Pararenal abdominal aortic aneurysms (p-AAA) require complex endovascular aortic repair or open surgical repair with suprarenal clamping. Custom made devices (CMD), including fenestrated and branched ...endovascular aortic repair (F/B-EVAR) or off the shelf (OTS) multibranched devices, are available treatment options. The aim of this study was to determine the additional healthy aortic coverage using an OTS multibranched endograft vs. a CMD for the treatment of p-AAAs.
This was a retrospective single centre analysis of prospectively collected data. Consecutive patients with p-AAAs requiring a proximal landing zone above the coeliac artery (CA), planned and treated with CMDs (Zenith Fenestrated) between January 2017 and December 2021 were included in this study. Treatment with supracoeliac coverage using available OTS multibranched devices was simulated using available pre-operative images: T-Branch; E-nside; and TAMBE. Study endpoints included the need for additional proximal aortic coverage, and the number of the segmental arteries additionally covered proximally from the CA for OTS devices compared with CMDs.
Eighty three patients with p-AAAs were treated with CMDs (all FEVAR), including juxtarenal AAAs (n = 46; 56%), suprarenal AAAs (n = 20; 24%), and short neck AAAs (n = 17; 20%). In this study, treatment with 249 (3 × 83) OTS endografts was simulated. When compared with CMDs, OTS devices required a mean of 74 ± 19 mm of additional proximal healthy aortic coverage from the CA (CMD: 33 ± 19 mm vs. OTS: 108 ± 6 mm; p ≤ .001), as well as an average sacrifice of 2.5 additional segmental arteries (CMD: 1.3 ± 0.8 vs. OTS: 3.8 ± 0.9; p ≤ .001). In 94% of patients, at least one of the available multibranched endografts could have been implanted in accordance with instructions for use.
Despite not requiring customisation time, OTS endografts for the treatment of p-AAA lead to more extensive healthy aortic coverage, as well as an average sacrifice of 2.5 additional segmental arteries, compared with CMDs. When compared with OTS devices, CMDs appear to limit the extent of unnecessary aortic coverage and the theoretical subsequent risk of spinal cord ischaemia.
Purpose
Calcifications of the visceral and renal arteries lead to chronic mesenteric ischemia and renal artery stenosis, and both open and endovascular treatments can be proposed. Intravascular ...lithotripsy (IVL) has emerged as a novel technique used in peripheral and coronary interventions.
Case Report
A 73-year-old man presented with chronic postprandial abdominal pain and weight loss. Computed-tomography-angiography (CTA) showed 93% calcified stenosis of the superior mesenteric artery (SMA). The plain old balloon angioplasty (POBA) was affected by immediate recoiling. The patient underwent ShockwaveTM IVL of the SMA via brachial access and stent-graft implantation. At 3-months follow-up, the patient showed symptoms resolution.
Conclusions
The use of Shockwave IVL can be an effective treatment for severely calcified SMA stenosis. A similar approach can be employed in both celiac and renal arteries as reported in 11 cases in literature and herein summarized. Intravascular lithotripsy resulted in high technical success and uneventful follow-up. However, given the small number of patients reported, larger studies are needed to confirm these findings.
Clinical Impact
This article reports a case of recanalization of superior mesenteric artery with heavily calcified lesion treated with intravascular lithotripsy (IVL) with Shockwave™ Intravascular Lithotripsy Balloon (Shockwave Medical Inc., Santa Clara, CA, USA). Beside, for the first time, we summarize the Literature on the use of IVL in the renal and visceral arteries district, providing indications, applications and useful hints for the endovascular treatment of chronic mesenteric ischemia and renal artery stenosis. This preliminary data show straightforward applicability, high technical success, and uneventful follow-up and IVL can be proposed as an useful tool for challenging revascularization of heavily calcified reno-visceral arteries.
Purpose:
To describe the transaxillary branch-to-branch-to-branch carotid catheterization technique (tranaxillary 3BRA-CCE IT) for cannulation of all supra-aortic vessels using only 1 femoral and 1 ...axillary access during triple-branch arch repair.
Technique:
After deployment of the triple-branch arch device, catheterization and bridging of the innominate artery (IA) should be performed through a right axillary access (cutdown or percutaneous). Then, the retrograde left subclavian (LSA) branch should be catheterized (if not preloaded) from a percutaneous femoral access, and a 12×90Fr sheath should be advanced to the outside of the endograft. Subsequently, catheterization of the left common carotid artery (LCCA) antegrade branch should be performed, followed by snaring of a wire in the ascending aorta which was inserted through the axillary access, creating a branch-to-branch-to-branch through-and-through guidewire. Over the axillary access, a 12×45Fr sheath should be inserted into the IA branch and looped in the ascending aorta using a push-and-pull technique so that it faces the LCCA branch, allowing for stable catheterization of the LCCA. The retrograde LSA branch should then be bridged following the standard fashion.
Conclusions:
This series of 5 patients demonstrates that triple-branch arch repair can be performed with the transaxillary 3BRA-CCE IT, allowing catheterization of the supra-aortic vessels without manipulation of the carotid arteries.
Clinical Impact
The transaxillary 3BRA-CCE IT allows catheterization and bridging of all supra-aortic vessels in triple-branch arch repair through only 2 vascular access points, the femoral artery and the right axillary artery. This technique avoids carotid surgical cutdown and manipulation during these procedures, reducing the risk of access site complications, including bleeding and reintervention, reintubation, cranial nerve lesions, increased operating time, and so on, and has the potential to change the current vascular access standard used during triple-branch arch repair.
The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver ...usage in patients undergoing complex endovascular procedures.
Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion CSBT), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality.
A total of 170 patients (77.1% male, mean age 71.2 ± 9.2 years) were included, with a median blood loss of 700 mL (interquartile range IQR 400–1,200 mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282 mL (IQR, 194.5–508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25 ± 1.55 vs. 10.36 ± 1.88 mg/dL; P < 0.001), both groups presented similar postoperative hemoglobin (Hb) levels.
Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.
