94.7%, respectively, for antegrade and retrograde approaches (p = .96). Mean follow up was 14.4 ± 11.3 months (median 12.5 months). Kaplan-Meier estimates (with 95% confidence interval [CI]) at twelve months revealed similar overall survival (87.7%, 95% CI 81 - 95% vs. 91.1%, 95% CI 82 - 100%; log rank = .009, p = .92). Competing risk analysis revealed similar one year estimates of TV instability and TV related re-intervention between groups both in patient centred and TV centred analyses.

CONCLUSION

A total transfemoral retrograde approach for TV cannulation of inner branches proved to be effective and was not associated with any neurological events.

Endovascular repair of pararenal and thoracoabdominal aortic aneurysms with inner and outer off-the-shelf multibranched endografts: A systematic review and meta-analysis

BACKGROUND

During the last years a great progress has been noted in device technology and operator experience in treating complex aortic aneurysms. Fenestrated and branched custom-made devices require detailed preoperative planning and production time that can take ≤12 weeks. During this awaiting period, aortic-related mortality is increased. To overcome this limitation, off-the-shelf standardized multibranched devices were launched in the market for the treatment of pararenal and thoracoabdominal aortic aneurysms (TAAAs). Our aim was to evaluate systematically all the published studies of off-the-shelf endografts for the treatment of pararenal and TAAAs.

METHODS

We performed a systematic review to identify all the eligible studies that reported outcomes to the off-the-shelf with inner or outer multibranched devices and then conducted a qualitative synthesis and meta-analysis of the results. The main outcomes were technical success, mortality, target visceral vessel instability, major adverse events, and reintervention rates. We estimated pooled proportions and 95% confidence intervals (CIs).

RESULTS

A total of 1605 study titles were identified by the initial search strategy, of which 13 (8 t-Branch, 3 E-nside, 1 We-Flow, and 1 TAMBE) were considered eligible for inclusion in the meta-analysis. A total of 595 patients (70% male) were identified among the eligible studies. In terms of procedures, 64.4% were elective, 19.2% (13.4% outer multibranched group [OMG]; 6.1% inner multibranched group [IMG]) were emergent, and 16.4% (15.6% OMG; 0.8% IMG) were urgent. The pooled technical success was 92.1% (95% CI, 83.8%-96.4%) and 96.9% (95% CI, 92.5%-98.8%) for the outer and inner multibranched endografts, respectively. The pooled 30-day mortality was 10.4 % (95% CI, 6.6%-16.1%,) and 4.2% (95% CI, 2.0%-8.6%) for the OMG and IMG, respectively. The pooled 30-day and late target visceral vessel instability for the OMG was 3.5% (95% CI, 2.0%-6.1%) and 6.2% (95% CI, 4.7%-8.0%) and for the IMG 10.4% (95% CI, 4.5%-22.5%) and 1.6% (95% CI, 0.7%-3.3%) respectively.

CONCLUSIONS

This pooled analysis indicated good technical success and mortality rates for both devices despite the high rate of urgent procedures. Pararenal and TAAAs can be treated safely using the included devices. However, further studies are required to draw additional conclusions for the IMG owing to the small sample size.

Anatomic Patterns of Distribution of the Renal Arteries' Origin from the Aorta

BACKGROUND

To characterize the variation of the renal arteries' origin from the aorta, through examination of computed tomography angiographies (CTAs) in a cohort of patients, and to evaluate any gender-related difference.

METHODS

CTA of the thoracoabdominal district in patients with a nondilated aorta (group A), patients with aortic aneurysm involving the origin of splanchnic and/or renal vessels (group B), and patients with abdominal aortic aneurysm (group C), were retrospectively analyzed. The diameter and angles of emergence (axial and craniocaudal) of the renal arteries were measured, as well as their mutual distance, and the distance between the renal vessels and the superior mesenteric artery/the aortic bifurcation. Shapiro-Wilk, one-way analysis of variance and bivariate Pearson's Correlation tests were performed as appropriate. A P value <0.05 was considered statistically significant.

