Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms.

Objective: To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). Summary of Background Data: FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. Methods: Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. Results: A total of 2,603 patients (69% males; mean age 72±10 y-old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2,187 patients (84%) and non-elective repair in 416 patients (16%; 268 [64%] symptomatic, 148 [36%] ruptured). Non-elective FB-EVAR was associated with higher early mortality (17% vs. 5%, P &lt;0.001) and rates of MAEs (34% vs. 20%, P &lt;0.001). Median follow-up was 15 months (interquartile range, 7-37 mo). Survival and cumulative incidence of ARM at 3-years were both lower for non-elective versus elective patients (50±4% vs. 70±1% and 21±3% vs. 7±1%, P &lt;0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio [HR], 1.92; 95% confidence interval [CI], 1.50-2.44; P &lt;0.001) and ARM (HR, 2.43; 95% CI, 1.63-3.62; P &lt;0.001). Conclusions: Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment. 

Outcomes of Elective and non-elective fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms

Type of Research: Retrospective descriptive study of prospectively collected data from the Vascular Quality Initiative. Key Findings (/50 words): The number of physician modified endografts has increased substantially in recent years, and has replaced custom manufactured endografts as the dominant repair modality for thoracoabdominal and complex abdominal aortic aneurysms. This trend was seen even in juxtarenal aneurysms, and was more pronounced in higher volume surgeons. Take home Message: Physician modified endografts have surpassed custom manufactured grafts outside of PS-IDEs as the predominant repair modality for thoracoabdominal, complex abdominal, and juxtarenal aortic aneurysms. Introduction Custom branched/fenestrated grafts are widely available in other countries, but in the United States they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEG). We therefore sought to determine how widespread the use of these grafts are. Methods We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the VQI from 2014-2022 to examine temporal trends. Results There were 5,826 repairs during the study period; 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7±0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256), and nearly twofold for juxtarenal repairs. In 3-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFEN (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P<.001). The differences in PMEG utilization were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEG and ZFEN. However, surgeons in the highest quartile of volume performed a median of 18 PMEG/year [IQR 10-21], but only 1.6 ZFEN/year [0.8-3.4]. The number of physician-sponsored investigational device exemption (IDE) trials of PMEGs has expanded from one in 2012 to 8 currently enrolling. As those data are not included in the VQI, the true number of PMEGs is likely substantially higher. Conclusion Physician-modified endografts have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of IDEs. The field of endovascular aortic surgery, and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes and comparisons to custom manufactured grafts. 

National Trends in Utilization of Surgeon Modified Grafts for Complex and Thoracoabdominal Aortic Aneurysms.

Minimally invasive staged segmental artery coil embolization (MIS2ACE) is an emerging technology for priming of the paraspinous collateral network prior to open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Its safety and efficacy have been previously proven in various experimental settings and confirmed in numerous multicentric pilot studies for open and endovascular repair. MIS2ACE is safe and has the potential to decisively reduce the risk of postoperative paraplegia, the most devastating complication of open and endovascular TAAA repair, still affecting up to 20% of patients. Up to now, MIS2ACE has been clinically implemented with excellent results, and is currently being investigated in the international, multicenter, randomized controlled trial PAPAartis, funded by the German Research foundation, and the European Union. MIS2ACE can be performed under local anesthesia, enabling continuous monitoring of neurological function, and in case of clinical signs of imminent ischemia, preemptive interruption of the procedure. A thorough evaluation of preoperative computed tomography (CT) imaging for identification of open and accessible segmental arteries (SAs) is critical. Segmental artery occlusion can be achieved with either micro coils, or vascular plugs. A maximum number of seven SAs is currently recommended to be occluded in the same session, and a minimum interval of 5 days should be awaited between either two MIS2ACE sessions or between MIS2ACE and the final repair. Adjuvant side-effects of MIS2ACE are the reduction in segmental back-bleeding during open repair leading to harmful steal phenomenon and the reduction of the incidence of type II endoleaks in endovascular repair. Current contraindications for MIS2ACE are emergency cases, hostile anatomy, and a shaggy aorta. Other neuroprotective adjuncts such as cerebrospinal fluid (CSF) drainage, permissive hypertension, motor-evoked potentials (MEP)/somato-sensory evoked potentials (SSEP) and monitoring of paraspinous muscle oxygenation by near-infrared spectroscopy should also be applied independent of prior MIS2ACE procedure.

Minimally invasive staged segmental artery coil embolization (MIS2ACE) for spinal cord protection

Evaluation of False Lumen Occluders implanted in the Abdominal Aorta False Lumen.

Comparison of single and multistage strategies during fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms.

OBJECTIVE
To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs).


SUMMARY OF BACKGROUND DATA
FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described.


METHODS
Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair.


RESULTS
A total of 2,603 patients (69% males; mean age 72±10 y-old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2,187 patients (84%) and non-elective repair in 416 patients (16%; 268 [64%] symptomatic, 148 [36%] ruptured). Non-elective FB-EVAR was associated with higher early mortality (17% vs. 5%, P<0.001) and rates of MAEs (34% vs. 20%, P<0.001). Median follow-up was 15 months (interquartile range, 7-37 mo). Survival and cumulative incidence of ARM at 3-years were both lower for non-elective versus elective patients (50±4% vs. 70±1% and 21±3% vs. 7±1%, P<0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio [HR], 1.92; 95% confidence interval [CI], 1.50-2.44; P<0.001) and ARM (HR, 2.43; 95% CI, 1.63-3.62; P<0.001).


CONCLUSIONS
Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.

Outcomes of Elective and non-elective fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms.

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Comparison of single and multistage strategies during fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms.

Outcomes of Elective and non-elective fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms.