Clinical Impact and Determinants of Fenestration to Target Vessel Misalignment in Fenestrated Endovascular Aortic Repair

Physician-Modified Endografts Achieve Similar Patient Survival and Target Visceral Vessel Related Outcomes to Factory-Made Fenestrated Endografts in Treating Complex Aortic Pathology

BACKGROUND

The purpose of this study was to conduct a real-world comparison of visceral stent branch related outcomes and patient survival in physician-modified endografts (PMEGs) versus factory-made fenestrated endografts (FMFEs).

METHODS

After exclusions, 544 PMEG and 1638 FMFE were identified in the Vascular Quality Initiative between 2014 and 2022. The four primary outcomes analyzed with Kaplan-Meier were freedom from mortality, new onset dialysis, visceral ischemia, and visceral stent-graft reintervention in follow-up. Multivariable Cox regression was also performed for visceral reintervention in follow-up utilizing variables with a univariable P < 0.10. Comparison of baseline demographics and co-morbidities in the PMEG versus FMFE group were performed as was univariable risks for perioperative adverse outcomes.

RESULTS

PMEG patients were a more comorbid cohort highlighted by: larger aneurysms; higher mean number of visceral vessels stented; higher rates of hypertension, anemia, prior coronary revascularization, prior open aortic surgery, and greater than 50% stenosis in one of the visceral target arteries (P < 0.01 for all). Further, PMEG patients had a 3-fold higher rate of intervention for a primary pathology of aortic dissection (9.7% vs. 2.3%, P < 0.001). Mean follow-up for survival was 1.9 years for PMEG and 3.0 years for FMFE. Mean follow-up for visceral stent-related data was 1.07 and 1.19 years for PMEG and FMFE, respectively. There was no significant difference between the PMEG and FMFE groups in mortality, new onset dialysis or intestinal ischemia in follow-up. Univariable Kaplan-Meier analysis for freedom from visceral stent branch reintervention showed an increased rate for PMEG (log rank P = 0.002). However, multivariable Cox regression rendered this nonsignificant (hazard ratio [HR] 1.25, P = 0.406) due to significantly more branches being treated on average in the PMEG group (3.48 vessels versus 3.01, P < 0.001). The only variable which achieved multivariable significance in association with visceral stent reintervention was the mean number of vessels stented (HR 2.15, P < 0.001).

CONCLUSION

Physician-modified fenestrated visceral segment endografts achieve similar mid-term freedom from mortality, visceral stent-graft reintervention, new onset dialysis, and intestinal ischemia relative to custom FMFEs. This is despite PMEG patients being a significantly more comorbid cohort, with more visceral vessels involved and more dissection related aneurysms.

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.

Carbon dioxide cone-beam computed tomography for the technical assessment of endovascular aortic intervention

Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

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.