Fenestrated Endovascular Aortic Aneurysm Repair for Failed EVAR with Suprarenal Fixation
Carlos Timaran, Shadman Baig, David Timaran, Tarik Ali, Martyn Knowles, R James Valentine
Univ of Texas Southwestern Med Ctr, Dallas, TX
Background: Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms, particularly useful after failed previous repairs. Previous EVAR with suprarenal fixation may be a contraindication for FEVAR secondary to difficulty in accessing target vessels through the bare suprarenal stent and risk of technical failure with loss of renal and visceral arteries. The purpose of this study was to assess the feasibility of FEVAR in high-risk patients after failed EVAR with suprarenal fixation.
Methods: Over an 18-month period, 10 high-risk patients underwent FEVAR after failed EVAR with suprarenal fixation. Eight patients presented with proximal type I endoleaks and aneurysm enlargement and two developed suprarenal pseudoaneurysms with a suprarenal stent fracture. Brachiofemoral pullthrough wire access was used in 8 patients. All renal and visceral vessels were catheterized through the fenestrations and suprarenal bare stent. Technical success was defined as complete exclusion of the aneurysm sac with successful catheterization and preservation of target vessel patency.
Results: Median age was 70 years (range, 65-83). Two patients had undergone EVAR revision with the Zenith Renu device and one with a Talent cuff after prior failed EVAR secondary to migration of an AneuRx device. One patient had undergone EVAR with the Talent device with migration and loss of proximal fixation. One patient had undergone EVAR with the Excluder device and developed a proximal type I endoleak, unsuccessfully treated with a cuff and a transrenal Palmaz stent. To assess feasibility for repair, 8 patients underwent visceral and renal artery IVUS prior to FEVAR. Bilateral renal arteries were accommodated in all fenestrated grafts in addition to 6 superior mesenteric and three celiac arteries. Despite the difficulty associated with the presence of a suprarenal stent, technical success was 100% and no target vessels were lost. The median procedure time was 220 minutes (range, 150-440). No 30-day mortality occurred and renal function remained stable. Median follow-up period was 14 months (range, 4-18 months). No residual type I or III endoleaks were evident on follow-up CT angiograms. All target vessels remain patent.
Conclusions: FEVAR for failed previous EVAR with suprarenal fixation is safe and effective despite the technical difficulty in accessing target vessels through the bare suprarenal stent.
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