Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms.

AIM: The aim was to conduct a systematic review of the literature investigating outcomes after interruption or preservation of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR). METHODS: A systematic review was undertaken using the MEDLINE and EMBASE databases to identify studies reporting IIA management during EVAR. The search identified 57 articles: 30 reported on IIA interruption (1468 patients) and 27 on IIA preservation (816 patients). RESULTS: The pooled 30 day buttock claudication (BC) rate was 29.2% (95% CI 24.2-34.7). Patients undergoing bilateral IIA interruption had a higher incidence of BC than patients with unilateral IIA interruption (36.5% vs. 27.2%, OR 1.7, 95% CI 1.11-2.6, p = .01). During a median follow up of 17 months, the pooled rate of persistent BC was 20.5% (95% CI 15.7-26.2). Of the patients, 93.9% underwent an endovascular revascularization procedure for IIA preservation. Most patients (87.6%) had an iliac branched device, and technical success was 96.2%. Within 30 days of EVAR, 4.3% of internal iliac branches occluded. During a median follow up of 15 months, the pooled occlusion rate at the site of IIA revascularization was 8.8% (95% CI 6.8-11.3). In patients treated with an iliac-branched device, 5.2% of internal iliac branches and 1.7% of external iliac arteries occluded. The pooled BC rate on the side of the IIA revascularization during follow up was 4.1% (95% CI 2.9-5.9). Pooled rates of late device related endoleak type I or III and secondary procedures on the side of the previous IIA revascularization were 4.6% (95% CI 3.2-6.5) and 7.8% (95% CI 5.7-10.7) respectively. CONCLUSION: Unilateral or bilateral IIA occlusion during EVAR seems to carry a substantial risk of significant ischemic complications in nearly one quarter of patients. Bilateral IIA occlusion was related to a significantly higher rate of BC. IIA preservation techniques represent a significant improvement in the treatment of aorto-iliac aneurysms and have been associated with high technical success and low morbidity.

Clinical Outcome of Isolated Popliteal Artery Aneurysms Treated with a Heparin-bonded Stent Graft.

OBJECTIVE: The use of self-expanding stent grafts for treatment of popliteal artery aneurysms (PAA) is a matter of debate, although several studies have shown similar results compared with open surgery. In recent years, a new generation stent graft, with heparin-bonding technology, became available. The aim of this study is to present the results of endovascular PAA repair with heparin-bonded stent grafts. METHODS: Data on all patients with PAA treated with a heparin-bonded polytetrafluoroethylene (ePTFE) stent graft between April 2009 and March 2014 were gathered in a database and retrospectively analyzed. Data were collected from four participating hospitals. Standard follow-up consisted of clinical assessment, and duplex ultrasound at 6 weeks, 6 months, 12 months, and annually thereafter. The primary endpoint of the study was primary patency. Secondary endpoints were primary-assisted and secondary patency and limb salvage rate. RESULTS: A total of 72 PAA was treated in 70 patients. Mean age was 71.2 ± 8.5 years and 93% were male (n = 65). The majority of PAA were asymptomatic (78%). Sixteen cases (22%) had a symptomatic PAA, of which seven (44%) presented with acute ischemia. Early postoperative complications occurred in two patients (3%). Median follow-up was 13 months (range 0-63 months). Primary patency rate at 1 year was 83% and after 3 years 69%; primary assisted patency rate was 87% at 1 year and 74% after 3 years. Secondary patency rate was 88% and 76% at 1 and 3 years, respectively. There were no amputations during follow-up. CONCLUSION: Endovascular treatment of PAA with heparin-bonded stent grafts is a safe treatment option with good early and mid-term patency rates comparable with open repair using the great saphenous vein.

Fenestrated Endovascular Aortic Aneurysm Repair as a First Line Treatment Option to Treat Short Necked, Juxtarenal, and Suprarenal Aneurysms.

