Comparison of Physician-Modified Fenestrated/Branched Stent-Grafts and Hybrid Visceral Debranching Plus Stent-Graft Placement for Complex Thoracoabdominal Aortic Aneurysm Repair
Restricted accessResearch articleFirst published online October, 2020
Comparison of Physician-Modified Fenestrated/Branched Stent-Grafts and Hybrid Visceral Debranching Plus Stent-Graft Placement for Complex Thoracoabdominal Aortic Aneurysm Repair
Purpose: To evaluate the immediate postoperative and midterm outcomes of complex thoracoabdominal aortic aneurysm (TAAA) treatment with fenestrated/branched physician-modified endovascular grafts (PMEGs) or open debranching of the visceral aorta with bypass graft revascularization plus endovascular aneurysm exclusion (hybrid repair). Materials and Methods: A retrospective analysis was conducted of 88 patients (mean age 70.0±10.6 years; 73 men) with complex TAAAs who underwent treatment with PMEGs (60, 68%) or a hybrid technique (28, 32%) between 2016 and 2019. The mean aneurysm diameter was 64.5±11.7 mm, and 37 patients (42%) were symptomatic. The Zenith TX2 and Ankura were the main stent-grafts used in the PMEG group. The hybrid technique involved visceral debranching with extra-anatomical bypass graft revascularization and subsequent stent-graft deployment (1- or 2-stage procedure). Results: In the PMEG group, 35 patients received modified stent-grafts with 4 fenestrations, 8 patients had 4 branches per device, and 17 patients had combinations (50 fenestrations and 18 branches) that successfully revascularized 228 of the 240 targets (95%). In the 28 hybrid cases, all 110 target vessels were successfully revascularized with bypass grafts. The overall 30-day mortality was 3.4% (2 PMEG and 1 hybrid), and the early rate of target vessel stenosis/occlusion was 3.3% (5 in PMEG group and 6 in the hybrid repair group). The 30-day morbidity was mainly attributed to pulmonary complications (15%), lower limb ischemia (8%), or spinal cord ischemia with paraplegia (6%). Eleven patients (13%) had deteriorated renal function with a >30% decrease in the glomerular filtration rate. The mean follow-up was 22.3±4.9 months, and mortality was 4.5% (3.3% in the PMEG group vs 7.1% in the hybrid repair group). Conclusion: PMEGs and hybrid techniques seem to be feasible treatment options for aortic aneurysms necessitating visceral vessel revascularization. PMEGs may have a lower morbidity than the hybrid technique, which nonetheless remains an important option available for complex aortic aneurysms.
ConradMFCrawfordRSDavisonJK, et al. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007;83:S856–S861.
2.
RigbergDAMcgoryMLZingmondDS, et al. Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience. J Vasc Surg. 2006;43:217–222.
3.
Quiñones-BaldrichWJPanettaTFVesceraCL, et al. Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach. J Vasc Surg. 1999;30:555–560.
4.
MendesBCOderichGS.Endovascular repair of thoracoabdominal aortic aneurysm using the off-the-shelf multibranched t-Branch stent graft. J Vasc Surg. 2016;63:1394–1399.
5.
GasperWJReillyLMRappJH, et al. Assessing the anatomic applicability of the multibranched endovascular repair of thoracoabdominal aortic aneurysm technique. J Vasc Surg. 2013;57:1553–1558.
6.
EagletonMJFollansbeeMWolskiK, et al. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63:930–942.
7.
MastracciTMEagletonMJKuramochiY, et al. Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms. J Vasc Surg. 2015;61:355–364.
8.
UflackerRRobisonJDSchonholzC, et al. Clinical experience with a customized fenestrated endograft for juxtarenal abdominal aortic aneurysm repair. J Vasc Interv Radiol. 2006;17:1935–1942.
9.
TsilimparisNHeidemannFRohlffsF, et al. Outcome of surgeon-modified fenestrated/branched stent-grafts for symptomatic complex aortic pathologies or contained rupture. J Endovasc Ther. 2017; 24:825–832.
10.
HiratzkaLFBakrisGLBeckmanJA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55:e27–e129.
11.
OderichGSRicottaJJ.Modified fenestrated stent grafts: device design, modifications, implantation, and current applications. Perspect Vasc Surg Endovasc Ther. 2009;21:157–167.
12.
SchepensMAHeijmenRHRanschaertW, et al. Thoracoabdominal aortic aneurysm repair: results of conventional open surgery. Eur J Vasc Endovasc Surg. 2009;37:640–645.
13.
O’NeillSGreenbergRKHaddadF, et al. A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc Surg. 2006;32:115–123.
14.
ScurrJRHBrennanJAGilling-SmithGL, et al. Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg. 2010;95:326–332.
15.
SpanosKKölbelTTheodorakopoulouM, et al. Early outcomes of the t-Branch off-the-shelf multibranched stent-graft in urgent thoracoabdominal aortic aneurysm repair. J Endovasc Ther. 2018;25:31–39.
16.
BisdasTDonasKPBosiersM, et al. Anatomical suitability of the t-Branch stent-graft in patients with thoracoabdominal aortic aneurysms treated using custom-made multibranched endografts. J Endovasc Ther. 2013;20:672–677.
17.
SweetMPStarnesBWTatumB.Endovascular treatment of thoracoabdominal aortic aneurysm using physician-modified endografts. J Vasc Surg. 2015;62:1160–1167.
18.
CochennecFKobeiterHGohelM, et al. Early results of physician modified fenestrated stent grafts for the treatment of thoraco-abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2015;50:583–592.
19.
MoulakakisKGMylonasSNAvgerinosED, et al. Hybrid open endovascular technique for aortic thoracoabdominal pathologies. Circulation. 2011;124:2670–2680.
20.
StarnesBWTatumB.Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts. J Vasc Surg. 2013;58:311–317.
21.
RicottaJJTsilimparisN.Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patients. J Vasc Surg. 2012;56:1535–1542.
22.
VerhoevenELGTielliuIFJMuhsBE, et al. Fenestrated and branched stent-grafting: a 5-years experiences. Acta Chir Belg. 2006;106:317–322.
23.
MarwanYAchimNFlorianJ, et al. Patency of renal and visceral vessels after open thoracoabdominal aortic replacement. J Vasc Surg. 2015;62:594–599.
24.
KatsargyrisAOikonomouKKouvelosG, et al. Spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms with fenestrated and branched stent grafts. J Vasc Surg. 2015;62:1450–1456.
25.
DrinkwaterSLGoebellsAHaydarA, et al. The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention. Eur J Vasc Endovasc Surg. 2010;40:729–735.
26.
EtzCDKariFAMuellerCS, et al. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg. 2011;141:1029–1036.
27.
O’CallaghanAMastracciTMEagletonMJ, et al. Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia. J Vasc Surg. 2015;61:347–354.
