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405
Devices
Thoracoabdominal Abdominal Both
Branch
stents
GORE TAG,
C-TAG
(W.L.Gore and
Assoc., Flagstaff,
AZ)
Zenith
Fenestrated
[ZFEN] (Cook
Medical,
Bloomington,
IN)
GORE
EXCLUDER
Thora
-
coabdominal
Branch
Endoprosthesis
(TAMBE)
(W.L.Gore and
Assoc., Flagstaff,
AZ)
Atrium
iCast
(Atrium
Medical,
Hudson,
NH, USA)
Medtronic Talent
(Medtronic, Santa
Rosa, CA)
Nellix EVAS
(Endologix,
Irvine, CA,
USA)
Cook Zenith
t-Branch
(Cook Medical,
Bloomington,
IN)
Gore VBX
(W.L.Gore,
Flagstaff,
AZ, USA)
Arch Branch
(IDE) (Cook
Medical,
Bloomington, IN,
USA)
GORE
EXCLUDER
Iliac Branch
Endoprosthesis
(IDE)
(W.L.Gore
and Assoc.,
Flagstaff, AZ)
Cook Zenith
p-Branch
(Cook Medical,
Bloomington,
IN)
Zenith Alpha
(Cook Medical,
Bloomington, IN,
USA)
Zenith TX2
(Cook Medical,
Bloomington IN)
Relay stent-graft
(Terumo Aortic,
Sunrise, Fla)
32
Hybrid and Complex Aortic Aneurysm…
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406
What imaging is performed for
postoperative surveillance?
CTA: 1, 6, 12months, and yearly
US Doppler of fenestrated
target visceral arteries 1, 6, and
12months
What medications are
prescribed status post complex
aortic repair?
Plavix for 3months and aspirin
for lifetime
What should the clinical exam
focus on after complex aortic
repair?
Neurological: paresthesias,
paralysis, and stroke
Cardiac: risk of perioperative
myocardial infarction (< 30days
post-op)
Renal: function
Complications
What complications
are seen with complex
hybrid thoracic aortic
repairs?
Paraplegia (Brat, 2018) and myocardial
infarction
What are the mortality
rates associated with
complex hybrid thoracic
aortic repairs?
Up to 30% (Brat, 2018)
Although, Zhao etal. and Kawaharada
report rates as low as 4–6% after
stented elephant trunk graft (ETG)
What are the most
common post-op
complications after zone
0 hybrid repair?
Stroke and retrograde type A dissection
What is the most
common cause of death
after zone 0 hybrid
thoracic aortic repairs?
Retrograde type A dissection (RTAD)
O. Adenikinju et al.
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407
What are the risk factors
of RTAD?
Native: Aneurysmal ascending aorta
and existing dissection.
Iatrogenic: clamp injury during
debranching and device injury.
Environmental change: alternate
anatomy leads to hemodynamic change
of blood flow and tissue mismatch
between graft and native aorta.
What eliminates the risk
of retrograde type A
dissections?
Use of Dacron ascending aortic
graft. Stent-assisted coil placement
(SACP) decreases the risk of RTADs
and neurological complications after
complex thoracic aortic repairs (Xydas,
2015).
Which complex thoracic
repair is associated with
highest mortality at
30days?
Zone 0; 1-year survival is similar for all
types of repair however at ~25%.
What is the most
common type of
endoleak after ETG
complex thoracic repair?
Type 2 (Brat, 2018)
What is the most
common type of
endoleak with fEVAR?
Hakim etal. report type 1c, which they
treat with coil embolization. However,
according to the Zenith trial, which
examined only ZFEN stent grafts, no
endoleaks were reported in that study.
Landmark Research
Andersen ND, Williams JB, Hanna JM, Shah AA, McCann
RL, Hughes GC. Results with an algorithmic approach to
hybrid repair of the aortic arch. Journal of Vascular Surgery.
2013;57(3):655–667. https://doi.org/10.1016/j.jvs.2012.09.039
• This study demonstrated ascending aorta zone 0 endograft
placement to be a univariate predictor of 30-day in-
32 Hybrid and Complex Aortic Aneurysm…
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408
hospital mortality after complex hybrid thoracic aortic
repairs.
• Developed an algorithm for stratifying complex thoracic
aortic repair. The study examined 87 patients who under-
went zone 1 endograft coverage with extra-anatomic left
carotid revascularization (n=19), zone 0 endograft cover-
age with aortic arch debranching (n = 48), or total arch
replacement with staged stented elephant trunk completion
(n=20). Their data demonstrated high rates of retrograde
type A dissections leading to higher 30-day periprocedural
mortality in patients who had grafts placed in zone 0.
• Currently, there is no FDA-approved thoracic endograft
for labeled use in zone 0. Current investigations are under-
way examining the effectiveness and safety of novel tho-
racic endografts in zones 0–2.
Which chEVAR registry
observed the most
common endoleak type
in the intraprocedural
setting, as well as the
factors associated with
it?