OBJECTIVES: The outcomes of fenestrated endovascular aneurysm repair (FEVAR) as a first line strategy is reported. METHODS: All consecutive patients treated with FEVAR for short neck, juxtarenal, or suprarenal aortic aneurysms under the guidance of the senior author within the period January 2010 to December 2014 were included. Data were collected from a prospectively maintained database. Analyzed outcomes included technical success, defined by successful stent graft implantation with patent stented target vessels and no Type I/III endoleak, operative mortality and morbidity, target vessel patency, endoleak, re-intervention, and death. Survival, target vessel stent patency, and re-intervention during follow up were calculated by Kaplan-Meier analysis. RESULTS: A total of 281 patients (245 male, mean age 72.1 ± 7.7 years) were treated. The mean aneurysm diameter was 60.2 ± 9.3 mm and median proximal neck length 2 mm (range 0-10 mm). Technical success was 96.8% (272/281). Technical failure included one intra-operative death due to embolization and cardiac arrest, one open conversion due to iliac rupture, and seven target vessel complications. The thirty day mortality was 0.7% (2/281). Mean follow up was 21 ± 15.9 months. Estimated survival at 1 and 3 years was 94.7% ± 1.6% and 84.6% ± 3.0%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 96.1% ± 1.4%, and 90% ± 2.7%. Estimated target vessel stent patency at 1 and 3 years was 98.6% ± 0.5%, and 98.1% ± 0.6%, respectively. Mean aneurysm sac diameter decreased from 60.2 ± 9.3 mm pre-operatively to 53.2 ± 12.8 mm (p < .001). CONCLUSIONS: FEVAR as a first line strategy was associated with high technical success and a low operative mortality rate. Efficacy and durability in the mid-term appear very good, with significant regression of aneurysm sac diameter, high target vessel patency, and acceptable rate of re-intervention.

Editor's Choice - Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair.

OBJECTIVES: The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. METHODS: Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. RESULTS: In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). CONCLUSION: There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Stent Graft Dislocation after EVAR Treated with an Endostapling Fixation System.

Stent-graft migration and type I endoleak are major complications after endovascular aneurysm repair (EVAR). We present a case of an 88-year-old female patient with a 56-mm-diameter progredient infrarenal AAA, with severely angulated proximal aneurysm neck and iliac arteries. EVAR was performed using a Gore Excluder stent-graft. -Computed tomography angiography (CTA) at one week postoperatively demonstrated a dislocation of the stent-graft and a proximal Type I endoleak. Placement of a proximal cuff with the use of 6 endostaples resulted in proximal neck seal and exclusion of the endoleak. CTA 2 years postoperatively showed no signs of a proximal type I endoleak. Use of an endostapling fixation system is a viable treatment option in cases of stent-graft dislocation resulting from angulation of the proximal neck.

Percutaneous endovascular thrombosuction for acute lower limb ischemia: a 5-year single center experience.

AIM: The aim of this paper was to report a 5-year single center experience with the use of percutaneous endovascular thrombosuction (PET) for acute lower limb ischemia (ALLI). METHODS: All patients that underwent PET for ALLI within the period January 2009-December 2013 in our institution were included. Data were collected retrospectively. RESULTS: A total of 262 patients (132 female, mean age 74.5±11 years) were treated. Level of severity of ALLI preoperatively was stratified as class I (viable) in 76% (199/262) of patients, class IIa (threatened marginally) in 19.4% (51/262), and class IIb (threatened immediately) in 4.6% (12/262). Initial technical success was 91% (237/262). Additional PTA was performed in 29.8% (78/262) of patients, and PTA with stenting in 27.5% (72/262). Open surgery due to technical failure of PET was required in 4.2% (11/262) of patients. Thirty-day mortality was 4.6% (12/262). Perioperative complications occurred in 9.2% (24/262). Thirty-day amputation rate was 3.8% (10/262). The mean duration of follow-up was 26.2±16 months. Estimated cumulative survival was 84.2±2.5% at 1 year, and 73.7±3.6% at 3 years. Estimated freedom from amputation during follow-up was 92.4±1.8% at 1 year, and 91.2±2% at 3 years. Estimated freedom from reintervention was 90.4±2% at 1 year, and 80±3.7% at 3 years. CONCLUSION: PET in selected patients with ALLI provides high initial technical success, low mortality and morbidity rates, and favorable early and mid-term limb salvage rates.

