Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts Gustavo S. Oderich, MD, Mauricio Ribeiro, MD, PhD,

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Presentation transcript:

Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts Gustavo S. Oderich, MD, Mauricio Ribeiro, MD, PhD, Leonardo Reis de Souza, MD, Jan Hofer, RN, Jean Wigham, RN, Stephen Cha, MS The Journal of Thoracic and Cardiovascular Surgery Volume 153, Issue 2, Pages S32-S41.e7 (February 2017) DOI: 10.1016/j.jtcvs.2016.10.008 Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Advantages of patient-specific fenestrated and off-the-shelf multibranched stent-grafts. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Graph of number of consecutive patients treated for type IV and type I to III TAAAs between 2008 and March 2016. Note the decrease in mortality from 7.5% in the first half to 1.2% in the second half experience (P = .04). TAAA, Thoracoabdominal aortic aneurysm; F-BEVAR, fenestrated and branched endovascular aortic repair. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Kaplan–Meier estimates of overall patient survival in 185 consecutive patients treated for type IV and type I to III TAAAs between 2008 and March 2016. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Kaplan–Meier estimates of freedom from any aortic and nonaortic-related reintervention in 185 consecutive patients treated for type IV and type I to III TAAAs between 2008 and March 2016. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Illustration of a patient who underwent prior elephant trunk repair for extensive thoracoabdominal dissection (A), followed by first-stage thoracic endovascular aortic repair with right iliac artery reconstruction (B and C). The patient had complete repair in 1 week using a multibranched off-the-shelf stent-graft (D and E). The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Computed tomography angiography of a patient with extent III TAAA (A), treated by patient-specific design using directional branches for the celiac axis and superior mesenteric artery (B) and fenestrations for the renal arteries (C). Illustration and computed tomography angiography of the complete repair (D and E). The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E3 Staging of extensive TAAAs can be done using proximal thoracic endovascular repair or perfusion branches. Printed with permission from Banga and colleagues.9 The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E4 Standardized maneuvers and protocol triggered by changes in motor and somatosensory evoked potentials. Printed with permission from Banga and colleagues.9 MEP, Motor evoked potential; SSEP, somatosensory evoked potential; CSF, cerebrospinal fluid; MAP, mean arterial pressure. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E5 Kaplan–Meier estimates of primary target vessel patency in patients treated for TAAAs with 681 renal-mesenteric fenestrations and branches. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Branch incorporation can be done with reinforced fenestrations or branches. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Video 1 The technique of endovascular repair of a TAAA using fenestrated-branched stent-grafts is shown. Preoperative imaging is reviewed using centerline of flow analysis for measurements of lengths, angle, and clock position of the mesenteric and renal target vessels. A patient-specific stent-graft is designed with 2 directional branches for the celiac and superior mesenteric arteries and 2 renal fenestrations. The procedure is performed using transfemoral and brachial access. Once the target vessels are located, the device is oriented and introduced via the femoral approach. Preloaded catheters allow guidewires to be snared via the brachial approach. The device is partially deployed to the level of the mesenteric arteries. By using the brachial approach, the celiac and superior mesenteric arteries are accessed and the hydrophilic sheaths are advanced over stiff guidewires. The rest of the device is deployed below the renal arteries. The renal fenestrations and renal arteries are accessed via the femoral approach. The device is completely deployed, followed by sequential stenting of the renal and mesenteric arteries using covered stent-grafts. The repair is extended distally using a bifurcated stent-graft and iliac limbs. A completion angiography is performed to document patency of the side branches and absence of endoleak. Video available at: http://www.jtcvsonline.org/article/S0022-5223(16)31379-4/addons. The Journal of Thoracic and Cardiovascular Surgery 2017 153, S32-S41.e7DOI: (10.1016/j.jtcvs.2016.10.008) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions