DÄ internationalArchive48/2015Fenestrated and Branched Aortic Grafts

Review article

Fenestrated and Branched Aortic Grafts

Patency, perioperative mortality, and spinal ischemia

Dtsch Arztebl Int 2015; 112: 816-22. DOI: 10.3238/arztebl.2015.0816

Rylski, B; Czerny, M; Südkamp, M; Russe, M; Siepe, M; Beyersdorf, F

Background: Abdominal and thoracic aortic aneurysms are diagnosed in 40 and 10 to 15 out of 100 000 persons per year, respectively. Fenestrated (fEVAR) and branched (bEVAR) stent grafts have been developed for abdominal juxtarenal and thoracoabdominal aneurysms. We discuss the patency and complication rates of fEVAR and bEVAR procedures and compare them with the outcome of open surgery.

Methods: This review is based on pertinent publications from 2011 to 2014 that were retrieved by a selective literature search. The clinical outcomes of case series involving a total of more than 1500 patients are presented. The discussion takes account of recommendations contained in the literature and the authors’ own experience.

Results: Open surgery and aortic stent grafting have not been compared in any randomized trial to date. We identified 7 clinical series that included a total of 1270 fEVAR patients and 5 with a total of 408 bEVAR patients. The perioperative mortality after fEVAR procedures was 0–4%. Spinal cord ischemia arose in 1% of cases. The stent patency rate in visceral vessels ranged from 93 to 98%. bEVAR procedures were associated with both higher mortality (4–7%) and more common spinal cord ischemia (4–13%). 5–8% of all patients needed dialysis perioperatively, and the stent patency rate in visceral vessels was 94–97%. Preoperative renal insufficiency was a risk factor for peri-interventional death. Impaired renal function after fEVAR/bEVAR procedures was mainly associated with intermittent lower limb ischemia.

Conclusion: The results of fEVAR/bEVAR procedures in the last 5 years are similar to those of open surgery. The high postoperative rate of spinal cord ischemia remains a serious problem in the endovascular treatment of thoracoabdominal aortic aneurysms. The decision to implant a stent graft by an endovascular approach or to treat surgically should be made on a case-to-case basis in an interdisciplinary vascular conference.

LNSLNS

The anatomy of the aorta changes in the course of life. Up to the age of 15, its diameter and length increase relatively swiftly. It continues to grow in adulthood: the diameter of the ascending aorta is 20 to 30% greater in 70-year-olds than in 20-year-olds (1). Rapid growth of the aorta—usually segmental—causes an aneurysm.

Three quarters of all aneurysms occur in the abdominal aorta. The annual incidence of abdominal aortic aneurysm (diameter >3.0 cm) is 40 in every 100 000 population. Six times more men than women are affected (24). Intervention is required (aneurysmal diameter >5.0 cm) in 10% of patients with a diagnosed abdominal aortic aneurysm (3). In up to 55% of these persons the aneurysm is not amenable to insertion of a conventional tube graft or Y-graft (5).

The annual incidence of thoracic aneurysm is 10–15 per 100 000 (6, 7). Men are 1.8 times more frequently affected than women. No population studies of the incidence of thoracic abdominal aneurysm have been published.

The pathological aorta can be treated surgically or via the endovascular route. One crucial advantage of the endovascular approach is the minimally invasive access with relatively low strain on the cardiovascular system and thus lower perioperative mortality. In a total of 22 830 patients, mortality was 1.2% for endovascular treatment and 4.8% for open surgery (8, 9).

Not every affected aorta is amenable to insertion of a thoracic tube stent graft or infrarenal Y-stent graft. In patients with a juxtarenal or thoracoabdominal aneurysm there is no proximal or distal zone for anchorage (landing zone) and therefore conventional tube and Y-grafts cannot be safely attached. These patients therefore often undergo open surgery. Relatively young and otherwise healthy patients recover comparatively quickly from an open thoracic, thoracoabdominal, or abdominal intervention. However, patients with vascular disease are usually of advanced age and not uncommonly have numerous comorbidities. One of the endovascular treatment options in such cases is the chimney technique. Chimney grafts are placed in the visceral vessels so that their aortic segments lie parallel to the aortic stent graft. However, use of this technique is limited by the elevated risk of leakage between the chimney graft, the aortic stent graft, and the aorta (10, 11).