Editor's Choice - Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients.

OBJECTIVE: To present a 10 year experience with endovascular thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent grafts. MATERIALS AND METHODS: Consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004-December 2013. Data were collected prospectively. RESULTS: 166 patients (125 male, 41 female, mean age 68.8 ± 7.6 years) were treated. The mean TAAA diameter was 71 ± 9.3 mm. Types of TAAA were: type I, n = 12 (7.2%), type II, n = 50 (30.1%), type III, n = 53 (31.9%), type IV, n = 41 (24.8%), and type V, n = 10 (6%). Fifteen (9%) patients had an acute TAAA (11 contained rupture, 4 symptomatic). One hundred and eight (65%) patients were refused for open surgery earlier. Seventy eight (47%) patients had previously undergone one or more open/endovascular aortic procedures. Technical success was 95% (157/166). Thirty day operative mortality was 7.8% (13/166), with an in hospital mortality of 9% (15/166). Peri-operative spinal cord ischemia (SCI) was observed in 15 patients (9%), including permanent paraplegia in two (1.2%). Mean follow up was 29.2 ± 21 months. During follow up 40 patients died, two of them probably from aneurysm related cause. Re-intervention, mostly by endovascular means, was needed in 40 (24%) patients. Estimated survival at 1, 2, and 5 years was 83% ± 3%, 78% ± 3.5%, and 66.6% ± 6.1%, respectively. Estimated target vessel stent patency at 1, 2, and 5 years was 98% ± 0.6%, 97% ± 0.8%, and 94.2% ± 1.5%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 88.3% ± 2.7%, and 78.4% ± 4.5%, respectively. CONCLUSIONS: Endovascular repair of TAAA with fenestrated and branched stent grafts in high volume centers appears safe and effective in the mid-term in a high risk patient cohort. A considerable reintervention rate should be acknowledged, however.

Common iliac and hypogastric aneurysms: open and endovascular repair.

Currently, there are a variety of open surgical, endovascular, and hybrid options to treat iliac artery aneurysms (IAA). Anatomy of the common iliac artery (CIA) with regard to proximal and distal neck, involvement of the iliac bifurcation, and choice to preserve the ipsilateral internal iliac artery (IIA) all play a role in the decision process towards the preferred treatment method. This manuscript describes the available open surgical and endovascular techniques for the treatment of IAA. Indications, advantages and limitations, and outcomes of each technique are discussed.

Outcomes of fenestrated/branched endografting in post-dissection thoracoabdominal aortic aneurysms.

OBJECTIVES: Fenestrated/branched thoracic endovascular repair (F/Br-TEVAR) is increasingly applied for atherosclerotic thoracoabdominal aortic aneurysm (TAAA); however, use in post-dissection TAAAs is still very limited. Experience with F/Br-TEVAR in the treatment of post-dissection TAAA is presented. METHODS: Data were analysed from prospectively maintained databases including all patients with post-dissection TAAAs that underwent F/Br-TEVAR within the period January 2010 to July 2013 in two vascular institutions. Evaluated outcomes included initial technical success, operative mortality and morbidity, late survival, endoleak, aneurysm diameter regression, renal function, and reintervention during follow-up (FU). RESULTS: A total of 31 patients (25 male, mean age 65 ± 11.4 years) were treated. Technical success was 93.5% and 30-day mortality 9.6%. Temporary spinal cord ischaemia occurred in four (12.6%) patients, with no case of permanent paraplegia. Mean FU was 17.0 ± 10 months. There were seven late deaths, all aneurysm unrelated. Estimated overall survival rates were 83.9 ± 6.7, 76.4 ± 7.9 and 71.6 ± 8.7% at 6, 12, and 18 months, respectively. Impairment of renal function occurred in two (6.4%) patients. Endoleaks were diagnosed in 12 patients during FU, including six type IB endoleaks and six type II endoleaks. Reintervention was required in seven (22.5%) patients. Mean aneurysm sac regression was 9.3 ± 8.7 mm, with a false lumen thrombosis rate of 66.7% and 88.2% for patients with a FU longer than 6 and 12 months respectively. CONCLUSIONS: F/Br-EVAR is feasible for patients with a post-dissection TAAA. Although associated with additional technical challenges, and a significant need for reintervention, it leads to favourable aneurysm morphologic changes, and may play a more prominent role in the future for this type of pathology if long-term results confirm the good initial outcome.

