Comparison of Fluid Dynamics Variations Between Chimney and Fenestrated Endografts for Pararenal Aneurysms Repair: A Patient Specific Computational Study as Motivation for Clinical Decision-Making

2019 ◽  
Vol 53 (7) ◽  
pp. 572-582 ◽  
Author(s):  
Konstantinos G. Moulakakis ◽  
John Kakisis ◽  
Eleni Gonidaki ◽  
Andreas M. Lazaris ◽  
Sokrates Tsangaris ◽  
...  
Keyword(s):  
Endovascular Repair ◽  
Clinical Decision Making ◽  
Computational Study ◽  
Fluid Dynamic ◽  
Renal Arteries ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Patient Specific ◽  
Aortic Repair ◽  
Before And After

Background-Aim: Limited data exist concerning the fluid dynamic changes induced by endovascular aortic repair with fenestrated and chimney graft modalities in pararenal aneurysms. We aimed to investigate and compare the wall shear stress (WSS) and flow dynamics for the branch vessels before and after endovascular aortic repair with fenestrated and chimney techniques. Methods: Modeling was done for patient specific pararenal aortic aneurysms employing fenestrated and chimney grafts (Materialise Mimics 10.0) before and after the endovascular procedure, using computed tomography scans of patients. Surface and spatial grids were created using the ANSYS CFD meshing software 2019 R2. Assessment of blood flow, streamlines, and WSS before and after aneurysm repair was performed. Results: The endovascular repair with chimney grafts leaded to a 43% to 53% reduction in perfusion in renal arteries. In fenestrated reconstruction, we observed a 15% reduced perfusion in both renal arteries. In both cases, we observed a decrease in the recirculation phenomena of the aorta after endovascular repair. Concerning the grafts of the renal arteries, we observed in both the transverse and longitudinal axes low WSS regions with simultaneous recirculation of the flow 1 cm distal to the ostium sites in both aortic graft models. High WSS regions appeared in the sites of ostium. Conclusions: We observed reduced renal perfusion in chimney grafts compared to fenestrated grafts, probably caused by the long and kinked characteristics of these devices.

scholarly journals Patient-Specific Computational Analysis of the Impact of Fenestrated and Chimney Endovascular Aortic Repair on Haemodynamics in Renal Arteries

2019 ◽  
Vol 58 (6) ◽  
pp. e761-e762
Author(s):  
Sabrina Ben Ahmed ◽  
Theodorus M.J. van Bakel ◽  
Eugenio Rosset ◽  
Jean-Pierre Favre ◽  
Jean-Noel Albertini ◽  
...  
Keyword(s):  
Computational Analysis ◽  
Renal Arteries ◽  
Endovascular Aortic Repair ◽  
Patient Specific ◽  
Aortic Repair ◽  
The Impact

Role of Endovascular Aortic Repair in the Treatment of Infected Aortic Aneurysms Complicated by Aortoenteric or Aortobronchial Fistulae

2017 ◽  
Vol 66 (03) ◽  
pp. 240-247 ◽  
Author(s):  
Hsin-Ling Lee ◽  
Yu-Jen Yang ◽  
Chung-Dann Kan
Keyword(s):  
Endovascular Repair ◽  
Open Surgery ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Salmonella Spp ◽  
Term Survival ◽  
Risk Of Death ◽  
Aortic Repair ◽  
Additional Surgery ◽  
Airway Pathology

Background The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). Methods Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. Results A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). Conclusion The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.

“Awake” Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair

2021 ◽  
pp. 152660282110282
Author(s):  
Said Abisi ◽  
Liam Musto ◽  
Oliver Lyons ◽  
Michelle Carmichael ◽  
Morad Sallam ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Length Of Stay ◽  
Local Anesthesia ◽  
Endovascular Repair ◽  
Conscious Sedation ◽  
Spinal Cord Ischemia ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Aortic Repair ◽  
Spinal Drain

Introduction Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). Materials and Methods Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. Results A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97–495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2–41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3–26 months). Conclusion LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

scholarly journals In-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts

2021 ◽  
Vol 108 (Supplement_4) ◽  
Author(s):  
V Makaloski ◽  
D Broger ◽  
S Weiss ◽  
S Jungi ◽  
D Becker ◽  
...  
Keyword(s):  
Stent Graft ◽  
Renal Arteries ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Mesenteric Arteries ◽  
Hospital Death ◽  
Stent Grafts ◽  
Term Outcome ◽  
Aortic Repair