The very first implantation of a stent graft into the thoracic aorta was performed by Volodos in 1987 (12). The first such interventions in Germany—in centers including Freiburg (13)—were carried out in 1995. There have been rapid developments in stent grafts, pre- and intraoperative diagnostic procedures, endovascular instrumentation, catheter techniques, and many other relevant areas. Preoperative diagnostic, high-resolution computed tomography, three-dimensional (3-D) reconstruction of the aorta, preoperative simulation of the intraoperative angiographic visualization, the possibility of treatment in hybrid operating suites, and printing of 3-D models all help in planning the intervention and now form part of standard management. Hydrophilic coating and reduced diameter of the insertion port permit access via distinctly sclerosed vessels. The first fenestrated endovascular aneurysm repair (fEVAR) was carried out by Park in 1996 (14). Fenestrated (Figures 1a, 2) and branched stent grafts (bEVAR) (Figure 1b) were developed for treatment of patients with juxtarenal, perirenal, or thoracoabdominal aneurysms. Now, with the sole exceptions of the aortic root and the proximal ascending aorta, all segments of the aorta are amenable to endovascular treatment with standard stent grafts.

T reatment of a juxtarenal abdominal aortic aneurysm with a fenestrated stent graft
Figure 2
T reatment of a juxtarenal abdominal aortic aneurysm with a fenestrated stent graft
Stent grafts
Figure 1
Stent grafts

Methods

This article is based on the data of studies published between January 2011 and December 2014 that were identified by a selective literature search of Medline, Google Scholar, ScienceDirect, and SpringerLink. We used the search terms “thoracic aortic aneurysm”, “abdominal aortic aneurysm”, “fenestrated endovascular aortic repair”, and “branched endovascular aortic repair.” The electronic reference lists of the following cardiac and cardiovascular journals were searched for these terms: Circulation, European Journal of Cardiothoracic Surgery, Journal of Vascular Surgery, Seminars in Vascular Surgery, European Journal of Vascular and Endovascular Surgery, Interactive CardioVascular and Thoracic Surgery, Journal of Endovascular Therapy, and Journal of Endovascular Surgery.

Results

fEVAR procedure

Following the first implantation of a fenestrated graft in 1996 (14), numerous series of patients treated by fEVAR have been described in the literature. In the first of these, an account of 13 patients published in 2001, the authors reported fixation of the main stent in the visceral vessels by means of Palmaz stents (balloon-expandable stents with high radial strength) (15). Nowadays each window is usually connected with the corresponding visceral vessel by a covered stent (a stent with its mesh covered over) to reduce the risk of an endoleak. The results of recent fEVAR studies are summarized in Table 1. Comparison of the individual studies with regard to the various fEVAR products or strategies is impossible because of the considerable variability of patients' risk profiles, the different degrees of experience with fenestrated grafts at the different aorta centers, and the still relatively small numbers of patients.

Results following implantation of fenestrated stent grafts in the aorta
Table 1
Results following implantation of fenestrated stent grafts in the aorta

Perioperative mortality—The fEVAR studies published in the past 5 years report perioperative mortality of 0 to 4% (1622). In most cases the cause of death was myocardial infarction or an intraoperative technical complication, e.g., rupture of the access vessel, rupture of the aneurysm, injury of the renal artery, or occlusion of the superior mesenteric artery (21). The cumulative perioperative mortality in these studies was 2%.

bEVAR procedure

The literature includes only a small number of series of patients treated with branched stent grafts (Table 2). To date, the most extensive experience has been described by Reilly in 2012 (23) and by Kasprzak in 2014 (24). Reilly et al. treated 81 patients and reported rates of 4% for perioperative mortality, 4% for spinal ischemia, 5% for perioperative dialysis, and 95% for patency of the stents in visceral vessels (23). In a total of 83 patients, Kasprzak et al. found 7% perioperative mortality, 13% permanent spinal ischemia, 8% perioperative dialysis, and 97% stent patency (24). The results of both series compare well with those of open surgery studies.

Results following implantation of branched stent grafts in the aorta
Table 2
Results following implantation of branched stent grafts in the aorta

Spinal ischemia after fEVAR/bEVAR

Implantation of fenestrated stent grafts may be followed by paraplegia owing to the reduced perfusion pressure in the collateral arterial network of the spinal cord. The risk of spinal ischemia increases with the number of spinal arteries originating from the stented portion of the aorta and is also greater in the case of occlusion of the internal iliac artery or subclavian artery or previous intervention involving the thoracic descending aorta (25). The average incidence of paraplegia after endovascular elimination of juxta- and perirenal aortic aneurysms is 1 to 2% (17, 19, 22). Endovascular treatment of thoracoabdominal aneurysms is associated with a far higher frequency of spinal ischemia, in most studies between 4 and 13% (23, 24, 26, 27).

