Editor's Choice - Long Term Outcomes of the Advanta V12 Covered Bridging Stent for Fenestrated and Branched Endovascular Aneurysm Repair in 1 675 Target Vessels

Systematic Review and Meta-analysis of Outcomes of the Advanta V12 or iCAST Bridging Stent Graft Used for Fenestrated and Branched Endovascular Aortic Repair

OBJECTIVE

Half of re-interventions after fenestrated and branched endovascular aortic repair (FB-EVAR) are target vessel related. Regarding bridging stent choice, existing data are controversial. This meta-analysis aimed to evaluate the performance of Advanta V12/iCAST as the bridging stent in FB-EVAR.

DATA SOURCES

The English medical literature was searched through MEDLINE, Embase (via Ovid), and Cochrane databases (end date 15 April 2024).

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PICO (Patient, Intervention, Comparison, Outcome) model were followed. A predefined protocol was registered to PROSPERO (CRD42024556603). Randomised controlled trials and observational studies (2010 - 2024) reporting on Advanta V12/iCAST related target vessel outcomes were eligible. Risk of bias was assessed using ROBINS-I, and evidence quality was assessed via Grading of Recommendations Assessment, Development and Evaluations (GRADE). Primary outcomes were freedom from instability, stenosis and or occlusion, types Ic and IIIc endoleak, and re-intervention of target vessels bridged with the Advanta V12/iCAST. Prevalence and regression meta-analysis were performed.

RESULTS

From 1 439 articles, ten retrospective studies (7 525 target vessels; 3 890 target vessels bridged with Advanta V12/iCAST) were included. According to ROBINS-I, no study was of high quality. Mean follow up was 24.3 (95% confidence interval [CI] 23.9 - 24.7) months. Freedom from instability, stenosis and or occlusion, and types Ic and IIIc endoleak were 94% (95% CI 91 - 96%; p < .010; I2 = 91%; GRADE certainty, very low), 97% (95% CI 96 - 98%; p =  .070, I2 = 44%; GRADE certainty, low), and 97% (95% CI 94 - 98%; p < .010; I2 = 81%; GRADE certainty, very low), respectively. Freedom from target vessel re-intervention was 95% (95% CI 92 - 97%; p < .010; I2 = 85%; GRADE certainty, very low). Four studies provided extractable data on Advanta V12/iCAST in fenestrations and four in branches. No difference was detected in freedom from instability (p = .47), stenosis and or occlusion (p = .36), and types Ic and IIIc endoleak (p = .90). Freedom from re-intervention was 93% (95% CI 87 - 96%; p < .010; I2 = 90%) in fenestrations and 95% (95% CI 91 - 97%; p = .060, I2 = 64%) in branches.

CONCLUSION

The Advanta V12/iCAST bridging stent showed high freedom from target vessel instability, stenosis and or occlusion, and endoleak. Freedom from re-intervention was 95%, being similarly high in fenestrations and branches.

Midterm Outcomes of the BeGraft and BeGraft Plus Bridging Covered Stents for Fenestrated and Branched Endovascular Aneurysm Repair

OBJECTIVE

The aim of this study was to report outcomes of the BeGraft and BeGraft Plus as bridging covered stents in fenestrated and branched endovascular aneurysm repair (FB-EVAR).

METHODS

Patients treated and followed in two institutions receiving at least one BeGraft or BeGraft Plus as bridging covered stent between January 2018 and July 2023 were included.

RESULTS

A total of 765 target vessels (TVs) in 281 patients were aimed to be bridged with the BeGraft or BeGraft Plus. Target vessel technical success was 99.5% (761/765). Estimated TV patency at one and two years was 98.5 ± 0.5% and 96.7 ± 0.9%, respectively, with no difference between fenestrations and branches. Estimated freedom from TV related endoleak at one and two years was 98.5 ± 0.5% and 97.9 ± 0.6%, respectively. Estimated freedom from endoleak at two years was lower for TVs targeted with branches compared with TVs targeted with fenestrations (94.2 ± 1.9% vs. 99.7 ± 0.3%, respectively; p < .001). Estimated freedom from TV related re-intervention at one and two years was 97.7 ± 0.6% and 97.1 ± 0.7%, respectively. Estimated freedom from TV related re-intervention at two years was lower for TVs targeted with branches compared with TVs targeted with fenestrations (93.1 ± 2.0% vs. 99.0 ± 0.5%, respectively; p < .001). Estimated freedom from TV instability at one and two years was 96.8 ± 0.7% and 94.5 ± 1.1%, respectively. Estimated freedom from TV instability at two years was 96.0 ± 1.3% for fenestrations and 91.2 ± 2.2% for branches (p = .003).