The Pericles Registry (898 chimney
grafts) observed intraoperative type Ia
endoleak in 41 patients (7.9%), which
only remained present in 2 patients
on follow-up imaging. Intraoperative
type Ia endoleak can be minimized
with landing zone >20mm, prolonged
kissing balloon inflation, or additional
cuff placement.
Which publication
contains the most
extensive data analysis
comparing outcomes of
FEVAR vs. chEVAR?
Yu Lie etal.– Systematic review and
pooled data analysis of FEVAR vs.
chEVAR compared outcomes for
juxtarenal aortic aneurysms (JAA)
for endoleak type I (3.7–7.6%), 30-day
mortality (1.1% vs. 3.8%), and all-
cause mortality (6.46% vs. 13.3%).
O. Adenikinju et al.
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409
Further Reading
AbuRahma AF, Campbell J, Stone PA, et al. The correlation of
aortic neck length to early and late outcomes in endovascular
aneurysm repair patients. J Vasc Surg. 2009;50(4):738–48. https://
doi.org/10.1016/j.jvs.2009.04.061
.
Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL,
Hughes GC. Results with an algorithmic approach to hybrid
repair of the aortic arch. J Vasc Surg. 2013;57(3):655–67.
https://
doi.org/10.1016/j.jvs.2012.09.039
.
Al-Hakim R, Schenning R. Advanced techniques in thoracic
endovascular aortic repair: chimneys/periscopes, fenestrated
endografts, and branched devices. Tech Vasc Interv Radiol.
2018;21(3):146–55. https://doi.org/10.1053/j.tvir.2018.06.004.
Bajzer CT. Thoracic aorta and the great vessels. In: Bhatt DL,
editor. Guide to peripheral and cerebrovascular intervention.
London: Remedica; 2004.
https://www.ncbi.nlm.nih.gov/books/
NBK27419/
. Accessed August 22, 2019.
Brat R.Chapter 32– Hybrid techniques for complex aortic surgery.
In: Ţintoiu IC, Ursulescu A, Elefteriades JA, Underwood MJ,
Droc I, editors. New approaches to aortic diseases from valve to
abdominal bifurcation. Academic Press; 2018. p.373–82. https://
doi.org/10.1016/B978-
0- 12- 809979- 7.00032- 8.
Chiesa R, Tshomba Y, Melissano G, Logaldo D.Is hybrid procedure
the best treatment option for thoraco-abdominal aortic aneu-
rysm? Eur J Vasc Endovasc Surg. 2009;38(1):26–34. https://doi.
org/10.1016/j.ejvs.2009.03.018.
Choo XY, Hajibandeh S, Hajibandeh S, Antoniou GA.The Nellix
endovascular aneurysm sealing system: current perspectives.
Med Devices (Auckl). 2019;12:65–79. https://doi.org/10.2147/
MDER.S155300.
Endovascular Today. Global experience with the Zenith p-branch
device. Endovascular Today. https://evtoday.com/2015/11/sup-
plement/global- experience- with- the- zenith- p- branch- device/.
Accessed July 21, 2019.
Endovascular Today. True long-term results: what have we learned?
Endovascular Today. https://evtoday.com/2017/03/true- long-
term- results- what- have- we- learned/. Accessed July 21, 2019.
Endovascular Today. Two-year data from EVAS FORWARD
IDE trial presented for Endologix’s Nellix EVAS system.
Endovascular Today. https://evtoday.com/2017/05/two- year- data-
32 Hybrid and Complex Aortic Aneurysm…
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410
from- evas- forward- ide- trial- presented- for- endologixs- nellix-
evas- system/. Accessed July 21, 2019.
Endovascular Today. Type IV thoracoabdominal aneurysms: what’s
next? Endovascular Today. https://evtoday.com/2012/03/type- iv-
thoracoabdominal- aneurysms- whats- next/. Accessed August 19,
2019.
Ganzel BL, Edmonds HL, Pank JR, Goldsmith LJ. Neurophysiologic
monitoring to assure delivery of retrograde cerebral perfu-
sion. J Thorac Cardiovasc Surg. 1997;113(4):748–57. https://doi.
org/10.1016/S0022-
5223(97)70234- 4.
Itagaki MW. Using 3D printed models for planning and guid-
ance during endovascular intervention: a technical advance.
Diagn Interv Radiol. 2015;21(4):338–41.
https://doi.org/10.5152/
dir.2015.14469
.
Kansagra K, Kang J, Taon M-C, et al. Advanced endografting
techniques: snorkels, chimneys, periscopes, fenestrations, and
branched endografts. Cardiovasc Diagn Ther. 2018;8(Suppl
1):S175–83.
https://doi.org/10.21037/cdt.2017.08.17.
Kasipandian V, Pichel AC.Complex endovascular aortic aneurysm
repair. Contin Educ Anaesth Crit Care Pain. 2012;12(6):312–6.
https://doi.org/10.1093/bjaceaccp/mks035.
Kim MH, Shin HK, Park JY, Lee T. Hybrid repair of suprarenal
abdominal aortic aneurysm: antegrade debranching with endo-
vascular aneurysm repair. Vasc Specialist Int. 2014;30(4):151–4.
https://doi.org/10.5758/vsi.2014.30.4.151.
