Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Abstract

Background: Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR).

Methods: A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates.

Results: During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively.

Conclusion: Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

Keywords: Aortic aneurysm; Failed EVAR; Fenestrated/branched endografts; Inverted iliac limb; Rescue.

Fig. 1

Creation of inverted iliac limb using the Cook Zenith Fenestrated distal bifurcated body stent graft. a Preparing the inverted limb. Note that the graft is partially deployed; the contralateral limb transected using an ophthalmologic cautery. The check mark is placed in the original orientation to facilitate gate cannulation. b Minimum distance to the flow divider post limb inversion. The length from the top of the stent graft to the gate has been reduced from 76 mm to 51 mm, allowing relining of the entire failed previous EVAR. c Securing the inverted limb to the bifurcated device. The transected limb is now inverted and sewn in place with a 5–0 double arm ethibond suture

Fig. 2

a Loading wires in a fenestrated device. The Cook Zen-fen proximal graft was ordered with 1 scallop to accommodate the SMA and 2 small fenestrations to accommodate renal arteries. The device is deployed on a sterile back table and a 0.014 and 0.018 long wires are placed through the scallop into the body of the fenestration device, out through the small (renal) fenestrations. b Re-sheathed the device after loading wires. The device is now re-sheathed and ready to be implanted. The preloaded wires allow for cannulation of target vessels and placement of bridging stents from the axillary access site prior to releasing constraining wires