Society For Clinical Vascular Surgery

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Parallel Endografts Extend the Applicability of Fenestrated Endovascular Aneurysm Repair with Minimal Impact on Complication Rates
Cheryl Richie, MD, Michael Bounds, MD, Nathan Orr, MD, Sam Tyagi, MD, Eleftherios Xenos, MD, Joseph Bobadilla, MD, David Minion, MD.
University of Kentucky, Lexington, KY, USA.

Objectives - Fenestrated Endovascular Aneurysm Repair (FEVAR) is an established treatment option for juxtarenal aortic aneurysms. However, there is a 3-vessel design limitation for the currently approved device. This limitation can be overcome by combining parallel endografts with FEVAR, termed Snorkestrated technique. The purpose of this study was to compare outcomes of the Snorkestrated technique to standard FEVAR.
Methods - A retrospective review of all FEVAR cases at our institution was undertaken, identifying 41 patients. Nine patients underwent a planned 4-vessel Snorkestrated repair. For 8 patients, the additional preserved vessel was the celiac artery, including two patients with Type III thoracoabdominal aneurysms where the celiac snorkel was deployed in a thoracic endograft as a sandwich configuration (Figure). In the remaining planned repair, the preserved vessel was a large accessory renal artery arising from the distal aorta.
There were also four unplanned Snorkestrated repairs, including two for intra-operative Type IA endoleak, one for intra-operative IIIb endoleak, and one for a fenestrated device that was maldeployed with a 180-degree rotation covering the SMA. A total of two antegrade celiac snorkels, three antegrade SMA snorkels, and 3 retrograde renal sandwich grafts were required to overcome the various complications of these four cases.
Results – Perioperative mortality occurred in one patient undergoing standard FEVAR (3.4%) and in none of Snorkestrated cases (P=NS). Average post-operative length of stay was 4.7 days for standard FEVAR and 5 days for Snorkestrated (P=NS). Late target vessel loss occurred in 3 FEVAR patients (10%) and no Snorkestrated patients (P=NS). There have been no late endoleaks, significant sac growth, or rupture in either group.
Conclusions - Parallel endografts can be combined with fenestrated repair with minimal impact to peri-operative mortality or length of stay, despite the involvement of more challenging anatomy. In our series, this strategy extended the applicability of FEVAR to nearly 30% more patients. The technique can also be used to correct unplanned endoleaks or maldeployment issues. Late target vessel loss was similar regardless of method of vessel preservation used.


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