Fenestrated Endografts Prove Viable Alternative To Open Surgery
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The use of fenestrated endografts to treat juxta-renal and para-renal aneurysms (adjacent to and involving the visceral segment of the aorta) after prior aortic reconstruction, is a viable alternative to open repair. These findings are from a study presented at the 63rd Annual Meeting of the Society for Vascular Surgery®.
"Para-anastomotic aneurysms and progressive aneurysmal degeneration after previous open aortic reconstruction pose a difficult scenario," said author Adam Beck, MD, a vascular surgery fellow at Dartmouth-Hitchcock Medical Center, Lebanon, N.H. "Due to proximity to the visceral arteries, endovascular exclusion is typically not an option. Fenestrated and branched endografts provide a less invasive means of repair. Although these procedures are technically difficult, outcomes are very good and they represent a major advance over 'redo' open aortic reconstruction, which carries a high morbidity and mortality rate."
Dr. Beck said he and fellow researchers found that endograft repair for these types of aneurysms has high success and low re-intervention rate, will broaden the available treatment modalities for these conditions, and will likely decrease the complication rate of treatment in these patients who are considered high risk for open surgery.
Eighteen patients with an average age of 72 years were included in the study that was done at the University Medical Center of Groningen in The Netherlands by Eric L. G. Verhoeven, MD, department of surgery, and his colleagues between March 2004 and November 2008. All of the patients had previously been treated for aortic aneurysms with open repair using Dacron tube or bifurcated grafts. The original procedures were performed from 1 to 15 years prior to their development of an anastomotic aneurysm or further aneurysmal degeneration of the aorta above the previous repair.
"The procedures were performed using customized Cook endografts created based on plans generated by the surgeons using preoperative 3-D imaging," said Dr. Beck. "The average length of these procedures was four hours and blood loss was 560mL. With the exception of one patient requiring a planned open access of a renal artery, all were successfully treated using totally endovascular means. In the perioperative period there were no deaths, but two major complications occurred, including one myocardial infarction and one groin wound infection. Patients were ambulating and eating at a median of one day and all but two were discharged from the hospital by four days."
The mean number of fenestrations per patient was three. Of 56 target vessels, all were successfully revascularized with a combination of: fenestrations with bare metal (12) or covered (25) stents; directional graft branches (1); or proximal graft scallops (18). There were no deaths at 30-days, and at one-year mortality was 11 percent (n=2). Mean follow-up time was 23 months and cumulative primary patency was 95 percent.
Long-term outcomes were good overall with no adjunctive procedures becoming necessary. However, two patients developed graft branch thrombosis of renal artery branches. Of these two, one patient had an asymptomatic unilateral renal artery thrombosis, while the other developed bilateral renal artery thrombosis leading to a need for hemodialysis.
"These procedures are inherently technically challenging and require a skilled team of physicians and nurses" said Dr. Beck. "Problems associated with this type of repair include arterial access difficulties related to the previous operations, difficulties associated with a very short working distance within existing bifurcated aortic grafts, and the inherent difficulties associated with access and stenting of the visceral vessels. Many challenges can be anticipated on preoperative imaging, but the need for intraoperative troubleshooting is common."
About the Society for Vascular Surgery®
The Society for Vascular Surgery (SVS) is a not-for-profit society that seeks to advance excellence and innovation in vascular health through education, advocacy, research and public awareness. SVS is the national advocate for 2,800 vascular surgeons dedicated to the prevention and cure of vascular disease
Source: Society for Vascular Surgery
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