Jesse Manunga

Objectives: To evaluate outcomes of patients with complex aortic aneurysms (cAAs) undergoing fenestrated/branched endovascular aortic aneurysm repair (f/b-EVAR) using a combination of endoprostheses from different manufacturers. Methods: The study is a 2-center retrospective analysis of prospectively maintained databases of patients with cAAs undergoing f/b-EVAR using a combination of endoprostheses from different manufacturers from 2013 to 2023. Primary endpoints included technical success, major adverse events and reintervention rates. Technical success was defined as implantation of the device without type I or type III endoleak or conversion to open repair. Secondary endpoints included mortality and mid-term device performance. Results: During this time, 353 patients with cAAs underwent f/b-EVARs at both centers. Of these, 80 (22.7%) required use of a combination of devices from 4 different manufacturers for repair. Fifty-one (64%) were treated for thoracoabdominal aortic aneurysms and 29 (36%) for pararenal aneurysms. Majority (74%) were male with a median age of 75 (69, 81) years and aneurysm size of 65 (59, 72) mm. Thirty-five (44%) patients required a proximal thoracic stent graft—W.L. Gore (17), Cook, Medtronic, and Terumo (6), respectively. Seventy-seven (96%) patients required a bifurcated device, including Cook Flex (34), Gore (40), and Medtronic (3). Twelve patients underwent common iliac artery aneurysm repair with a Gore iliac branched endoprosthesis. One hundred fifty-four limbs were implanted: Gore: 68, Cook: 82 and Medtronic: 4. Three hundred fourteen target vessels were incorporated. Median operating room time, estimated blood loss, fluoroscopy time and dose were 209 (186, 278) minutes, 100 (50, 663) mL, 77 (59, 100) minutes, 2385 (1415, 3885) mGy, respectively. Three endoleaks were observed on completion angiography—2 type Ic and 1 type IIIa—all of which resolved at 1 month. Fifteen MAEs were observed in 11 patients at 30 days, including 3 (3.9%) deaths, 7 renal insufficiency, 1 renal failure requiring dialysis, 2 MI and paraplegia, respectively. At a median follow-up of 400 (85, 1132) days, there were 8 reinterventions for endoleaks in 7 patients. Conclusions: The use of mixed devices proximal and distal to f/b-devices built to treat patients with cAAs is safe and has good mid-term results. Clinical Impact: While not yet formally assessed in randomized clinical trials or endorsed by the Food and Drug Administration (FDA), the practice of utilizing devices from various manufacturers to address complex aortic anatomy is widespread in everyday clinical settings, yet outcomes remain insufficiently documented. To our knowledge, ours is the first manuscript demonstrating that the use of endoprostheses from different manufacturers for treating patients with complex aortic aneurysms is both safe and yields favorable mid-term results. This frequently employed strategy warrants further exploration through meticulously designed clinical trials, aiming to furnish vascular specialists with a well-founded guideline based on robust clinical evidence.

Purpose: To evaluate the effect of iliac tortuosity on procedural metrics and outcomes of patients with complex aortic aneurysms (cAAs) undergoing repair with fenestrated/branched endografts (f/b-EVAR [endovascular aortic aneurysm repair]). Material and Methods: The study is a single-center, retrospective review of a prospectively maintained database of patients undergoing aneurysm repair using f/b-EVAR between the years 2013 and 2020 at our institution. Included patients had at least 1 preoperative computed tomography angiography (CTA) available for analysis. Iliac artery tortuosity index (TI) was calculated using centerline of flow imaging from a 3-dimensional work station based on the formula: (centerline iliac artery length / straight-line iliac artery length). The associations between iliac artery tortuosity and procedural metrics, including total operative time, fluoroscopy time, radiation dose, contrast volume, and estimated blood loss (EBL), were evaluated. Results: During this period, 219 patients with cAAs underwent f/b-EVAR at our institution. Ninety-one patients (74% men; mean age = 75.2±7.7 years) met criteria for inclusion into the study. In this group, there were 72 (79%) juxtarenal or paravisceral aneurysms and 18 (20%) thoracoabdominal aortic aneurysms and 5 patients (5.4%) with failed previous EVAR. The average aneurysm diameter was 60.1±0.74 mm. Overall, 270 vessels were targeted, and 267 (99%) were successfully incorporated, including 25 celiac arteries, 67 superior mesenteric arteries, and 175 renal arteries. The mean total operative time was 236±83 minutes, fluoroscopy time was 87±39 minutes, contrast volume was 81±47 mL, radiation dose 3246±2207 mGy, and EBL was 290±409 mL. The average left and right TIs for all patients were 1.5±0.3 and 1.4±0.3, respectively. On multivariable analysis, the interval estimates suggest positive association between TI and procedural metrics to a certain degree. Conclusions: In the current series, we found no definitive association between iliac artery TI and procedural metrics, including operative time, contrast used, EBL, fluoroscopy time, and dose in patients undergoing cAA repair using f/b-EVAR. However, there was a trend toward association between TI and all these metrics on multivariable analysis. This potential association needs to be evaluated in a larger series. Clinical Impact: Iliac artery tortuosity should not exclude patients with complex aortic aneurysms from being offered fenestrated or branched stent graft repair. However, special considerations should be taken to mitigate the impact of access tortuosity on alignment of fenestrations with target vessels, including use of extra stiff wires, through and through access and delivering the fenestrated/branched device into another (larger) sheath such as a Gore DrySeal in patients with arteries large enough to accommodate such sheaths.