Results of chimney endovascular aneurysm repair as used in the PERICLES Registry to treat patients with suprarenal aortic pathologies.

BACKGROUND: The prevailing evidence calls for using chimney/snorkel endovascular repair (ch-EVAR) with one or two chimney grafts. No studies up to now focus on its applicability and results for the treatment of suprarenal aortic pathologies (SRAP). Hence, we evaluated the clinical and radiologic results of ch-EVAR treatment for SRAP placing three or more chimney grafts within the PERICLES Registry. METHODS: Data from 517 patients suffering complex aortic pathologies treated by ch-EVAR between 2008 and 2014 at 13 European and U.S. centers were retrospectively reviewed and analyzed. RESULTS: Sixty-seven ch-EVAR-treated patients (12.9% of the entire PERICLES cohort) presented SRAP (83.5% elective, 16.5% urgent). The majority of patients (95.5%) received three chimney grafts; four patients received four chimney grafts. The Endurant device was the most commonly used (35.8%) followed by the Zenith abdominal endograft (19.4%). Overall, 204 chimney grafts were placed (56.7% covered self-expandable, 40.3% covered balloon-expandable stents, and 10.4% bare metal balloon-expandable stents). At a median follow-up of 24 months (range, 0.1-67.0 days), 30-day mortality was 6.1% (4 patients), and the overall mortality was 16.4% (11 patients). Overall survival was 87.4% (range, 79.5%-96.0%) at 1 year, 81.8% (range, 72.2%-92.2%) at 2 years and thereafter. Type IA endoleak was noted in nine patients (13.4%) intraoperatively and successfully treated in seven cases (97.1% technical success). Aneurysm sac diameter significantly decreased from 70.5 ± 19.3 mm to 66.9 ± 20.6 mm (P < .001) at last follow-up. Ischemic stroke or transient ischemic attack were noted in two patients (2.9%). Chimney occlusion was detected in six renal arteries (9.5%) and two superior mesenteric arteries (3.2%). No patients required chronic hemodialysis. All occluded superior mesenteric artery grafts were successfully rescued using endovascular approaches. CONCLUSIONS: The midterm use of ch-EVAR for the treatment SRAP seems to be safe, highlighting its applicability for the treatment of rupture threatening pathologies and seal zone lengthening as in type IA endoleaks after EVAR. However, the incidence of type IA endoleaks, chimney graft occlusions, and ischemic stroke rates is higher compared with the prevailing single chimney evidence. Longer follow-up with more cases is needed to establish the exact performance of this treatment in SRAP.

Patient-Specific Rehearsal Feasibility Before Endovascular Repair of Ruptured Abdominal Aortic Aneurysm.

Purpose: To evaluate the feasibility of a patient-specific rehearsal (PsR) before emergency endovascular aneurysm repairs (eEVAR) and its influence on the operation. Materials and Methods: From February 2016 to October 2016, 10 consecutive patients (mean age 75±7.4 years; 9 men) presenting with a ruptured abdominal aortic aneurysm (rAAA) suitable for standard EVAR were enrolled in the study. A 3-dimensional (3D) model of the abdominal aorta was generated on a virtual reality simulator based on the patient's computed tomography (CT) images. Following the patient-specific simulation setup, PsR was conducted during patient admission or in parallel with the preoperative eEVAR workup. Measured outcomes were PsR feasibility only in the first 4 patients and impact on operative performance thereafter (changes in device selection, the planning process, clinical outcomes, perioperative mortality, and complication rates). Technical metrics and timing of system setup, rehearsal, interval from patient arrival to the actual procedure, and eEVAR were recorded. Results: Mean time for 3D model creation was 21.3±7.8 minutes (range 13-37); there was a significant positive relationship between aortic neck diameter and segmentation time (p=0.003). The overall mean time for simulator setup and PsR was 54±14 minutes (range 37-80); PsR alone was completed in a mean 31±40 minutes (95% confidence interval -60 to -2.2). The actual eEVAR procedure duration was 69±16 minutes (range 45-90). No delay in the actual eEVAR procedure was registered owing to the PsR pathway. In 6 patients, preprocedure rehearsal induced changes in operative strategy, including device selection, main body introduction side, and/or deployment configuration. In 4 cases, rehearsal was performed twice to achieve optimal performance. Conclusion: PsR before eEVAR was feasible in all cases and caused no time delays in the actual eEVAR procedure. PsR optimized eEVAR planning by identifying optimal strategy for stent-graft component selection and deployment.