RESULTS

Six-hundred CTA of patients (452 males) were examined, being 286 in group A, 119 in group B, and 195 in group C. When examining the whole population and also the subgroup of female patients, the clock position of the right renal artery (RRA) was the only parameter that followed a Gaussian distribution, and its ostium raised from the aorta with a mean axial angle of -61.5° ± 16.6°. There was a negative correlation between left renal artery (LRA) and RRA's coronal angle and aortic diameter at the same level, as well as between the LRA's clock position and the aortic diameter at the same level. The longitudinal distances between established landmarks and both renal arteries positively correlated to the aortic diameter.

CONCLUSIONS

The LRA showed a high anatomic variability, both in males and in females. With the increase of the aortic diameters in the juxtarenal/infrarenal portion of the aorta, the renal vessels tended to have a more horizontal course in the coronal view, a more acute "clock-position" and longer longitudinal distances between their ostia and the aortic bifurcation.

Early Experience with Inner Branch Stent-Graft System for Endovascular Repair of Thoraco-Abdominal and Pararenal Abdominal Aortic Aneurysm

OBJECTIVES

This study aims to evaluate the technical and clinical outcomes of the E-nside stent graft for thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA) endovascular treatment at our University Hospital Center.

METHODS

We conducted a retrospective analysis of patients electively treated by inner branched EVAR (iBEVAR) between 05/2021 and 03/2023. Demographic, procedural, and clinical data were analyzed. The technical success and clinical outcomes, such as access-site-related complications were reported. The perioperative and early mortality rate, freedom from aortic reintervention, target vessels' (TVs) patency, and the endoleak rate were evaluated during the follow-up. The technical aspects (external iliac artery diameter, iliac tortuosity, extent of aortic coverage) were retrospectively analyzed.

RESULTS

Twenty-two patients were included (age 75.9 ± 5.5; 72.7% male). The aneurism extent was Crawford I = 4 (18.2%), III = 8 (36.4%), IV = 5 (22.7%), V = 1 (4.5%), and PAAA = 4 (18.2%). The mean aortic diameter was 63.5 ± 9.9 mm. The technical success was 95.5% (assisted primary success 100%). The clinical success was 86.4%. The perioperative and early freedom from all-cause mortality rates were 90.9% and 90%, respectively. No case of inter-stage aortic-related mortality was reported, and there was no permanent/temporary spinal cord ischemia (SCI). Seventy-eight out of 81 patent TVs were incorporated through a bridging stent (96.3%). The TV success was 95.1%. The mean external iliac artery (EIA) diameter was 7.5 ± 1.1 mm. Twelve patients (54.5%, including all female patients) were considered outside the instructions for use (IFU) due to narrow iliac arteries. One access-site-related complication was reported.

CONCLUSIONS

Our experience confirms that E-nside has promising technical and clinical success rates, as well as a low reintervention rate, but it requires a significant compromise of the healthy aortic tissue and adequate iliac arteries that still represents a limitation, especially among women. Mid- to long-term studies and prospective registries are mandatory to evaluate the long-term efficacy and safety, as a comparison between E-nside and other alternative off-the-shelf solutions.

Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft

OBJECTIVE

The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion).

METHODS

Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months.

RESULTS

Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year.

CONCLUSIONS

The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.

Thoracoabdominal aneurysm repair using the Unitary Manifold Device

OBJECTIVE

To present a single-center prospective study of 126 consecutively treated patients who underwent endovascular repair of a thoracoabdominal aortic aneurysm with the physician-modified, nonanatomic-based Unitary Manifold (UM) device.

METHODS

Data were collected from 126 consecutive all-comer patients treated with the physician-modified, nonanatomic-based UM from 2015 to 2023. Treatment was performed at a single center by a single physician under a Physician Sponsored Investigation Exemption G140207.

