“Impossible” cannulations in fenestrated/branched endografts: can we

leave some fenestrations unstented?

Eric Verhoeven MD, PhD, A. Katsargyris, MD, K. Oikonomou, MD Department of Vascular and Endovascular Surgery,

Paracelsus Medical University, Nuremberg, Germany

Disclosures

• William Cook Europe/Cook Inc.– Consultant & Research grants

• W.L. Gore & Associates– Consultant & Research grants

• Atrium– Consultant

• Siemens– Consultant

Why to stent a Fenestration/Branch?

• Fenestration– Achieve better sealing (covered stent)– Maintain the fenestration in position

• Branch– Bridging covered stent to seal

To answer the Question…

• Review of our database (2001-2014)

– FEVAR for complex AAA

– FEVAR/BEVAR for TAAA

Overview

• FEVAR for complex AAA

– 457 pts

• F/B-EVAR for TAAA– 214 pts

Total target vessels: N=1712*– Impossible cannulation (antegrade): N=29/1712 (1.7%)

* Scallops excluded

Impossible Antegrade Cannulation (N=29)

• Vessels lost: N= 12/1712 (0.7%)

• Vessels attempted to save by Retrograde Cannulation: N= 13/1712 (0.8%)

• Patent Vessels (aligned fenestration): N= 4/1712 (0.2%)

Vessels lost (N=12)

• Renal arteries in FEVAR: N= 7/942 (0.7%)

– Occlusion, no endoleak: N=4– Rupture → Embolisation: N=1– False bridging with lumbar artery: N=1– Occlusion with endoleak in RAAA N=1

(Graft for other pt: Endoleak → Cuff + Chimney + Endostaples)

RAAA (Graft for other patient)

Unstented LRA Fenestration - Endoleak

After 1st cuff After 2nd cuff + RRA chimney After endoanchors

RAAA (Graft for other patient)

Vessels lost (N=12)

• Vessels in TAAAB: N= 5/770 (0.6%)

– Celiac Branch: N=1• Covered with cuff

– Renal Branch: N=1• Amplatzer plug, Ileorenal bypass

– Untreated lost renals: N=3• Death within 30 days: N=2• Complicated postop course: N=1

Retrograde Cannulation (N=13)

• Celiac Artery: N=3– Planning mistake: N=1– Deployment mistake: N=1– Catheterization mistake: N=1

• Renal Artery: N=10

Technical Success: 12/13 (92.3%)

Retrograde Cannulation #1 Rule: Flairing of stents: top to bottom

Retrograde Cannulation #2 Difficult Angle for LRA

Patent Vessels (N=4)Aligned Fenestration

• No Endoleak: N=3

• Endoleak: N=1 – Fenestration stented

secondarily from above

F#183

Conclusion

• Target Vessel Cannulation– ↑Technical success in high volume centers• Primary: 1683/1712 (98.3%)• Assisted: 1695/1712 (99.1%)• Patent: 1699/1712 (99.2%)

– Unstentable Fenestrations• Rare scenario• 4 remained open w/ο endoleak