Single-Disk’s Plug-Based Embolization of Directional Branches During Urgent Complex Endovascular Aortic Aneurysm Repair

Abstract

Objective:

The introduction of off-the-shelf (OTS) multibranch stent-grafts represented an advancement in the endovascular treatment of thoraco-abdominal aortic aneurysms (TAAAs), particularly in urgent settings. In certain cases (e.g, target vessel [TV] occlusion), unused directional branches (DBs) require proper occlusion with a vascular plug to prevent type III endoleaks. However, no standardized technique for DB closure has been established. We aim to evaluate the safety, feasibility, time-effectiveness and cost-effectiveness of using single-disk vascular plug (Amplatzer Vascular Plug [AVP]) for DB closure during urgent branched endovascular aneurysm repair (B-EVAR).

Methods:

Retrospective analysis of 16 patients (16/101, 15.8%) undergoing urgent B-EVAR with OTS devices requiring intentional occlusion of at least 1 DB using vascular plug due to unavailable TVs or anatomical constraints. Amplatzer Vascular Plugs were deployed in 2 different techniques: with or without DB elongation with balloon-expandable stent-grafts. Technical success, clinical outcomes, side branches plugging time, and plug-constrained length after its deployment were assessed.

Results:

Balloon-expandable stent-graft plus AVP were used to occlude 7 unused DBs (36.8%), whereas AVP without elongation was used in 8 (42.1%), with a median oversizing rate of 58.7%. The technical success rate was 100%, with no instances of plug migration or endoleak during a median follow-up of 20.9±14.4 months. Perioperative mortality rate was 25%, exclusively in patients with ruptured aneurysms. Clinical success was maintained in all patients, with no late reinterventions or DBs recanalization. Side-branch plugging time was significantly shorter when performed without elongation (3.9±0.6 vs. 6.4±1.3 minutes; p=.0003). Despite greater oversizing, even without elongation, the mean plug-constrained length (15.1±4.5 mm) did not exceed the shortest DB, effectively reducing the risk of complications associated with increased plug-constrained length while ensuring proper and secure deployment.

Conclusions:

Single-disk vascular plugs without DB elongation provide a safe, feasible, time-effective and cost-effective solution for DB closure during B-EVAR, with favorable outcomes and reduced procedural complexity, even in urgent setting. Multicenter studies are needed to validate these findings and establish standardized DB management techniques for challenging anatomical and urgent cases.

Clinical Impact

Our study demonstrated the feasibility, safety, and time- and cost-effectiveness of single-disc vascular plug (AVP) embolization for directional branches during urgent or emergent branched endovascular aortic aneurysm repair using off-the-shelf devices, even without elongation using balloon-expandable stent-grafts. This technique simplifies the procedure, reducing complexity and potential complications. It is particularly advantageous in urgent scenarios, where minimizing procedural time is critical to improve patient outcomes and survival. Moreover, it offers significant benefits in resource-limited settings by ensuring efficient use of healthcare resources. Overall, this approach represents a practical, effective solution that can enhance procedural efficiency and broaden clinical applicability.

Keywords

embolization technique branched endovascular aortic aneurysm repair thoraco-abdominal aortic aneurysm vascular plug urgent procedure

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