Real-world performance of the new C3 Gore Excluder stent-graft: 1-year results from the European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT).

OBJECTIVES: The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) provides "real-world" outcomes for the new C3 Gore Excluder stent-graft, and evaluates the new deployment mechanism. This report presents the 1-year results from 400 patients enrolled in this registry. METHODS: Between August 2010 and December 2012, 400 patients (86.8% male, mean age 73.9 ± 7.8 years) from 13 European sites were enrolled in this registry. Patient demographics, treatment indication, case planning, operative details including repositioning and technical results, and clinical outcome were analyzed. RESULTS: Technical success was achieved in 396/400 (99%) patients. Two patients needed intraoperative open conversion, one for iliac rupture, the second because the stent-graft was pulled down during a cross-over catheterization in an angulated anatomy. Two patients required an unplanned chimney renal stent to treat partial coverage of the left renal artery because of upward displacement of the stent-graft. Graft repositioning occurred in 192/399 (48.1%) patients, most frequently for level readjustment with regard to the renal arteries, and less commonly for contralateral gate reorientation. Final intended position of the stent-graft below the renal arteries was achieved in 96.2% of patients. Thirty-day mortality was two (0.5%) patients. Early reintervention (≤30 days) was required in two (0.5%) patients. Mean follow-up duration was 15.9 ± 8.8 months (range 0-37 months). Late reintervention (>30 days) was required in 26 (6.5%) patients. Estimated freedom from reintervention at 1 year was 95.2% (95% CI 92.3-97%), and at 2 years 91.5% (95% CI 86.8-94.5%). Estimated patient survival at 1 year was 96% (95% CI 93.3-97.6%) and at 2 years 90.6% (95% CI 85.6-93.9%). CONCLUSIONS: Early real-world experience shows that the new C3 delivery system offers advantages in terms of device repositioning resulting in high deployment accuracy. Longer follow-up is required to confirm that this high deployment accuracy results in improved long-term durability.

Fenestrated and branched stent-grafting after previous open or endovascular aortic surgery.