Abstract Objective The aim of the study is to evaluate in-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts (fEVAR / bEVAR). Methods This is a single-center retrospective analysis from a prospectively collected database of all patients treated electively with fEVAR or bEVAR for para/suprarenal (PAA) and thoraco-abdominal aortic aneurysm (TAAA) between September 2010 and June 2019. In-hospital and mid-term mortality, major adverse events and re-interventions were assessed. Results Fifty-one patient (84% male) with a mean age of 74±7 years were analysed. Eighteen patients (35%) had TAAA, four patients (8%) suprarenal, and 29 patients (57%) pararenal aortic aneurysms. Mean aneurysm diameter was 64±8 mm. Thirty-eight patients (75%) underwent fEVAR and 13 patients (25%) bEVAR. A total of 157 target vessels were incorporated: 22 celiac trunks (CT), 40 superior mesenteric arteries (SMA), 92 renal arteries (RA), two separate hepatic arteries and one splenic artery. No in-hospital death or stroke was recorded. One patient suffered from early postoperative paraplegia and did not recover and one had paraparesis after 38 days and recovered completely. Six patients (12%) with patent renal arteries experienced acute postoperative kidney injury; one required temporary dialysis. Five in-hospital re-interventions were stent-graft related (four bridging stents angioplasty and one iliac leg extension) and seven re-interventions were not stent-graft related. Mean follow-up was 19±17 months. Eleven patients (22%) died during follow-up: nine were not aortic-related and two were unknown. The Kaplan-Meier estimated survival rates at 1 and 2 years were 81% and 77%, respectively. Five renal stents (5%, 5/92) occluded during follow-up: three were successfully recanalized and two remained occluded. Ten stents (three CT, five SMA, and two RA stents required relining after 13±16 months postoperatively, resulting with estimated primary assisted patency at 2 years of 100%, 100%, 93%, and 95% for the CT, SMA, right RA and left RA, respectively. Conclusion Complex endovascular aortic repair with fEVAR / bEVAR for PAA and TAAA is safe with very low early mortality and morbidity. In-stent stenosis/occlusions occurred within the first two years. However, primary assisted patency was high. A surveillance program to detect potential stent-graft related complications is mandatory.

Endovascular treatment of proximal para-anastomotic aneurysms after previous surgical repair of infrarenal aortic aneurysms by the chimney technique

Vascular ◽  
2018 ◽  
Vol 27 (1) ◽  
pp. 3-7
Author(s):  
Georgios I Karaolanis ◽  
Marco Damiano Pipitone ◽  
Giovanni Torsello ◽  
Martin Austermann ◽  
Konstantinos P Donas
Keyword(s):  
Endovascular Repair ◽  
Open Repair ◽  
Abdominal Aortic Aneurysms ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Short Neck ◽  
Aortic Repair ◽  
Aortic Neck ◽  
Abdominal Aortic

Objectives To evaluate the use of chimney grafts in the treatment of para-anastomotic aneurysms after previous abdominal aortic aneurysms open repair with short neck. Methods A retrospective analysis of prospectively collected data of consecutive patients who underwent endovascular repair for proximal aortic para-anastomotic aneurysms following previous open repair for infrarenal abdominal aortic aneurysms was performed. All included patients had a short infrarenal aortic neck (<10 mm) excluding standard endovascular aortic repair. Five patients were symptomatic at the admission needed urgent treatment. Results Twelve patients with para-anastomotic aneurysms underwent placement of chimney grafts. The median time between the original operations to redo endovascular procedure was 11 years (interquartile range, 9.5 years). The mean infrarenal length was 4.3 mm (1–9 mm). A total of 28 chimneys grafts were deployed for the 12 patients. The technical success rate was 91.7%. At a median radiologic follow-up of 16 months (2.0–29.4, 95% confidence interval), one patient died, while two late endoleaks and two reinterventions at one and three years for type Ia endoleak were performed by proximal extension and triple chimney graft placement. Conclusion The results of the present study show that ch-endovascular aortic repair is a safe technique for patients who suffered from proximal para-anastomotic aneurysms and having short neck unsuitable for standard endovascular repair. Longer follow up warranted to evaluate the durability of ch-endovascular aortic repair for this specific indication.

scholarly journals Linking Aortic Mechanical Properties, Gene Expression and Microstructure: A New Perspective on Regional Weakening in Abdominal Aortic Aneurysms

2021 ◽  
Vol 8 ◽  
Author(s):  
Arianna Forneris ◽  
Jacob Kennard ◽  
Alina Ismaguilova ◽  
Robert D. Shepherd ◽  
Deborah Studer ◽  
...  
Keyword(s):  
Gene Expression ◽  
Clinical Decision Making ◽  
Fluid Dynamic ◽  
Abdominal Aortic Aneurysms ◽  
Aortic Aneurysms ◽  
Patient Specific ◽  
Tissue Samples ◽  
Non Invasive ◽  
Abdominal Aortic ◽  
Aortic Pathology

