Para-anastomotic aneurysms and progressive aneurysmal degeneration after previous open aortic reconstruction pose a difficult scenario. Due to proximity to the visceral arteries, endovascular exclusion is typically not an option. Fenestrated and branched endografts provide a less invasive means of repair. We sought to evaluate our experience with fenestrated endografts in the management of juxta- and para-renal aneurysms after previous open reconstruction.
Methods
This analysis was based on a prospective database gathered from March 2004 to November 2008. Patients underwent repair under the direction of a single surgeon using customized Cook endografts manufactured based on preoperative imaging.
Results
18 patients were treated over the study interval. All patients had a previous open aortic reconstruction. Mean time since the operation was 8.5 years (range 1 to 15 years). Mean patient age was 72 years (range 57 to 80 years). All patients were considered high risk for open surgery due to co-morbidities and/or the redo nature of their surgery. The mean number of fenestrations per patient was 3, including proximal graft scallops. All but one (94%) was completed by totally endovascular means. One operation required a planned celiotomy for retrograde access to a left renal artery. Of 56 target vessels, all were successfully re-vascularized with a combination of: fenestrations with bare metal (12) or covered stents (25), as well as graft branches (1), or graft scallops (18). Mean operative time was 215 minutes (range 135-420 minutes) and mean blood loss was 560cc (range 100 to 1500cc). 30-day and 1-year mortality was 0 and 11%, respectively. Peri-operative complications occurred in 2 patients. One developed a congestive heart failure exacerbation and myocardial infarction and one a groin wound infection. Mean follow-up time was 23 months and cumulative primary patency was 95% (53/56 vessels), with no follow-up interventions required.
Conclusions
Endovascular treatment of juxta- and para-renal aneurysms after prior aortic reconstruction is a viable alternative to open repair with high success and low re-intervention rates. These devices will broaden the available treatment modalities for these conditions, and will likely decrease the complication rate of treatment in these high-risk patients.
1Dartmouth-Hitchcock Medical Center, West Lebanon, NH
2University Medical Center of Groningen, Groningen, The Netherlands, Netherlands
3General Military Hospital of Athens, Athens, Greece, Greece
Author Disclosures: A.W. Beck, None; W.T.G. Bos, None; G. Vourliotakis, None; C.J. Zeebregts, None; I.F.J. Tielliu, None; E.L.G. Verhoeven, Cook, Inc.; W.L. Gore and Associates; Cook, Inc.; W.L. Gore and Associates.
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