CONCLUSION

The BeGraft and BeGraft Plus covered stents showed good midterm outcomes as bridging covered stents in FΒ-EVAR. Branches showed higher instability rates compared with fenestrations. Branches showed similar patency rates to fenestrations.

Pre-clinical Evaluation of a New Generation Bridging Stent for Fenestrated Endovascular Aneurysm Repair Using Realistic 3D Printed Aneurysm Models

OBJECTIVE

The aim of this study was to perform a comparative pre-clinical evaluation of a new fenestrated endovascular aneurysm repair dedicated stent using perfused 3D printed patient anatomies.

METHODS

The test setup included a pulsatile pump set to reproduce human haemodynamics, four 3D printed pararenal aneurysms connected to a bench test, and four corresponding fenestrated grafts (Zenith Fenestrated; Cook, Bloomington, IN, USA). Bridging stents were sized based on analysis of patients computed tomography scans and included either four standard covered stents (BeGraft [BG]; Bentley, Hechingen, Germany) or four similar covered stent grafts mounted on a modified balloon to allow stent implantation and flaring in one step (BeFlared [BF]; Bentley). Each anatomy and corresponding endograft was used for four sets of four bridging stent implantations. Selective angiography following each stent implantation was used to assess efficacy (patency and absence of type Ic or IIIc endoleak), procedure time was recorded, and cone beam computed tomography at the end of each set of four stent implantations enabled comparison of geometric layout between stents. Physician assessment evaluated technical performance and failure modes.

RESULTS

Sixty four stents were successfully implanted. Selective angiograms depicted three type IIIc (two in BG, one in BF) and seven type Ic (four in BG, three in BF) endoleaks, which were all corrected intra-operatively. Compared with BG, the BF had a larger mean proximal diameter inside the endograft (10.5 mm vs. 9.2 mm; p < .001) and greater opening flaring angle (46.1° vs. 33.4°; p < .001). The eight procedures performed with the BF were quicker than BG (17.0 ± 4 minutes vs. 23.9 ± 4.7 minutes; p = .004). Physician assessment did not reveal any failure mode and concluded an excellent technical performance of both devices.

CONCLUSION

The BF demonstrated similar efficacy and performance compared with the BG for bridging target vessels in an innovative test setup using 3D printed patient anatomies.

Semi-Branched Endovascular Aortic Repair: A New Feature in the Treatment of Complex Aortic Aneurysms

PURPOSE

To report a case series on using a novel semi-branch feature in custom-made stent-grafts in the endovascular treatment of complex aortic aneurysms and summarize the contemporary usage of this technology.

CASE SERIES

Four patients underwent endovascular aortic aneurysm repair (EVAR) with a custom-made semi-branch stent-graft (Semi-Branch Endovascular Aortic Aneurysm Repair [SBEVAR]). Two male patients, 75- and 76-year-old, were treated due to failed EVAR with late-type Ia endoleak, and the other two, 80- and 55-year-old male patients, due to a juxta-renal aortic abdominal aneurysm (JRAAA). In 3 cases, the celiac trunk (CT) vessel was targeted through an inner semi-branch; in the other case, all target vessels were bridged through inner semi-branches. Intra-operative technical success was accomplished in all 4 patients. Post-operative recovery was uneventful in all cases. The 30-day computed tomography angiography (CTA) follow-up for each patient showed patent target vessels, excellent apposition of the bridging stent to the semi-branch, and complete exclusion of the aneurysm.

CONCLUSION

The present report and the literature review demonstrate that introducing this novel semi-branch technology for the endovascular treatment of complex aortic aneurysms is feasible and holds great potential. The encouraging outcomes in cases of JRAAA and failed EVAR with late-type Ia endoleak inspire further studies to explore additional uses of this new tool in treating aortic pathologies.

CLINICAL IMPACT

The inner semi-branch is a novel technology for the incorporation of the renal and mesenteric vessels during complex endovascular aortic aneurysm repair. This new feature allows the use of a branched stent graft with a shorter length of the proximal sealing zone, reducing, consequently, the aortic coverage. It efficiently treats pathologies in which fenestrations could be inappropriate because precise stent graft placement might be difficult and in which tiny diameters leave inadequate room for typical inner branches. Although encouraging findings have been reported, long-term outcomes in target vessel stability have yet to be described.