RESULTS

The UM was indicated for repair of all Crawford extents including juxtarenal, pararenal, and short-neck infrarenal aneurysms (<10 mm) in 126 consecutive patients. Patients were not excluded from the study based on presentation, extent of aneurysm or dissection, or history of a spinal cord event. Patients with a thoracoabdominal aortic aneurysm were categorized by Crawford classification: types I and V (3.3%, n = 4), type II (3.3%, n = 4), type III (1%, n = 1), and type IV (93.3%, n = 117). The type IV classification patients were further categorized with 33 (28.2%) true type IV, 68 (58.1%) pararenal or infrarenal, and 16 (13.7%) with dissection. Technical success was 99.2% (n = 125). The most common major adverse event within both 30 days and 365 days of all patients was respiratory failure (11.9%, n = 15, and 13.5%, n = 17, respectively). One patient (0.8%) experienced persistent paraplegia at 365 days. Reintervention for patients at 365 days was 5.6% (n = 7). Of the 444 branches stented, the primary patency rate was remarkably high as only three patients (2.4%) required reintervention due to loss of limb patency within 365 days. Aneurysm enlargement (≥5 mm) occurred in 1.6% (n = 2) patients, and no patients experienced aneurysm rupture. No patients underwent conversion to open repair. The aneurysm-related mortality at 365 days for all patients was 4.0% (n = 5), whereas all-cause mortality was 16.7% (n = 21). Physician-modified endograft device integrity failure was not observed in any patient.

CONCLUSIONS

The UM device demonstrated remarkable technical surgical success, treatment success, and device patency rates with very reasonable major adverse events and reintervention rates. This study is the most representative example of the general population in comparison with other studies of off-the-shelf devices, with 126 consecutive all-comer patients with diverse pathologies.

Editor's Choice - Outcomes of Off the Shelf Outer Branched Versus Inner Branched Endografts in the Treatment of Thoraco-Abdominal Aortic Aneurysm in the B.R.I.O. (BRanched Inner - Outer) Study Group

OBJECTIVE

This study aimed to compare two commercially available off the shelf branched endografts for thoraco-abdominal aortic aneurysm (TAAA) repair, namely the E-nside (Artivion) and Zenith t-Branch (Cook Medical) devices.

METHODS

This multicentre retrospective study (2020 - 2023) included patients treated by branched endovascular aortic repair (BEVAR) for TAAA using the inner branched E-nside or the outer branched t-Branch. Endpoints were 30 day technical success and major adverse events (MAEs) as well as one year freedom from target vessel instability and main endograft instability.

RESULTS

The study included 163 patients: 79 (307 target vessels) treated with E-nside and 84 (325 target vessels) with t-branch. Aneurysm extent was I - III in 91 patients (55.8%; 47% of E-nside and 66% of t-Branch) and IV in 72 patients (44.2%; 53% of E-nside and 34% of t-Branch) (p = .011). An adjunctive proximal thoracic endograft was used in 43% of E-nside vs. 69% of t-Branch (p < .001), with less frequent thoracic endografting (14% vs. 76%; p < .001) and shorter length of coverage (p = .024) in extent IV TAAA treated by E-nside. E-nside cases had shorter renal artery bridging lengths (66 ± 17 mm vs. 76 ± 20 mm; p < .010) and less frequent use of a distal bifurcated endograft (53% vs. 80%; p < .001). Comparing 30 day results, the mortality rate was 1% vs. 2% (p = .62), any MAE occurred in 18% vs. 21% (p = .55), the stroke rate was 3% vs. 0% (p = .23), and the elective spinal cord ischaemia rate was 5% vs. 8% (p = .40) for E-nside and t-Branch, respectively. At one year, freedom from target vessel instability was 96 ± 3% for E-nside and 95 ± 3% for t-Branch (p = .58), and freedom from endograft instability was 98 ± 2% vs. 97 ± 3% (p = .46), respectively.

CONCLUSION

Both off the shelf devices provided excellent early and one year results. The E-nside may require shorter thoracic aortic coverage and bridging length for the renal arteries, and less frequent implantation of a concomitant proximal thoracic or distal abdominal bifurcated endograft. However, these aspects did not determine significant differences in clinical outcomes.

