Endovascular repair of abdominal and thoracoabdominal aneurysms using chimneys and periscopes is associated with poor outcomes.

OBJECTIVE: Chimneys and periscopes are often used to treat pararenal or thoracoabdominal aneurysms de novo or after failed open or endovascular repair. We sought to describe our institutional experience, given their limited success and questionable long-term outcomes. METHODS: We retrospectively reviewed the electronic records for patients treated with chimneys/periscopes from 1997 through 2020. Baseline characteristics, procedural details, periprocedural complications, reinterventions, and midterm outcomes were collected. RESULTS: Fifty-eight patients (86 vessels) were treated; the median follow-up was 32 months (range, 0.03-104 months). There were 36% (n = 21) juxta-renal, 2% (n = 1) para-visceral, and 21% (n = 12) thoracoabdominal aneurysms, and 41% (n = 24) had pararenal failure of prior endovascular aneurysm repair (n = 17) or open repair (n = 7). Stent configuration for the majority of the 86 vessels (n = 80; 93%) treated were chimney configuration (n = 6 periscopes; 7%). The most common stent graft utilized was Viabahn, and 8.1% (n = 7) were reinforced with a bare metal stent. Although the majority of the cases were elective, 36.2% (n = 21) of the cases were urgent/emergent. At the conclusion of the initial procedure, 16 of 58 patients had an endoleak (gutter, 50% [8/16]; type Ia, 25% [4/16]; and type II, 25% [4/16]). On follow-up, 14 of 58 patients developed one or more endoleaks, with the most common endoleaks being a gutter endoleak (35% [7/20]). Other endoleaks observed included 30% (6/20) type III, 15% (3/20) type Ia, 15% (3/20) type Ib, and 5% (1/20) type II. Eleven of 58 patients underwent interventions for one or more endoleak (gutter, 33% [5/15]; type Ib, 20% [3/15]; type II, 7% [1/15]; and type III, 40% [6/15]). Twelve of 58 patients returned to the operating room for one or more procedures during the index hospitalization (five laparotomies, three dialysis access, three acute limb ischemia, and four chimney/periscope interventions). Ten of 58 patients underwent angioplasty/stenting for chimney/periscope compression or occlusion during the follow-up period. Survival was 61.3% at 1 year by Kaplan-Meier analysis (75% for elective, 37% for urgent/emergent) (aneurysm-related death, 22%). Cox hazard modeling showed that aneurysm diameter (hazard ratio, 1.03; 95% confidence interval, 1.004-1.05; P = .02) and urgent/emergent interventions (hazard ratio, 3.6; 95% confidence interval, 1.33-9.74; P = .01) were predictors of mortality. CONCLUSIONS: Endovascular repair of aortic aneurysms with chimneys/periscopes is associated with poor outcomes, including limited technical success and aneurysm exclusion, as well as high morbidity and mortality, with a high rate of reinterventions both in the immediate postoperative period and on follow-up. They should be used only when other surgical or endovascular options are not possible.

The combined use of thoracic and abdominal aortic stent grafts for endovascular repair of wide neck abdominal aortic aneurysms in high risk patients.

INTRODUCTION: Treatment of abdominal aortic aneurysms (AAA) with large (28 mm to 34 mm) and wide diameter (> 35 mm) necks remains a challenge in patients who are high-risk candidates for open repair. While several case reports describe the use of a thoracic stent graft in conjunction with a traditional modular bifurcated stent graft, most patients do not have the aortic length to accommodate such a configuration. We present our experience utilizing a distal unibody bifurcated aortic stent graft (Endologix, Irvine, CA) in conjunction with a proximal thoracic aortic stent graft (Medtronic, Minneapolis, MN) to treat wide-necked non-ruptured AAAs in patients who were otherwise poor candidates for open or fenestrated repair. METHODS: A single center retrospective review of patients treated with a combination of a distal unibody bifurcated aortic stent graft and a proximal thoracic aortic stent graft extension from 2013 to 2019 was performed. Demographics, perioperative details and long-term outcomes were collected and summarized. Standard statistical methods were utilized. RESULTS: We identified 7 patients who underwent this procedure during the study interval. Of these, all 7 (100%) were male with an average age of 69.1 ± 5.1 years. Average Charlson Comorbidity Index was 5.0. Average pre-operative maximum aortic and neck diameters were 57.9 mm (± 5.8) and 37.4 mm (± 4.5) respectively. All patients underwent repair with a distal 28 mm diameter unibody bifurcated aortic stent graft and proximal extension with a thoracic aortic stent graft that ranged from 40 to 46 mm in diameter. Technical success was achieved in all 7 patients. There were no perioperative mortalities or aorta-related deaths. Follow up was a mean of 1.98 years with a mean survival of 4.75 years (± 0.86). One patient required an aneurysm-related intervention for a late type III endoleak. CONCLUSION: The combined use of thoracic and abdominal aortic stent grafts is a safe and effective endovascular method to treat high-risk surgical candidates with wide-necked AAAs.