Renal failure after fEVAR/bEVAR

Renal function may worsen considerably after implantation of fenestrated or branched stents. Alongside exposure to contrast medium, the principal potential cause is lower-limb ischemia. During the operation, the relatively large introducer sheaths hamper blood flow into the external iliac artery and not infrequently also the internal iliac artery, potentially leading to crural ischemia with an increase in the concentration of creatine kinase, resulting in deterioration of renal function. Other possible causes of impaired kidney function include overstenting of the renal arteries, dissection of the renal arteries by wire manipulation, and occlusion or stenosis of renal artery stents. In a review published in 2009, an increase of over 30% in blood creatinine levels was found in 15% of fEVAR patients (28). A study from Birmingham in which cystatin C and creatinine were measured revealed that renal dysfunction following endovascular interventions is greatly underestimated and may occur up to 12 months after treatment (29). Pre-existing renal failure increases the risk of peri-interventional mortality eightfold (30).

In the early years of fEVAR the fenestrations over the renal arteries were not always extended with subsidiary stents. Stenting of the renal arteries is now recommended to reduce the danger of kidney malperfusion owing to dislocation of the main graft (2).

Patency rate of stents in the visceral vessels after fEVAR/bEVAR

Studies with short (up to 1 year) and medium-term (up to 5 years) follow-up show patency rates of between 93% and 98% for side stents implanted in the fenestrations (16, 17, 19, 20, 23, 24, 31, 32). To reduce the risk of stenosis or a type III endoleak (leak due to a defective implant), fenestrations are currently extended with covered stents.

In a Cleveland Clinic report on 650 patients with fenestrated and branched stent grafts who were followed up for a mean 3 years, the 30-day, 1-year, and 5-year patency rates after visceral stent reintervention were 98 % (95% confidence interval [96; 99]; 94 % [92–96]; and 84 % [78; 90] respectively (33). The rates of reintervention in the visceral vessels were as follows: celiac trunk 0.6%, superior mesenteric artery 4%, right renal artery 6%, left renal artery 5%. Three patients (0.5%) died owing to complications of the stents implanted in the visceral vessels. Multivariate analysis revealed no risk factors for reintervention on stents in the visceral vessels (23). In a study from Münster reporting the findings in 150 fEVAR and bEVAR patients (523 target vessels, mean follow-up 1.2 years), 2% of stents in the visceral vessels were occluded and 4% required reintervention. The sole identified risk factor for complications was implantation of branched stent grafts (34).

Discussion

Setting up a fEVAR/bEVAR program

Successful establishment of a fEVAR/bEVAR program depends on many factors. A high degree of expertise in vascular surgical and interventional techniques is important to reduce the danger of mishaps. The procedures should be carried out exclusively at centers with extensive experience in endovascular and open aortic surgery. In the early phase of a new fEVAR/bEVAR program, advice is generally provided by product specialists from the manufacturers. The companies also offer the assistance of a proctor for the first interventions. It is advisable to begin with less complex procedures (e.g., insertion of double-fenestrated grafts) and only move on to implantation of branched stents when the fEVAR techniques have been mastered. Particularly in more complex interventions it is sensible to use shunts to decrease the risk of crural ischemia, which may result from occlusion of the arteries used for access by large introducer sheaths (35, 36).

The treatment can be planned by an interdisciplinary team of vascular surgeons, angiologists, and radiologists (37). Three-dimensional evaluation of the CT scans using programs such as Aquarius iNtuition or 3-Mensio is standard and is indispensable for planning of the procedures. Implantation of stent grafts is best carried out in hybrid operating rooms that not only possess modern angiography equipment but also offer the possibility of conversion to open surgery.

Because of the complexity of fEVAR/bEVAR techniques and the specific complications that may arise from the treatment, postoperative follow-up should take place in the same hospital as the intervention. Regular diagnostic imaging is important and should also be carried out at the same center each time for the sake of consistent assessment of the patient's progress.

If the nearest aorta center is a long way from where the patient lives, or if medical considerations make transport problematic, follow-up can be carried out by a local specialist. However, the findings of diagnostic imaging must always be made available to the staff of the center where the intervention took place.

Close cooperation with local specialists is particularly crucial in the treatment of arterial hypertension and other comorbidities such as renal failure, obesity and diabetes mellitus, and risk factors such as smoking, because these influence the aortic pathology.

Endovascular versus open surgical treatment of the aorta

Endovascular interventions can be carried out in all patients whose aorta is anatomically suitable. The only exceptions are patients who suffer from congenital weakness of the connective tissues, e.g., Marfan, Loeys–Dietz, or Ehlers–Danlos syndrome. In these cases endovascular treatment is feasible only if the landing zone for the stent graft has already been replaced by a vascular implant (38, 39).

The decision whether a patient should undergo endovascular treatment or open surgery must always be taken on an individual basis. Endovascular intervention should be preferred in the case of several comorbidities or advanced age. The same applies to both covered and traumatic aortic ruptures (40). Young, otherwise healthy patients, on the other hand, benefit from open surgery, as it has been demonstrated that endovascular treatment of the aorta is associated with an elevated reintervention rate (28). Open surgery is also advantageous for patients with renal failure and for those who are allergic to contrast medium. In the latter case this is because postoperative CT scanning is far less frequently necessary after open surgery. The regular exposure to contrast medium is therefore much lower.

No randomized studies comparing open surgery with fEVAR/bEVAR procedures have been published, for the simple reason that no long-term results are yet available and fEVAR/bEVAR is currently being used only for patients for whom open surgery would be a high-risk option. The retrospective studies comparing the two courses of action are summarized in Table 3. The results of a systematic review that compared fEVAR studies with open surgery studies seem to show that fEVAR has the advantage of lower perioperative mortality (28) but the disadvantages of an elevated reintervention rate and higher late mortality (e1).

Results of studies comparing fEVAR/bEVAR procedures with open aortic surgery
Table 3
Results of studies comparing fEVAR/bEVAR procedures with open aortic surgery

Summary and prospects

Fenestrated and branched grafts form an alternative to open surgery, and are already increasingly being offered as part of the standard spectrum of treatment in aorta centers. The past 20 years have seen rapid advances in fEVAR/bEVAR technology, to the point where the results are attractive and can compete with those of conventional surgery. Further developments can be expected in the areas of high-resolution preoperative diagnostic imaging, improved intraoperative visualization with no or only minimal use of ionizing radiation, the design of stent grafts and the instruments for implanting them, and possibly robot-assisted implantation techniques.

Endovascular surgery is a standardized option for the entire aorta, with the sole exceptions of the aortic root and the proximal ascending segment. The aortic arch can be successfully treated with chimney grafts (e2). These grafts are released in supra-aortic branching vessels, lie parallel with the aortic stent graft in the aortic arch, and extend beyond the stent into the free aortic lumen. Alternatively, an aneurysm of the aortic arch can be treated by inserting an endograft with two inner branches that is connected via supra-aortic branching vessels with two further stent grafts (e3). However, experience with this implant is extremely limited. The University Heart Center Freiburg is developing a new endovascular implant for the ascending aorta in cooperation with the Hospital of the University of Pennsylvania in Philadelphia. Details of the new concept and the early stages of product planning have been published (e4).

Conflict of interest statement
Dr. Südkamp has received reimbursement of conference fees and travel costs from Cook.

The remaining authors declare that no conflict of interest exists.

Translated from the original German by David Roseveare.

Manuscript received on 19 April 2015, revised version accepted on 10 August 2015.

Corresponding author
Dr. med. Bartosz Rylski
Universitäts-Herzzentrum Freiburg Bad Krozingen
Herz- und Gefäßchirurgie
Hugstetter Str. 55, 79106 Freiburg, Germany
bartosz.rylski@universitaets-herzzentrum.de

@Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref4815

1.
Rylski B, Desjardins B, Moser W, Bavaria JE, Milewski RK: Gender-related changes in aortic geometry throughout life.
Eur J Cardiothorac Surg 2014; 45: 805–11 MEDLINE CrossRef
2.
Lederle FA, Johnson GR, Wilson SE, et al.: Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 1997; 126: 441–9 MEDLINE CrossRef
3.
Khashram M, Jones GT, Roake JA: Prevalence of abdominal aortic aneurysm (AAA) in a population undergoing computed tomography colonography in Canterbury, New Zealand. Eur J Vasc Endovasc Surg 2015. DOI: 10.1016/j.ejvs.2015.04.023
(Epub ahead of print) CrossRef
4.
Pleumeekers HJ, Hoes AW, van der Does E, et al.: Aneurysms of the abdominal aorta in older adults. The Rotterdam Study. Am J Epidemiol 1995; 142: 1291–9 MEDLINE
5.
EVAR trial participants: Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365: 2179–86 CrossRef
6.
Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F: Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006; 114: 2611–8 MEDLINE CrossRef
7.
Clouse WD, Hallett JW Jr, Schaff HV, et al.: Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA 1998; 280: 1926–9 MEDLINE CrossRef
8.
Rylski B, Blanke P, Siepe M, et al.: Results for high-risk endovascular procedures in patients with non-dissected thoracic aortic pathology: Intermediate Outcomes. Eur J Cardiothorac Surg 2013; 44: 156–62 MEDLINE CrossRef
9.
Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE: Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358: 464–74 MEDLINE CrossRef
10.
Bin Jabr A, Lindblad B, Dias N, Resch T, Malina M: Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair. J Vasc Surg 2015; 61: 886–94 MEDLINE CrossRef
11.
Filippi F, Ficarelli R, Tirotti C, Stella N, Taurino M: Emergent fully endovascular treatment of a free ruptured thoracoabdominal aneurysm. Ann Vasc Surg 2015; 29: 842.e9–13 MEDLINE CrossRef
12.
Volodos’ NL, Karpovich IP, Shekhanin VE, Troian VI, Iakovenko LF: A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm. Grudn Khir 1988; 6: 84–6 MEDLINE
13.
Blum U, Voshage G, Lammer J, et al.: Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336: 13–20 MEDLINE CrossRef
14.
Park JH, Chung JW, Choo IW, et al.: Fenestrated stent-grafts for preserving visceral arterial branches in the treatment of abdominal aortic aneurysms: preliminary experience. J Vasc Interv Radiol 1996; 7: 819–23 CrossRef
15.
Anderson JL, Berce M, Hartley DE: Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001; 8: 3–15 CrossRef
16.
Tambyraja AL, Fishwick NG, Bown MJ, et al.: Fenestrated aortic endografts for juxtarenal aortic aneurysm: medium term outcomes. Eur J Vasc Endovasc Surg 2011; 42: 54–8 MEDLINE CrossRef
17.
British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry: Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012; 125: 2707–15 MEDLINE CrossRef
18.
Canavati R, Millen A, Brennan J, et al.: Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg 2013; 57: 362–7 MEDLINE CrossRef
19.
Vemuri C, Oderich GS, Lee JT, et al.: Postapproval outcomes of juxtarenal aortic aneurysms treated with the Zenith fenestrated endovascular graft. J Vasc Surg 2014; 60: 295–300 MEDLINE CrossRef
20.
Oderich GS, Greenberg RK, Farber M, et al.: Results of the United States multicenter prospective study evaluating the Zenith fenestrated endovascular graft for treatment of juxtarenal abdominal aortic aneurysms. J Vasc Surg 2014; 60: 1420–8 MEDLINE CrossRef
21.
Sveinsson M, Sobocinski J, Resch T, et al.: Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm. J Vasc Surg 2015. DOI: 10.1016/j.jvs.2014.11.007 (Epub ahead of print) CrossRef
22.
Glebova NO, Selvarajah S, Orion KC, et al.: Fenestrated endovascular repair of abdominal aortic aneurysms is associated with increased morbidity but comparable mortality with infrarenal endovascular aneurysm repair. J Vasc Surg 2015; 61: 604–10 MEDLINE CrossRef
23.
Reilly LM, Rapp JH, Grenon SM, Hiramoto JS, Sobel J, Chuter TA: Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique. J Vasc Surg 2012; 56: 53–63 MEDLINE CrossRef
24.
Kasprzak PM, Gallis K, Cucuruz B, Pfister K, Janotta M, Kopp R: Editor’s choice-Temporary aneurysm sac perfusion as an adjunct for prevention of spinal cord ischemia after branched endovascular repair of thoracoabdominal aneurysms.
Eur J Vasc Endovasc Surg 2014; 48: 258–65 MEDLINE CrossRef
25.
Czerny M, Eggebrecht H, Sodeck G, et al.: Mechanisms of symptomatic spinal cord ischemia after TEVAR—insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). J Endovasc Ther 2012; 19: 37–43 MEDLINE CrossRef
26.
Guillou M, Bianchini A, Sobocinski J, et al.: Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2012; 56: 65–73 MEDLINE CrossRef
27.
Verhoeven EL, Katsargyris A, Bekkema F, et al.: Editor’s choice – Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: Results from 166 consecutive patients. Eur J Vasc Endovasc Surg 2015; 49: 524–31 MEDLINE CrossRef
