Endovascular Treatment of the Aorta with Fenestrated and Branched Grafts

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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

Disclosures William Cook Europe/Cook Inc. Consultant & Research grants W.L. Gore & Associates Consultant & Research grants Atrium Maquet Consultant Siemens Consultant

Vascular surgery has changed

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

F&B Procedures per year 160 140 120 100 80 60 TAAA All Cases 40 20 0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18

Lay-out Complex Abdominal Aortic Aneurysms Thoraco-abdominal Aneurysms

Complex Abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)

Complex Abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)

Solution: Fenestrated Grafts

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...

Fenestrated Technique Maturity Catheterization of target vessels Stenting of small fenestrations Atrium covered stents Technical tricks: Tilting, Flairing, Relining Long overlap between components

Fenestrated Technique Composite System

Bridging Stent-grafts Balloon-expandable Atrium V12 Life Stream Bentley Jotec

2x, 3x, or 4x FEVAR Choice According to Landing Zone JVS 2015;62:319-25

Evolution of Stent-graft Design 120 100 80 60 40 20 0 19 35 32 36 50 75 90 96 98 81 65 68 64 50 25 10 4 2 2010 2011 2012 2013 2014 2015 2016 2017 2018 2x FEVAR (%) 3x-4x FEVAR (%) Use of 3x-4x FEVAR over the years

F-EVAR Technique

Indication? Cardio-Pulmonary Contra-Indications Hostile abdomen Redo Aortic surgery After EVAR After Open Surgery

Indication? Cardio-Pulmonary Contra-Indications Hostile abdomen Redo Aortic surgery After EVAR After Open Surgery Normal risk patients

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):730-737. Verhoeven et al. Eur J Vasc Endovasc Surg 2010;39(5):529-536. Amiot, Haulon, et al. Eur J Vasc Endovasc Surg 2010;39(5):537-44.

5-years experience with FEVAR 281 pts Mortality 0.7%

Thoraco-abdominal Aneurysms AAA with shorter proximal neck Juxtarenal AAA Suprarenal AAA Thoraco-abdominal aneurysms (TAAA)

Open repair for TAAA Coselli et al. Ann Thorac Surg 2002 Safi et al. J Vasc Surg 1998

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

TAB054

TAB054 Postop CTA

Nuremberg Experience 300 Consecutive pts F&B stent-grafts for TAAA April 2004 January 2017 Suprarenal aortic aneurysms excluded

Stent-graft Design Branches only N=93 (31.0%) Fenestrations only N=92 (30.7%) Branches + Fenestrations N=115 (38.3%)

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%)

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

Avoid treating ASA IV? Or: Only if good anatomy? Evaluate Co-M better?

Conclusion - TAAA Endovascular repair of TAAA Feasible M & M vs Open surgery SCI Reinterventions (endovascular) First choice in the great majority of pts Limitations.

Prerequisites for Endovascular Repair of TAAA Team Set-up Hybrid room Stock High volume

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

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

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