A Comprehensive Review of In Situ Fenestration of Aortic Endografts

Abstract

Objective/Background: The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI.Methods: A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition.Results: Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graft and situations where direct communication between the prosthesis and a nonsterile site exists, including fistulae, exposed grafts in open wounds, and deployment of an endovascular stent-graft into an infected field (e.g., mycotic aneurysm); minor criteria are localized AGI features or fever $38 C, where AGI is the most likely cause. (ii) Radiological major criteria comprise increasing perigraft gas volume on serial computed tomography (CT) imaging or perigraft gas or fluid ($7 weeks and $3 months, respectively) postimplantation; minor criteria include other CT features or evidence from alternative imaging techniques. (iii) Laboratory major criteria comprise isolation of microorganisms from percutaneous aspirates of perigraft fluid, explanted grafts, and other intraoperative specimens; minor criteria are positive blood cultures or elevated inflammatory indices with no alternative source.Conclusion: This AGI definition potentially offers a practical and consistent diagnostic standard, essential for comparing clinical management strategies, trial design, and developing evidence-based guidelines. It requires validation that is planned in a multicenter, clinical service database supported by the Vascular Society of Great Britain & Ireland.

Favourable Outcomes of Endovascular Total Aortic Arch Repair Via Needle Based In Situ Fenestration at a Mean Follow-Up of 5.4 Months

“…The cTAG is covered with expanded polytetrafluoroethylene (ePTFE), which has proved easier to puncture than other endograft fabrics in in vitro experiments. 11 Therefore, this can facilitate the needle penetration and shorten the cerebral ischaemic time in LCCA and BCT revascularisation. In addition, it has also been reported that the orifices created on ePTFE membrane by plain balloons are markedly circular not elliptical, 12 which can better conform to the bridging endografts and diminish the chance of endoleak.…”

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

“…In situ fenestration of standard stent grafts is another option to extend the proximal landing zone by covering the supra-aortic branches and performing a fenestration via a retrograde access in vivo. 217,218 Graft perforations can be performed by laser or mechanical means. This technique is new, and long-term data in humans are missing.…”

A case report of a hybrid procedure (visceral and partial aortic arch debranching) in the treatment of a challenging aneurysm of the thoracoabdominal aorta in the endovascular era

“…Fenestrated stent-grafting in the aortic arch is technically challenging due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration techniques might avoid these problems, but because of possible issues with stent-grafts durability and ischemic complications during temporary carotid arteries coverage, this technique has not been widely adopted [16,17,18]. In recent years, arch branched endografts have been developed as a new technique for revascularization of supra-aortic branches.…”