Kourliouros A, Vecht JA, Kakouros N, et al. Frozen elephant
trunk as an effective alternative to open and hybrid two-stage
procedures for complex aortic disease. Hellenic J Cardiol.
2011;52(4):337–44.
Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS.Bovine aortic
arch variant in humans: clarification of a common misnomer. Am
J Neuroradiol. 2006;27(7):1541–2.
Li Y, Hu Z, Bai C, et al. Fenestrated and chimney technique for
juxtarenal aortic aneurysm: a systematic review and pooled data
analysis. Sci Rep. 2016;6:20497.
https://doi.org/10.1038/srep20497.
Oderich GS, Farber MA, Silveira PG, etal. Technical aspects and
30-day outcomes of the prospective early feasibility study
of the GORE EXCLUDER Thoracoabdominal Branched
Endoprosthesis (TAMBE) to treat pararenal and extent IV tho-
racoabdominal aortic aneurysms. J Vasc Surg. 2019;70(2):358–
368.e6. https://doi.org/10.1016/j.jvs.2018.10.103.
O. Adenikinju et al.
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411
Patel RP, Katsargyris A, Verhoeven ELG, Adam DJ, Hardman
JA. Endovascular aortic aneurysm repair with chimney and
snorkel grafts: indications, techniques and results. Cardiovasc
Intervent Radiol. 2013;36(6):1443–51. https://doi.org/10.1007/
s00270-
013- 0648- 5.
Preventza O, Aftab M, Coselli JS. Hybrid techniques for complex
aortic arch surgery. Tex Heart Inst J. 2013;40(5):568–71.
Quatromoni JG, Orlova K, Foley PJ. Advanced endovascular
approaches in the management of challenging proximal aortic
neck anatomy: traditional endografts and the snorkel tech-
nique. Semin Intervent Radiol. 2015;32(3):289–303. https://doi.
org/10.1055/s-
0035- 1558825.
Schanzer A, Simons JP, Flahive J, etal. Outcomes of fenestrated and
branched endovascular repair of complex abdominal and thora-
coabdominal aortic aneurysms. J Vasc Surg. 2017;66(3):687–94.
https://doi.org/10.1016/j.jvs.2016.12.111.
Tadros R, Safir SR, Faries PL, etal. Hybrid repair techniques for
complex aneurysms and dissections involving the aortic arch and
thoracic aorta. Surg Technol Int. 2017;30:243–7.
Xu J, Zhou Y, Guo J, etal. Mid- and long-term effects of endovas-
cular surgery and hybrid procedures for complex aortic diseases.
Biomed Res Int. 2019;2019(18):1–5.
https://www.hindawi.com/
journals/bmri/2019/3247615/
. Accessed July 21, 2019.
Xydas S, Mihos CG, Williams RF, etal. Hybrid repair of aortic arch
aneurysms: a comprehensive review. J Thorac Dis. 2017;9(Suppl
7):S629–34.
https://doi.org/10.21037/jtd.2017.06.47.
32
Hybrid and Complex Aortic Aneurysm…
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Part IV
Oncology
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415© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_33
Evaluating Patient
What are the most
essential labs required to
workup for possible liver-
directed therapy?
Depending on the primary indication
and procedure, common labs include
albumin, bilirubin, platelet count,
INR, alpha-fetoprotein (AFP),
carcinoembryonic antigen (CEA), and
eGFR.
What is the serum
bilirubin level at which
arterial embolotherapy
is generally
contraindicated?
Bilirubin >3mg/dL (if segmental
treatment can be performed, a higher
bilirubin level may be acceptable)
Why are hepatic
embolotherapies
avoided in patients with
diminished functional
liver reserve and liver
failure?
Ischemic insult of the procedure can
worsen liver function.
Chapter 33
Hepatic Interventional
Oncology
SethI.Stein
S. I. Stein (*)
Department of Radiology, NewYork-Presbyterian Hospital, Weill
Cornell Medical Center, New York, NY, USA
(continued)
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416
How is lung shunt
fraction (LSF) calculated
and why is it relevant for
TARE?
LSF is calculated by delivering
Tc99m-MAA to the intended
treatment vessel during the mapping
angiographic procedure and
subsequently performing planar
nuclear scintigraphy and/or SPECT/
CT.Borderline (i.e., 10–20% LSF)
or elevated LSF may necessitate
dose reduction or preclude TARE
altogether. Absolute dose to the lung
>30Gy per treatment or >50Gy over
time is considered more relevant
to avoiding the risk of radiation
pneumonitis.
How is liver reserve/
cirrhosis mortality
determined?
The Child-Pugh scoring system
utilizes clinical factors and laboratory
values to estimate cirrhosis mortality:
Useful for selecting the appropriate
liver-directed therapy.
Factors include INR,
encephalopathy, bilirubin, albumin,
and ascites, which combine
to classify patients into three
categories:
Class A= Score 5–6
Class B= Score 7–9
Class C= Score 10–15
S. I. Stein
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