AIM: Aim of the study was to review our experience with fenestrated and branched stent-grafts to treat juxtarenal (JAA) and thoracoabdominal (TAAA) aortic aneurysms after previous open or endovascular aortic surgery. METHODS: A prospectively maintained database including all consecutive patients with JAA or TAAA treated with fenestrated/branched stent-grafts after previous open or endovascular aortic surgery within the period March 2002-November 2013 was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity and late procedure-related events with regard to survival, target vessel patency, and re-intervention. RESULTS: A total of 122 patients (110 male, 12 female; mean age mean age 70±9.5 years) were treated. Median time interval from previous aortic surgery to current fenestrated/branched stent-grafting was 80 months (range 3-261 months). Seventy-seven (63.1%) patients had previous open infrarenal aortic surgery, 33 (27%) had previous endovascular abdominal aortic aneurysm repair (EVAR), nine (7.4%) had previous open thoracic aortic surgery, and three (2.5%) had previous endovascular thoracic aortic repair (TEVAR). Indication for current treatment was a JAA in 65 (53.3%) patients and a TAAA in 57 (46.7%) patients. Technical success was achieved in 115 (94.3%) patients. Seven patients were considered as technical failure (open conversion; N.=1, target vessel loss; N.=6). Operative target vessel perfusion success rate with endovascular means was 98.5% (391/397). Intraoperative technical difficulties due to pre-existing stent-graft/surgical graft were encountered in 28 (23%) patients (access, N.=12; target vessel catheterisation, N.=16). Thirty-day operative mortality was 4.1% (5/122), with zero mortality in 65 JAA, and 8.8% (5/57) in TAAA, respectively. Cause of death was multiple organ failure (N.=3), acute gastrointestinal bleeding (N.=1), and subdural hematoma (N.=1). Major complications occurred in 20 (16.4%) patients. Median hospital stay was 7 days (range 3-50 days), and mean ICU stay 1.5±3.2 days. Mean follow-up was 22.5±21 months. All-cause late mortality was encountered in 23 patients, including one aneurysm-related mortality. Estimated survival was 91.2±3%, 83.3±4.2% and 81.1±4.6% at one, two and three years, respectively. During follow-up, eight target vessels occluded. Estimated target vessel patency was 97.2±1.1%, and 96.3±1.2% at one and three years, respectively. Reintervention during follow-up was required in 13 (10.6%) cases accounting for an estimated freedom from reintervention of 91.6±3.1%, and 82.1±5.4% at one and three years, respectively. CONCLUSION: Fenestrated and branched stent-grafting represents a feasible option for the repair of JAA and TAAA after prior endovascular or open aortic surgery. Despite increased technical difficulties it is associated with high technical success rate and is advantageous in terms of mortality and morbidity compared to redo open aortic surgery.

The new C3 Gore Excluder stent-graft: single-center experience with 100 patients.

OBJECTIVES: To present results from the first 100 patients treated with the new C3 Gore Excluder stent-graft in a single institution. METHODS: All patients treated with the C3 Excluder stent-graft between August 2010 and July 2013 in our institution were included. Patient demographics, treatment indication, need for intraoperative stent-graft repositioning, immediate technical success, survival, endoleak and migration rate, and need for reintervention during follow-up were analyzed. RESULTS: A total of 100 patients (86% male, mean age 71.1 ± 9.3 years) were enrolled. Elective abdominal aortic aneurysm (AAA) was the most common indication for treatment (n = 90), followed by common iliac artery aneurysm (n = 5), ruptured AAA (n = 2), type Ia endoleak (n = 1), and type IV endoleak (n = 1) after prior EVAR, and penetrating aortic ulcer (n = 1). Technical success was achieved in 98 patients. In two patients a small type I endoleak persisted at completion angiography, but had disappeared at the first control computed tomography angiogram. Stent-graft repositioning after initial deployment was required in 49 patients, almost equally distributed for level and contralateral gate reorientation. Exact positioning of the proximal trunk was achieved in 98 patients, with the remaining two cases within 5 mm of the intended location. Adverse events related to repositioning maneuvers were noticed in two cases. Mean follow-up duration was 12.2 ± 9.4 months (range 0-36 months). Eight patients died, none from aneurysm related causes. Cumulative patient survival was 96.2 ± 2.1% at 1 year, and 84 ± 6.1% at 2 years, respectively. No migration, or type I or III endoleak was detected during follow-up. Estimated freedom from reintervention was 96 ± 2.4% at 1 year, and 91 ± 5.2% at 2 years, respectively. CONCLUSIONS: The new C3 Excluder stent-graft provides excellent short-term outcomes and offers important advantages in terms of stent-graft repositioning to achieve high proximal deployment accuracy. Longer follow-up is required to confirm improved long-term outcome compared with the previous generation Excluder stent-graft.

