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

T-branch by partial deployment technique in the endovascular repair of complex aortic and thoracoabdominal aneurysms with narrow or severe angulated para-visceral aorta

OBJECTIVE

The partial deployment technique (PDT) is an unconventional option of T-branch deployment to allow target arteries (TAs) cannulation/stenting from the upper arm access, in case of narrow (NPA <25 mm) or severely angulated (APA >60°) aorta. Aim of this study was to report outcomes of the endovascular repair of complex aortic (c-AAAs) and thoracoabdominal (TAAAs) aneurysms by T-branch and PDT.

METHODS

All consecutive patients underwent urgent endovascular repair of c-AAAs and TAAAs by T-branch (Cook Medical) and PDT from 2021 to 2023 were analyzed. Technical success (TS), 30-day mortality, and TA instability within 30 days and 1 year, as well as reinterventions, were assessed as primary endpoints. Time of intraoperative pelvic/lower limb ischemia, spinal cord ischemia (SCI), and perioperative stroke were assessed as secondary endpoints.

RESULTS

Thirty-three cases were analyzed. There were six type I endoleaks (18%) in failed endovascular aortic repair, nine juxta/para-renal aneurysms (28%), six post-dissection TAAAs (18%), and 12 degenerative TAAAs (36%), respectively. The median para-visceral aortic lumen diameter was 23 mm (interquartile range [IQR], 19-27 mm), and 10 cases (30%) had APA. Of 128 TAs, 111 (87%) were cannulated/stented with distally captured aortic graft. The median time of pelvic/lower limb ischemia was 120 minutes (IQR, 90-150 minutes). TS was achieved in all patients. One patient (3%) suffered SCI, and there were no cases of stroke. An asymptomatic renal artery occlusion was detected at postoperative imaging, which was recanalized by thrombus-aspiration/relining. This was the only case of TA instability (1/128; 0.8%) and reintervention (1/33; 3%) within 30 days. Two patients (6%) died within 30 days. Median follow-up was 14 months (IQR, 6-22 months). One case (3%) of bilateral renal artery occlusion occurred at 6 months. No superior mesenteric artery or celiac trunk events occurred, with an overall TA instability rate of 2% (3/128). Eighteen patients (55%) completed the radiologic follow-up at 1 year with no new cases of TA instability. Freedom from TA instability was 91% at 1 year.

CONCLUSIONS

T-branch by PDT seems to be safe and effective in the management of c-AAAs/TAAAs with NPA or APA. Results were satisfactory in terms of TS and mid-term TA instability, suggesting a possible enlargement of the anatomical feasibility criteria for outer branches in urgent cases.

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.

A three-year experience with the balloon expandable GORE VIABAHN VBX in the treatment of thoraco-abdominal aortic aneurysms within the EXPAND trial

OBJECTIVE

The EXPAND registry is a post-market, multicenter registry that aims at evaluating the safety and performance of the GORE VIABAHN VBX balloon expandable endoprosthesis (VBX stent) implanted in peripheral vessels. This subgroup analysis assesses the 3-year outcomes of the VBX stent as a bridging stent graft for visceral vessels during branched endovascular aortic repair.

METHODS

This prospective, multicenter, observational registry includes 16 European sites. Patients were enrolled from November 2018 to March 2022. Endpoints included 3-year primary patency (PP), secondary patency (SP), and stent graft-related death and serious adverse events.

RESULTS

Seventy-three patients, of whom 57 (78.1%) were male, with a mean age of 73 years (±8.1 years) were included. At 3 years, 42 patients (57.5%) returned for follow-up. Overall, 223 target vessels (TVs) were treated. The estimated freedom from loss of TV PP was 93.6%. Per TV PP rates were 97.0% for the celiac trunk, 93.9% for the superior mesenteric artery, 91.2% for the left renal artery, and 92.5% for the right renal artery. The overall estimated freedom from loss of SP was 96.8%, and freedom from TV instability was 94.5%.

CONCLUSIONS

The VBX stent demonstrated excellent sustained results at 3 years with almost 94% PP, 97% SP, and 94.5% freedom from TV instability. Patency in the renal arteries was lower than in the celiac trunk and superior mesenteric artery. The VBX stent appears to be a reliable bridging stent for target vessels in branched endovascular aortic repair.

A novel inner-branched stent-graft to overcome narrowed lumen in branched endovascular aneurysm repair

A narrowed patent aortic lumen (<25 mm) represents a challenging scenario frequently observed during thoraco-abdominal and abdominal aortic pathologies involving the visceral vessels. The paper aims to describe the characteristics of a novel tapered-shape inner-branched custom-made stent-graft designed to specifically address the narrowed patent aortic lumen and its applicability in a wider spectrum of aortic scenarios at the reno-visceral segment.

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.

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.