Computed Tomography Angiography Prediction of Successful Trasnscatheter Embolization for Type II Endoleak of Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: To evaluate the utility of computed tomography (CT) angiography before transarterial embolization (TAE) in predicting TAE's technical success for type II endoleaks (T2ELs). MATERIALS AND METHODS: Fifty-eight patients (mean age, 74.4 years; range, 46-89 years) who underwent attempted TAE for T2EL from July 2014 to August 2019 and underwent CT angiography before the procedure were included. Each CT angiography result was assessed for a feeding artery that was traceable over its entire course from either the superior mesenteric artery or the internal iliac artery to the endoleak cavity. TAE was performed using coils and was considered technically successful if embolization of the endoleak cavity and feeding artery was performed. The technical success rates were compared between patients with and without traceable feeding arteries. RESULTS: A fully traceable feeding artery supplying 75% (44/59) of endoleaks in the cohort was identified. TAE was technically successful in 95% (42/44) of these cases but only in 13% (2/15) of the cases without a fully traceable feeding artery (P < .001). When the inferior mesenteric artery was the feeding artery, it was always fully traceable, and TAE was technically successful in 100% (33/33) of the cases. When a lumbar artery was the feeding artery, it was fully traceable in only 42% (11/26) of the cases. When the lumbar artery was not fully traceable, TAE was technically successful in only 13% (2/15) of the cases. CONCLUSIONS: The traceability of a feeding artery over its entire course to an endoleak cavity using CT angiography was associated with TAE's technical success. Lumbar feeding arteries were less likely to be fully traceable. TAE's high failure rate when the feeding artery was not fully traceable suggests that translumbar embolization can be considered as an initial approach for theses patients.

Late type II endoleaks after endovascular aneurysm repair require intervention more frequently than early type II endoleaks.

OBJECTIVE: Type II endoleaks (T2ELs) are commonly observed after endovascular aneurysm repair (EVAR). We sought to determine whether time at onset of T2ELs correlated with the need to intervene based on sac expansion or rupture. METHODS: Between 1998 and 2015, 462 EVARs performed at our institution had duplex ultrasound surveillance in our accredited noninvasive vascular laboratory. Computed tomography and arteriography were reserved for abnormal duplex ultrasound findings. The need for intervention for T2ELs was classified according to time at onset after EVAR. Interventions for T2ELs were performed only for sac expansion >5 mm or rupture. We defined early-onset T2ELs as <1 year after EVAR and delayed or late onset as >1 year of follow-up. RESULTS: Of the 462 EVARs, 96 patients (21%) developed T2ELs after implantation. Of these, 65 (68%) had early and 31 (32%) had late onset (mean, 12 months; range, 1-112 months). Early T2ELs resolved without treatment in 75% (49/65) of cases compared with only 29% (9/31) of late T2ELs (P < .0001). Intervention was required for only 8% (5/65) of patients with early T2ELs (5 sac expansions, 0 ruptures) compared with 55% (17/31) for late T2ELs (16 sac expansions, 1 rupture; P < .0001). The remaining patients were observed for persistent T2ELs with no sac growth (17% [11/65] early vs 16% [5/31] late; P = .922). CONCLUSIONS: Less than one-third (29%) of T2ELs that develop after 1 year will resolve spontaneously and about half (55%) will require intervention for sac growth or rupture. T2ELs that develop >1 year after EVAR should be followed up with a more frequent surveillance protocol and perhaps with a lower threshold to intervene.

The fate of endovascular aortic aneurysm repair after 5 years monitored with duplex ultrasound imaging.

