Endovascular Treatment of the Aorta with Fenestrated and Branched Grafts
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1 Endovascular Treatment of the Aorta with Fenestrated and Branched Grafts Eric LG Verhoeven,MD, PhD, A. Katsargyris, MD Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
2 Disclosures William Cook Europe/Cook Inc. Consultant & Research grants W.L. Gore & Associates Consultant & Research grants Atrium Maquet Consultant Siemens Consultant
3 Vascular surgery has changed
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5 Purpose of F & B grafts To treat complex AAA and TAAA by endovascular means Important basic rule: strong fixation and sealing proximally Custom made, individually tailored grafts
6 F&B Procedures per year TAAA All Cases
7 Lay-out Complex Abdominal Aortic Aneurysms Thoraco-abdominal Aneurysms
8 Complex Abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)
9 Complex Abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)
10 Solution: Fenestrated Grafts
11 Fenestrated EVAR Goal Achieve sealing in short or absent neck Position of first sealing stent better portion aorta completely in neck Turn a short/no neck into a long neck...
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13 Fenestrated Technique Maturity Catheterization of target vessels Stenting of small fenestrations Atrium covered stents Technical tricks: Tilting, Flairing, Relining Long overlap between components
14 Fenestrated Technique Composite System
15 Bridging Stent-grafts Balloon-expandable Atrium V12 Life Stream Bentley Jotec
16 2x, 3x, or 4x FEVAR Choice According to Landing Zone JVS 2015;62:319-25
17 Evolution of Stent-graft Design x FEVAR (%) 3x-4x FEVAR (%) Use of 3x-4x FEVAR over the years
18 F-EVAR Technique
19 Indication? Cardio-Pulmonary Contra-Indications Hostile abdomen Redo Aortic surgery After EVAR After Open Surgery
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23 Indication? Cardio-Pulmonary Contra-Indications Hostile abdomen Redo Aortic surgery After EVAR After Open Surgery Normal risk patients
24 Results Expert Centers Follow-up up to 10 years Early mortality: <2% Target vessel patency at 2 years: > 90% Dialysis during follow-up: < 2% Decrease of renal function: 10-20% Very few endoleaks type I No late rupture Greenberg et al. J Vasc Surg. 2009;50(4): Verhoeven et al. Eur J Vasc Endovasc Surg 2010;39(5): Amiot, Haulon, et al. Eur J Vasc Endovasc Surg 2010;39(5):
25 5-years experience with FEVAR 281 pts Mortality 0.7%
26 Thoraco-abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)
27 Open repair for TAAA Coselli et al. Ann Thorac Surg 2002 Safi et al. J Vasc Surg 1998
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32 Acute/Ruptured TAAA Zenith t-branch prosthesis The only off-the-shelf endovascular stent graft indicated to treat thoracoabdominal aneurysms Suitable for a wide range of TAAA anatomy Modular system
33 TAB054
34 TAB054 Postop CTA
35
36 Nuremberg Experience 300 Consecutive pts F&B stent-grafts for TAAA April 2004 January 2017 Suprarenal aortic aneurysms excluded
37 Stent-graft Design Branches only N=93 (31.0%) Fenestrations only N=92 (30.7%) Branches + Fenestrations N=115 (38.3%)
38 Postoperative Data Mortality 30d: N=18 (6.0%) In-hospital: N=21 (7.0%) in ASA IV vs. ASA III pts (25% vs 6.2%, p=0.006) Major complications N=78 (26.0%)
39 Late Mortality All cause late mortality: N=42 2 Related deaths (aortoesophageal fistula, graft infection) Late mortality in ASA IV vs ASA III pts (50% vs 13.4%, p=0.004) Estimated Survival 83.2 ± 3% at 1 year 79.1 ± 3.3% at 2 years 70 ± 5.4% at 5 years
40 Avoid treating ASA IV? Or: Only if good anatomy? Evaluate Co-M better?
41 Conclusion - TAAA Endovascular repair of TAAA Feasible M & M vs Open surgery SCI Reinterventions (endovascular) First choice in the great majority of pts Limitations.
42 Prerequisites for Endovascular Repair of TAAA Team Set-up Hybrid room Stock High volume
43 Conclusions Complex Abdominal AAA: endovascular first choice TAAA: endovascular whenever possible Our task is to select the best option (and graft/technique) for each patient, irrespective of
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45 Endovascular Treatment of the Aorta with Fenestrated and Branched Grafts Eric LG Verhoeven,MD, PhD, A. Katsargyris, MD Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
Aortic Neck Issues Associated Clinical Sequelae/Implications for Graft Choice
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Considerations for a Durable Repair
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