Mid-term results of zone 0 thoracic endovascular aneurysm repair after ascending aorta wrapping and supra-aortic debranching in high-risk patients

Objectives Surgical repair of aneurysmal disease involving the ascending aorta, aortic arch and eventually the descending aorta is generally associated with significant morbidity and mortality. A less invasive approach with the ascending wrapping technique (WT), supra-aortic vessel debranching (SADB) and thoracic endovascular aneurysm repair (TEVAR) in zone 0 was developed to reduce the associated risk in these patients. Methods During a 10-year period, consecutive patients treated by the ascending WT, SADB and TEVAR in zone 0 were included. All patients were considered at high risk for conventional surgery. Measured outcomes included perioperative deaths and morbidity, maximal aortic trans…

Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure

Objective The aim was to report on chimney and periscope grafts (CPGs) and their mid- and longer-term outcomes when they are used to preserve reno-visceral artery (RVA) perfusion in endovascular repair of pararenal (PRAAs) or thoraco-abdominal aortic aneurysm (TAAAs). In addition, factors associated with CPG failure are presented. Limited data exist on the outcomes of CPGs, and mid- and long-term results are generally not reported. Methods This was a prospective study in a cohort of 100 patients with PRAA (69) or TAAA (31). A total of 224 (mean 2.24 per patient) RVAs were preserved with 136 (61%) chimney and 88 (39%) periscope grafts. CPGs were constructed mainly using self expandable stent…

Predilation technique with balloon angioplasty to facilitate percutaneous groin access of large size sheath through scar tissue

Purpose Percutaneous remote access for endovascular aortic repair is an advantageous alternative to open access. Previous surgery in the femoral region and the presence of synthetic vascular grafts in the femoral/iliac arteries represent major limitations to percutaneous remote access. The aim of this study was to evaluate an original technique used for enabling percutaneous remote access for thoracic or abdominal endovascular aortic repair in patients with scar tissue and/or a vascular graft in the groin. Methods Twenty-five consecutive patients with a thoracic (11/25; 44%) or an aortic aneurysm (14/25; 66%) and with a synthetic vascular graft in the groin (16/25; 64%) or a redo groin acce…

A clampless and sutureless aortic anastomosis technique using an endograft connector for aortoiliac occlusive disease in which the aorta cannot be clamped or sewn due to calcification or scarring

Bypass surgery in aortoiliac or aortofemoral occlusive disease can be technically demanding and hazardous due to huge calcifications and/or patient co-morbidities. We report about mid-term results of a telescoping sutureless aortic anastomosis technique using endografts as connectors to address such challenging situations. This is a single-center experience (2004–2011) in seven patients (63 ± 6 years) requiring aortoiliac (three) or aortofemoral (four) bypass surgery. In six cases, an aortic stent graft was telescoped into the infrarenal aorta and partly deployed within the aorta and partly outside the aorta. In the first case, a bifurcated stent graft was deployed and the iliac legs were …

The Gore Hybrid Vascular Graft in renovisceral debranching for complex aortic aneurysm repair.

Objective This study reports our initial experience with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) for staged hybrid open renovisceral debranching and endovascular aneurysm repair in patients affected by thoracoabdominal aortic aneurysms and pararenal abdominal aortic aneurysms (PAAAs). Methods Between December 2012 and December 2013, we analyzed outcomes of 13 patients who underwent open surgical debranching of renovisceral vessels for thoracoabdominal aortic aneurysm and PAAAs. All patients were considered at high risk for conventional surgery. Inclusion criterion was treatment by open surgical debranching of at least one visceral artery (renal artery…

Outpatient endovascular aortic aneurysm repair: Experience in 100 consecutive patients

OBJECTIVES:: To present the safety, feasibility, costs, and patient satisfaction of outpatient endovascular aneurysm repair (EVAR). BACKGROUND:: Our experience in more than 1000 patients indicated that in technically uncomplicated EVAR procedures, the only need for hospitalization was for access vessel complications (bleeding or occlusion) requiring secondary procedures. These complications could always be identified within the first 3 hours after EVAR. METHODS:: Two-center retrospective analysis of prospectively gathered data on 100 consecutive elective outpatient EVAR cases (Outpt EVAR). Inclusion criteria for Outpt EVAR were as follows: asymptomatic clinical state, informed consent, trav…

