Parallel Grafting Should Be Considered as a Viable Alternative to Open Repair in High-Risk Patients With Paravisceral Aortic Aneurysms.

MedStar author(s):
Citation: Annals of Vascular Surgery. 74:237-245, 2021 Jul.PMID: 33549798Institution: MedStar Heart & Vascular Institute | MedStar Washington Hospital CenterDepartment: Surgery/Vascular SurgeryForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Aortic Aneurysm/su [Surgery] | *Blood Vessel Prosthesis Implantation | *Celiac Artery/su [Surgery] | *Endovascular Procedures | *Mesenteric Artery, Superior/su [Surgery] | *Renal Artery/su [Surgery] | Aged | Aortic Aneurysm/dg [Diagnostic Imaging] | Aortic Aneurysm/mo [Mortality] | Aortic Aneurysm/pp [Physiopathology] | Blood Vessel Prosthesis | Blood Vessel Prosthesis Implantation/ae [Adverse Effects] | Blood Vessel Prosthesis Implantation/is [Instrumentation] | Blood Vessel Prosthesis Implantation/mo [Mortality] | Celiac Artery/dg [Diagnostic Imaging] | Celiac Artery/pp [Physiopathology] | Clinical Decision-Making | Endovascular Procedures/ae [Adverse Effects] | Endovascular Procedures/is [Instrumentation] | Endovascular Procedures/mo [Mortality] | Female | Humans | Male | Mesenteric Artery, Superior/dg [Diagnostic Imaging] | Mesenteric Artery, Superior/pp [Physiopathology] | Postoperative Complications/mo [Mortality] | Renal Artery/dg [Diagnostic Imaging] | Renal Artery/pp [Physiopathology] | Renal Circulation | Retrospective Studies | Risk Assessment | Risk Factors | Splanchnic Circulation | Stents | Time Factors | Treatment Outcome | Vascular PatencyYear: 2021Local holdings: Available online from MWHC library: 1995 - present, Available in print through MWHC library:1999-2007ISSN:
  • 0890-5096
Name of journal: Annals of vascular surgeryAbstract: CONCLUSIONS: Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta. Copyright (c) 2021. Published by Elsevier Inc.INTRODUCTION: Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA/Celiac artery involvement.METHODS: A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with/without Celiac artery parallel grafting.RESULTS: Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA1 score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1cm (4.6-15cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6mm, mean celiac 8.3mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56min, and EBL was 250ml. Peri-operative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, two required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5cm.All authors: Abramowitz SD, Alfawaz AA, Dearing JA, Dunphy KM, Kiguchi MM, Shults CC, Woo EYOriginally published: Annals of Vascular Surgery. 2021 Feb 04Fiscal year: FY2021Fiscal year of original publication: FY2021Digital Object Identifier: Date added to catalog: 2021-02-18
Holdings
Item type Current library Collection Call number Status Date due Barcode
Journal Article MedStar Authors Catalog Article 33549798 Available 33549798

Available online from MWHC library: 1995 - present, Available in print through MWHC library:1999-2007

CONCLUSIONS: Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta. Copyright (c) 2021. Published by Elsevier Inc.

INTRODUCTION: Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA/Celiac artery involvement.

METHODS: A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with/without Celiac artery parallel grafting.

RESULTS: Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA1 score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1cm (4.6-15cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6mm, mean celiac 8.3mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56min, and EBL was 250ml. Peri-operative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, two required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5cm.

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