BACKGROUND: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long-term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. METHODS: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. RESULTS: There were 156 patients who underwent EVAR with follow-up >5 years (mean, 7.5 years; range, 5.1-14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow-up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. CONCLUSIONS: Long-term follow-up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow-up. First-time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first-time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.

Embolization by micro navigation for treatment of persistent type 2 Endoleaks after endovascular abdominal aortic aneurysm repair / Embolização por micronavegação para tratamento de Endoleak tipo 2 persistente após reparo endovascular do aneurisma de aorta abdominal

Background: Endovascular repair has become established as a safe and effective method for treatment of abdominal aortic aneurysms. One major complication of this treatment is leakage, or endoleaks, of which type 2 leaks are the most common. Objective: To conduct a brief review of the literature and evaluate the safety and effectiveness of embolization by micronavigation for treatment of type 2 endoleaks. Method: A review of medical records from patients who underwent endovascular repair of abdominal aortic aneurysms identified 5 patients with persistent type 2 endoleaks. These patients were submitted to embolization by micronavigation. Results: In all cases, angiographic success was achieved and control CT scans showed absence of type 2 leaks and aneurysm sacs that had reduced in size after the procedure. Conclusion: Treatment of type 2 endoleaks using embolization by micronavigation is an effective and safe method and should be considered as a treatment option for this complication after endovascular repair of abdominal aortic aneurysms. .

Contexto: O reparo endovascular se estabeleceu como uma modalidade segura e efetiva no tratamento do Aneurisma de Aorta Abdominal. Uma das principais complicações deste tipo de tratamento é o Vazamento ou Endoleak, sendo o do tipo 2 o mais frequente deles. Objetivo: Fazer uma breve revisão de literatura e avaliar a segurança e a efetividade da embolização por micronavegação para o tratamento do Vazamento tipo 2. Método: A revisão dos prontuários dos pacientes submetidos ao Reparo Endovascular do Aneurisma de Aorta abdominal identificou cinco pacientes que apresentavam Endoleak tipo 2 persistente. Esses pacientes foram submetidos à embolização por micronavegação. Resultado: Em todos os casos, houve sucesso angiográfico e as tomografias de controle evidenciavam ausência de Vazamento tipo 2 e diminuição do saco aneurismático, após o procedimento. Conclusão: O tratamento do Endoleak tipo II por embolização por micronavegação é um método efetivo e seguro, sendo considerado uma opção para esta complicação após o Reparo Endovascular do Aneurisma de Aorta Abdominal. .

Tratamiento endovascular de los endoleaks provenientes de los ramos lumbares de la aorta / Tratamento endovascular dos endoleaks provenientes dos ramos lombares da aorta / Endovascular treatment of endoleaks of lumbar aortic branches

Introducción: Los endoleaks tipo II constituyen la principal causa de reoperación a mediano y largo plazo. Tienen la potencialidad de llevar al crecimiento y ruptura del aneurisma. Exige un seguimiento imaginológico distinto. Por otro lado no existen pautas claras en cuanto al diagnóstico o tratamiento, pudiéndoselo confundir con endoleaks tipo I o III. El abordaje es diferente de acuerdo a la anatomía y al origen del endoleak. El motivo de la presentación es mostrar un abordaje efectivo para pacientes con endoleak tipo II proveniente de ramos lumbares.Material y Método: Se estudioì una población de 210 pacientes con aneurismas de aorta, luego de la colocación de una endoprótesis de última generación. Mediante seguimiento clínico y estudios tomograìficos, fueron incluidos sólo aquellos pacientes que cumplieron con un estricto control de seguimiento. Los datos fueron volcados en una base de datos (Microsoft Excel 97) y luego fueron analizados empleando el paquete estadístico (Medcalc v 11). Resultados: El 13,3% de la población estudiada presentó un endoleak tipo II temprano,mientras que el 6,1% de la población un endoleak tipo II persistente. El 4,2% del total de la población estudiada desarrolló además crecimiento del saco aneurismático. La causa del crecimiento fue en todos los casos un endoleak tipo II persistente. El tratamiento efectivo consistió en la embolización del vaso aferente, eferente y del nido con coils electro-coagulables. Conclusión: Endoleak tipo II presuriza el saco y tiene la potencialidad de producir crecimiento del aneurisma. Tiene en general un comportamiento benigno. La gran mayoría se trombosa espontáneamente. El estudio demostró que tratar sólo aquellos endoleaks persistentes con crecimiento aneurismático es una conducta segura. El tratamiento endovascular con coils del vaso aferente, eferente y el nido por vía transarterial parece ser seguro y efectivo.

