Standardization of the CHEVAR procedure: How a standard approach has improved outcomes. Prof Peter Holt St George s, London
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1 Standardization of the CHEVAR procedure: How a standard approach has improved outcomes Prof Peter Holt St George s, London
2 Disclosure Speaker name: Prof Peter Holt I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company X Other(s) Institutional research grant Medtronic I do not have any potential conflict of interest
3 Juxta-renal Aneurysms
4 Fenestrated EVAR Chimney procedure Aorto-iliac morphology Comorbidity EVAR + anchors EVAR alone Life expectancy
5 Open Repair of Complex Aneurysms
6 Endovascular Treatment Complex AAA CMD gold-standard but temporal, cost and manufacturing constraints Turndown rate 7% early reintervention Appreciable mortality in most complex Off the shelf f-evr limited by applicability and durability
7 Parallel Grafts and EVAR
8 Parallel Graft Options Ch-EVAR (ENCHANT) Ch-EVAS (ASCEND) Previous studies (PERICLES / PROTAGORAS)
9 Parallel Grafts and EVAR Current evidence Ideal features Standardisation
10 prospective study 2yr follow-up Endurant / Atrium 30% oversize new neck >15mm Patients high risk for OAR & contraindicated for FEVAR 187 chimneys in 128 pts 1= 64.1% 2= 28.1% 3= 6.3% 4=1.6%
11 PROTAGORAS study Mean Preoperative proximal neck diameter 24.9 ± 3.7 mm Preoperative suprarenal neck angulation 22.8 ± 22.6 Preoperative proximal neck length Postoperative new neck length after use of chimney grafts 4.7 ± 3.2 mm 18.7 ± 6.3 mm TV per patient 1.5 Technical success 100% 30 day mortality 0.8%
12 PROTAGORAS study 90.6 % patients had reduced or stable diameter Sac regression: mm, p <0.001 Increased 9% Stable 23% Reduced 68% Sac shrinkage/stabilization comparable to standard EVAR at two years
13 PROTAGORAS study Primary chimney graft patency 95.7% through 24.6 months Freedom from Chimney graft reinterventions 93.1% through 24.6 months New onset type Ia endoleak 1.6% at 2 years
14 retrospective review 13 centres with experience of >10 chimneys 13 centres with 517 patients Any graft combination AAA, Acute Aortic Syndromes, post-evar 1a leak, para-anastomotic aneurysm
15 Pericles: Outcomes Intra-op type Ia endoleak: 7.9% Persistent intra-op type Ia endoleak: 2.9% Type IA endoleak at latest FU: 5.8% Technical Success 97.1% for 517 patients from 13 international centers
16 Pericles: Outcomes Mean Pre-op Sac Diameter (mm): 65.9 ± 21.6 Mean Latest F/U Sac Diameter (mm): 61.2 ± 19.7 p = 0.001
17 ENCHANT 2mm SMA Lowest Renal Proximal Aspect of AAA Two Chimne y One Chimney
18 Chimney-Endurant SMA Primary indication 2mm Lowest Renal Proximal Aspect of AAA Two Chimn ey One Chimney Minimum sealing zone For one Chimney: 15 mm from proximal aspect of AAA to highest renal For two Chimney: 15 mm from proximal aspect of AAA to SMA MINIMUM infrarenal neck of 2 mm 18
19 Chimney-Endurant 19 mm to 30 mm Aortic diameter treatment range 19 mm to 30 mm Oversizing recommendations 20 to 30% Oversizing incorporates additional diameter to seal around the renal stent Oversizing recommendations remain the same for one or two parallel grafts 19
20 ChEVAR Indication detail 20 to 30% oversizing is recommended Oversizing incorporates seal around renal stents Less oversizing guttering type 1a endoleaks More oversizing renal stent collapse / main body infolding/invagination Oversizing the same for one or two parallel grafts
21 The Need for A Neck
22 Risks / Benefits Benefits Off the shelf No lead time Urgent / Emergent cases Few morphological contraindications Cost Standardisation optimizes outcome Risks Upper limb access Vascular injury Nerve injury Stroke Procedural blood loss Durability needs defining Endoleak Reinterventions difficult
23
24 Standardization of the CHEVAR procedure: How a standard approach has improved outcomes Prof Peter Holt St George s, London
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