Evaluation of Hemodynamic Properties After Chimney and Fenestrated Endovascular Aneurysm Repair

BACKGROUND

Fenestrated (FEVAR) and chimney (ChEVAR) endovascular aortic repair have been applied in anatomically suitable complex aortic aneurysms. However, local hemodynamic changes may occur after repair. This study aimed to compare FEVAR's and ChEVAR's hemodynamic properties, focusing on visceral arteries.

METHODS

Preoperative and postoperative computed tomography angiographies have been used to reconstruct patient-based models. Data of 3 patients, for each modality, were analyzed. Following geometric reconstruction, computational fluid dynamics simulations were used to extract near-wall and intravascular hemodynamic indicators, such as pressure drops, velocity, wall shear stress, time averaged wall shear stress, oscillatory shear index, relative residence time, and local normalized helicity.

RESULTS

An overall improvement in hemodynamics was detected after repair, with either technique. Preoperatively, a disturbed prothrombotic wall shear stress profile was recorded in several zones of the sac. The local normalized helicity results showed a better organization of the helical structures at postoperative setting, decreasing thrombus formation, with both modalities. Similarly, time averaged wall shear stress increased and oscillatory shear index decreased postoperatively, signaling nondisturbed blood flow. The relative residence time was locally reduced. The flow in visceral arteries tended to be more streamlined in ChEVAR, compared to evident recirculation regions at renal and superior mesenteric artery fenestrations (P = 0.06).

CONCLUSIONS

ChEVAR and FEVAR seem to improve hemodynamics toward normal values with a reduction of recirculation zones in the main graft and aortic branches. Visceral artery flow comparison revealed that ChEVAR tended to present lower recirculation regions at parallel grafts' entries while FEVAR showed less intense flow regurgitation in visceral stents.

Antithrombotic Therapy and Freedom From Bridging Stent Occlusion After Elective Branched Endovascular Repair: A Multicenter International Cohort Study

CLINICAL IMPACT

Based on our study, no antithrombotic therapy is significantly associated with bridging stent occlusion, and no evidence of the superiority of other antithrombotic therapy exists. Nevertehless, due to the low number of bridging stent occlusions, this study can neither support nor reject the PRINCE2SS recommendations. Further studies with larger cohorts are needed to determine clear guideliness of the best antithrombotic treatment regimen after complex enfovascular aortic repair.

Outcome of the Be Graft Bridging Stent in Fenestrated Endovascular Aortic Repair in a High-Volume Single Center and an Overview of Current Evidence

OBJECTIVE

Fenestrated endovascular aneurysm repair (FEVAR) has become one of the standard treatment options for complex abdominal aortic aneurysms (cAAAs) and thoraco-abdominal aortic aneurysms (TAAAs). Despite technological advances in the main endograft design, the lack of dedicated bridging stent-grafts (BSGs) is still the Achilles heel of the procedure. The aim of this study was to evaluate the mid-term outcomes of the BeGraft stent-graft as a dedicated bridging stent for FEVAR and to review the current evidence in literature.

METHODS

Retrospective single center study, including all consecutive FEVARs performed between September 2018 and December 2022 for the treatment of cAAAs and TAAAs with implantation of at least one BeGraft peripheral as the main BSG in one of the target vessels (TVs). Primary endpoints were technical success and TV instability of TV bridged with a BeGraft stent, as well as 30-day mortality and re-intervention rates. Secondary endpoints were follow-up TV instability, re-interventions, and mortality.

RESULTS

A total of 113 patients (93 male, mean age 71.1±9.7) and 440 TV (14 scallops and 426 fenestrations) were included. Of the 440 TV, 406 received primary stenting. Be Grafts were used in 88.9% of these (n=361; celiac trunk [CT]=67, superior mesenteric artery [SMA]=98, right renal artery [RRA]=97, and left renal artery [LRA]=99). The technical success rate was 99.4% (359/361). The 30-day TV instability rate was 0.27% (1/361) with one early renal artery occlusion. During a median follow-up of 20 months (6-32), TV instability rate was 0.8% (3/361). Freedom from TV instability was 99.3%, 98.8%, and 98.8% at 1, 2, and 3 years, respectively.

