Branched and fenestrated stent grafts - a reasonable option for thoraco-abdominal aortic aneurysm repair

Objectives: To evaluate the feasibility of totally endovascular repair for patients unfit for open thoraco-abdominal aortic aneurysm (TAAA) repair.

Methods: In 31 patients, mean age 71 (45-85) years, 68% male (n = 21), TAAA of Crawford extent I-II in 39% (n = 12) and III-V in 61% (n = 19) were repaired. The procedures were part of a staged aortic repair with previous or secondary open or endovascular repair in 74% (n = 23). All procedures were performed under general anesthesia in a hybrid OR. Customized branched and/or fenestrated stent grafts were implanted: 16 Zenith and 15 E-vita E-xtra. A total of 112 celiac (CA), superior mesenteric (SMA) and renal arteries (RA) were connected to the stent grafts by 80 branches (72%) and 32 fenestrations (28%) with covered Advanta or Fluency stents reinforced by self-expandable bare stents for bridging to the target vessels. All fenestrations were stented with covered Advanta stents.

Results: All stent grafts were implanted successfully and all target vessels were connected except 1 RA due to a kink at the origin, and 1 CA due to subtotal occlusion. In both cases the side branch socket at the stent graft was occluded with a plug, and 1 iliaco-renal bypass was performed. The occluded celiac artery showed excellent collaterals from the SMA. Mean procedure time was 430 (190-720) min and fluoroscopy time 103 min (52--246). In all patients discharge CT scans showed successful exclusion of the TAAA without Type I or Type III endoleak: in 25 patients (80%) primary and in 6 (20%) secondary exclusion (spontaneous closure in 2, secondary interventions in 4). Mortality at 30 days was 6.5% (1 due to pneumonia and 1 due to cerebral bleeding); incidence of spinal cord ischemia was 6.5% (n = 2) with 1 permanent paraplegia (3.2%).

Conclusion: Endovascular repair with branched and fenestrated stent grafts proved a reasonable option for TAAA repair in a high-risk and advanced age cohort with low mortality and low incidence of paraplegia. This therapy is meanwhile available for urgent cases, since production time for the newer customized device has been reduced to 2-3 weeks. The procedures are time-consuming and technically demanding and the amount of radiation exposure is a concern. The bridging stent graft issue remains unsolved. In particular there is a risk of loose renal arteries with contemporary stiff stents. Thus further improvement of stent-graft technology, endovascular equipment and intraoperative imaging technology is required.