Strategies to treat EVAR in short proximal necks

Giovanni Torsello Münster, Germany

e-mail: giovanni.torsello@sfh-muenster.de home page: www.gefaesschirurgie-muenster.de

Fenestrated endografts

Therapy of AAA with short or no neck

Disadvantages of the new technologies

-  Price for endograft and covered stents -  Complicated implantation technique -  Angiosuite -  Unsuitable arterial anatomy -  Delay in manufacture (acute case)

Therapy of juxtarenal aortic aneurysm

Chimney technique

Typical indication for chimney

•  Old (83 y) male patient, NYHA III-IV •  6.8 cm max. aneurysm diameter •  Abdominal pain •  Juxtarenal aneurysm with insufficient landing zone

stainless steel endoskeleton Nitinol endoskeleton

Choice of the endograft is essential

1.  Insertion of the wire into the TV 2.  Advancement of catheter/sheath 3.  Controll angiography 4.  Insertion of the atraumatic Rosen wire

1. Deployment of the endograft 2. Insertion of the chimney graft 3. Insertion of the lining stent

Standard endovascular equipment

•  Wires: Terumo, 0.014“ and Rosen 0.035“ •  Catheters: Vertebral (120-150cm), MPA (125 cm) •  Sheath: Shuttle (Cook); 7F and 90 cm shaft •  Endograft: Endurant (Medtronic) •  Chimney graft: Advanta V12 (Maquet)

Postoperative CT angiography

Postoperative monitoring

CT angiography postoperatively Duplex ultrasound at 6 months CT angiography at 12 months, annually Antiplatelet medication: ASS and Clopidogrel for 2 months ASS lifelong

Chimneys vs. F-EVAR

Pararenal aortic aneurysm

Open fenestrated- or chimney endografting?

Münster algorithm for pararenal aortic pathologies

Surgery

low surgical risk relevant polar renal arteries

Chimneys high-risk patient ≤ 2 side branches symptomatic aneurysm Severe iliac tortouosity

and calcification

f-EVAR

high-risk patient > 2 side branches

Delay in the treatment > 6 weeks

January 2008 - December 2010 Surgery: 31 pts F-EVAR: 29 pts Chimneys:

30 pts

30-day outcomes

Donas KP, Torsello G et al J Vasc Surg

Chimneys F-EVAR OR P

Mortality 0 0 2 .023

Dialysis 0 0 2 .023

ICU 0.7 1.1 5.1 .001

RBCs 0.5 0.3 3.48 .001

EL-Type I 0 0 -

EL-Type II 2 2 -

Fluoroscopy 44.8 58.4

•  early mortality, blood loss, LOS and acute kidney injury were significantly less in the endovascular group than in patients undergoing OR

•  both Ch-EVAR and F-EVAR offer a lower risk alternative for the management of JAAA

•  long-term durability, including preservation of graft fixation, seal, and branch vessel patency remain to be determined after Ch-EVAR

Conclusions

Our algorithm for proximal necks

Proximal AAA neck

Neck > 15 mm - Any device - Higher LoE for Endurant

Neck 10-15 mm Endurant

Neck 7-10 mm Endurant

Neck < 5-7 mm fEVAR Chimney

Universitätsklinik Münster St. Franziskushospital Münster

home page: www.gefaesschirurgie-muenster.de

Thank you !

•  Chimneys are a lower risk alternative for the management of JAAA and TAA

•  Careful selection of patients, graft and stents for the target vessels is the key for success

•  Stiff endografts and low-radial force stents should be avoided

•  Long-term durability, including preservation of graft fixation, seal, and branch vessel patency after Chimneys remain to be determined

Conclusions

Fenestrated and branched grafts (1.1.2001-1.9.2011; n:131)

30-day mortality rate 1.9% Follow-up 25 months 3-year survival 77% 3-year freedom from sec proced ures 76% 3-year freedom from type I leak/migration 92%

From: Troisi N. et al. J Endovasc Ther 2011;18:146-153

1st author year No of pat

30-d mortallity (% - n)

Renal faillure(% - n)

Perm dialysis (% - n)

Endoleak T- I (% - n)

Endoleak T-II (% - n)

Endoleak T- III (% - n)