28.
Nordon IM, Hinchliffe RJ, Holt PJ, et al.: Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review. Eur J Vasc Endovasc Surg 2009; 38: 35–41 MEDLINE CrossRef
29.
Abdelhamid MF, Davies RS, Vohra RK, Adam DJ, Bradbury AW: Assessment of renal function by means of cystatin C following standard and fenestrated endovascular aneurysm repair.
Ann Vasc Surg 2013; 27: 708–13 MEDLINE CrossRef
30.
Haddad F, Greenberg RK, Walker E, et al.: Fenestrated endovascular grafting: the renal side of the story. J Vasc Surg 2005; 41: 181–90 MEDLINE CrossRef
31.
Ferreira M, Lanziotti L, Cunha R, d’Utra G: Endovascular repair of thoracoabdominal aneurysms: results of the first 48 cases. Ann Cardiothorac Surg 2012; 1: 304–10 MEDLINE PubMed Central
32.
Oikonomou K, Kopp R, Katsargyris A, Pfister K, Verhoeven EL, Kasprzak P: Outcomes of fenestrated/branched endografting in post-dissection thoracoabdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 48: 641–8 MEDLINE CrossRef
33.
Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV: Durability of branches in branched and fenestrated endografts. J Vasc Surg 2013; 57: 926–33 MEDLINE CrossRef
34.
Panuccio G, Bisdas T, Berekoven B, Torsello G, Austermann M: Performance of bridging stent grafts in fenestrated and branched aortic endografting. Eur J Vasc Endovasc Surg 2015; 50: 60–70 MEDLINE CrossRef
35.
Österberg K, Falkenberg M, Resch T: Endovascular technique for arterial shunting to prevent intraoperative ischemia.
Eur J Vasc Endovasc Surg 2014; 48: 126–30 MEDLINE CrossRef
36.
Österberg K, Falkenberg M, Resch T: Endovascular technique for arterial shunting to prevent intraoperative ischemia.
Eur J Vasc Endovasc Surg 2014; 48: 126–30 MEDLINE CrossRef
37.
Grabenwöger M, Alfonso F, Bachet J, et al.: Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases:
a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
Eur J Cardiothorac Surg 2012; 42: 17–24 MEDLINE CrossRef
38.
Nordon IM, Hinchliffe RJ, Holt PJ, et al.: Endovascular management of chronic aortic dissection in patients with Marfan syndrome. J Vasc Surg 2009; 50: 987–91 MEDLINE CrossRef
39.
Rylski B, Beyersdorf F, Desai ND, et al.: Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair. Eur J Cardiothorac Surg 2015; 48: 258–63 MEDLINE CrossRef
40.
Erbel R, Aboyans V, Boileau C, et al.: 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873–926.
e1.
Rao R, Lane TR, Franklin IJ, Davies AH: Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms. J Vasc Surg 2015; 61: 242–55 MEDLINE CrossRef
e2.
Shahverdyan R, Gawenda M, Brunkwall J: Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review. Eur J Vasc Endovasc Surg 2013; 45: 28–35 MEDLINE CrossRef
e3.
Haulon S, Greenberg RK, Spear R, et al.: Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014; 148: 1709–16 MEDLINE CrossRef
e4.
Rylski B, Szeto WY, Bavaria JE, et al.: Development of a single endovascular device for aortic valve replacement and ascending aortic repair. J Card Surg 2014; 29: 371–6 MEDLINE CrossRef
e5.
Kitagawa A, Greenberg RK, Eagleton MJ, Mastracci TM, Roselli EE: Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg 2013; 58: 625–34 MEDLINE CrossRef
e6.
Shahverdyan R, Majd MP, Thul R, Braun N, Gawenda M,
Brunkwall J: F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
Eur J Vasc Endovasc Surg 2015. DOI: 0.1016/j.ejvs.2015.04.028 (Epub ahead of print).
e7.
Barillà D, Sobocinski J, Stilo F, Maurel B, Spinelli F, Haulon S: Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR. Int Angiol 2014; 33: 466–73.
e8.
Chisci E, Kristmundsson T, de Donato G, et al.: The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts. J Endovasc Ther 2009; 16: 137–46 MEDLINE CrossRef
e9.
Raux M, Patel VI, Cochennec F, et al.: A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms. J Vasc Surg 2014; 60: 858–63 MEDLINE CrossRef
e10.
Michel M, Becquemin JP, Clément MC, Marzelle J, Quelen C, Durand-Zaleski I: WINDOW trial participants. Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms. Eur J Vasc Endovasc Surg 2015. DOI: 10.1016/j.ejvs.2015.04.012 (Epub ahead of print) CrossRef
e11.
Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd: Endovascular repair with fenestrated-branched stent grafts improves 30-day outcomes for complex aortic aneurysms compared with open repair. Ann Vasc Surg 2013; 27: 267–73 MEDLINE CrossRef
Department of Cardiovascular Surgery, University Heart Center Freiburg: Dr. Rylski, PD Dr. Czerny, PD Dr. Südkamp, Prof. Siepe, Prof. Beyersdorf
Center for Diagnostic and Therapeutic Radiology, Medical Center—University of Freiburg: Dr. Russe
Stent grafts
Figure 1
Stent grafts
T reatment of a juxtarenal abdominal aortic aneurysm with a fenestrated stent graft
Figure 2