Standardized approach for four-fenestrated physician-modified endograft to treat complex abdominal aortic aneurysms using Valiant Captivia

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

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.

Off the Shelf Multibranched Endograft for Thoraco-Abdominal and Pararenal Abdominal Aortic Aneurysms: a Prospective, Single Centre Study of the G-Branch Endograft

OBJECTIVE

To investigate outcomes of a novel, off the shelf multibranched endovascular stent graft for the treatment of thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA).

METHODS

A prospective, single centre study including 15 patients (mean age, 63.4 ± 10.7 years; 13 male) with TAAA or PAAA treated from October 2019 to March 2021 with a G-Branch endograft (Lifetech Scientific, Shenzhen, China) featuring a mixed multibranch design with two inner and two outer branches for reconstruction of the visceral and bilateral renal arteries, respectively. Follow up assessments were scheduled before discharge and at 30 days, six and 12 months after the index procedure. Annual telephone interviews were performed beyond the initial 12 months. The Kaplan-Meier method was used to estimate cumulative mortality and morbidity rates after endovascular repair.

RESULTS

Technical success was achieved in all 15 patients. Nine patients (60%) had TAAA and six (40%) had PAAA (mean maximum aneurysm diameter, 73.7 ± 15.8 mm). The median follow up was 31.4 months (range, 10.1 - 44.0 months). At 30 days, there was no death and 7% morbidity (one case of temporary spinal cord ischaemia on Day 4). At one year, the mortality rate was 7% (one death from stroke at 10 months) and morbidity was 13% (one other case of renal function decline at six months). There were no aneurysm dilatations, re-interventions, or access related complications, and two (13%) persistent type II endoleaks. The one year primary branch patency rate was 100% for the four renovisceral arteries in all 13 patients who underwent computed tomography examinations. One patient died of hepatocellular carcinoma 29 months post-operatively, resulting in an estimated three year mortality rate of 13%.

CONCLUSION

The G-Branch endograft yielded high technical success with good early and midterm outcomes for the treatment of TAAA and PAAA. A large multicentre study is warranted.

Fate of primary determinate and indeterminate target vessel endoleaks after fenestrated-branched endovascular aortic repair

OBJECTIVE

The aim of this study was to investigate the outcomes of primary determinate and indeterminate target vessel endoleaks (TVELs) after fenestrated-branched endovascular aortic repair (F-BEVAR).

METHODS

We conducted a single-center retrospective study (2014-2023) on F-BEVAR for thoracoabdominal (TAAAs) or pararenal aortic aneurysms (PRAAs). TVELs were classified as "primary" if present at the first postoperative computed tomography angiogram. Endoleaks were defined "determinate" (dELs) if the cause (type Ic or IIIc) and implicated target vessel were identifiable and "indeterminate" (iELs) if contrast enhancement was detectable at the level of fenestrations/branches without any evident source. Endoleaks involving multiple inflows (type II and target vessels) were defined as "complex" (cELs). Endpoints were endoleak spontaneous resolution, 1-year aneurysm sac failure to regress (>5 mm diameter decrease), and 4-year endoleak-related secondary interventions. Kaplan-Meier estimates and Cox regression were used for the analysis.

