ABSTRACT
PURPOSE: The purpose of the study is to describe a new bailout maneuver for use during branched endovascular thoracoabdominal aneurysm repair (BEVAR) while dealing with challenging target vessel cannulation. TECHNIQUE: A 54-year-old woman underwent urgent BEVAR with a low-profile T-branch device to exclude a type 2 thoracoabdominal aneurysm (TAAA). The endovascular procedure was challenging because the left renal artery ostium was covered by the endograft fabric, compounded by diseased target vessels. A novel bailout maneuver is described. After angioplasty of the left renal artery (LRA), the LRA remained precannulated and a low-profile T-branch was implanted. The 3 proximal branches (superior mesenteric artery, inferior mesenteric artery, and the right renal artery) were connected to their respective target vessels swiftly with a steerable sheath from a femoral approach. Access to the left renal artery was not achieved because it was obstructed by the fully deployed endograft. We subsequently stented the LRA over the "pre-positioned buddy wire," using a balloon-expandable covered stent protruding inside the aneurysm lumen. The proximal stent was then flared and lifted upward using an 8.5 Fr steerable sheath, which made cannulation and stenting of the LRA through the side-branch from above finally achievable. CONCLUSION: The elevator technique described in this article will help achieve technical success in challenging BEVAR cases. CLINICAL IMPACT: We describe in this technical note the "elevator technique" that will complement the "Snare-Ride" and "Balloon Anchoring" techniques over a buddy wire positioned in a target vessel, to provide successful bailout options for challenging TV cannulations during BEVAR.After failed access to the renal artery through the renal branch, a covered stent was implanted in the renal artery over the buddy wire with 10 mm protruding into the aortic lumen. This stent was then flared, prior to advancing a curved steerable sheath into the stent, which shaped it with a superior-facing funneled aortic segment. This maneuver resulted in the renal stent facing its corresponding branch, finally easy to access from the endograft lumen.
ABSTRACT
BACKGROUND: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. METHODS: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. RESULTS: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90-100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1-40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. CONCLUSIONS: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.
ABSTRACT
OBJECTIVE: We evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft-related complications and, consequently, reintervention. METHODS: All consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft-related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft-related reinterventions. All-cause and aneurysm-related deaths were also recorded. RESULTS: Overall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft-related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft-related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft-related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47). CONCLUSIONS: To the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft-related complications associated.