T reatment of a juxtarenal abdominal aortic aneurysm with a fenestrated stent graft
Key messages
Results following implantation of fenestrated stent grafts in the aorta
Table 1
Results following implantation of fenestrated stent grafts in the aorta
Results following implantation of branched stent grafts in the aorta
Table 2
Results following implantation of branched stent grafts in the aorta
Results of studies comparing fEVAR/bEVAR procedures with open aortic surgery
Table 3
Results of studies comparing fEVAR/bEVAR procedures with open aortic surgery
1.Rylski B, Desjardins B, Moser W, Bavaria JE, Milewski RK: Gender-related changes in aortic geometry throughout life.
Eur J Cardiothorac Surg 2014; 45: 805–11 MEDLINE CrossRef
2.Lederle FA, Johnson GR, Wilson SE, et al.: Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 1997; 126: 441–9 MEDLINE CrossRef
3.Khashram M, Jones GT, Roake JA: Prevalence of abdominal aortic aneurysm (AAA) in a population undergoing computed tomography colonography in Canterbury, New Zealand. Eur J Vasc Endovasc Surg 2015. DOI: 10.1016/j.ejvs.2015.04.023
(Epub ahead of print) CrossRef
4.Pleumeekers HJ, Hoes AW, van der Does E, et al.: Aneurysms of the abdominal aorta in older adults. The Rotterdam Study. Am J Epidemiol 1995; 142: 1291–9 MEDLINE
5.EVAR trial participants: Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365: 2179–86 CrossRef
6.Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F: Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006; 114: 2611–8 MEDLINE CrossRef
7.Clouse WD, Hallett JW Jr, Schaff HV, et al.: Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA 1998; 280: 1926–9 MEDLINE CrossRef
8.Rylski B, Blanke P, Siepe M, et al.: Results for high-risk endovascular procedures in patients with non-dissected thoracic aortic pathology: Intermediate Outcomes. Eur J Cardiothorac Surg 2013; 44: 156–62 MEDLINE CrossRef
9.Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE: Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358: 464–74 MEDLINE CrossRef
10.Bin Jabr A, Lindblad B, Dias N, Resch T, Malina M: Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair. J Vasc Surg 2015; 61: 886–94 MEDLINE CrossRef
11.Filippi F, Ficarelli R, Tirotti C, Stella N, Taurino M: Emergent fully endovascular treatment of a free ruptured thoracoabdominal aneurysm. Ann Vasc Surg 2015; 29: 842.e9–13 MEDLINE CrossRef
12.Volodos’ NL, Karpovich IP, Shekhanin VE, Troian VI, Iakovenko LF: A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm. Grudn Khir 1988; 6: 84–6 MEDLINE
13.Blum U, Voshage G, Lammer J, et al.: Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336: 13–20 MEDLINE CrossRef
14.Park JH, Chung JW, Choo IW, et al.: Fenestrated stent-grafts for preserving visceral arterial branches in the treatment of abdominal aortic aneurysms: preliminary experience. J Vasc Interv Radiol 1996; 7: 819–23 CrossRef
15.Anderson JL, Berce M, Hartley DE: Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001; 8: 3–15 CrossRef
16.Tambyraja AL, Fishwick NG, Bown MJ, et al.: Fenestrated aortic endografts for juxtarenal aortic aneurysm: medium term outcomes. Eur J Vasc Endovasc Surg 2011; 42: 54–8 MEDLINE CrossRef
17.British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry: Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012; 125: 2707–15 MEDLINE CrossRef
18.Canavati R, Millen A, Brennan J, et al.: Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg 2013; 57: 362–7 MEDLINE CrossRef
19.Vemuri C, Oderich GS, Lee JT, et al.: Postapproval outcomes of juxtarenal aortic aneurysms treated with the Zenith fenestrated endovascular graft. J Vasc Surg 2014; 60: 295–300 MEDLINE CrossRef
20.Oderich GS, Greenberg RK, Farber M, et al.: Results of the United States multicenter prospective study evaluating the Zenith fenestrated endovascular graft for treatment of juxtarenal abdominal aortic aneurysms. J Vasc Surg 2014; 60: 1420–8 MEDLINE CrossRef
21.Sveinsson M, Sobocinski J, Resch T, et al.: Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm. J Vasc Surg 2015. DOI: 10.1016/j.jvs.2014.11.007 (Epub ahead of print) CrossRef
22.Glebova NO, Selvarajah S, Orion KC, et al.: Fenestrated endovascular repair of abdominal aortic aneurysms is associated with increased morbidity but comparable mortality with infrarenal endovascular aneurysm repair. J Vasc Surg 2015; 61: 604–10 MEDLINE CrossRef
23.Reilly LM, Rapp JH, Grenon SM, Hiramoto JS, Sobel J, Chuter TA: Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique. J Vasc Surg 2012; 56: 53–63 MEDLINE CrossRef
24.Kasprzak PM, Gallis K, Cucuruz B, Pfister K, Janotta M, Kopp R: Editor’s choice-Temporary aneurysm sac perfusion as an adjunct for prevention of spinal cord ischemia after branched endovascular repair of thoracoabdominal aneurysms.
Eur J Vasc Endovasc Surg 2014; 48: 258–65 MEDLINE CrossRef
