Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.

BACKGROUND: The aim of this study was to evaluate the cost-effectiveness of chimney (ch-EVAR) vs. fenestrated aneurysm repair (f-EVAR) for treatment of complex abdominal aortic pathologies. Endovascular repair of complex abdominal aortic pathologies with involvement of renal arteries includes use of f-EVAR as first line treatment. However, lack of availability and suitability has necessitated an alternative strategy employing parallel or snorkel/chimney grafts (ch-EVAR). METHODS: Between January 2013 and January 2017, prospectively collected data of elective and symptomatic patients with complex aortic pathologies treated by single or double ch-EVAR (N.=111) or by f-EVAR with three fenestrations (N.=37) were evaluated. The primary endpoint was cost-effectiveness analysis defined as the summary of material costs, in-hospital costs and additional costs due to procedure-related reinterventions during a follow-up period averaging 37.2 months. RESULTS: No differences between both groups were found in terms of demographics (P=0.32), age (P=0.058) and hospital stay at initial procedure (P=0.956). Index procedure and hospitalization median costs were € 22,171 for ch-EVAR and € 42,116 for f-EVAR, respectively (P<0.001). The median overall costs including costs after reinterventions during follow-up were € 22,872 for ch-EVAR and € 42,128 for f-EVAR (P<0.001). Six patients (5.4%) in the ch-EVAR group required readmission compared to three patients (8.1%) required readmission for reinterventions in the f-EVAR group (P=0.69). CONCLUSIONS: Ch-EVAR is significantly more cost-effective compared to f-EVAR. The two procedures have comparable readmission rates for reinterventions.

CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms.

Purpose: To evaluate chimney stent-graft position and morphological changes of the aneurysm sac as visualized by postoperative computed tomography angiography (CTA) over a minimum 24-month follow-up period. Materials and Methods: Twenty-one patients (mean age 75.7±8.6 years; 20 men) with juxtarenal aortic aneurysms who underwent successful chimney endovascular aneurysm repair (ch-EVAR) with the Endurant stent-graft and had 2 postoperative CTAs separated by at least 24 months were included in the study. CTA-based measurements of aortic stent-graft migration, target vessel angle, and chimney angle were compared between the serial scans. Results: During a mean follow-up of 34.9 months (range 24-69.2), the mean migration of the aortic stent-grafts was under 5 mm (2.76±2.4 mm). The average migration distance per year was 1.15 mm. The aneurysm diameter reduced a mean 3.25 mm (p=0.048). The right renal artery angle moved significantly upward 6.72° (p=0.025), while the right renal chimney stent-graft moved significantly downward 7.83° (p=0.042). The left renal artery angle also moved upward 1.87° (p=0.388) and the corresponding chimney moved downward 5.68° (p=0.133). During the study period, no type I/III endoleak or chimney occlusion was observed. Conclusion: Midterm morphometric assessment of ch-EVAR using CTA showed significant aneurysm sac shrinkage and a stable 3-year position of the abdominal devices, with the mean downward migration of the aortic stent-graft being <5 mm in the majority of cases. The chimney grafts seem to be prone to take an oblique rather than parallel configuration during follow-up. However, there was no relevant clinical consequence related to this phenomenon.

Technical assessment of the preloaded fenestrated stent-graft in the management of pararenal aortic aneurysms.

PURPOSE: To assess the effectiveness of the 20-F preloaded fenestrated stent-graft (FSG) to facilitate safe and quick catheterization of both renal arteries and its impact on relevant procedure variables in the management of pararenal aortic aneurysms (PAAs). METHODS: Between June 2012 when preloaded FSG became available in our institution and February 2013, 10 patients (9 men; mean age 70±10 years) with PAAs were treated by the same surgeon with preloaded FSGs consisting of 3 fenestrations with/without a scallop for the celiac trunk. In the same time frame, 12 patients (11 men; mean age 72±8 years) received standard FSGs with the same fenestration configuration by the same surgeon and were considered as controls. The decision to use the standard vs. preloaded FSG was random; no selection criteria were applied. Main outcome measures were the time interval between insertion of the main graft and advancement of sheaths in all target vessels, total operating time, the amount of iodine, the radiation dose area product, and the fluoroscopy time. RESULTS: The median time to sheath introduction into the fenestrations in the preloaded FSG group was significantly shorter (19 minutes, range 15-36) vs. the 48 minutes (range 30-65) of the control group (p=0.001). The mean operating time was 178±28 minutes in test group and 251±50 minutes in the controls (p=0.006). The median fluoroscopy time was shorter in the preloaded FSG group (61 minutes, range 41-73) vs. 83 minutes (range 51-290) in the controls (p=0.002). The radiation dose was significantly lower [3 mGym(2) (range 1.4-6.1) vs. 4.9 mGym(2) (range 3.6-12.7), p=0.004], as was the amount of iodine (37.4±9.5 g vs. 50±11.7 g, p=0.01). CONCLUSION: The technique of fenestrated stent-grafting for PAAs using a preloaded device is feasible. Compared to standard FSGs, the preloaded design seems to be beneficial in terms of reducing the times for catheterization of all target vessels (60% shorter), fluoroscopy (27% shorter), and the procedure (29% shorter). The radiation dose and the amount of iodine used were less as well (39% and 25%, respectively).