SS8. Chimney and Periscope Grafts: Mid-term Results in 77 Consecutive Patients with Complex Aortic Aneurysms

Author Disclosures: N. D. Andersen: Nothing to disclose; G. Hughes: W.L. Gore and Associates,Research Grants W.L. Gore and Associates, Consulting fees or other remuneration (payment) W.L. Gore and Associates, Speaker’s bureauMedtronic Vascular, Consulting fees or other remuneration (payment) Medtronic Vascular, Speaker’s bureauVascutek Terumo, Consulting fees or other remuneration (payment) Vascutek Terumo, Speaker’s bureau; R. L. McCann: Nothing to disclose; A. A. Shah: Nothing to disclose; J. B. Williams: Nothing to disclose.

Endoluminal Stent-Graft Relining of Visceral Artery Bypass Grafts to Treat Perigraft Seroma

PURPOSE: To describe the endovascular treatment of intra-abdominal perigraft seromas associated with small-caliber expanded polytetrafluoroethylene (ePTFE) grafts. CASE REPORTS: Two patients who underwent hybrid repair of thoracoabdominal aortic aneurysms in which renovisceral bypass grafts were implanted presented with large, symptomatic perigraft seromas. The 5- to 8-mm-diameter ePTFE bypass grafts believed to be involved in the seromas were successfully relined with self-expanding Viabahn stent-grafts in percutaneous procedures. The patients' symptoms were relieved, and imaging follow-up (18 and 10 months, respectively) has shown near complete resorption of the seromas. CONCLUSION: It is…

Chimney and periscope grafts observed over 2 years after their use to revascularize 169 renovisceral branches in 77 patients with complex aortic aneurysms

^ ^Purpose: To evaluate the performance of periscope and/or chimney grafts (CPGs) in theendovascular treatment of pararenal or thoracoabdominal aneurysms using off-the-shelfdevices.Methods: Between February 2002 and August 2012, 77 consecutive patients (62 men; meanage 7369 years) suffering from pararenal aortic (n¼55), thoracoabdominal (n¼16), or arch tovisceral artery aneurysms (n¼6) were treated with aortic stent-graft implantation requiringchimney and/or periscope grafts to maintain side branch perfusion. CPGs were planned inadvance and were not used as bailout. A standardized follow-up protocol includingcomputed tomographic angiography, laboratory testing, and clinical examination wasp…

A New Off-Pump Hybrid Open and Endovascular Repair to Treat Ductus Botalli and Ascendens Aneurysms

To report a combined ascending aorta and aortic arch hybrid repair, we performed off-pump with no aortic graft replacement. A 65-year-old man, developing progressive recurrent laryngeal nerve paralysis, underwent a computed tomography (CT) angiography detecting nonpatent residual ductus Botalli aneurysm and ascending aorta aneurysm. Due to severe multimorbidities, a less-invasive alternative was elaborated. In a first step, appropriate proximal landing zone for aortic stent grafting was achieved by ascending aorta diameter reduction, with epiaortic wrapping, and debranching the supra-aortic trunks. In the second step, endovascular stent grafts were deployed from proximal ascending aorta to…

Improved technique for sheath supported contralateral limb gate cannulation in endovascular abdominal aortic aneurysm repair

Summary: Background: To present a technique of sheath supported contralateral limb gate (CLG) cannulation of modular bifurcated stent-graft in endovascular abdominal aortic repair. Materials and methods: After totally percutaneous bilateral femoral access, the 9F introducer sheath is exchanged to a 30 cm 12 fr introducer sheath over a stiff wire contralateral to the intended main stent-graft insertion side and advanced into the aorta below the lowest renal artery. Parallel to the stiff wire within the sheath an additional standard J-tip guidewire with a 5 fr Pigtail angiographic catheter is advanced to the level of the renal arteries. After main body deployment, the 12 fr introducer sheath…

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. Measur…

Identification of optimal device combinations for the chimney endovascular aneurysm repair technique within the PERICLES registry

Abstract Objective The ideal stent combination for chimney endovascular aneurysm repair remains undetermined. Therefore, we sought to identify optimal aortic and chimney stent combinations that are associated with the best outcomes by analyzing the worldwide collected experience in the PERformance of chImney technique for the treatment of Complex aortic pathoLogiES (PERICLES) registry. Methods The PERICLES registry was reviewed for patients with pararenal aortic disease electively treated from 2008 to 2014. Eleven different aortic devices were identified with three distinct subgroups: group A (n = 224), nitinol/polyester; group B (n = 105), stainless steel/polyester; and group C (n = 69), n…

Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection

Objective We report our experience with the treatment of femoral artery aneurysms (FAAs) under local anaesthesia with limited dissection, using endografts to facilitate the proximal anastomosis and some distal anastomoses. Method Between January 2006 and December 2010, six males, mean age 72 years (range, 65–80 years) with FAAs were treated at the University Hospital of Zurich. All operations were performed under local anaesthesia with analgosedation, except for one performed under spinal anaesthesia. After limited dissection and puncture of the anterior wall of the FAA, a sheath and a self-expanding endograft were introduced over a guide wire and with fluoroscopy they were guided intralumi…

Classification of Chimney EVAR-Related Endoleaks: Insights from the PERICLES Registry

Juxtarenal aortic aneurysms (JAAs) pose significant challenges for endovascular aneurysm repair (EVAR). A short or absent infrarenal neck typically excludes standard EVAR as a viable or reasonable treatment option. In this context, the use of chimney grafts (chEVAR) is gaining in popularity and applicability. These grafts are designed to course in the aortic lumen outside the main stent-graft to maintain normal perfusion to the involved target branches. As such, they may represent a promising and less resource-intensive option for management of JAAs. However, this technical strategy is not without challenges of its own, particularly the inevitable creation of “gutters” that result from the …

Incidence and prognostic factors related to major adverse cerebrovascular events in patients with complex aortic diseases treated by the chimney technique

Abstract Objective Endovascular aneurysm repair (EVAR) with the chimney technique (ch-EVAR) has been used for the treatment of aortic aneurysms as an alternative approach to fenestrated endografting or open repair. Nonetheless, the need for an upper extremity arterial access may contribute to a higher risk for periprocedural cerebrovascular events. This study reports on the perioperative cerebral and major adverse cardiac and cerebrovascular events (MACCE) after ch-EVAR. Methods The PERICLES registry (PERformance of the chImney technique for the treatment of Complex aortic pathoLogiES) is an international, retrospective multicenter study evaluating the performance of ch-EVAR for the treatme…

A 12-Year Experience With Chimney and Periscope Grafts for Treatment of Type I Endoleaks.

Purpose: To evaluate the midterm outcomes of chimney and/or periscope grafts (CPGs) in patients presenting type I endoleak after a previous endovascular aneurysm repair (EVAR). Methods: Between June 2002 and April 2014, 24 consecutive patients (mean age 73.9±9.2 years; 23 men) presenting a type I endoleak were addressed with CPGs to extend the proximal and/or distal landing zone and to maintain side branch perfusion. Indication for treatment was a type Ia endoleak in 23 (96%) patients and a type Ib endoleak in one. Median interval from the previous EVAR to endoleak treatment with CPGs was 52.2±48.9 months (range 0.2–179). All patients had proximal/distal landing zones precluding any standa…

Chronic Mesenteric Ischemia: Critical review and guidelines for management

Background CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist. Methods A systematic literature review of the last 25-years was conducted through MEDLINE, Embase, and Cochrane Review/Trials register to identify studies reporting on CMI treatment with more than 10 patients. Primary outcomes were perioperative mortality and morbidity rates. Secondary outcomes were survival rates, primary and secondary patency rates, vessels treated, CMI recurrence, follow-up (FU), technical success (TS), and in-hospital leng…

Hypotensive Hemostasis in Patients Presenting with Ruptured Aortic Aneurysm

Hypotensive hemostasis in aortic rupture has been showed to be feasible and advantageous, especially in trauma patients. To date, there are no randomized studies on hypotensive hemostasis in patients with ruptured abdominal aortic aneurysm (rAAA), but observational studies indicate similar advantages when hypotensive hemostasis is used for endovascular aneurysm repair (EVAR) as in trauma patients. Actually, in EVAR for rAAA, a target systolic blood pressure of 90 mmHg or even lower is considered safe in conscious patients. Fluids should be administrated judiciously with the sole aim of maintaining adequate cardiac output and tissue oxygenation, whereas vasoactive pressors or dilatators may …