Current status of Hemobahn/Viabahn endografts for treatment of popliteal aneurysms.

The aim of the present study was to review the literature reporting the use of the Hemobahn/Viabahn endograft (W. L. Gore and Assoc Inc., Flagstaff, AZ, USA) for endovascular treatment of popliteal artery aneurysms (PAA). A PubMed database search was performed looking for studies reporting endovascular treatment of PAA with the Hemobahn/Viabahn endograft within the period January 2000-December 2012. All relevant studies were independently assessed and all references were examined for potentially missed relevant reports. Studies were included if they reported experience with five patients or more. Eight studies with 222 patients (mean age 72.4 years, 92.3% male) and 251 PAA (mean diameter 2.9 mm, 14.3% symptomatic) were included. Thirteen cases (5.2%) were treated on an urgent basis, including three cases of ruptured PAA and 10 cases of acute limb ischemia. Initial technical success was 99.2%. The mean number of implanted endografts/PAA was 1.8 (range 1-4). Thirty-day mortality was 1 (0.4%) patient. Perioperative complications occurred in 1.6%, consisting of three access site hematomas and one acute endograft thrombosis. Cumulative mean follow-up duration was 36.9 months. During this period, a total of 46 endograft failures (42 occlusions, 4 stenoses) were observed within a mean postoperative time interval of 10.8 months. Cumulative primary and secondary patency rates were 85.6% and 93.4% at one year, and 78.5% and 90.4% at 2 years, respectively. Limb salvage rate during follow-up was 99.2%. Endoleak was noticed in 15 (6%) cases and endograft migration in 13 (5.2%) cases. Endograft fracture was reported in 14 (5.6%) cases, resulting in occlusion in six patients, and in type III and IV endoleaks in two patients. Secondary intervention during follow-up was required in 47 (18.7%) cases, including 32 reinterventions for endograft occlusion, four for endograft stenosis, and 11 for endoleak repair. Endovascular PAA repair with the Hemobahn/Viabahn endograft is feasible and safe yielding excellent initial technical success rates, minimum perioperative mortality and morbidity, and mid-term patency and limb salvage rates comparable to open surgery. These results suggest that a significant proportion of patients might benefit from endovascular PAA repair.

Early outcome of endovascular aneurysm repair in challenging aortic neck morphology based on experience from the GREAT C3 registry.

AIM: The aim of this paper was to evaluate early outcome of the GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System in subjects with aortic neck anatomy outside IFU. METHODS: Individual patient data prospectively collected over a 2 year period from the Global Registry for Endovascular Aortic Treatment (GREAT). For each subject a minimum data set was collected containing demographic, pre/intra- and postoperative variables. Main outcome measures were successful exclusion of the AAA and occurrence of any major endoleak at 1 month. In this study, outside IFU was defined as aortic neck length less than 15 mm and/or aortic neck angle greater than 60 degrees. RESULTS: A total of 400 subjects, (86.6% male, mean age 73.9 years). Primary pathology was AAA in 94.2% with 98.2% undergoing EVAR as a primary procedure. Sixty-eight subjects underwent EVAR outside IFU (neck length <15 mm N.=32, neck angle >60˙N.=47 and neck length <15 mm and angle >60° N.=11). The graft was successfully deployed within 5 mm of its intended location in 63 (94%) cases utilising a total of 33 repositioning episodes. Eight aortic cuffs were used, 5 to treat a type 1 endoleak. At 30 days we recorded 2 type 2 endoleaks both successfully treated and 1 type 1b also successfully treated. There were 2 deaths, one in each group. CONCLUSION: GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System allows re-positioning to be performed safely in cases outside IFU. Repositioning is an effective operative manoeuvre and facilitates EVAR in challenging anatomy. Longer follow-up is required to evaluate the durability of these results at 30 days.

Fenestrated stent-grafts for salvage of prior endovascular abdominal aortic aneurysm repair.