RESULTS

There were 142 patients with JRAAs/PRAAs (n = 85; 60%) or TAAAs (n = 57; 40%), with 513 target arteries incorporated through a fenestration (n = 294; 57%) or directional branch (n = 219; 43%). Fifty-nine primary TVELs (12%) were identified in 35 patients (25%), a dEL in 20 patients (14%) and iEL in 15 (11%); 22 (15%) had a determinate or indeterminate cEL. Overall spontaneous resolution rate was 75% (95% confidence interval [CI], 51%-87%) at 4 years. cELs (odds ratio [OR], 5.00; 95% CI, 1.10-49.4; P < .001) and iELs after BEVAR (OR, 9.43; 95% CI, 3.41-56.4; P = .002) were more likely to persist >6 months, and persistent forms were associated with sac failure to regress at 1 year (OR, 1.72; 95% CI, 1.03-12.59; P = .040). Overall freedom from endoleak-related reinterventions was 85% (95% CI, 79%-92%) at 4 years, 92% (95% CI, 87%-97%) for those without primary TVELs and 62% (95% CI, 46%-84%) for those with any primary TVEL (P < .001). In particular, cELs (hazard ratio, 1.94; 95% CI, 1.4-18.81; P = .020) were associated with an increased need for reintervention. In case a secondary intervention was needed, iEL or cEL had an increased risk for multiple secondary procedures (hazard ratio, 2.67; 95% CI, 1.22-10.34; P = .034).

CONCLUSIONS

Primary TVELs are frequent after F-BEVAR, and a clear characterization of the endoleak source by computed tomography angiogram is not possible in 40% of patients. Most primary TVELs spontaneously resolve, but during follow-up, patients with any primary TVEL experience a worsened freedom from endoleak-related reinterventions that is mostly driven by persistence of cELs and post-BEVAR iELs. Multiple secondary procedures may be required in case of iELs or cELs.

Effect of narrow paravisceral aorta on target vessel instability after fenestrated and branched endovascular aortic repair

OBJECTIVE

To investigate the effect of narrow paravisceral aorta (NPA) on target vessel instability (TVI) after fenestrated-branched endovascular aortic repair.

METHODS

We conducted a single-center retrospective study (2014-2023) of patients treated by fenestrated-branched endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. The paravisceral aorta was defined as the aortic segment limited by the diaphragmatic hiatus proximally and the emergence of lower renal artery distally, and was considered "narrow" in case of a minimum inner diameter of <25 mm. The minimum aortic diameter, location, longitudinal extension, angulation, calcification, and thrombus thickness of NPA were evaluated at the preoperative computed tomography angiogram. End points were 30-day technical success and freedom from TVI.

RESULTS

There were 142 patients with JRAA/pararenal aortic aneurysm (n = 85 [59%]) and extent IV (n = 24 [17%]) or extent I-III (n = 33 [23%]) TAAA, with 513 target arteries successfully incorporated through a fenestration (n = 294 [57%]) or directional branch (n = 219 [43%]). A NPA was present in 95 patients (70%), 73 (86%) treated by fenestrated endovascular aortic repair (FEVAR) and 22 (39%) by branched endovascular aortic repair (BEVAR). The overall 30-day mortality was 2% and technical success was 99%, without differences between NPA and non-NPA (P = .99). Kaplan-Meier estimated freedom from TVI at 4 years was 82%, 81% (95% CI, 75-95) in patients with a NPA and 80% (95% CI, 68-94) and in those without NPA (P = .220). The result was maintained for both FEVAR (NPA: 81% [95% CI, 62-88]; non-NPA: 76% [95% CI, 60-99]; P = .870) and BEVAR (NPA: 77% [95% CI, 69-99]; non-NPA: 80% [95% confidence interval (CI) 66-99]; P = .100). After multivariate analysis, the concomitant presence of a NPA <20 mm and angulation of >30° was significantly associated with TVI in FEVAR (HR, 3.21; 95% CI, 1.03-48.70; P = .036), being the result mostly driven by target vessel occlusion. In BEVAR, a NPA diameter of <25 mm was not associated with TVI (HR, 2.02; 95% CI, 0.59-5.23; P = .948); after multivariate analysis, the use of outer branches in case of a NPA longitudinal extension of >25 mm (hazard ratio [HR], 3.02; 95% CI, 1.01-36.33; P = .040) and NPA severe calcification (HR, 1.70; 95% CI, 1.00-22.42; P = .048) were associated with a higher chance for TVI.