Introdução: Os vazamentos do tipo II são a principal causa de operação re no médio e longo prazo. Têm o potencial de levar a um crescimento e ruptura do aneurisma. Requer monitoramento imaginológico diferente. Por outro lado, não há diretrizes claras quanto ao diagnóstico ou tratamento, confundido com o tipo I ou III endoleak. A abordagem é diferente de acordo com a anatomia e a origem do endoleak. Materiais e Métodos: Estudamos uma população de 210 pacientes com aneurismas da aorta após arte colocação de stent. Através clínica e tomográfica estudos foram incluídos apenas os pacientes que preencheram o controle de rastreamento rigoroso. Os dados foram inseridos em um banco de dados (Microsoft Excel 97) e, em seguida, analisados com o pacote estatístico (Medcalc v 11). Resultados: O 13,3% da população do estudo apresentou um vazamento tipo II cedo, enquanto 6,1% da população com vazamento tipo II persistente. O 4,2% da população total do estudo desenvolvido crescimento aneurisma saco. O tratamento eficaz consistiu navio embolização aferentes e eferentes ninho coils com eletro-coagulável. Conclusão: Tipo II endoleak pressuriza o saco e tem o potencial para produzir crescimento do aneurisma. Ele tem um comportamento benigno. A grande maioria são trombose espontaneamente. Somente aqueles devem ser tratados com vazamentos persistentes crescimento de aneurisma. O tratamento endovascular com bobinas de vidro aferentes e eferentes através ninho transarterial parece ser seguro e eficaz.

Introduction: The treatment of type II endoleaks remains controversial because little is known about their long-term natural history and impact on changes in aneurysm morphology.The objective of this presentation is to show a safe and effective approach to treat type II endoleaks associated to aneurysm sac enlargement. Materials and Methods: We studied a population of 210 patients with aortic aneurysms afterstent-graft placement. Through clinical and tomographic studies were included only those patients who met strict follow up control. The data were entered into a database (Microsoft Excel 97) and then analyzed using the statistical package (Medcalc v 11). Results: Early Type II endoleaks were present in 13.3% of the study. Thirteen patient (6.1%)developed a persistent type II endoleak and only 9(4.2%)with aneurysm sac enlargement of >5mm. Effective treatment consisted afferent and efferent coils vessel embolization and the nidus with electro-detachable coils.Conclusion: We observed that type II endoleaks have a relatively benign course, and in the absence of sac expansion, can be followed for a prolonged course of time without the need for intervention. Only those associated with sac enlargement should be treated. Endovascular treatment with coils of afferent and efferent arteries appears to be safe and effective.

Safety and feasibility of balloon-expandable stent implantation for the treatment of type I endoleaks following endovascular aortic abdominal aneurysm repair.

AIMS: The occurrence of type I endoleaks represent an ominous sign after endovascular aneurysms repair (EVAR). We report our experience using balloon-expandable stents (BES) for the treatment of proximal Type I endoleaks at five high-volume hospitals in Argentina. METHODS AND RESULTS: Of 1,395 patients who underwent EVAR, we retrospectively collected data of 29 (2%) consecutive patients who underwent additional BES to repair proximal type I endoleaks. The mean age was 75.8 years old (range 63-87) and 93% were male. A hostile anatomy was found in 89.6% of the cases. BES oversize (balloon/neck diameter ration ≥ 30%) was frequent (69%); whereas, BES/prosthesis diameter ratio was less than 1 in 79% of the cases. Complete and partial sealing was obtained 72 and 28% of the cases, respectively. There were no immediate or late surgical conversion or major complications related with stent implantation. At a median time follow-up of 14.9 months (25-75% interquartiles: 4.5-17.5 months), there were no cardiovascular deaths, evidence of aneurysm sac enlargement or need for re-intervention. CONCLUSIONS: Our preliminary results suggest that BES implantation for the treatment of proximal type I endoleaks is feasible and safe with favourable mid-term results and may preclude the need for surgical conversion.