OBJECTIVES: To review our experience with fenestrated endovascular aneurysm repair (F-EVAR) to treat complications after previous standard infrarenal endovascular aneurysm repair (EVAR). METHODS: A prospectively maintained database including all consecutive patients with juxtarenal abdominal aortic aneurysm that were treated with F-EVAR after failed previous EVAR within the period March 2002 to November 2012 at the University Medical Center of Groningen, Netherlands (up to October 2009), and the Klinikum Nürnberg Süd, Germany (from November 2009) was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity, and late procedure-related events with regard to survival, target vessel patency, endoleak, renal function, and reintervention. RESULTS: A total of 26 patients (24 male, mean age 73.2 ± 6.5 years) were treated. All patients had proximal anatomies precluding endovascular reintervention with standard techniques. In 23 patients a fenestrated proximal cuff was used, and in three patients a bifurcated fenestrated stent graft. Technical success was achieved in 24 (92.3%) patients. One patient required on-table open conversion because of impossibility to retrieve the top cap as a result of twist of the ipsilateral limb. In the second patient the right kidney was lost due to inadvertent stenting in a smaller branch of the renal artery. Catheterization difficulties, all related to the passage through the limbs or struts of the previous stent graft, were encountered in 11 (42.3%) cases, including five (19.2%) patients with iliac access problems and six (23.1%) with challenging renal catheterization. Operative target vessel perfusion success rate was 94.6% (70/74). Operative mortality was 0%. Mean follow-up was 26.8 ± 28.5 months. No proximal type I endoleak was present on first postoperative CTA. The mean aneurysm maximal diameter decreased from 73 ± 20 mm to 66.7 ± 21 mm (p < .05). There were six late deaths, one of them aneurysm related. Estimated survival rates at 1 and 2 years were 94.1 ± 5.7% and 87.4 ± 8.4%, respectively. Patency during follow-up for the target vessels treated successfully with a fenestrated stent graft was 100% (70/70). Reintervention was required in four cases, including one acute conversion due to rupture, one for iliac limb occlusion and two for type Ib and II endoleak. Renal function deterioration was observed solely in the two cases of primary technical failure. CONCLUSIONS: F-EVAR represents a feasible option for the repair of juxtarenal abdominal aortic aneurysm after prior EVAR failure. It is advantageous in terms of mortality and less morbid than open surgery, but is associated with increased technical challenges because of the previously placed stent graft. Outcome seems related to initial technical success.

Endovascular strategies for infrarenal aneurysms with short necks.

The aim of this paper was to review the current options for endovascular treatment of abdominal aortic aneurysms (AAAs) with short infrarenal neck. Studies reporting endovascular treatment of AAAs with short proximal neck were reviewed. Fenestrated endovascular aneurysm repair (F-EVAR) is most frequently reported for the treatment of patients with short neck AAA, with high technical success rates (≥ 99%), low operative mortality (≤ 3.5%) and excellent mid- and long-term results in terms of target vessel patency (≥ 97%). Chimney-EVAR (Ch-EVAR) is far less reported, but also presents with high technical success rates (>97%), varying operative mortality rates (0-12.5%), and excellent short- and mid-term target vessel patency (≥ 96%). Ch-EVAR, however, seems to be associated with high postoperative stroke up to 6.3%, and increased proximal type I endoleak (5-31%). Standard EVAR performed outside manufacturers' instructions for use (IFU) is also documented in the treatment of short proximal neck AAA, but is associated with increased operative mortality and morbidity, type I endoleak, and migration, compared to standard EVAR in AAA with longer proximal neck length. F-EVAR currently represents the most validated and reliable endovascular option for the treatment of short-neck AAA. Ch-EVAR is feasible, but lacks long-term data. Its use seems only favored in acute high surgical risk patients, in elective cases complicated with unintentional renal artery coverage or in anatomies unsuitable for F-EVAR. Standard EVAR in short neck AAA is associated with poorer outcomes and should not be recommended as first choice.