13.02 verhoeven impossible cannulations iv site
TRANSCRIPT
“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