Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

Abstract

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Keywords: aortic aneurysm; aortic disease; complications; fenestrated-branched endovascular repair; outcomes; review.

Figure 1

Technical solutions for bridging of target vessels during F/BEVAR. (A) Short balloon-expandable stent-graft for juxtarenal AAA treated with FEVAR; (B) long balloon-expandable stent-graft for suprarenal AAA treated with FEVAR (the gap between fenestration and inner aortic wall may lead to target vessel instability); (C) self-expanding stent-graft for TAAA treated with BEVAR and adjunctive distal relining with bare metal stent to accommodate smooth transition between edge of stent-graft and native artery in a tortuous segment.

Figure 2

Technical solutions with different configurations (upward outer branches, inner branches, downward outer branches) for incorporation of renal arteries during BEVAR. I: complex AAA with upward orientation of renal arteries; IV: complex AAA with downward orientation of renal arteries.

Figure 3

(A,B) Type IIIb endoleak from the right renal stent (red arrow), with sac enlargement and simultaneous asymptomatic thrombosis of the celiac trunk stent-graft (blue arrow).

Figure 4

(A) Type 1B endoleak after BEVAR (red arrow). (B) Aortic rupture in zone 4 (Ishimaru’s classification) after TEVAR (red arrow) and BEVAR procedure to treat a large type III TAAA.

Figure 5

(A,B) Distal left renal artery rupture after bridging stent deployment during a TAAA repair, as observed on selective angiography (blue arrow).

Figure 6

The presence of constraining wires on the back of the endograft allows for some degrees of rotation of the endograft (when partially deployed) in order to facilitate cannulation of the target vessels until the position is stabilized with the use of long introducers and the endograft may be completely deployed. (A) Counterclockwise and (B) clockwise rotation of the stent-graft to facilitate catheterization of target vessels; (C) sheaths inplace in the renal arteries before releasing the diameter-constraining wires on the stent-graft.

Figure 7

During this procedure, the branched endograft was positioned incorrectly (turned 180°). Note in (A,B) the posterior origin of the branches for celiac trunk and superior mesenteric artery, respectively. In (C), there is evidence of a type 1C endoleak due to an inadequate sealing zone in the superior mesenteric artery (blue arrow).

Figure 8

Sequential coverage of the aorta with continuous perfusion of the left subclavian and hypogastric arteries will permit safe and efficient development of the spinal cord collateral network, thereby allowing for reduction in the risk of spinal cord ischemia even after extensive endografting for TAAA. Yellow arrows indicate sources of continued aneurysmal sac perfusion to allow for staging of the procedure through continued perfusion of the spinal cord collateral network.