Rescue of failed endovascular aortic aneurysm repair using the fenestrated Anaconda device

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Abstract

Objective

Endovascular aortic aneurysm repair (EVAR) with a fenestrated device (FEVAR) allows an extension of the proximal sealing zone above the renal arteries to an adequate, healthier segment of the aorta. This feature makes FEVAR an option to treat patients with a diseased aortic neck or type Ia endoleak after EVAR. The aim of this investigation was to present a single-center experience with FEVAR for patients with an abdominal aortic endograft in situ compared with primary FEVAR.

Methods

A prospectively held database on FEVAR patients treated with the fenestrated Anaconda device (Vascutek/Terumo, Inchinnan, Scotland, United Kingdom) at our institution was screened for individuals who had previously undergone EVAR.

Results

Between April 1, 2013, and July 31, 2016, 94 fenestrated Anaconda devices were implanted at our institution. Twelve patients with prior EVAR were treated for pathology of the proximal neck: type I endoleak (n = 7), for stent migration with aneurysm progression but no visible endoleak (n = 2), and progressive aortic disease at the level of the visceral segment (n = 3). When redo cases and primary FEVARs were compared, primary technical success rates were 58.3% and 87.8% (P = .02) and primary functional success rates were 91.7% and 95.1%, respectively (P = .62). Perioperative rate of major deployment-related (14.6% and 16.7%) and systemic complications (8.5% and 8.3%) as well as 30-day mortality (6.1% and 0%; P = .5) were comparable between groups. After an average follow-up interval of 10 months (range, 0-43 months), no late occlusions of connecting stents were observed. The late reintervention rates were 11.0% and 16.7%, respectively (P = .57).

Conclusions

The risk of a failure to cannulate one or more visceral arteries through the respective fenestrations was increased in patients who had previously undergone EVAR. This is most likely caused by increased friction between the fenestrated endograft and the failing graft in situ, which may impair the adaption of the unsupported Anaconda device to the aortic wall. As a consequence, fenestrations may not line up perfectly at the respective openings of the visceral or renal arteries, and folding of the fabric may be increased, making cannulation of the fenestrations more difficult.

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