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.

Impact of aortic stent-graft oversizing on outcomes of the chimney endovascular technique based on a new analysis of the PERICLES Registry.

OBJECTIVE: Chimney endovascular aortic aneurysm repair is gaining ever greater acceptance. However, persistent gutters leading to type IA endoleaks represent an unsolved issue. The aim of the current study was to analyze the impact of abdominal endograft oversizing to the occurrence of this phenomenon. METHODS: The PERformance of the snorkel/chImney endovascular teChnique in the treatment of compLex aortic PathologiesES registry includes the largest experience with chimney endovascular aortic aneurysm repair from 13 vascular centers in Europe and the U.S. Prospectively collected data from centers with standard use of the Endurant stent-graft and balloon-expandable covered stents as chimney grafts only were included in the present analysis. The parameter which varied was the degree of oversizing of the aortic stent-graft classifying the cohort in two groups, group A (20% and less oversizing) and group B (>20% of oversizing). The primary endpoint was the incidence of persistent type IA endoleak needed reintervention. Secondary endpoints were all-cause mortality and freedom from reintervention. RESULTS: Group A included 21 patients while group B 144. The mean preoperative pathology's neck length and diameter was 5.8 mm (±4.4) versus 4.9 mm (±3.8) and 27.6 mm (±4.7) versus 24.9 mm (±3.7) for group A and group B, respectively. The mean length of the new sealing zone after chimney graft placement was similar for both groups (group A versus group B; 17.9 mm versus 18.3 mm, respectively, P = .21). The percentage of oversizing of the aortic stent-graft ranged between 13.8 and 20% versus 22.2 and 30%, for group A and group B, respectively. Patients of group A had more type 1A endoleaks, (14.3%) versus patients of group B (2.1%) based on the first follow-up imaging, P = .02. The incidence of persistent type IA endoleaks needing a reintervention was 14.3 and 1.4% for the group A and group B, respectively, P = .01. The mean volume of contrast medium used was greater in group A versus group B with 239 ml versus150 ml, P = .05. Additionally, 14.3% of patients of group A experienced acute renal failure compared to those in group B which was 1.0%, P = .01. CONCLUSIONS: Oversizing of ideally 30% of the Endurant stent-graft is associated with significant lower incidence of type IA endoleaks requiring reintervention for patients treated by chimney endovascular aortic aneurysm repair.

Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2.

PURPOSE: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). METHODS: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22-87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. RESULTS: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1-72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. CONCLUSION: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.

Multicenter European Registry for Patients with AAA Undergoing EVAR Evaluating the Performance of the 36-mm-Diameter Endurant Stent-Graft.

INTRODUCTION: The use of and results with the Endurant stent-graft have been reported extensively. However, there has been little if any focus placed on performance and outcomes when a 36-mm-diameter device is used. METHODS: Data were collected and retrospectively analyzed on EVAR patients treated with a 36-mm-diameter Endurant device at 3 European academic vascular centers between 2007 and 2015. Primary endpoints were the absence of type Ia endoleak in the early and mid-term follow-up period, and aneurysm sac stabilization or shrinkage. Secondary endpoints were 30-day mortality, overall survival and secondary interventions. Subgroup analysis of outcomes in the on-label (ONL) versus off-label (OFL) device use cohorts was also performed. RESULTS: Seventy-three patients were included in the study. Mean follow-up was 30.1 ± 16.2 months. Mean aortic neck diameter was 29.5 ± 1.9. Primary technical success was achieved in 69 patients (94.5%). Five patients (6.8%) were found to have developed a type Ia endoleak, 3 during the first month, and the other 2 at 2 years. Overall EVAR-related mortality was 4.1% (n = 3). Subgroup analysis focused on the OFL cohort (n = 44) versus the ONL patients (n = 29). Two of the OFL patients (4.5%) had a type Ia endoleak, and 3 (10.3%) in the ONL group. CONCLUSION: The use of the largest diameter Endurant stent-graft device emerges as a reasonable option for EVAR treatment of AAA featuring a large-diameter proximal neck. Assessment of a larger group of patients followed in the long term will be necessary for a more definitive statement on such strategy.

Importance of Early Aortic Surveillance after Endovascular Treatment of Type B Aortic Dissection with Malperfusion Syndrome.