CONCLUSIONS

FEVAR and BEVAR are both feasible in cases of NPA and provide satisfactory target vessels durability. The use of outer branches should be avoided in cases with an inner aortic diameter of <25 mm with a longitudinal extension of >25 mm or moderate to severe NPA calcifications. In FEVAR, bridging stent patency may be negatively influenced by NPA of <20 mm in association with aortic angulation of >30°.

Systematic Review and Meta-analysis of Short-term and Mid-term Outcomes After Use of t-Branch Off-the-shelf Multibranched Endograft for Elective and Urgent Treatment of Thoracoabdominal Aortic Aneurysms

OBJECTIVE

To conduct a meta-analysis to assess the safety and efficacy of t-Branch off-the-shelf multibranched endograft for the treatment of thoracoabdominal aortic aneurysm (TAAA).

DATA SOURCES

PubMed, Embase, and Web of Science.

REVIEW METHODS

Online databases were searched from June 2012 to March 2023. The data were pooled together using a random-effects model of proportions. The outcomes overall included technical success, spinal cord ischemia, target vessel occlusion, type I or III endoleak, reintervention, early mortality (30-day), and mid-term outcomes. Subgroup meta-analyses and meta-regression were performed to explore variation among studies.

RESULTS

A total of 15 studies containing 1238 patients were included in the meta-analysis. The overall study quality assessment was found to be moderate to good. The pooled technical success was 97.0% (95% confidence interval [CI]=95.5-98.6, I2=53.01%, 1185/1238 cases, 15 studies). Overall, early mortality was 7.3% (95% CI=4.4-10.1, I2=74.48%, 124/1238 cases, 15 studies). Early spinal cord ischemia was 13.4% (95% CI=9.6-17.2, I2=67.24%, 160/1238 cases, 15 studies), and early type I or III endoleak was 6.0% (95% CI=3.4-8.5, I2=53.71%, 68/1032 cases, 9 studies). Mid-term outcomes showed target vessel occlusion was 4% (95% CI=1.4-6.5, I2=65.18%, 28/528 cases, 10 studies, 5-21.2 months), type I or III endoleak was 4.7% (95% CI=2-7.5, I2=49.74%, 38/512 cases, 10 studies, 5-21.2 months), reintervention was 11.2% (95% CI=8.1-14.3, I2=31.06%, 85/650 cases, 10 studies, 5-21.2 months), and pooled mortality was 13.9% (95% CI=7.2-20.7, I2=76.32%, 84/550 cases, 11 studies, 5-21.2 months). Meta-regression found a significant linear association between higher technical success and earlier publication year (p=0.014) and studies with anatomic inclusion criteria (p=0.037). Urgent patients (p=0.021) and later publication year (p=0.048) were significantly associated with higher early mortality.

CONCLUSION

The use of the off-the-shelf t-Branch multibranched endograft for elective or urgent endovascular TAAA repair is associated with high technical success rates and proved to be safe and effective at early and mid-term follow-up. However, the heterogeneity between the included studies is high, and prospective, randomized studies along with future larger studies with long-term follow-up are needed.

CLINICAL IMPACT

The Zenith t-Branch (Cook Medical, Bloomington, Ind) was approved as a commercially available device in Europe in June 2012. Although a decade has past, the outcomes of t-Branch have rarely been synthesized at the global level. This meta-analysis included 15 studies containing 1238 patients. The meta-analyses included technical success, major adverse events, reintervention, early mortality, and mid-term outcomes. The outcome was very meaningful and representative for the use of t-Branch. It is helpful for endovascular surgeons to make decisions on the treatment of TAAA patients.

Experience with inner branch off the shelf device for thoracoabdominal aneurysms

Endovascular treatment of complex aortic aneurysms (cAAA) including thoracoabdominal aortic aneurysms is becoming more common. Most patients require custom made devices and until recently the off the shelf (OTS) options were limited. The aim of this manuscript was to describe a new inner branch OTS device and its clinical applications. A review of the current literature on the ENSIDE device from Artivion was performed and the authors' experience presented. The short outcomes of this particular OTS device are acceptable and the anatomical suitability on par with other similar devices. The preloaded configuration of the device can offer benefits in complex anatomy. New OTS devices for cAAA can provide treatment in emergent or urgent situations in many patients. Long term follow-up is needed and caution must be made against excessive use in less extensive aneurysms due to the risk of spinal cord ischemia.

Suitability of current off-the-shelf devices for endovascular TAAA repair: a systematic review

INTRODUCTION

The aim of the present study is to perform a systematic review of published papers regarding the suitability of the current off-the-shelf (OTS) devices for endovascular thoracoabdominal aortic aneurysm (TAAA) repair.

EVIDENCE ACQUISITION

A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed.

EVIDENCE SYNTHESIS

A total of 19 studies were published between 2014 and 2023. Thirteen clinical studies and six theoretical feasibility studies were included. Eleven studies reported the clinical outcomes of the t-Branch stent-graft, one detailed the observational results of the use of the E-nside endoprosthesis, and one described the TAMBE stent-graft results. The following data primarily involve the t-Branch device outcomes. A total of 1131 patients that underwent aneurysm repair using an OTS stent-graft were identified. Among those, 1002, 116 and 13 patients received a t-Branch, E-nside, and TAMBE stent-grafts, respectively. A total of 767 (67.8%) were men, with a mean age of 71.6±7.4 years old, and a mean Body Mass Index (BMI) of 26.3±3.8 kg/m2. Technical success ranged from 64% to 100%. A total of 4172 target visceral vessels (TVV) were planned for bridging, with a success rate ranging from 92 to 100%. The total of early and late reinterventions reported were 64 and 48, respectively, mainly due to endoleaks and visceral branch occlusions. Among the theoretical feasibility studies, six described the feasibility of the t-Branch device in a total of 661 patients, two described the E-nside and the TAMBE devices feasibility comprising 351 patients for each stent-graft. The overall feasibility of the t-Branch device varied from 39% to 88%, the E-nside from 43% to 75%, and the TAMBE stent-graft ranged from 33% to 94%.

CONCLUSIONS

This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA.

Urgent and emergent repair of complex aortic aneurysms using an off-the-shelf branched device

Introduction

Endovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft.

Methods

Prospectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed.

Results

225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I-III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p < .001) were more common in emergent cases. Technical success was 97.8%. Thirty-day mortality and MAE rates were 17.8% and 30.6%, respectively. SCI rate was 14.7%, (4.8% paraplegia rate) with 22.2% of patients receiving prophylactic cerebrospinal drainage. Thirty-day mortality (13.3% vs. 26.7%, p = .04) and MAE (26.0% vs. 43.0%, p = .02) were more common among emergent cases while technical success (97.6% vs. 98.3%, p = .9), and SCI (13.3% vs. 18.3%, p = .4) were similar. Survival at 12-months was 83.5% (SE 5.9%) for the urgent and 77.1% (SE 8.2%) for the emergent group (log rank, p = 0.96).

Conclusion

T-Branch represents an effective and safe solution for the management of urgent and emergent cases with complex aortic aneurysms, with high technical success, promising early mortality and SCI rates.

The "safe-line" technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm

We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the "safe-line" can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery.

Treatment of late-presenting malperfusion and aneurysmal degeneration in chronic type B aortic dissection with an off-the-shelf four-vessel inner-branched endograft

Acute complicated type B aortic dissection is increasingly treated with endovascular techniques to manage contained rupture or end-organ malperfusion. Most cases of malperfusion occur during the acute phase of the dissection. We report a case of a patient treated for late presentation of lower body malperfusion 4 years after successful endovascular intervention for contained rupture of an acute type B dissection. The anatomic complexity required multiple staged procedures culminating in endovascular repair of the paravisceral aorta with an off-the-shelf four-vessel inner-branched endograft, used for the first time, to the best of our knowledge, in North America in the present case. The patient involved provided written informed consent for the report of his case details and imaging studies.

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.