Alma Mater Studiorum Bologna University. S.Orsola-Malpighi, Bologna, Italy Vascular Surgery
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1 Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery L orientamento dell arteria renale influenza gli outcomes renali nel trattamento endovascolare degli aneurismi toracoaddominali con endoprotesi fenestrate e branched E Gallitto, M Gargiulo, G Faggioli, R Pini, C Mascoli, S Ancetti, M Abualhin, A Stella
2 Background FB-EVAR available options for aneurysms involving renal / splanchnic arteries Amiot, EJVS, 2010 Verhoeven, EJVS 2010
3 Background FB-EVAR available options for aneurysms involving renal / splanchnic arteries Amiot, EJVS, 2010 Verhoeven, EJVS 2010 TVVs-patency is crucial for technical and clinical success after FB-EVAR of TAAAs
4 Background Satisfactory TVVs-patency rate during F-up * 94% 5-yr * 93% 5-yr Verhoeven, EJVS 2015 Oderich, J Thorac Cardiovasc Surg 2017
5 Background Satisfactory TVVs-patency rate during F-up Higher Occlusion rate for Renal Artery (RA) - RA vs SMA & CT branches HR: 3.5; CI: ; p RA branches vs fenestration 10% vs 2%; p < yr 90% vs 97%; p <.001 Mastracci, EJVS, 2016 Martinez-Gonzales, EJVS, 2016
6 Background Specific details about the angle of renal artery in the native aorta, length of artery stented, the angles of the stents placed, the amount of routine oversizing are not available in this study Mastracci, EJVS, 2016 Renal artery angulation before and after endovascular treatment was not analyzed and neither was the distance from the endograft main body to the origin of the target vessel and the length of bridging stent into the target vessel. Martinez-Gonzales, EJVS, 2016
7 Aim To evaluate the impact of renal artery anatomy on the renal outcome of FB - EVAR for TAAAs
8 Methods TAAAs underwent F/B-EVAR Prospective enrollment Retrospective Data Analysis Anatomy Procedure Post-operative
9 Methods RA - anatomy VR, MPR & CLL reconstruction by 3Mensio software Diameter Length Ostial stenosis/calcification Orientation Aortic angles of the para-visceral aorta
10 Methods RA orientation A Horizontal B Upward C Downward D Downward + Upward RA revascularization Fenestrations vs Branches Stentgraft
11 Endpoints 1. Intraoperative RA - Loss inability to cannulate and stent RA 2. Early RA - occlusion < 3-month F-up 3. Composite RA - events intra-operative RA-lesion / RA-loss / RA-related redo / RA-occlusion
12 Results Patients 73 D TAAA (mm) 66 ± 17 ASA III/IV 66 / 33% Crawford n % Type I, II, III Type IV Total RAs 128
13 Results Patients 73 D TAAA (mm) 66 ± 17 ASA III/IV 66 / 33% Crawford n % Type I, II, III Type IV Total RAs 128 n % Male Hypertension Smoke Dyslipidemia Diabetes 3 4 Obstructive Pulmonary Disease Coronary Artery Disease Atrial Fibrillation 8 11 Oral Anticoagulant Cerebrovascular Disease 7 10 Transit Ischemic Attack 3 4 Stroke 3 4 Body Mass Index > Peripheral Artery Disease 4 6 Chronic Renal Failure Dialysis 5 7 Previous Aortic Surgery 43 59
14 Results RA Anatomy mean SD Diameter (mm) 6 1 Length (mm) n % Ostial stenosis Ostial calcification Angle of paravisceral aorta > RA orientation 51-40% 18-14% 48-36% 11 10%
15 Results FB-EVAR endograt n % Custom made Off the Shelf 20 27
16 Results FB-EVAR endograt n % Custom made Off the Shelf RAs accommodation Fenestrations Branches Total
17 Results TVV Stentgraft n % BE SE 1 1 BE + SE 10 8 Relining SE bare metal stent BE: Balloon Expandable; SE: Self Expandable
18 Results 1. Intraoperative RA Loss 10 (8%)
19 Results 1. Intraoperative RA Loss 10 (8%) UNIVARIATE MULTIVARIATE OR 95% CI p OR 95% CI p Type B orientation Type C orientation Para-visceral aortic angle > Branches
20 Results 2. Early RA - Occlusion 4 (3%) n Bilateral* 1 Single kidney patients** 2 * Temporary hemodialysis ** Persistent hemodialysis
21 Results 2. Early RA - Occlusion 4 (3%) n Bilateral* 1 Single kidney patients** 2 UNIVARIATE OR 95% CI p Type D orientation Branches * Temporary hemodialysis ** Persistent hemodialysis
22 Results 3. Composite RA - events 17 (13%) n % Intra-operative RA lesion 4 3 RA-loss 10 8 RA-related redo 5 7 RA-occlusion 4 3
23 Results 3. Composite RA - events 17 (13%) n % Intra-operative RA lesion 4 3 RA-loss 10 8 RA-related redo 5 7 MULTIVARIATE OR 95% CI p Type B orientation Type D orientation Branches RA-occlusion 4 3
24 Conclusion RA orientation significantly affects early RA-outcomes of FB-EVAR for TAAA Intraoperative RA-loss is predicted by Type B RA-orientation & Branches Early RA-occlusion is predicted by Type D orientation and Branches Our data suggest that in TAAAs Fenestrations should be preferred for renal revascularization in type B and D RA-orientation
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