BACKGROUND: The aim of the study was to assess the incidence and timing of adverse events and complications occurring after endovascular treatment of type B aortic dissection (TBAD) complicated with malperfusion syndrome (MPS). METHODS: Twenty-eight patients with TBAD and MPS treated endovascularly at our center from January 2006 to January 2015 were evaluated through a retrospective scrutiny of the medical records. The primary end point of the study was aorta-related reintervention. The secondary end point was all-cause mortality. RESULTS: The MPS included the mesenteric and renal arteries in 14 (50%) and 21 (75%) patients, respectively, the lower extremities in 14 (50%) patients and the spinal cord in 3 (10.7%). The 1-year and 5-year freedom of reintervention rate were 86.2% and 74.7%, respectively. The median time to reintervention was 4.5 months. The main reason for reintervention was type I proximal endoleak which was treated by proximal endograft extensions and appropriate arch-branch management. The perioperative mortality was 14.3% (4 of 28). The mean follow-up was 61.7 months (range, 2-96 months). The short-term and long-term survivals were 82.1% at 1 and 5 years, respectively. CONCLUSIONS: The results suggest that closer follow-up and imaging surveillance of the aorta are warranted after thoracic endovascular aortic repair treatment of TBAD and MPS. And especially so during the first 6 months to enable timely detection and correction of potential complications.

European Multicenter Registry for the Performance of the Chimney/Snorkel Technique in the Treatment of Aortic Arch Pathologic Conditions.

BACKGROUND: To study the performance of the chimney technique in the treatment of aortic arch pathologic conditions. METHODS: We retrospectively evaluated the clinical and procedural outcome data of patients undergoing endovascular treatment in the aortic arch by use of the chimney technique at four European centers between June 2002 and December 2014. The primary endpoint was technical success. The secondary endpoints were type I endoleak, 30-day mortality, stroke, primary patency of the chimney graft, and freedom from reintervention. RESULTS: Ninety-five patients were included in the study. The underlying pathologic conditions were degenerative aneurysm (n = 45, 47.4%), type B aortic dissection (n = 30, 31.6%), dissecting aneurysm (n = 6, 6.5%), penetrating atherosclerotic ulcer (n = 5, 5.3%), type I endoleak after previous thoracic endovascular aortic repair (n = 6, 6.3%), and aortic embolic disease (n = 3, 3.2%). Twenty-one patients (22%) underwent arch-branch debranching before chimney graft implantation. The majority of patients were treated electively (n = 49, 51.6%). Forty-six patients (48.4%) underwent urgent placement of chimney grafts because of their symptoms (n = 25) or rupture (n = 21). Technical success was 89.5%. The 30-day mortality was 9.5% (9 patients). No aorta-related death was observed. A type Ia endoleak occurred in 10 patients (10.5%) intraoperatively, resolving spontaneously within the first 30 days in 50% of these cases. Major stroke was diagnosed in 2 patients (2%). Primary patency of the chimney grafts was 98%, and 5 patients (5.2%) required a reintervention. CONCLUSIONS: The chimney technique in the aortic arch proved highly and predictably successful, with a low rate of reinterventions.

Periscope endograft technique to revascularize the left subclavian artery during thoracic endovascular aortic repair.

PURPOSE: To present early and midterm results of the periscope endograft (PG) technique to maintain left subclavian artery (LSA) blood flow in thoracic endovascular aortic repairs (TEVAR) involving zone 3. METHODS: From April 2010 to January 2013, 14 consecutive high-risk patients (11 men; mean age 70±8 years, range 56-87) underwent TEVAR with the PG technique for 10 thoracic aortic aneurysms (TAA), 2 traumatic aortic ruptures, and 2 aortic dissections without a suitable landing zone (>2 cm distal to the LSA). Five procedures were performed emergently for rupture (3 TAAs and the 2 trauma cases). Two patients had a periscope deployed in an aberrant right subclavian artery. The periscope endografts were sized 1 to 2 mm larger than the branch artery at the intended landing zone. The caudal end was extended distal to the intended distal landing site of the thoracic stent-graft, which was usually deployed after the PG. Both the PG and thoracic stent-grafts were generally molded using the kissing balloon technique. Outcomes analyzed were immediate technical success, perioperative mortality and morbidity, aneurysm diameter change, and periscope endograft patency. RESULTS: Immediate technical success was 100%, with all procedures completed as planned. Perioperatively, one periscope occluded and one of the ruptured TAA patients died. One percutaneous access site hematoma required only conservative management. At a mean follow-up of 26±9 months (range 9-37), there was no additional PG occlusion. The Kaplan-Meier estimate of PG patency was 93% at 2 years. CONCLUSION: The periscope endograft is a simple technique to maintain perfusion to the LSA in cases where the aortic stent-graft crosses its ostium. The PG technique can be performed transfemorally and even percutaneously, and it can be applied to all supra-aortic branches. Early and midterm results are encouraging, but more experience and long-term results are mandatory before this technique can be widely recommended.

