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In stent grafts with four fenestrations (4×FEVAR), there is a need to catheterise and stent the coeliac artery (CA). The CA often presents with a steep take off, angulation, and early splitting, which make catheterisation and stenting more challenging. In addition, the CA is subject to respiratory motion which may cause damage and subsequent occlusion of the bridging stent.
To overcome these issues, a strategy of 4×FEVAR without stenting of the CA in selected cases was developed and initiated at the authors’ institution.
To evaluate the outcomes of this strategy, a retrospective single centre study was conducted including all patients with a J/SAAA undergoing elective 4×FEVAR with a fenestration for the CA between January 2018 and March 2020. Data collection and extraction was authorised by the local ethical committee and all patients signed informed consent.
Fenestrated stent grafts were customised based on the Cook Zenith system (William A. Cook Australia, Ltd., Brisbane, Australia). Indications for treatment of J/SAAA at the authors’ centre and the deployment technique have been described previously.
All CA fenestrations were 8 mm in diameter, reinforced, and strut free.
In the study population, it was planned that patients who presented with a straight sealing zone longer than 20 mm below the CA would receive a 4×FEVAR without implantation of a bridging stent in the CA. Within this group, two distinct scenarios were defined: a CA with undemanding anatomy for catheterisation and stenting, and a CA with difficult catheterisation (steep take off, angle > 150 degrees, and/or stenosis of the CA > 80%). In the first scenario, the CA was catheterised and a wire left in situ. After stenting of the other target vessels, lateral angiography was performed to demonstrate perfusion of the CA and absence of endoleak. If this was confirmed, the CA was left unstented. If an endoleak or perfusion alteration was demonstrated, the CA was stented. In the second scenario, the CA was not catheterised in the hope that the fenestration would fall into place and keep the CA perfused. The treatment algorithm is explained in Figure 1.
The endpoints of the study were technical success, primary patency of the CA, presence of endoleak from this artery, and CA related re-interventions. Technical success was defined as successful implantation of the stent graft with antegrade flow to the target vessels and absence of type I/III endoleaks on completion angiography. Outcomes during follow up were subjected to Kaplan–Meier life table analysis.
During the study period, 48 patients (46 male; mean age 72 ± 9 years) were treated electively for a J/SAAA with 4×FEVAR and were included. Fifteen (31%) patients had a suprarenal aneurysm and 33 (69%) a juxtarenal aneurysm. It was planned that 31 (65%) of patients with a segment of straight non-aneurysmal aorta > 20 mm below the CA would not have CA stenting. Within this group, 14 (45%) patients had a CA with a steep take off or stenotic disease in the pre-operative CTA and catheterisation was not attempted at all. In the remaining 17 (55%) patients, the anatomy of the CA was regarded as undemanding and therefore it was catheterised, with angiographic control after stenting of the other target vessels. In four patients, the angiography showed an endoleak (n = 1) or suspicion of inadequate alignment (n = 3), and the CA was finally stented. In the remaining 13 patients, the angiography showed adequate perfusion of the CA and absence of endoleak and the CA was left unstented. In total, 27 (56%) CAs were not stented.
Technical success was achieved in 47 (98%) patients. During a median follow up of 13 months (range 1 – 27), two patients presented with CA occlusion 6 and 13 months after surgery, respectively. In both patients, the CA was left unstented with no attempt to catheterise it, and both remained asymptomatic during follow up. Estimated primary CA patency at 12 months was 97.1% ± 2.9%. No patient underwent a re-intervention for the CA and no endoleaks from this vessel were detected during follow up.
This strategy has several potential advantages. It decreases the complexity and duration of the procedure, virtually converting a 4×FEVAR into a 3×FEVAR procedure. It may also lower the radiation time, the volume of iodinated contrast used, and the cost of the intervention. Finally, it potentially facilitates the repair of a proximal endoleak, as it allows implantation of thoracic stent graft sealing in the previous fenestrated stent graft covering the CA fenestration if needed.
In this series, leaving the CA fenestration unstented was considered in two thirds of the patients and was finally carried out in more than half of the cases. This strategy could be applied in a significant proportion of patients with J/SAAA and seems safe and effective in cases with a suitable anatomy. Further studies with longer follow up are needed to analyse the effect of this strategy on CA patency.
Conflict of interest
Eric LG Verhoeven has received research grants from Cook Inc . and W.L. Gore & Ass. , and honoraria as speaker and consultant from Cook Inc, W.L. Gore & Ass, Maquet-Getinge, Bentley InnoMed and Siemens Healthineers. Athanasios Katsargyris has received honoraria as speaker for W.L. Gore & Ass. and Cook Inc.
Van Herzeele I.
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