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% elect…

Early outcomes with a single-sided access endovascular stent

Abstract Objective The objective of this study was to report the 1-year follow-up study results of the new Horizon stent graft (Endospan, Herzliya, Israel) from two different prospective consecutive trials. The Horizon abdominal aortic aneurysm stent graft system is a 14F profile system requiring only a single access site. It consists of three modules, introduced separately: base limb (iliac to iliac limb); distal aortic limb; and proximal aortic limb with a bare suprarenal crown and active fixation. Methods Data from the first in man (FIM) clinical study with 10 patients enrolled and the pivotal study with 30 patients were analyzed. Outcomes measured were freedom from major adverse events …

Chimney and periscope grafts to facilitate endovascular treatment of aortic transection in a patient with aberrant right subclavian artery

Purpose: To report the use of parallel grafts to extend the proximal landing zone for stentgraft repair of aortic transection involving an aberrant right subclavian artery (ARSA). Case Report: A 28-year-old patient was referred for treatment of traumatic aortic transection with contained rupture at the level of an ARSA. Immediate thoracic endovascular aortic repair (TEVAR) was planned because of hemodynamic instability. To achieve rapid sealing and maintain perfusion to both subclavian arteries, a chimney stent to the left subclavian artery (LSA) and a periscope stent-graft to the ARSA were deployed successfully. After surgical repair of all fractures, the patient was discharged 1 month aft…

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

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.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 …

Treatment of isolated ascending aortic aneurysm by off-pump epiaortic wrapping is safe and durable.

OBJECTIVES: Isolated ascending aortic aneurysm (iAA) is usually treated by open graft repair requiring sternotomy, cardiopulmonary bypass (CPB) and cardioplegia. This approach carries significant mortality in older patients or those presenting with comorbidities. We report an original series of patients presenting with iAA and treated with epiaortic wrapping by using a synthetic mesh. This less invasive aortic repair technique allows reducing the aortic diameter to a predefined value and is performed without CPB. METHODS: Data from patients presenting with an iAA and treated with the wrapping technique (WT) by polypropylene/polyester mesh from November 2006 to July 2015 were collected. The …

Mid-term Results of Chimney and Periscope Grafts in Supra-aortic Branches in High Risk Patients

Purpose Report mid-term outcomes of thoracic endovascular aneurysm repair (TEVAR) with chimney and periscope grafts (CPG) in supra-aortic branches (SAB). Methods Retrospective analysis, from October 2009 to May 2014, of patients with aneurysms requiring TEVAR with zone 0/1/2 proximal landing in association with at least one CPG in the SAB. All patients were considered at high risk for conventional surgery. Peri-operative mortality and morbidity, retrograde type A dissection, maximum aortic transverse diameter (TD) and its post-operative evolution, endoleak, survival, freedom from cardiovascular re-interventions, and CPG freedom from occlusion during the follow-up were analysed. Results Fort…

Multiple periscope and chimney grafts to treat ruptured thoracoabdominal and pararenal aortic aneurysms

Purpose: To report midterm outcomes after urgent endovascular repair of ruptured pararenal or thoracoabdominal aortic aneurysms using multiple periscope and chimney grafts to preserve renovisceral branch perfusion and facilitate aneurysm exclusion. Methods: Nine consecutive men (mean age 72614 years, range 40–88) presenting with ruptured thoracoabdominal (n56), pararenal (n52), or infrarenal (n51) aortic aneurysm underwent urgent endovascular repair with at least 1 periscope graft delivered via a transfemoral access; chimney grafts were installed from an axillary access. In all, 17 periscope and 7 chimney grafts were used to reperfuse 11 renal and 13 visceral arteries in the 9 patients. The…

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a co…

RS12. Sustained Late Branch Patency and Low Incidence of Persistent Type Ia Endoleaks Following Snorkel/chimney EVAR Shown in the Updated PERICLES Registry

Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results

Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). O…

Early endovascular aneurysm repair after percutaneous coronary interventions

Objective The objective of this study was to report long-term results of early endovascular aortic aneurysm repair after percutaneous coronary intervention (PCI). Methods This was a retrospective analysis of all patients presenting with abdominal aortic aneurysm and coronary artery disease treated during the same hospitalization by endovascular aortic aneurysm repair performed soon after PCI. Primary outcomes were perioperative mortality, perioperative complications, survival after treatment, and freedom from reintervention. Results A total of 20 patients were included, and all completed both procedures. No deaths or abdominal aortic aneurysm ruptures occurred between the PCI and the aortic…