Results with the Talent thoracic stent graft in the VALOR trial.

OBJECTIVE: We report the 5-year outcomes of thoracic endovascular aneurysm repair (TEVAR) using the Medtronic Vascular Talent Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) in patients considered low or moderate risk for open surgical repair. METHODS: The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial was a prospective, nonrandomized, multicenter, pivotal study conducted at 38 U.S. sites. Between December 2003 and June 2005, VALOR enrolled 195 patients who were low or moderate risk (0, 1, and 2) per the modified Society for Vascular Surgery and American Association for Vascular Surgery criteria. The patients had fusiform thoracic aortic aneurysms (TAAs) and/or focal saccular TAAs/penetrating atherosclerotic ulcers. Standard follow-up interval examinations were conducted at 1 month, 6 months, 1 year, and annually thereafter. RESULTS: Over the 5-year follow-up, 76 deaths occurred (43.9%). Freedom from all-cause mortality was 83.9% at 1 year and 58.5% at 5 years. Most deaths were due to cardiac, pulmonary or cancer-related causes. Freedom from aneurysm-related mortality (ARM) was 96.9% at 1 year and 96.1% at 5 years. There was only 1 case of ARM after the first year of follow-up. Over the 5-year follow-up period, four patients were converted to open surgery and four patients experienced aneurysm rupture. The 5-year freedom from aneurysm rupture was 97.1% and the 5-year freedom from conversion to surgery was 97.1%. The incidence of stent graft migration (>10 mm) was ≤ 1.8% in each year of follow-up. The rate of type I endoleak was 4.6% at 1 month, 6.3% from 1 month to 1 year, and 3.8% during year 5. The rate of type III endoleak was 1.3% at 1 month, 1.9% from 1 month to 1 year, and 1.9% during year 5. Through 5 years, 28 patients (14.4%) underwent 31 additional endovascular procedures on the original target lesion. The 5-year freedom from secondary endovascular procedures was 81.5%. CONCLUSIONS: Through 5-year follow-up in patients who were candidates for open surgical repair, TEVAR using the Talent Thoracic Stent Graft System has demonstrated sustained protection from ARM, aneurysm rupture, and conversion to surgery, and durable stent graft performance. Close patient follow-up remains essential after TEVAR.

Aortic dissection: a 250-year perspective.

Two hundred fifty years have passed since Frank Nicholls' history-making, accurate observations on the anatomic findings and cause of death of King George II were published. Several decades later, the disease was named, using--for the first time--the terms dissection and dissecting attached to an aortic disease process. Another century went by before effective surgical treatment was developed. In sharp contrast, the evolution of the last 20 years has been nothing short of amazing. Our understanding of AD, while not yet complete, has improved dramatically. In addition, the introduction of nonsurgical endovascular therapy has had a profoundly transformative impact--and we are just at the beginning! It would not be unreasonable to predict that stent-graft repair will likely replace (or nearly replace) open surgery in the treatment of complicated type B dissection in the near future, especially as technologies continue to improve and indication-specific designs are developed and tested in the clinical setting. Moreover, it is predictable that endovascular solutions for some patients with type A aortic dissection will become available in the years to come as surgical results continue to be suboptimal. Finally, and amidst this plethora of "good news," it is appropriate to reflect on the formidable challenge that endovascular therapies face as they gear to "compete" with optimal medical therapy in the management of patients with acute uncomplicated type B dissection, because it will obviously be difficult (if not impossible) to improve on the already-achieved 30-day mortality rate of less than 10%. Long-term gains may well become the winning card when and if the late results of TEVAR can be shown to improve on the rather compromised outlook of medically treated dissection patients. Stay tuned.