Fenestrated endovascular aneurysm repair

Cross, Jennifer; Gurusamy, Kurinchi Selvan; Gadhvi, Vijay M.; Simring, Dominic; Harris, Peter L.; Ivancev, Krassi; Richards, Toby

doi:10.1002/bjs.7804

Cited by 81 publications

(73 citation statements)

References 32 publications

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“…Some designs are without fenestrations but with branches (pre-attached limbs or cuffs) targeted for the visceral aortic vessels, suitable for the endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs). At least for short-necked and juxtarenal aortic aneurysms (JRAs), fenestrated stent-grafting technology has been shown to be feasible, [12][13][14][15][16][17][18][19][20] with published results of highvolume experienced single centers [21][22][23][24][25][26][27][28][29][30][31] and a few recent multicenter trials 32,33 sharing remarkable short-and midterm results, with the durability of the technique being satisfactory (technical success > 95%, low mortality rates averaging 1-2% and low rates of mid-term branch vessel occlusion averaging 4-9%). [25][26][27][28][29]34 Other imaginative procedures have also been developed or modified to allow for the segmental or complete coverage of the aorta in the region of vital branches, including the 'chimney', 'snorkel', 'periscope' [35][36][37] and combined endovascular exclusion and extra-anatomic mesenteric/renal bypasses (hybrid visceral revascularization).…”

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confidence: 99%

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

et al. 2016

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The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).

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

et al. 2016

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“…A systematic review by Nordon et al 51 reported that non-RCTs were identified and they included eight cohort studies reporting 368 fEVAR cases and 12 cohort studies reporting 1164 OSRs of JRAAs. One systematic review by Cross et al 52 identified 11 fEVAR studies describing 660 procedures with no comparison. However, this study also acknowledged in its conclusions that 'there are currently no controlled trials comparing fEVAR with OSR, and current evidence is weak with many unanswered questions'.…”

Section: Chapter 7 Discussionmentioning

confidence: 99%

“…However, this study also acknowledged in its conclusions that 'there are currently no controlled trials comparing fEVAR with OSR, and current evidence is weak with many unanswered questions'. 52 Another systematic review included five single-arm studies on fEVAR and seven studies on OSR (one prospective and six retrospective). 4 They also identified and included a study in the form of an abstract that compared the results of fEVAR with those of OSR.…”

Section: Chapter 7 Discussionmentioning

confidence: 99%

The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis

Armstrong

Burgers

Deshpande

et al. 2014

Health Technology Assessment

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BackgroundPatients with large abdominal aortic aneurysms (AAAs) are usually offered reparative treatment given the high mortality risk. There is uncertainty about how to treat juxtarenal AAAs (JRAAAs) or thoracoabdominal aortic aneurysms (TAAAs). Endovascular repair of an abdominal aortic aneurysm (EVAR) is often seen as safer and easier than open surgical repair (OSR). However, endovascular treatment of JRAAAs or TAAAs requires specially manufactured stent grafts, with openings to allow blood to reach branches of the aorta. Commissioners are receiving increasing requests for fenestrated EVAR (fEVAR) and branched EVAR (bEVAR), but it is unclear whether or not the extra cost of fEVAR or bEVAR is justified by advantages for patients.Objective(s)To assess the clinical effectiveness, safety and cost-effectiveness of fEVAR and bEVAR in comparison with conventional treatment (i.e. no surgery) or OSR for two populations: JRAAAs and TAAAs.Data sourcesResources were searched from inception to October 2013, including MEDLINE (OvidSP), EMBASE (OvidSP) and the Cochrane Central Register of Controlled Trials (Wiley) and, additionally, for cost-effectiveness, NHS Economic Evaluation Database (NHS EED; Wiley) and EconLit (EBSCOhost). Conference abstracts were also searched.Review methodsStudies were included based on an intervention of either fEVAR or bEVAR and a comparator of either OSR or no surgery. For clinical effectiveness, observational studies were excluded only if they were not comparative, i.e. explicitly selected on the basis of prognosis.ResultsFor clinical effectiveness, searches retrieved 5253 records before deduplication. Owing to overlap between the databases, 1985 duplicate records were removed. Of the remaining 3268 records, based on titles and abstracts, 3244 records were excluded, leaving 24 publications to be ordered. All 24 studies were excluded as none of them satisfied the inclusion criteria. Sixteen studies were excluded on study design, six on intervention and two on comparator. Five out of 16 studies excluded on study design reported a comparison. However, all of the studies acknowledged that they had groups that were not comparable at baseline given that they had selectively assigned younger, fitter patients to OSR. Therefore, these studies were considered ‘non-comparative’. For cost-effectiveness, searches identified 104 references before deduplication. Owing to overlap between the databases, 34 duplicate records were removed. Of the remaining 70 records, seven were included for the full assessment based on initial screening. After a full-text review, no studies were included. Because of the lack of clinical effectiveness evidence and difficulty in estimating costs given the rapidly changing and variable technology, a cost-effectiveness analysis (CEA) was not performed. Instead a detailed description of modelling methods was provided.ConclusionsDespite a thorough search, no studies could be found that met the inclusion criteria. All studies that compared either fEVAR or bEVAR with either OSR or no surgery explicitly selected patients based on prognosis, i.e. essentially the populations for each comparator were not the same. Despite not being able to conduct a CEA, we have provided detailed methods for the conduct if data becomes available.Future workWe recommend at least one clinical trial to provide an unbiased estimate of effect for fEVAR/bEVAR compared with OSR or no surgery. This trial should also collect data for a CEA.Study registrationThis study is registered as PROSPERO CRD42013006051.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…Standard EVAR with infra-renal fi xation is possible with a less than 10 mm neck, but a higher rate of intraoperative and late complications can be expected [ 4 ] . Fenestrated EVAR (FEVAR) is a technically challenging endovascular alternative with a 30-day pooled mortality of 2 % [ 10 ] . Currently these are usually customized to individual patient anatomy creating a signi fi cant delay to treatment ( Fig.…”

Section: Alternative Treatment Optionsmentioning

confidence: 99%

Chimney Technique in the Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysm

Neequaye

Gill

Abraham

2013

Endovascular Interventions

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IntroductionThe treatment of aortic aneurysms via an endovascular approach was fi rst described in 1991 [ 1 ] . In the 20 years since that time, endovascular aneurysm repair (EVAR) has become an accepted standard of care for aortic aneurysms with suitable anatomical criteria [ 2 ] . Exclusion of the aneurysm relies on obtaining a mechanical seal proximal and distal to the aneurysm. A signi fi cant proportion of patients, 20-50 % in some series, are not candidates for EVAR based on their anatomy [ 3 ] . Of those excluded based on anatomical considerations, up to half are excluded because of insuf fi cient aneurysm neck length to achieve a seal proximally. EVAR attempted on abdominal aortic aneurysms (AAAs) with short necks (<10-15 mm) are more likely to fail with subsequent migration, or endoleak, and possible aneurysm rupture [ 4,5 ] .Neck lengths less than 5-10 mm do not offer a suf fi cient infra-renal sealing zone. Extending the sealing zone proximally can be achieved by using custom-made devices with either fenestrations or branches through which bridging stents can be placed.In the medium term, these techniques appear to be safe and durable alternatives when standard EVAR is not appropriate [ 6,7 ] . Fenestrated devices have recently been approved in the USA, for juxtarenal aneurysm EVAR in selected centers [ 8 ] . The disadvantage of this technology includes cost and lengthy manufacturing times of these custom-made devices preventing timely repair in very large or symptomatic aneurysms. In some settings of extreme arterial tortuosity, fenestrated stent grafting may be technically impossible.The chimney technique was initially described as a bailout solution in cases where important aortic branch vessels were accidentally partially covered by an aortic endograft [ 9 ] . Since their initial description, chimney grafts have been used in all major branches of the aorta. They have also been used in both emergent and elective settings. The technique effectively extends the proximal sealing zone above important aortic branches by placing covered stents within arterial branches and then deploying an endograft across this region (Fig. 29.1a-c ).

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Fenestrated endovascular aneurysm repair

Abstract: FEVAR for repair of suprarenal and juxtarenal aneurysms is a viable alternative to open repair. However, there is no level 1 evidence for FEVAR, and current evidence is weak with many unanswered questions.

Cited by 81 publications

References 32 publications

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

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

The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis

Chimney Technique in the Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysm

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