Abstract Background Octogenarians with complex abdominal aortic aneurysms are at higher risk of death and morbidity after open repair. Fenestrated endovascular aneurysm repair (FEVAR) is an ...alternative to open repair for high-risk patients, such as octogenarians. The aim of this study was to evaluate perioperative and midterm outcomes of FEVAR among octogenarians at high and standard risk for open repair. Methods During a 2-year period, 85 patients (68 men 78% and 17 women 22%) underwent FEVAR using Zenith (Cook Medical, Bloomington, Ind) Fenestrated AAA Endovascular Grafts (70%), Zenith p-Branch (7%), and fenestrated custom-made devices (22%). Demographics and perioperative and follow-up outcomes of patients aged >80 years (n = 18 21%) and patients aged <80 years (n = 67 79%) were compared. The χ2 or Fisher test was used for categorical variables, and nonparametric tests were used for continuous variables. Kaplan-Meir curve was used for survival analysis. Results Median age was 73 years (interquartile range IQR, 68-79 years) for the entire cohort, 84 years (IQR, 81-86 years) among octogenarians, and 71 years (IQR, 67-75) for younger patients. Median aneurysm size was 56 mm (IQR, 53-62 mm). The median number of fenestrations was three. Preoperatively, octogenarians had higher Society for Vascular Surgery score (5.5 IQR, 5-7 vs 5 IQR, 3-6; P = .01) and lower body mass index (26 IQR, 21-27 vs 28 24-32; P = .04). Intraoperatively, technical success was 100% for both groups. The median operative time for octogenarians was 224 minutes (IQR, 160-272) vs 212 minutes (IQR, 177-281) in patients <80 years ( P = .59). The median hospital length of stay was 3.5 days (IQR, 2-5) for octogenarians vs 4 days (IQR, 2-5) in younger patients ( P = .87). Intensive care unit length of stay was 2 days for patients from both groups (IQR, 1-3). The rate of postoperative complications was 28% for octogenarians and 36% for patients aged <80 years ( P = .5). None of the patients in this series required dialysis. No 30-day deaths occurred. The 20-month estimated survival rate was 75% in octogenarians and 91% in patients <80 years ( P = .1). The rate of reinterventions at 20 months was 10% for octogenarians and 57% for younger patients ( P = .09). Conclusions FEVAR is a safe and effective procedure in octogenarians at high and standard risk for open repair and those who are not eligible for standard endovascular aneurysm repair. Octogenarians have a similar technical success and low major adverse events similar to patients younger than 80 years.
In this long-term follow-up of a randomized trial comparing endarterectomy with stenting for carotid-artery stenosis, the risks of periprocedural stroke, myocardial infarction, or death and ...subsequent ipsilateral stroke did not differ between groups over a 10-year period.
We previously reported the outcomes up to 4 years in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
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No significant difference was shown between patients assigned to stenting and those assigned to endarterectomy with respect to the composite primary end point of periprocedural stroke, myocardial infarction, or death and subsequent ipsilateral stroke. At baseline, the mean age of the patients was 69 years, and at that age the average life expectancy is 15 years for men and 17 years for women.
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As such, long-term treatment differences should be central to treatment decisions. We now report whether the outcomes after stenting . . .
Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) is a complex procedure that generates high radiation doses. Magnification aids in vessel cannulation but increases radiation. The aim of ...the study was to compare radiation doses to patients and operating room staff from two fluoroscopy techniques, standard magnification vs dual fluoroscopy with live-image digital zooming during F/B-EVAR.
An observational, prospective, single-center study of F/B-EVAR procedures using Philips Allura XperFD20 equipment (Philips Healthcare, Amsterdam, The Netherlands) was performed during a 42-month period. Intravascular ultrasound, three-dimensional fusion, and extreme collimation were used in all procedures. Intraoperative live-image processing was performed with two imaging systems: standard magnification in 123 patients (81%) and dual fluoroscopy with live-image digital zooming in 28 patients (18%). In the latter, the live “processed” zoomed images are displayed on examination displays and live images are displayed on reference displays. The reference air kerma was collected for each case and represents patient dose. Operating staff personal dosimetry was collected using the DoseAware system (Philips Healthcare). Patient and staff radiation doses were compared using nonparametric tests.
