Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

Abstract

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta‐analysis

“…Furthermore, studies have indicated additional benefits of TFA, including a lower incidence of spinal cord ischemia, reduced thromboembolic events, and a decreased occurrence of lower leg ischemia and associated complications, compared to the brachial approach. 16,23 Knowles et al reported in their study that there was no increased risk of stroke in patients undergoing EVAR using either TFA or UEA. 15 This finding is corroborated by other studies.…”

“…The positioning of the operator, along with reduced operation time, can contribute to a notable reduction in radiation exposure for both the patient and the medical team during the TFA route. Furthermore, studies have indicated additional benefits of TFA, including a lower incidence of spinal cord ischemia, reduced thromboembolic events, and a decreased occurrence of lower leg ischemia and associated complications, compared to the brachial approach 16,23 …”

Novel Technique for Intentional Occlusion of Directional Branches During Complex Endovascular Aortic Repair Using Microvascular Plugs

“…Contemporary reports of BEVAR have shown high technical success rates, with low mortality and morbidity that have contributed to expanding its indications and applicability. 12,13 The technique of BEVAR invariably requires catheterization of DB and, through them, of their intended target vessels which may be accomplished using different technical options. 14 Variations of the normal renal and mesenteric arterial anatomy have been described and provide the rationale basis for off-the-shelf devices that are currently available or under investigations.…”

A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms

“…Indeed, it is well known that achieving a seal zone in a morphologically infrarenal hostile neck will make the repair more prone to lower durability over time, especially for patients with larger proximal requiring higher oversize. Fenestrated-branched EVAR (F-B/EVAR) moves the proximal zone above the renal-visceral vessel where the native aorta is less prone to dilation and it may represent a feasible and safe alternative to EVAR in the case of hostile neck, especially for patients unfit for open surgical repair or for those with long life expectancy [ 38 ]. According to the outcomes of high-volume aortic centers, F-B/EVAR may be also proposed as the first-line approach in the case of proximal complication after EVAR, with satisfactory clinical outcomes comparable with patients undergoing treatment for native aneurysm [ 39 , 40 ].…”