Impact of Hybrid Operating Rooms on Long-Term Clinical Outcomes Following Fenestrated and Branched Endovascular Aortic Repair

Tinelli, Giovanni; Bonnet, Marie; Hertault, Adrien; Sica, Simona; Tanna, Gian Luca Di; Bianchini, Aurélia; Fabre, Dominique; Sobocinski, Jonathan; Haulon, Stéphan

doi:10.1177/1526602821996725

Cited by 13 publications

(8 citation statements)

References 21 publications

(43 reference statements)

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“…19 Newer generation hybrid ORs also showed better long-term clinical outcomes in complex endovascular aortic procedures as compared with mobile C-arms. 20 In contrary to conventional CTA scanners, it is important to emphasize that CBCTA image acquisition with selective intra-arterial contrast injection in the hybrid OR provides higher fidelity image data, with isotropic image resolution, making it easier to create high-quality 3D reconstructions and segmentations (for optimizing working projections) and MPR to accurately measure the parent vessel size.…”

Section: Discussionmentioning

confidence: 99%

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms

et al. 2022

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Purpose: The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. Materials and Methods: Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. Results: A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0–4 vs 2,1–3 vessels). Conclusion: Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. Clinical Impact Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.

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Section: Discussionmentioning

confidence: 99%

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms

et al. 2022

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“…The accurate placement of all endograft components is crucial for a durable result. In fenestrated and branched endovascular aortic repair (f-bEVAR), satisfactory assessment of all endograft components can be difficult with two-dimensional angiography and fluoroscopy alone ( 3 – 9 ). Unwanted findings such as stent compression or kinking, insufficient bridging or flaring of branch stents are easily detected on conventional CT or cone beam computed tomography (CBCT) imaging ( 4 , 7 – 11 ).…”

Section: Introductionmentioning

confidence: 99%

Intraoperative computed tomography during fenestrated and branched endovascular aortic repair: a feasibility study

et al. 2023

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Background Endovascular aortic repair with fenestrated or branched endografts is technically challenging, and proper intraoperative assessment of all stent graft components with only angiography and fluoroscopy can be difficult. Intraoperative computed tomography (CT) imaging can be a valuable aid for the operators in the evaluation of stent grafting results prior to completion of surgery. Purpose To examine the feasibility of performing intraoperative CT imaging during fenestrated and branched endovascular aortic repair (f-bEVAR) under sterile conditions and with patients under general anesthesia. Material and Methods Intraoperative CT imaging was performed in 10 patients undergoing elective aortic repair with fenestrated or branched endografts. Adverse events, time consumption for CT set-up and image acquisition, and additional radiation dose to the patient were recorded. CT image quality was graded. Immediate corrective maneuvers performed based on the CT findings was registered. Results There were no adverse events related to intraoperative CT imaging. The median additional operating time by including intraoperative CT was 16 min (interquartile range [IQR] = 12–19), comprising 7% of the median total operating time. The median estimated additional radiation dose to the patient was 4.8 mSv (IQR = 3.8–4.9). All intraoperative CT examinations were considered to be of sufficient quality for stent graft evaluation. No immediate corrective procedures were performed on the basis of CT findings in this study cohort. Conclusion CT imaging intraoperatively during f-bEVAR is feasible with an acceptable increase in operating time and radiation dose.

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“…Learning curve as well as technological development, for example, with integration of intraoperative navigation and use of modern hybrid operating theaters, has resulted in improved outcome despite increasing complexity of the aneurysmal anatomies treated. 1 As part of this development, an increasing proportion of FEVAR procedures being performed in high-volume centers involve 4-vessels solution to secure a durable proximal landing zone. [2][3][4] In this setting, 1 of the key points is to avoid the loss of access to visceral vessels.…”

Section: Introductionmentioning

confidence: 99%

A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair

et al. 2022

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Purpose: The aim of this study was to present a new technique for fenestrated endovascular aortic aneurysm repair (FEVAR) and to review its preliminary results. The SiMplified bARe-wire Target vessel (SMART) technique for FEVAR aims to simplify the procedure by avoiding guiding sheaths into visceral arteries during the main graft deployment. Materials and Methods: The SMART technique requires a 12 to 16Fr contralateral introducer, depending on number of fenestrations—compared with standard 18 to 22Fr for 3 to 4 FEVAR—to achieve target vessel catheterization and stenting during FEVAR by avoiding the use of parallel 6 to 7Fr guiding sheaths into each visceral vessel. Fenestrations are sequentially catheterized, assisted by a steerable sheath. A Rosen wire is maintained in each fenestration, with a single sheath parked in the final target vessel while releasing the fenestrated graft. Data on patients treated for pararenal or thoracoabdominal aortic aneurysms with FEVAR, adopting the SMART technique, were retrospectively reviewed. End points were technical success, intraprocedural variables, 90-day mortality, major adverse events (MAEs), and target vessel patency. Results: From May 2018 to December 2020, 57 consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. Median total procedure time and total fluoroscopy time were 223 (196–271) minutes and 81 (71–94) minutes, respectively. Primary technical success was 96.4% (55/57). No misalignment occurred from graft deployment. The total number of fenestrations was 169, including 54 left and 53 right renal arteries, 43 superior mesenteric arteries and 18 celiac trunks (3.0±0.9 vessels/patient), with target vessel technical success of 98.2%. During the first 90 days, there were no deaths (0%). The MAEs included acute kidney injury (AKI) in 3 patients (5%) with no new dialysis onset, respiratory failure requiring prolonged ventilation in 2 patients (4%), myocardial ischemia in 1 patient (2%), but no lower limb ischemia, stroke, or spinal cord ischemia (SCI) occurred. After a mean follow-up of 14±10 months, there was 1 aortic-related death. Primary and assisted primary target vessel patency was 94.6%±1.8 and 97.0%±1.3% respectively. Conclusions: The SMART technique proved to be a safe alternative to standard FEVARs, with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity. Clinical Impact This study evalautes the outcome of fenestrated endovascular aortic repair (FEVAR) procedures at Uppsala university hospital using a simplified bare-wire Target vessel (SMART) technique. The SMART technique requires a smaller contralateral introducer compared to standard 18-22Fr for 3-4 FEVAR to achieve target vessel catetherization and stenting. Fifty-seven consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. The SMART technique proved to be a safe alternative to standard FEVARs with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.

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Impact of Hybrid Operating Rooms on Long-Term Clinical Outcomes Following Fenestrated and Branched Endovascular Aortic Repair

Cited by 13 publications

References 21 publications

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms

Intraoperative computed tomography during fenestrated and branched endovascular aortic repair: a feasibility study

A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair

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