Anderson 2001 13 0.0 0 7.7 1 0.0 0 0.0 0 15.4 2 0.0 0

Greenberg 2004 32 3.1 1 18.8 6 3.1 1 0.0 0 6.3 2 0.0 0

Halak 2006 17 0.0 0 0.0 0 5.9 1 0.0 0 41.2 7 0.0 0

Muhs 2006 38 2.6 1 5.3 2 0.0 0 2.6 1 50.0 19 0.0 0

O´Neill 2006 119 0.8 1 25.2 30 2.5 3 5.9 7 1.7 2 3.4 4

Semmens 2006 58 3.4 2 6.9 4 0.0 0 6.9 4 0.0 0 0.0 0

Ziegler 2007 63 0.0 0 22.2 14 1.6 1 6.3 4 0.0 0 1.6 1

Scurr 2008 45 2.2 1 0.0 0 0.0 0 2.2 1 0.0 0 0.0 0

Bicknell 2008 15 0.0 0 6.7 1 0.0 0 0.0 0 0.0 0 0.0 0

Verhoeven 2010 100 1.0 1 25.0 25 2.0 2 0.0 0 0.0 0 0.0 0

Amiot 2010 134 2.2 3 4.5 6 1.5 2 2.2 3 9.0 12 0.7 1

Tambyraja 2011 29 0.0 0 0.0 0 0.0 0 6.9 2 6.9 2 6.9 2

663 10 89 10 22 46 8

Overall 1.5% 13.4% 1.5% 3.3% 6.9% 1.2%

Fenestrated EVAR series

1st author year No of pat

30d mortallity (% - n)

Renal faillure(% - n)

Perm dialysis (% - n)

Endoleak T- I (% - n)

Endoleak T-II (% - n)

Endoleak T- III (% - n)

Ohrlander 2008 6 0.0 0 16.7 1 16.7 1 0.0 0 0.0 0 0.0 0

Hiramoto 2009 8 0.0 0 0.0 0 12.5 1 0.0 0 0.0 0 0.0 0

Bruen 2011 21 4.8 1 28.6 6 9.5 2 4.8 1 0.0 0 0.0 0

Coscas 2011 16 12.5 2 18.8 3 0.0 0 6.3 1 0.0 0 0.0 0

Donas 2011 73 0.0 0 8.2 6 0.0 0 1.4 1 8.2 6 0.0 0

124 3 16 4 3 6 0

Overall 2.4% 12.9% 3.2% 2.4% 4.8

% 0%

Chimney EVAR series

FEVAR vs chimneys

F-EVAR Chimneys 30-d mortality: 1.5% 2.4% -  Renal failure: 13.8% 12.9%

-  Postoperative dialysis: 1.5% 3.5%

Endoleak type Ia: 3.2% 2.4%

ns

ns

ns

ns

P

Postoperative CT angiography

AAA shrinkage

87-year old man with symptomatic AAA

Endurant stentgraft and V12 covered stent in the „chimney technique“

Oversizing

25-30% Proximal neck Endograft

24-25mm 32mm

26-28mm 36mm

Suggested devices

Mestres G, et al. EJVES 2012

Endurant V12

Excluder Viabahn

Positioning the patient…

Long tables

7F Shuttle sheath (Cook)

Femoral access

Prostar XL (Abbott) 10 F

ACT > 250 sec

Surveillance imaging in case of renal insufficiency

CTA via transbrachial straight flush catheter (20ml contrast agent)

When they don’t work or are technically demanding/

with increased risk

Technical success n=128 (96 %) Secondary patency n=129 (98%)

Typ 1 Endoleak n=4 (3%) Typ 2 Endoleak n=24 (18 %) 30 day mortality n=1 (0.8%) Overall mortality n=5 (4%), non EVAR related

Münster Experience: 132 patients operated for aortic pathology with the

Chimney technique

Unsuitable anatomy for Chimneys: subclavian a. stenosis or type III aortic arch

Demanding anatomy for Chimneys: Tortuous descending aorta

! Pushability ! Stability

Demanding anatomy for Chimneys: Tortuousity of the pararenal aorta

Demanding anatomy for Chimneys: Aorto-iliac tortuosity

Demanding anatomy for Chimneys: Overcoming extreme tortuousity of the

aneurysm neck and iliacs

Use of flexible and low-profile abdominal endografts

Demanding anatomy for Chimneys: Renal artery stenosis?

Pre-OP Post-OP

Placement of additional bare self-expanding stents

Demanding anatomy for Chimneys: Early splitting of renal arteries

The larger the number of side branches, the greater the risk for gutters and potential persistent endoleaks.

48

Ruptured Aneurysm

49

Ruptured aneurysm treated with parallel grafts

50

CT scan after treatment of ruptured AAA with parallel grafts

12.9.2011 19.9.2011 28.11.2011

Lift technique