Analysis of predisposing factors for type III endoleaks from directional branches after branched endovascular repair for thoracoabdominal aortic aneurysms.

BACKGROUND: Mid-term durability of branches has already been established, and BF-branched and fenestrated endovascular repair has shown comparable results with open repair in the treatment of thoracoabdominal aortic aneurysms (TAAAs). Nevertheless, target vessel instability remains the most frequent adverse event after complex endovascular aortic repair. Type III endoleaks from directional branches have been reported with a low incidence, but risk factors for this complication have not been investigated yet. METHODS: This was a dual-center observational retrospective cohort study. Data were collected prospectively for each patient treated with branched endovascular repair between April 2008 and December 2019. The primary outcome was to assess potential risk factors for branch disconnection and fracture. A logistic regression analysis was performed, including preoperative and postoperative measurements as well as intraoperative details. A Cox regression hazard analysis was performed to evaluate the influence of preoperative aneurysm diameter and target vessel angulation on the outcome during follow-up. RESULTS: Two hundred ninety-five target visceral vessels (TVVs) in 91 patients were considered suitable for cannulation. Technical success was 96.9% (286/295 TVVs). The median follow-up was 32.5 months (interquartile range, 14.2-50.1 months). Twelve type III endoleaks from directional branches were detected (4.2%; 5 bridging stent graft fractures and 7 disconnections). Five type III endoleaks involved the celiac trunk (one fracture and four disconnections), five the superior mesenteric artery (four fractures and one disconnection), and two the renal arteries (both disconnections). The median time to type III endoleak was 22.2 months (interquartile range, 10.9-37.6 months). Preoperative TAAA diameter (P = .028), preoperative TVV angulation (P = .037), the use of a BeGraft stent graft as bridging stent graft (P = .001), and different stent types on the same vessel (P = .048) were associated with type III endoleak at univariable analysis. Using a BeGraft stent graft (P = .010) was the only significant factor predisposing to type III endoleak at multiple logistic regression. The Cox regression analysis showed a two-fold increased risk for type III endoleak for every 10-mm increase in preoperative TAAA diameter (hazard ratio, 2.00; 95% confidence interval, 1.08-3.72; P = .028) and a 1.5 increased risk every 12° increase of preoperative TVV angulation (hazard ratio, 1.47; 95% confidence interval, 1.02-2.10; P = .037). CONCLUSIONS: Type III endoleaks from directional branches are a non-negligible complication after branched endovascular repair, with a relevant incidence. They tended to be clustered on specific patients, and aneurysm diameter and TVV angulation are strictly associated with the outcome. Different stent types on the same vessel should be avoided whenever possible. An intensified follow-up should be adopted for patients with large aneurysms, implanted with first-generation BeGraft, or who have been already diagnosed with type III endoleaks.

Effectiveness of the Rotarex Excisional Atherectomy System in Both Subacute and Chronic Aortoiliac Endograft Thrombosis: An Innovative Option for the Modern Endovascular Surgeon Toolkit.

PURPOSE: To report a successful revascularization case using the Rotarex™S atherothrombectomy system in a recent iliac limb thrombosis, and chronic hypogastric stent obstruction after previous aortoiliac aneurysm endovascular repair (EVAR). CASE REPORT: A 72-year-old patient was treated for recent right iliac limb thrombosis and left iliac branch chronic hypogastric stent occlusion, 5 years after EVAR. A total endovascular approach, using both upper extremity and femoral vascular access, was settled with 2 Rotarex™S (6Fr and 10Fr) devices. The Rotarex™S catheters removed most of the intraluminal material, allowing additional endografts and bare metal stents to be deployed to support a new healthy lumen surface. CONCLUSION: The total endovascular approach provided by the Rotarex™S device appears to be safe and effective in treating aortoiliac endografts occlusions, both in subacute and chronic phases. Larger studies could highlight differences and eventual advantages compared with more traditional solutions.

Ceiling Technique to Facilitate Target Vessel Catheterization During Complex Aortic Repair.

Aim of this paper is to describe a simple and helpful technique for challenging visceral vessel catheterization during complex aortic endovascular procedures. In demanding anatomies when standard visceral vessel cannulation maneuvers result ineffective, inflating a compliant balloon above the target arteries may allow easy and safe advancement of the introducer sheath inside selected vessel. This approach lowers the shear forces enhancing device pushability. The use of a compliant aortic balloon with the Ceiling technique is a useful, easy and reproducible endovascular option that can be adopted for challenging vessel catheterization during advanced endovascular procedures.

Branched Endograft Partial Deployment to Save Space for Vessel Cannulation When Treating Aneurysms with Narrow Aortic Lumen.

PURPOSE: To describe a novel technique developed for the treatment of patients with thoracoabdominal aortic aneurysms having narrow aortic lumens using branched endografts. TECHNIQUE: When treating patients with a narrow aortic inner diameter with branched endografts, we propose a partial graft deployment leaving the distal portion of the device inside the delivery system with the aim of spare space and facilitate target vessel cannulation. CONCLUSIONS: Partial endograft deployment could be considered in the case of expected difficulty associated with encumbrance deriving from the distal straight graft portion. This technique could be useful to avoid target vessel loss and therein save procedural and fluoroscopy time.

