Fenestrated Endografts for Complex Abdominal Aortic Aneurysm Repair.

Since the introduction of fenestrated endovascular aneurysm repair (FEVAR) in 1996, great advances have been made in endograft development. Custom-made and off-the-shelf fenestrated and branched endografts have been used to treat patients with complex abdominal aortic and thoraco-abdominal aneurysms. Most experience has been gained with the Cook Zenith® fenestrated endograft (Cook Medical Inc., Limerick, Ireland). The Cook Zenith® endograft is customized with fenestrations, (fixed) inner or outer branches, or a combination of them, to cover a wide range of complex aneurysms. There are limitations to the number, location, and size of the fenestrations and to the maximal angulation of the aorta. Because the production of a custom-made fenestrated endograft takes several weeks, and is therefore not available for emergency cases, off-the-shelf fenestrated endograft were developed. One of these grafts was the Endologix Ventana™ (Endologix, Inc., Irvine, California). This endograft was withdrawn from enrollment due to a high reintervention rate. Vascutek Ltd. developed the custom-made Vascutek Fenestrated Anaconda™ endograft (Vascutek Ltd., Inchinnan, Scotland) to treat patients where other endografts were not suitable-like in a more tortuous aorta with an angulation up to 90°. Additionally, the unsupported proximal body enables a high number and large size of fenestrations if needed. First reports of custom-made fenestrated and (inner and outer) branched JOTEC E-xtra DESIGN ENGINEERING (JOTEC GmbH, Hechingen, Germany) for aortic aneurysms seem promising, but larger series need to be reported to be able to draw conclusions. Both custom-made Cook Zenith® and Vascutek Fenestrated Anaconda™ endografts have good reported clinical outcomes with a perioperative mortality between 4.1 and 6.7% and a reintervention rate of <10% at one year. Knowledge on the long-term outcome of both devices is still limited.

Midterm changes in iliac limb apposition after endovascular aortic aneurysm repair.

BACKGROUND: Literature is scarce on the course of iliac endograft limb apposition after endovascular aortic aneurysm repair (EVAR), which is why this study was conducted. METHODS: A retrospective observational imaging study was performed to measure iliac apposition of endograft limbs on the first post-EVAR computed tomography angiography (CTA) scan and on the latest available follow-up CTA scan. With center lumen line reconstructions and CT-applied dedicated software, the shortest apposition length (SAL) of the endograft limbs was assessed as well as the distance between the end of the fabric and the proximal border of the internal iliac artery or the endograft-internal artery distance (EID). RESULTS: Ninety-two iliac endograft limbs were eligible for measurements, with a median follow-up of 3.3 years. At the first post-EVAR CTA, the mean SAL was 31.9±15.6 mm, and the mean EID was 19.5±11.8. At the last follow-up CTA, there was a significant decrease in apposition of 10.5±14.1 mm (P<0.001) and a significant increase in EID of 5.3±9.5 mm (P<0.001). A type Ib endoleak developed in three patients due to a reduced SAL. The apposition was <10 mm in 24% of limbs at the last follow-up vs. 3% at the first post-EVAR CTA. CONCLUSIONS: This retrospective study documented a significant decrease in post-EVAR iliac apposition over time, partly due to retraction of iliac endograft limbs at mid-term CTA follow-up. Further research is required to identify whether regular determination of iliac apposition may predict and prevent type IB endoleaks.