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Endovascular Aneurysm Repair in Challenging Anatomy
127
asymptomatic [57]. The annual rupture risk in case of endotension is low but increases over
the years. Currently, there is no consensus about the need of treatment [58]. It seems plausible
that growing aneurysms without detection of endoleaks should be treated [
59]. It is essential
to rule out endoleak or stent graft infection before treatment of endotension, because most
cases of endoleaks are treatable by endovascular means whereas endotension most often is
treated by conversion to open surgery [60].
Migration
Stent graft migration remains an important issue in EVAR and is associated with late
aneurysm rupture, proximal endoleak, graft kinking, and graft thrombosis [61]. The reported
incidence of migration varies between 1 and 42 percent and is partly device dependent [62-
65].
Iliac endograft fixation, along with proximal fixation, is a significant predictor for
endograft migration [66]. Failure of proximal fixation as a result of longitudinal migration or
aortic dilatation beyond the nominal diameter of the endograft can result in a late Type-I
endoleak and aortic rupture. Unfavorable shape of the proximal neck might also lead to
proximal endograft failure.
Modern endografts provide proper fixation through a variety of features incorporated in
the stent graft design and procedure, including radial force, columnar rigidity, and suprarenal
or infrarenal hooks or barbs [67, 68].
Figure 4. Intraoperative view of an endostaple impantation.
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Pieter Broos, Rutger Stokmans, Bianca Bendermacher et al.
128
Some proximal oversizing of the stent graft is necessary to obtain a seal between the stent
graft and the aortic wall. Stent graft oversizing results in increased radial force of the stent
graft on the aortic wall and is preventative for stent graft migration [
61]. Oversizing of 10-
20% appears to be safe and preferable [69].
More than half of the migrated stent graft, without loss of proximal fixation length, do
not require re-intervention [63, 64, 70]. However, in cases of increased infrarenal aortic neck
diameter beyond oversizing, infrarenal aortic neck shortening and loss of proximal fixation
length there are more clinically relevant predictors of proximal stent graft failure and a
secondary procedure is needed. Traditionally through proximal extension, placement of a new
endograft, or conversion to an open procedure [
71, 72].
There is need for improved fixation technique at the proximal neck, especially in
challenging anatomy. Vascular endostapling is a promising technique to prevent migration or
to fixate migrated endografts (Figure 4) [73, 74]. Endostaples secure the stent graft to the full
thickness of the vessel wall resulting in a longitudinal fixation force comparable to open
suturing [
75]. Endostaples are also indicated for use in patients whose endovascular grafts
have exhibited endoleak Type-I and to secure endovascular components together to prevent
endoleak Type-III.
HOW TO OVERCOME COMPLEX ANATOMY
Nowadays, with improved surgical skills and modern stent
EVAR
morphology and many stent grafts are used outside their IFU [16, 17, 36, 39, 76, 77]. There
are different techniques to deal with anatomic high-risk AAAs where the traditional
procedure is likely to fail.
Fenestrated and Branched Stent Grafts
The principle of fenestrated stent grafting is to create an opening in the graft fabric to
accommodate the orifice of the blood vessel that is targeted for preservation [78, 79]. This
technique is not only used for complex proximal necks but also to treat juxtarenal AAAs and
thoraco-abdominal aortic aneurysms. The fenestrated stent graft is placed proximal to the
renal and/or visceral arteries in order to gain additional attachment length. The term
fenestrated endovascular repair is used when the visceral branch target vessels arise from the
sealing region of the stent-graft in the normal aorta. In contrast, branched endovascular repair
is used when the target arteries arise form an aneurysmal aorta creating a gap between the
device and the aortic wall at the vessel origin. In branched devices, these can either be
separated into fenestrated branch stent-graft, in which a reinforced fenestrated device uses a
stent-graft to traverse the aneurysmal sac to the visceral branch or, more typically, a
directional cuff attached to the device, which facilitates placement of the branch artery stent-
graft (Figure 5A-B) [80-83]. With the introduction of fenestrated and branched stent grafts,
the therapeutic range for EVAR is expanded; however, as they are custom-made, they cannot
be used in emergency cases.
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Endovascular Aneurysm Repair in Challenging Anatomy
129
Figure 5. Schematic views of the proximal neck at the level of the renal arteries. (A) Fenestrated stent
graft with additional stents in the renal arteries. (B) Branched device with directional cuffs attached. (C)
Chimney technique with renal stents parallel placed to the main aortic stent graft.