25.Czerny M, Eggebrecht H, Sodeck G, et al.: Mechanisms of symptomatic spinal cord ischemia after TEVAR—insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). J Endovasc Ther 2012; 19: 37–43 MEDLINE CrossRef
26.Guillou M, Bianchini A, Sobocinski J, et al.: Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2012; 56: 65–73 MEDLINE CrossRef
27.Verhoeven EL, Katsargyris A, Bekkema F, et al.: Editor’s choice – Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: Results from 166 consecutive patients. Eur J Vasc Endovasc Surg 2015; 49: 524–31 MEDLINE CrossRef
28.Nordon IM, Hinchliffe RJ, Holt PJ, et al.: Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review. Eur J Vasc Endovasc Surg 2009; 38: 35–41 MEDLINE CrossRef
29.Abdelhamid MF, Davies RS, Vohra RK, Adam DJ, Bradbury AW: Assessment of renal function by means of cystatin C following standard and fenestrated endovascular aneurysm repair.
Ann Vasc Surg 2013; 27: 708–13 MEDLINE CrossRef
30.Haddad F, Greenberg RK, Walker E, et al.: Fenestrated endovascular grafting: the renal side of the story. J Vasc Surg 2005; 41: 181–90 MEDLINE CrossRef
31.Ferreira M, Lanziotti L, Cunha R, d’Utra G: Endovascular repair of thoracoabdominal aneurysms: results of the first 48 cases. Ann Cardiothorac Surg 2012; 1: 304–10 MEDLINE PubMed Central
32.Oikonomou K, Kopp R, Katsargyris A, Pfister K, Verhoeven EL, Kasprzak P: Outcomes of fenestrated/branched endografting in post-dissection thoracoabdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 48: 641–8 MEDLINE CrossRef
33.Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV: Durability of branches in branched and fenestrated endografts. J Vasc Surg 2013; 57: 926–33 MEDLINE CrossRef
34.Panuccio G, Bisdas T, Berekoven B, Torsello G, Austermann M: Performance of bridging stent grafts in fenestrated and branched aortic endografting. Eur J Vasc Endovasc Surg 2015; 50: 60–70 MEDLINE CrossRef
35.Österberg K, Falkenberg M, Resch T: Endovascular technique for arterial shunting to prevent intraoperative ischemia.
Eur J Vasc Endovasc Surg 2014; 48: 126–30 MEDLINE CrossRef
36.Österberg K, Falkenberg M, Resch T: Endovascular technique for arterial shunting to prevent intraoperative ischemia.
Eur J Vasc Endovasc Surg 2014; 48: 126–30 MEDLINE CrossRef
37.Grabenwöger M, Alfonso F, Bachet J, et al.: Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases:
a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
Eur J Cardiothorac Surg 2012; 42: 17–24 MEDLINE CrossRef
38.Nordon IM, Hinchliffe RJ, Holt PJ, et al.: Endovascular management of chronic aortic dissection in patients with Marfan syndrome. J Vasc Surg 2009; 50: 987–91 MEDLINE CrossRef
39.Rylski B, Beyersdorf F, Desai ND, et al.: Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair. Eur J Cardiothorac Surg 2015; 48: 258–63 MEDLINE CrossRef
40.Erbel R, Aboyans V, Boileau C, et al.: 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873–926.
e1.Rao R, Lane TR, Franklin IJ, Davies AH: Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms. J Vasc Surg 2015; 61: 242–55 MEDLINE CrossRef
e2.Shahverdyan R, Gawenda M, Brunkwall J: Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review. Eur J Vasc Endovasc Surg 2013; 45: 28–35 MEDLINE CrossRef
e3.Haulon S, Greenberg RK, Spear R, et al.: Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014; 148: 1709–16 MEDLINE CrossRef
e4.Rylski B, Szeto WY, Bavaria JE, et al.: Development of a single endovascular device for aortic valve replacement and ascending aortic repair. J Card Surg 2014; 29: 371–6 MEDLINE CrossRef
e5.Kitagawa A, Greenberg RK, Eagleton MJ, Mastracci TM, Roselli EE: Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg 2013; 58: 625–34 MEDLINE CrossRef
e6.Shahverdyan R, Majd MP, Thul R, Braun N, Gawenda M,
Brunkwall J: F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
Eur J Vasc Endovasc Surg 2015. DOI: 0.1016/j.ejvs.2015.04.028 (Epub ahead of print).
e7.Barillà D, Sobocinski J, Stilo F, Maurel B, Spinelli F, Haulon S: Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR. Int Angiol 2014; 33: 466–73.
e8.Chisci E, Kristmundsson T, de Donato G, et al.: The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts. J Endovasc Ther 2009; 16: 137–46 MEDLINE CrossRef
e9.Raux M, Patel VI, Cochennec F, et al.: A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms. J Vasc Surg 2014; 60: 858–63 MEDLINE CrossRef
e10.Michel M, Becquemin JP, Clément MC, Marzelle J, Quelen C, Durand-Zaleski I: WINDOW trial participants. Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms. Eur J Vasc Endovasc Surg 2015. DOI: 10.1016/j.ejvs.2015.04.012 (Epub ahead of print) CrossRef
e11.Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd: Endovascular repair with fenestrated-branched stent grafts improves 30-day outcomes for complex aortic aneurysms compared with open repair. Ann Vasc Surg 2013; 27: 267–73 MEDLINE CrossRef