The Effect of Manufacturer's Instructions for Use Compliance on Cook ZBIS Iliac-Branched Endograft Long-Term Outcomes.

BACKGROUND: Current guidelines indicate iliac-branched endografts (IBDs) as the ideal means to preserve pelvic perfusion during endovascular aortic repair. Because patient vascular anatomy represents the main limitation to extensive use of these devices, off-label application may be considered to expand the number of patients being treated. The aim of this study is to evaluate long-term outcomes obtained using the Cook ZBIS endograft in the treatment of aortoiliac aneurysms as per or outside manufacturer's instruction for use (IFU). METHODS: Data from all patients who underwent IBD implant in a single center were reviewed. Study population was divided into two subgroups: Group I treated as per manufacturer's IFU and group II treated outside IFU. RESULTS: During the study period (2008-2018), 119 patients were treated with 130 IBDs. Eighty-six patients were treated as per IFU (group I) and 44 outside IFU (group II). Overall technical success was 99.2%. Mean follow-up was of 63.5 ± 38.3 months for group I and 58.3 ± 35.9 months for group II (P = 0.45). Freedom from reintervention at ten years was 79.8% in group I and 69.6% in group II (P = 0.29). Freedom from IBD-related reintervention rate was 98.7% and 95.3% in groups I and II, respectively (P = 0.240). Iliac-branched module thrombosis occurred significantly more in patients treated outside IFU with 4 cases in group I (4.7%) and 10 cases in group II (22.7%), (P = 0.005). Cox regression analysis identified hypogastric artery aneurysm as the only independent predictor for both IBD thrombosis and hypogastric artery occlusion during follow-up. CONCLUSIONS: When used by an experienced team, Cook IBDs are safe and effective in the treatment of aortoiliac aneurysms both inside and outside IFU. Anyway a lower target hypogastric patency rate should be expected when treating patients with hypogastric aneurysms.

Forced Complete Femoral Approach for Urgent Thoracoabdominal Aneurysm Repair Using an Inner Branched Endograft.

BACKGROUND: A successful case of urgent type II thoracoabdominal aneurysm repair with an inner branched endograft conducted entirely through femoral accesses without the bailout possibility to achieve an upper extremity approach for bridging stents delivery is described. CASE REPORT: A 70-year-old male patient underwent hybrid treatment for a thoracic aortic aneurysm on complicated type B dissection in 2 steps. First, arch debranching with carotid-carotid-subclavian bypass and then ascending aortic replacement with reimplantation of the anonymous trunk plus TEVAR were performed. The scheduled 1-month control computed tomography angiography (CTA) showed a rapid increase of the false lumen thoracoabdominal aneurysm, with axial diameter measuring more than 10 cm. The repair procedure was based on the use, as off-the-shelf graft, of a prosthesis customized for another patient with inner branches for visceral vessels that well suited the characteristics of the case. A steerable guiding sheath was essential to stabilize the system in the selective and sequential cannulation of 2 of the 4 inner branches (for celiac trunk and superior mesenteric artery) and to complete the bridging stents deployment. Procedure was carried out without complications. CONCLUSIONS: In an urgent setting, total endovascular correction of a thoracoabdominal aortic aneurysm exclusively through femoral accesses appears to be feasible when the appropriate tools are available.

Off-label use of the Gore Excluder iliac branch endoprosthesis in association with the Rotarex S catheter to achieve total endovascular recanalization of an occluded aortobifemoral bypass.

We describe a successful case of hybrid revascularization of a totally occluded aortobifemoral bypass with retrograde use of the Rotarex S catheter (BD) and complete relining with a Gore Excluder iliac branch endoprosthesis (W.L. Gore & Associates). The repair procedure was performed with femoral surgical access and percutaneous brachial access. Despite left renal artery endoclamping, after the final angiography, deployment of a covered stent in the left renal artery was needed because of residual thrombotic material at the vessel ostium. The procedure was completed with reconstruction using a common femoral artery Dacron graft and bilateral complete iliac surgical branch relining using self-expanding covered stents, with recovery of distal pulses.

Endovascular thrombectomy devices for acute limb ischemia management.

Acute limb ischemia still represents a challenge for the contemporary vascular surgeon, representing an immediate threat for patients' limb but potentially also for the proper patient life in some settings. Technology recently evolved and focused on the treatment of such complex situation. Several devices are available as of today allowing a complete acute limb ischemia endovascular management, aiming to remove intraluminal material while leaving the possibility for treating the underlying pathology when needed. In this review, proper specific device characteristics, indications and advantages are reported and discussed. Despite the broad spectrum of different available devices could appear as potentially confounding, each device has its own features, indications, weak and strength point. Ideally the modern endovascular surgeon should master every single tool, tailoring revascularization strategy and timing for the proper patient and arterial segment to be treated, maximizing the benefits coming from technological improvements.