Background: Current clinical practice for the assessment of abdominal aortic aneurysms (AAA) is based on vessel diameter and does not account for the multifactorial, heterogeneous remodeling that results in the regional weakening of the aortic wall leading to aortic growth and rupture. The present study was conducted to determine correlations between a novel non-invasive surrogate measure of regional aortic weakening and the results from invasive analyses performed on corresponding ex vivo aortic samples. Tissue samples were evaluated to classify local wall weakening and the likelihood of further degeneration based on non-invasive indices.Methods: A combined, image-based fluid dynamic and in-vivo strain analysis approach was used to estimate the Regional Aortic Weakness (RAW) index and assess individual aortas of AAA patients prior to elective surgery. Nine patients were treated with complete aortic resection allowing the systematic collection of tissue samples that were used to determine regional aortic mechanics, microstructure and gene expression by means of mechanical testing, microscopy and transcriptomic analyses.Results: The RAW index was significantly higher for samples exhibiting lower mechanical strength (p = 0.035) and samples classified as low elastin content (p = 0.020). Samples with higher RAW index had the greatest number of genes differentially expressed compared to any constitutive metric. High RAW samples showed a decrease in gene expression for elastin and a down-regulation of pathways responsible for cell movement, reorganization of cytoskeleton, and angiogenesis.Conclusions: This work describes the first AAA index free of assumptions for material properties and accounting for patient-specific mechanical behavior in relation to aneurysm strength. Use of the RAW index captured biomechanical changes linked to the weakening of the aorta and revealed changes in microstructure and gene expression. This approach has the potential to provide an improved tool to aid clinical decision-making in the management of aortic pathology.

scholarly journals Pressure gradient measurement to verify hemodynamic results of the chimney endovascular aortic repair (chEVAR) technique

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0249549
Author(s):  
Artur Igor Milnerowicz ◽  
Aleksandra Milnerowicz ◽  
Tomasz Bańkowski ◽  
Marcin Protasiewicz
Keyword(s):  
Pressure Gradient ◽  
Renal Artery ◽  
Aortic Pressure ◽  
Computed Tomographic Angiography ◽  
Renal Arteries ◽  
Endovascular Aortic Repair ◽  
Computed Tomographic ◽  
Aortic Repair ◽  
Before And After ◽  
Artery Flow

Purpose The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR). Methods The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts. Results All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients. Conclusions The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.

Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: A propensity-matched analysis

Vascular ◽  
2016 ◽  
Vol 25 (4) ◽  
pp. 339-345 ◽  
Author(s):  
Nathan T Orr ◽  
Daniel L Davenport ◽  
David J Minion ◽  
Eleftherios S Xenos
Keyword(s):  
Length Of Stay ◽  
Mortality Rates ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Hospital Length Of Stay ◽  
Perioperative Outcomes ◽  
Propensity Scoring ◽  
Aortic Repair ◽  
Open Aortic Repair ◽  
Significant Difference

Objective Endoluminal aortic aneurysm repair is suitable within certain anatomic specifications. This study aims to compare 30-day outcomes of endovascular versus open repairs for juxtarenal and pararenal aortic aneurysms (JAA/PAAs). Methods The ACS-NSQIP database was queried from 2012 to 2015 for JAA/PAA repairs. Procedures characterized as emergent were included in the study; however, failed prior repairs and ruptured aneurysms were excluded. The preoperative and perioperative patient characteristics, operative techniques, and outcome variables were compared between the open aortic repair and the endovascular aortic repair groups. Propensity scoring was performed to clinically match open aortic repair and endovascular aortic repair groups on preoperative risk and select perioperative factors that differed significantly in the unmatched groups. Outcome comparisons were then performed between matched groups. Results A total of 1005 (789 JAAs and 216 PAAs) aneurysm repairs were included in the study. Of these, there were 395 endovascular aortic repairs and 610 open aortic repairs. Propensity scoring created a matched group of 263 endovascular aortic repair and 263 open aortic repair patients. There was no statistically significant difference in 30-day mortality rates between matched endovascular aortic repair and open aortic repair patients (2.7% vs. 5.7%). The endovascular aortic repair group had a shorter ICU length of stay and overall hospital stay. The 30-day morbidity significantly favored endovascular aortic repair over open aortic repair (16% vs. 35%, p < 0.001). The main drivers of morbidity for endovascular aortic repair versus open aortic repair included return to the OR (6.8% vs. 15%, p < 0.001), rate of cardiac or respiratory failure (7.6% vs. 21%, p = 0.001), rate of renal insufficiency or failure (3.8% vs. 9.9%, p = 0.009), and rate of pneumonia (1.5% vs. 6.8%, p = 0.004). Conclusions There is no difference in mortality rates between endovascular aortic repair versus open aortic repair when repairing JAAs/PAAs. There is a significant difference in overall morbidity, and ICU and hospital length of stay favoring endovascular aortic repair over open aortic repair. This supports the expanded applicability and efficacy of endovascular repair for complex aneurysms.

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