European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 5 , Pages 545-546, May 2010

Fenestrated Stent Grafting for Aortic Aneurysm in Europe

  • J.-B. Ricco

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    • Corresponding Author InformationTel.: +33 6 07 15 57 26; fax: +33 5 4950 0550.

Vascular Surgery Department, J. Bernard University Hospital, Rue de la Milétrie, 86000 Poitiers, France

Received 19 January 2010; accepted 20 January 2010. published online 22 February 2010.

Article Outline

 

In this issue of the journal, Amiot et al.1 and Verhoeven et al.2 presented their experience of fenestrated stent grafting for short-necked and juxta-renal abdominal aortic aneurysms.

Amiot et al.1 report a series of 134 consecutive patients treated during a 4-year period in 16 French academic hospitals. In this series, 403 visceral vessels were perfused through a fabric fenestration. Only one acute surgical conversion was necessary and discharge computed tomography (CT) scan showed that 99% of target vessels were patent. The 30-day mortality rate was 2%. The median duration of follow-up was 15 months with no rupture or surgical conversion. During this period, four renal artery occlusions were detected. Twelve procedure-related re-interventions were done.

In parallel, Verhoeven2 reports an 8-year experience of a single tertiary reference centre in Groningen with 100 consecutive patients managed with a fenestrated stent graft. In this series, 99% of the target vessels were patent. The 30-day mortality was 1% with one acute surgical conversion. Median follow-up was 24 months with three renal artery occlusions and 25 patients presenting with a significant increase in serum creatinine, two of them requiring dialysis.

These two outstanding articles represent together the largest experience of fenestrated stent-graft repair ever published. They both support the concept described by Greenberg3 that placement of fenestrated endovascular graft is effective and safe. These reports are important since the mortality benefit of endovascular aortic repair versus open surgical repair has the potential to be more significant for aortic aneurysms extending at the level of renal and visceral arteries.4 However, the use of such fenestrated devices includes a challenge for planning and sizing the fenestrated Zenith graft, and a knowledge of procedural parameters for adequate graft deployment. It is rewarding that 16 regional centres in France were able to successfully develop this technology with adequate training and resources.

At this point, a word of caution is necessary. First, the ‘renal side of the story’ is certainly of more concern than the rare intraoperative events. Haddad et al.5 found renal occlusion in 10% of 142 renal arteries treated by fenestration and deterioration in renal function was found in 10% of patients in the French study1 and in 25% of patients in the Groningen experience.2 Second, fenestrated stent grafts remain a technology only suitable for selected patients and limited by a number of anatomical factors such as ostial stenoses, tortuosity and severe vessel angulations. In addition, planning, device design and manufacturing create inherent delays in treatment. These grafts are, therefore, inappropriate for urgent patients and the potential for aneurysm rupture in the intervening period should be considered when adopting this technique. In addition, the costs of these new stent grafts are prohibitive to many centres around the world despite potential patient benefits. Finally, even if long-term follow-up was not within the scope of these articles, nearly 50% of patients receiving a fenestrated stent graft in Groningen died within the first 5 years and not from an aneurysm rupture;2 and one may ask if patients unfit for open repair will really benefit from fenestrated stent grafts.

In conclusion, these two outstanding articles1, 2 show that fenestrated stent-graft repair of aortic aneurysms involving the visceral segment of the aorta is done in Europe in a relatively large number of dedicated centres. Mortality and morbidity appeared low considering the high-risk population studied, but assessment of durability will require longer and careful follow-up.

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References 

  1. Amiot S, Haulon S, Becquemin JP, Magnan PE, Lermusiaux P, Goueffic Y, et al. Fenestrated endovascular grafting: the French multicentre experience. Eur J Vasc Endovasc Surg. 2010;39:537–544
  2. Verhoeven ELG, Vourliotakis G, Bos WTGJ, Tiellu IFJ, Zeebregts CJ, Prins TR, et al. Fenestrated stent grafting for short-necked and juxta renal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39:529–536
  3. Greenberg RK, Haloun S, O'Neill S, Lyden S, Ouriel K. Primary endovascular repair of juxtarenal aneurysm with fenestrated endovascular grafting. Eur J Vasc Endovasc Surg. 2004;27:484–491
  4. Sarac TP, Clair DG, Hertzer NR, Greenberg RK, Krajewski LP, O'Hara PJ, et al. Contemporary results of juxtarenal aneurysm repair. J Vasc Surg. 2002;36:1104–1111
  5. Haddad F, Greenberg RK, Walker E, Nally J, O'Neill S, Kolin G, et al. Fenestrated endovascular grafting: the renal side of the story. J Vasc Surg. 2005;41:181–190

PII: S1078-5884(10)00050-X

doi:10.1016/j.ejvs.2010.01.014

Refers to article:

  • Fenestrated Stent Grafting for Short-necked and Juxtarenal Abdominal Aortic Aneurysm: An 8-Year Single-centre Experience , 04 March 2010

    E.L.G. Verhoeven, G. Vourliotakis, W.T.G.J. Bos, I.F.J. Tielliu, C.J. Zeebregts, T.R. Prins, U.M. Bracale, J.J.A.M. van den Dungen
    European Journal of Vascular & Endovascular Surgery May 2010 (Vol. 39, Issue 5, Pages 529-536)

  • Fenestrated Endovascular Grafting: The French Multicentre Experience , 21 January 2010

    S. Amiot, S. Haulon, J.-P. Becquemin, P.-E. Magnan, P. Lermusiaux, Y. Goueffic, E. Jean-Baptiste, F. Cochennec, J.-P. Favre, Association Universitaire de Recherche en Chirurgie Vasculaire (AURC)
    European Journal of Vascular & Endovascular Surgery May 2010 (Vol. 39, Issue 5, Pages 537-544)

European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 5 , Pages 545-546, May 2010

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