Endovascular treatment of abdominal aortic aneurysms

Abstract

Patients with abdominal aortic aneurysms (AAAs) are usually treated with endovascular aneurysm repair (EVAR), which has become the standard of care in many hospitals for patients with suitable anatomy. Clinical evidence indicates that EVAR is associated with superior perioperative outcomes and similar long-term survival compared with open repair. Since the randomized, controlled trials that provided this evidence were conducted, however, the stent graft technology for infrarenal AAA has been further developed. Improvements include profile downsizing, optimization of sealing and fixation, and the use of low porosity fabrics. In addition, imaging techniques have improved, enabling better preoperative planning, stent graft placement, and postoperative surveillance. Also in the past few years, fenestrated and branched stent grafts have increasingly been used to manage anatomically challenging aneurysms, and experiments with off-label use of stent grafts have been performed to treat patients deemed unfit or unsuitable for other treatment strategies. Overall, the indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms. Ongoing studies and optimization of imaging, in addition to technological refinement of stent grafts, will hopefully continue to broaden the utilization of EVAR.

Occupational Radiation Exposure During Endovascular Aortic Repair

“…The increasing number of endovascular interventions for aortic pathology, particularly in challenging anatomies, results in increasing radiation exposure to operating room personnel [1][2][3]. Endovascular aortic repair procedures are frequently performed at hybrid operating rooms, where also staff members may be present who are not sufficiently educated in radiobiology, radiation safety, and dose reduction principles [4,5].…”

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

“…The sandwich technique involves the use of CVs placed in the abdominal aorta branches, like chimneys, that are 'sandwiched' between two aortic endografts. 75 This concept of parallel endografting, although off-label, has been popularized, but the additional seal achieved is imperfect. As such, concern remains about the effects of type I endoleak through the 'gutters' created by the multiple side-by-side CVs outside the main endograft on long-term durability as well as branched vessel patency.…”

“…These were first described by Greenberg et al, 35 and use commercially available devices by creating parallel channels with covered stents (CVs) to maintain renal and visceral branch perfusion and to intentionally relocate the EVAR seal zone cranially. The chimney, snorkel, periscope and sandwich grafts are cheaper than the fenestrated graft, require limited endovascular tools for implantation, and have immediate availability and broader applicability in the acute setting; 75 for example, in patients suffering from large or rapidly expanding aneurysms (> 0.5 cm/annually), emergent ruptured or symptomatic aneurysms 40 and in those who cannot withstand the time required by the manufacturer for device customization. 76 This approach, which is considered as another off-theshelf solution, can also be used as a bailout from accidental coverage of vital side branches during deployments requiring close approximation of the main body to the branch artery in question.…”

“…42 As increasingly complex aortic pathology is treated via endovascular means, innovation has been driven through the use of novel techniques and devices customized in consultation with manufacturers. 75 For example, the combination of fenestrations and branches in the same proximal SG component has been used in narrow or angulated reno-visceral aortic segments, 86 or internal/external cuffs (axially oriented or caudally directed) for TAAAs and PRAs. 87 Moreover, to overcome the necessity of aortic main body customization, off-the-shelf devices have become apparent.…”

Anesthesia for the Endovascular Management of Aortic Disease

“…11 A number of techniques have been developed for the endovascular treatment of more complex aortic diseases such as suprarenal AAAs and thoracoabdominal aortic aneurysms, or infrarenal AAAs with short or absent necks. 12 In these cases, the endovascular technique must exclude the aneurysm while preserving blood flow to the renal and visceral arteries. 13 The use of fenestrated stent grafts to solve this problem was first described in 1996.…”