CONCLUSION

Early-term and mid-term results regarding TV instability are satisfactory and support the use of BeGraft as BSG in FEVAR for cAAAs and TAAAs.

CLINICAL IMPACT

The findings of the current study show that the use of the BeGraft stent graft as bridging stent in FEVAR is associated with a high technical success and low early and mid-term instability rate and support the standard use as a bridging stent in fenestrated aneurysm repair.

Target Vessel-Related Outcomes in Patients Managed With Branch Thoracic Aortic Endovascular Repair

INTRODUCTION

Data on target vessel (TV)-related outcomes in patients managed with branched thoracic endovascular aortic repair (BTEVAR) are limited. This study aimed to present the TV-related outcomes of BTEVAR in patients managed for aortic arch pathologies at 30 days and during follow-up.

METHODS

A retrospective analysis of consecutive patients, managed between September 1, 2011, and June 30, 2022, with custom-made aortic arch endografts (Cook Medical, Bloomington, IN, USA), presenting at least one branch configuration, were eligible. Primary outcomes were technical success, TV-related patency, and reinterventions at 30 days.

RESULTS

In total, 255 TVs were revascularized using branches: 107 innominate arteries (IAs), 108 left common carotid arteries (LCCAs), and 40 left subclavian arteries (LSAs). Covered stents were used as bridging stents of which 10.2% were balloon expandable. Relining, using bare-metal stents (BMS), was performed in 14.0% of IAs, 35.2% of LCCAs, and 22.5% of LSAs. Technical success on case basis was 99.2%; no failure was related to unsuccessful TV bridging. At 30 day follow-up, no TV occlusion was detected. In 5.6% of cases, a type Ic or III endoleak, attributed to TVs, was recorded. Two patients needed early branch-related reintervention. The mean follow-up was 18.3±9.2 months. Freedom from TV instability was 94.6% (standard error [SE] 2.5%] at 12 months. No TV stenosis or occlusion was detected up to 48 months of follow-up. Freedom from TV-related reinterventions was 95.4% [SE 2.4%] at 12 months.

CONCLUSION

TV stenosis or occlusion in BTEVAR cases is rare and TV-related reinterventions and instability events are mainly attributed to type Ic and III endoleak formation.

CLINICAL IMPACT

Previous studies focusing on target vessel (TV) outcomes after endovascular aortic arch repair are limited. In this study, including 255 TVs revascularized using branched arch devices, bridging was performed with covered stents, of which 90% were self-expanding. Relining was at the discretion of the operator and was 14% for the innominate, 35.2% for the left common carotid and 22.5% for the left subclavian artery branches. No 30-day occlusion was detected. The freedom from TV instability was almost 95% at 12 months. TV instability and reintervention were mainly attributed to endoleaks type Ic and IIIc.

The Semibranch: A New Tool for Complex Aortic Pathologies

PURPOSE

To describe the semibranch as new tool to treat patients with thoracoabdominal, para- and juxtarenal aortic pathologies.

TECHNIQUE

The technique is demonstrated in 2 patients with aortic pathologies. First, a 76-year-old woman with a type Ia endoleak after endovascular repair of abdominal aneurysm (EVAR). Due to the short mainbody of the EVAR and suprarenal extension of the pathology, a 4-branched device with integrated bifurcation was chosen. To realize a branched device in small diameters of the suprarenal aorta, 2 semibranches, for the superior mesenteric artery (SMA) and the celiac trunc (CT), were planned. The second patient, a 75-year-old man, had a juxtarenal aneurysm. Due to small diameters of the aorta, semibranches for the SMA and the CT were planned. In both cases, a total transfemoral approach was used with a steerable sheath. Placement, cannulation of the semibranch, forwarding of the bridging stentgraft, and sealing was uneventful. All 4 semibranches were successful in sealing the aneurysm.

CONCLUSION

The semibranch is another tool in the armamentarium of the endovascular interventionalist, which can expand the range of patients that can be treated. Especially patients with small aortic diameter or short distances between target vessels with the same offspring angle can profit from the semibranch design.

CLINICAL IMPACT

The semibranch is a new tool to treat thoracoabdominal as well para- and juxtarenal aortic pathologies. Due to its reduced length, packaging density can be higher and diameter of the stentgraft can be larger. It closes the gap in pathologies where fenestration are not suitable (kinked aortas) and there is not enough space for standard inner branches (small diameters).