Mean age was 71.6 ± 11.4 years. The median body mass index was 27 kg/m2 (interquartile range IQR, 24.4-30.6 kg/m2) and was the same for both groups. Procedures performed with dual fluoroscopy with digital zooming demonstrated significantly lower median patient (1382 mGy IQR, 999-2045 mGy vs 2458 mGy IQR, 1706-3767 mGy; P < .01) and primary operator radiation doses (101 μSv IQR, 34-235 μSv vs 266 μSv IQR, 104-583 μSv; P < .01) compared with standard magnification. Similar significantly reduced radiation doses were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with dual fluoroscopy. According to device design, procedures performed with four-fenestration/branch devices generated higher operator radiation doses (262 μSv IQR, 116.5-572 μSv vs 171 μSv IQR, 44-325 μSv; P < .01) compared with procedures with three or fewer fenestration/branches. Among the most complex design (four-vessel), operator radiation dose was significantly lower with digital zooming compared with standard magnification (128.5 μSv IQR, 70.5-296 μSv vs 309 μSv IQR, 150-611 μSv; P = .01).
Current radiation doses to patients and operating personnel are within acceptable limits; however, dual fluoroscopy with live-image digital zooming results in dramatically lower radiation doses compared with the standard image processing with dose-dependent magnification. Operator radiation doses were reduced in half during procedures performed with more complex device designs when digital zooming was used.
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Objective Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms who are neither fit nor suitable for standard ...open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives but frequently require bilateral upper extremity access that has been associated with a 3% to 10% risk of stroke. However, upper extremity access is also frequently required for FEVAR because of the caudal orientation of the visceral vessels. The purpose of this study was to assess the use of upper extremity access for FEVAR and the associated morbidity. Methods During a 5-year period, 148 patients underwent FEVAR, and upper extremity access for FEVAR was used in 98 (66%). Outcomes were compared between those who underwent upper extremity access and those who underwent femoral access alone. The primary end point was a cerebrovascular accident or transient ischemic attack, and the secondary end point was local access site complications. The mean number of fenestrated vessels was 3.07 ± 0.81 (median, 3) for a total of 457 vessels stented. Percutaneous upper extremity access was used in 12 patients (12%) and open access in 86 (88%). All patients who required a sheath size >7F underwent high brachial open access, with the exception of one patient who underwent percutaneous axillary access with a 12F sheath. The mean sheath size was 10.59F ± 2.51F (median, 12F), which was advanced into the descending thoracic aorta, allowing multiple wire and catheter exchanges. Results One hemorrhagic stroke (one of 98 1%) occurred in the upper extremity access group, and one ischemic stroke (one of 54 2%) occurred in the femoral-only access group ( P = .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0%) compared with the left being accessed 92 times with one stroke (1%; P = .8). Four patients (4%) had local complications related to upper extremity access. One (1%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath, and two patients (2%) with small hematomas did not require intervention. Two (two of 12 17%) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (two of 86 2%; P = .02). Conclusions Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.
Renal function impairment is a common complication after open repair of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). The purpose of this study was to assess renal ...perioperative outcomes and renal function deterioration after fenestrated-branched endovascular aneurysm repair (F/BEVAR) in patients with chronic kidney disease (CKD).
The study included 186 patients who underwent F/BEVAR between 2013 and 2018 for suprarenal, juxtarenal, and type I to type IV TAAAs. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Postoperative acute kidney injury (AKI) and CKD were defined using RIFLE criteria (Risk, Injury, Failure, Loss, and End-stage renal disease) and CKD staging system (stage ≥3, GFR <60 mL/min/1.73 m2), respectively. For those without baseline CKD, renal decline was defined as a drop in GFR <60 mL/min/1.73 m2 (ie, progression to CKD stage 3 or higher). For patients with baseline renal dysfunction, GFR decline ≥20% or progression in CKD stage (ie, from stage 3 to stage 4) was considered renal decline.
CKD was present in 83 patients (44.6%). Postoperative AKI was diagnosed in 27 patients (14.5%); 13 (48.1%) had history of CKD and 14 (51.9%) had adequate renal function preoperatively (P = .8). None of these patients required permanent renal replacement therapy. Intraoperative technical success was 100%. Overall 30-day mortality was 1.1%. There was no difference in 30-day mortality in patients with (1.2%) and without (1.0%) CKD (P = .5). During a median follow-up time of 12 months (interquartile range, 6-23 months), renal decline was observed in 21 patients (25.3%) with previous CKD and in 11 patients (10.6%) without CKD (P = .01). Among patients with previous CKD, 18 patients (9%) progressed from stage 3 CKD to stage 4. In patients with progression in CKD stage, two (5%) had renal stent stenosis requiring restenting. Among patients with renal decline, 13 had juxtarenal aneurysms (21.3%), 27 had suprarenal aneurysms (44.3%), and 21 had TAAAs (34.3%; P = .4). Subset analysis of patients who developed AKI in the immediate postoperative period found that patients with a history of CKD were less likely to experience freedom from renal decline.
F/BEVAR is an effective and safe procedure for patients with complex abdominal aortic aneurysms and TAAAs, even among patients with CKD. The frequency of AKI was not affected by pre-existing CKD. Midterm outcomes demonstrated that progression of CKD was more frequent among patients with pre-existing CKD, but permanent renal replacement therapy was not required. Anatomic extent of aneurysms did not affect CKD progression. CKD patients are susceptible to renal decline over time if they experience AKI in the postoperative period. Therefore, preventing AKI in the postoperative period should be regarded as a priority. Long-term effects of CKD after F/BEVAR remain to be elucidated.
We evaluated the outcomes of total endovascular aortic arch repair using three-vessel inner branch stent-grafts for aneurysms and chronic dissections.
We reviewed the clinical data and outcomes of ...consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent-grafts (William Cook Europe, Bjaeverskov, Denmark) from 2016 to 2019. All patients received three-vessel designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via a carotid or an upper extremity approach. A preloaded catheter was used for access to the retrograde left subclavian artery branch via a transfemoral approach. The endpoints were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality, and patient survival.
A total of 39 patients (31 men 79%; mean age, 70 ± 7 years) had undergone treatment of 14 degenerative (36%) and 25 chronic (64%) postdissection arch aneurysms. The clinical characteristics included American Society of Anesthesiologists class ≥III in 28 patients (95%) and previous median sternotomy for ascending aortic repair in 28 patients (72%). The technical success rate was 100%. Two patients had died in-hospital or within 30 days (5%), and two patients had experienced a stroke (one minor). The combined mortality and any stroke rate was 8% (n = 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 (10%) and estimated blood loss >1 L, myocardial infarction, and acute kidney injury in 2 patients each (5%). The median follow-up was 3.2 months (interquartile range, 1-14 months). Of the 39 patients, 12 (31%) required secondary interventions to treat vascular access complications in 5, endoleak in 6 (three type II, one type Ic, one type Ia/Ib, one type IIIa), and target vessel stenosis in 1 patient. At 1 year, the primary and secondary patency rates and freedom from target vessel instability were 95% ± 5%, 100%, and 91% ± 5%, respectively. Freedom from aortic-related mortality and patient survival was 94% ± 4% and 90% ± 6%, respectively.
The findings from the present multicenter global experience have demonstrated the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent-grafts. The mortality and stroke rates compare favorably with those after open surgical repair in a higher risk group of patients. However, the rate of secondary interventions was high (31%), emphasizing need for greater experience and longer follow-up.
Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to treat complex abdominal aortic aneurysms. Patency of visceral vessels remains high when covered stents are used. The use of ...distal uncovered stents to prevent kinking has been associated with loss of branch patency. The aim of this study was to evaluate branch-related outcomes of FEVAR using covered stents only vs the use of uncovered stents distal to covered stents.
During a 4-year period, 142 patients underwent FEVAR. Patients with suprarenal, juxtarenal, and type IV thoracoabdominal aneurysms were included. Patients treated with side branch devices were excluded. Covered iCAST (Maquet, Hudson, NH) stents were used as bridging stents in all cases. The primary end point was primary patency, defined as the absence of stenosis or occlusion that required intervention. Secondary end points included secondary patency, branch-related outcomes (kidney injury and gastrointestinal complications), branch instability, and mortality rates.
A total of 442 target vessels were incorporated (49 scallops and 393 fenestrations). Uncovered stents were used in 38 (9.6%) visceral vessels. Median follow-up time was 11 (interquartile range, 6-13) months. Overall, visceral vessel primary patency was 91% at 12 and 24 months. The overall primary patency rate was 86% in the distal extension group vs 93% when only covered stents were used at 12 and 24 months (P = .8). Similarly, the rate of branch-related reinterventions at 12 months was 9% and 15% for each group, respectively, and 22% vs 32% at 24 months, respectively (P = .5). Overall, freedom from branch instability was 87% at 12 months and 81% at 24 months. Freedom from branch instability in the distal extension group was 82% at 12 and 24 months vs 89% at 12 months and 81% at 24 months when only covered stents were used (P =. 08). Mortality rate at 24 months was 15% for the bare-metal stent extension group vs 14% for the covered stent only group (P = .4). We found no statistical difference in acute kidney injury at any Kidney Disease: Improving Global Outcomes stage (P = 1.0) or gastrointestinal complications (P = 1.0) between the groups.
The use of distal uncovered stents to prevent kinks was not associated with decreased early branch patency. The long-term outcomes of bare-metal stents remain to be determined. For now, the use of uncovered stents distal to covered stents may be considered to prevent kinks in complex anatomy.
Objective Determine the proportion of patients with chronic critical limb ischemia (CLI) who failed to adhere to Trans-Atlantic Inter-Society Consensus II guidelines of medical therapy and to ...quantify the effect of baseline suboptimal medical management on amputation-free survival (AFS). Methods The patients were identified from a prospectively maintained database of consecutive patients presenting with CLI to the Vascular Surgery service at a single hospital. The primary outcome variable was AFS. The effects of baseline demographics, comorbid medical conditions, ambulatory status, optimal medical management, and Rutherford classification were assessed. Significant univariate predictors ( P < .10) of AFS were entered into a multivariate Cox proportional hazards model. Results From August 1, 2010 through January 1, 2012, 98 patients (median age, 59.0; interquartile range, 53, 64 years; 58 men) were evaluated with rest pain (n = 40) or tissue loss (n = 58). Optimal medical management was identified in 31 (32%) patients at initial presentation. Compliance rates for the entire cohort were 61% for statin use, 69% for antiplatelet therapy, 56% for angiotensin-converting enzyme inhibitor use, and 53% for beta-blocker use. Significant univariate predictors of major amputation or death included: Rutherford classification (hazard ratio HR, 1.56; 95% confidence interval CI, 1.01-2.41; P = .04); nonambulatory status (HR, 2.17; 95% CI, 1.68-2.81; P < .01); unrevascularized patients (HR, 2.77; 95% CI, 1.32-5.85; P < .01); a history of tobacco abuse (HR, 1.49; 95% CI, 0.57-3.86; P = .09); a history of end-stage-renal disease (HR, 7.97; 95% CI, 3.10-20.52; P < .01); suboptimal medical management (HR, 4.25; 95% CI, 1.28-14.07; P = .02); and an absence of antiplatelet agents (HR, 1.94; 95% CI, 0.92-4.11; P = .08). Independent predictors of major amputation or death included: initial nonambulatory status (HR, 2.43; 95% CI, 1.03-2.05; P < .01); unrevascularized status (HR, 2.43; 95% CI, 1.76-3.34; P = .01); and suboptimal medical management at presentation (HR, 8.54; 95% CI, 2.05-35.65; P < .01). Conclusions Despite guidelines advocating the optimization of atherosclerotic risk factors, less than one-third of patients with CLI present with their risk factors optimally managed. Patients who are medically undertreated have an eight-fold risk of major amputation and/or death. The magnitude of the effect suggests that future trials and quality assessments should stratify outcomes by the quality of baseline medical management. Of the risk factors affecting AFS medical therapy optimization is the variable that can be most significantly improved by vascular surgeons and the medical community.
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