Chimney Graft
The chimney procedure is also referred to as double-barrel or snorkel technique and is
developed to extend the proximal sealing zone of a complex aneurysm neck, distally or
proximally [84-87]. The chimney graft technique preserves flow over aortic branches using
conventional stent graft components and peripheral stents. The proximal parts of the visceral
stents are placed parallel to the main aortic stent graft and extend above or beyond it to ensure
perfusion (Figure 5C). The technique can be used in the renal arteries and superior mesenteric
artery and are approached in an antegrade fashion [88]. Because custom-made endografts are
not necessary it can be used for the treatment of acute aneurysm in patients with challenging
anatomy.[89].
“Advanced” Endovascular Repair
The fenestrated, branched and chimney techniques are developed to circumvent anatomic
limitations. However, these are complex endovascular procedures which require high level
interventional skills. Nowadays, an increasing number of AAAs with challenging anatomy
are treated with the conventional EVAR technique. Multiple studies show comparable results
in patients with conservative and challenging anatomy regarding mortality, proximal Type-1
endoleaks and reinterventions (Table 3). These studies indicate that EVAR with simple
infrarenal stent graft placement can be used, with cautious, in patients with unfavorable
anatomy [90]. However the quality of the evidence in challenging cases is still scarce, due to
a lack of long-term results and high consecutive series. Therefore, the EAGLE (Endurant for
Challenging Anatomy: Global Experience] Registry is designed to register the performance of
a newest generation stent graft in challenging anatomy in a real-world setting, and to critically
assess whether or not it is reasonable and safe to expand current guidelines of anatomic
eligibility for endovascular treatment. To minimize the risks of selection bias and enhance
data quality, EAGLE eligibility will be determined by an independent core-lab and efforts
will be made to secure consecutive enrolment of challenging cases. Aiming at a high number
of challenging cases with a long-term follow-up, future results from the EAGLE registry may
give an answer to how far boundaries can be safely stretched, and broaden the applicability
rate of EVAR.
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Table 3. Overview of recent studies comparing EVAR in challenging and friendly anatomy
Study
Setacci (2012)
Stather (2012)
Torsello (2011)
Goncalves (2010)
AbuRahma (2011)
Challengi
ng
(n = 72)
Friendly
(n = 65)
Challengi
ng (n =
199)
Friendly
(n = 353)
Challeng
ing
(n = 56)
Friendly
(n = 121)
Challeng
ing
(n = 45)
Friendly
(n = 65)
Challeng
ing (n =
149)
Friendly
(n = 89)
30-day mortality (%)
2 (3)
1 (2)
1 (0.5)
4 (2.0)
1 (2)
2 (2)
1 (2)
2 (3)
NR
NR
Type I endoleak at 30
days (%)
0 (0)
0 (0)
5 (2.5)
3 (0.8)
2 (4)
0 (0)
0 (0)
0 (0)
1 (1)
0 (0)
Type I endoleak at 1 year
(%)
NR
NR
NR
NR
4 (7)
0 (0)
NR
NR
16 (11)
3 (3)
Reintervententions at 1
year (%)
NR
NR
NR
NR
5 (9)
6 (5)
NR
NR
7 (5)
5 (5)
Aneurysm-related
mortality at 1 year (%)
NR
NR
NR
NR
1 (2)
0 (0)
NR
NR
1 (1)
0 (0)
NR: Not Reported
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Endovascular Aneurysm Repair in Challenging Anatomy
131
CONCLUSION AND FUTURE PROSPECTS
Endovascular aneurysm repair is considered a safe and effective alternative to open repair
for the treatment of selected cases of abdominal aortic aneurysm. The success of EVAR is,
however, dependent upon patient-specific factors, including aortic dimensions and aneurysm
morphology. Severely angulated or short infrarenal necks are associated with an increased
risk of operative failure and late aneurysm rupture due to proximal Type-I endoleaks and graft
migration. To limit these risks, guidelines for commercially available stent grafts indicate use
within a specific range of aortic anatomy. As a consequence, a substantial proportion of AAA
patients are considered ineligible for EVAR as they fall outside instructions for use criteria.
In the past two decades, many technological advances have been introduced to improve
feasibility and durability of EVAR. Also, operators have become more proficient with
endovascular techniques. These developments have led to an increasing interest and
confidence to extend treatment to challenging anatomies. Currently, >70% of elective AAA
repairs are performed with EVAR, and approximately 30% of these patients are considered
outside IFU criteria [9]. Despite the widespread use of stent grafts in challenging anatomy, so
far, only small numbers and non-consecutive series of patients are reported [
40]. Thus, solid
evidence on the effectiveness and safety of latest devices such cases are missing.
Separate studies on the performance of EVAR in challenging anatomy is necessary to
demonstrate safety and effectiveness of the latest generation stent grafts, which is essential in
making a balanced judgment about the optimal management of AAAs.
ACKNOWLEDGEMENTS
I would like to offer my special thanks to Mr. Toon van der Krieken for his assistance
and advice regarding the images shown in this chapter. His willingness to give his time has
been very much appreciated.
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