Akute komplexe endovaskuläre Aortenchirurgie – Off-the-Shelf vs. Surgeon-modified Stentgrafts

Zusammenfassung

Hintergrund Die Behandlung komplexer abdomineller und thorakoabdomineller Aortenaneurysmen stellt für alle Beteiligten eine Herausforderung dar. Die offene chirurgische Versorgung ist ein Hochrisikoeingriff und ist besonders im Notfall mit erhöhter Morbidität und Mortalität assoziiert. Die endovaskuläre Ausschaltung mithilfe eines patientenspezifischen maßgefertigten Stentgrafts steht aufgrund der erforderlichen Herstellungszeit bei Patienten mit symptomatischen oder rupturierten komplexen Aneurysmen nicht zur Verfügung. In diesen Fällen müssen alternative endovaskuläre Techniken angewendet werden.

Ergebnisse Zu den endovaskulären Therapieoptionen komplexer Aneurysmen in dringenden Fällen und Notfällen zählen die „off-the-shelf“ und die „surgeon-modified“ Stentgrafts. Die ersten sind standardisiert hergestellte fenestrierte oder gebranchte Endoprothesen, die aufgrund der anatomischen Gegebenheiten bei etwa 50 – 80% der Patienten eingesetzt werden können. Die „surgeon-modified“ oder „vom Chirurgen modifizierten“ Stentgrafts beschreiben eine Technik, bei der eine kommerzielle Stentprothese unter sterilen Bedingungen und direkt vor der Implantation durch den Operateur bearbeitet wird, damit die benötigten Fenestrierungen, Scallops und Branches geschaffen werden. Die Modifikationsdauer beträgt 60 – 120 min angepasst an die Anatomie des Patienten. Es handelt sich um einen „off-label“-Gebrauch eines kommerziellen Stentgrafts außerhalb der Anweisungen des Herstellers und wenn möglich, sollte eine entsprechende ausführliche Patientenaufklärung als Behandlungsversuch stattfinden. In der Literatur sind ähnliche Ergebnisse bez. Morbidität und Mortalität zwischen „off-the-shelf“ und „surgeon-modified“ Prothesen publiziert. Ein direkter Vergleich dieser Verfahren scheint aus mehreren Gründen (unterschiedliches Prothesendesign, Selektionsbias, unterschiedliche Techniken in der Prothesenmodifikation) jedoch schwierig und anhand der Literatur allein nicht eindeutig durchführbar.

Schlussfolgerung Die „surgeon-modified“ sowie die „off-the-shelf“ fenestrierten/gebranchten Stentprothesen werden in der Versorgung von Hochrisikopatienten mit symptomatischen oder gedeckt rupturierten komplexen Aortenaneurysmen angewendet. Die Ergebnisse beider Techniken sind vergleichbar gut, obwohl die langfristige Funktionsdauer der modifizierten Stentprothesen weiter getestet werden sollte.

Abstract

Introduction Treatment of complex abdominal and thoracoabdominal aortic aneurysms is challenging. Open surgical repair is a high-risk operation, especially in emergency cases. Endovascular aneurysm repair with a patient-specific custom-made stent graft in patients with symptomatic or ruptured complex aortic aneurysms is not possible, due to the manufacturing time required. In such cases, alternative endovascular techniques can be used.

Results The “off-the-shelf” and “surgeon-modified” stent grafts are valid options for the endovascular treatment of complex aneurysms in urgent and emergent patients. The former are standardised commercially manufactured fenestrated or branched stent grafts, which are available off-the-shelf with an anatomical feasibility in 50 – 80% of the patients. The “surgeon-modified” stent grafts refer to a technique, in which a commercially available stent graft is modified by the surgeon under sterile conditions directly before the implantation, in order to add the required fenestrations, scallops and/or branches. The modification takes approximately 60 – 120 min and haemodynamic stability of the patient is mandatory. Because of the off-label use of the commercial stent graft, detailed patient consent about the modification complications and risks should be performed whenever possible. A comparison of results on mortality and morbidity between “off-the-shelf” and “surgeon-modified” stent grafts has been published, although a direct comparison would be unfair for several reasons (different design, lack of extensive outcomes reports, long learning curve and different modification techniques).

Conclusion The “surgeon-modified” and “off-the-shelf” fenestrated/branched stent grafts are used in the treatment of high-risk patients with symptomatic or contained ruptured complex aneurysms. The outcomes of the two techniques are good, although the long-term durability of the former should be further investigated.

Schlüsselwörter

Aortenaneurysma - juxtarenales Aortenaneurysma - thorakoabdominelles Aortenaneurysma - fenestrierte Stentprothese - gebranchte Stentprothese

Key words

juxtarenal aortic aneurysm - thoracoabdominal aortic aneurysm - fenestrated stent graft - branched stent graft

Publication History

Article published online:
19 October 2021

• Literatur

• 1 Patel VI, Lancaster RT, Conrad MF. et al. Comparable mortality with open repair of complex and infrarenal aortic aneurysm. J Vasc Surg 2011; 54: 952-959 DOI: 10.1016/j.jvs.2011.03.231.
• 2 Dayama A, Sugano D, Reeves JG. et al. Early outcomes and perioperative risk assessment in elective open thoracoabdominal aortic aneurysm repair: An analysis of national data over a five-year period. Vascular 2016; 24: 3-8 DOI: 10.1177/1708538114568416.
• 3 Tallarita T, Sobreira ML, Oderich GS. Results of open pararenal abdominal aortic aneurysm repair: Tabular review of the literature. Ann Vasc Surg 2011; 25: 143-149 DOI: 10.1016/j.avsg.2010.10.005.
• 4 Schermerhorn ML, Bensley RP, Giles KA. et al. Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995–2008: a retrospective observational study. Ann Surg 2012; 256: 651-658 DOI: 10.1097/SLA.0b013e31826b4f91.
• 5 Tsilimparis N, Perez S, Dayama A. et al. Endovascular repair with fenestrated-branched stent grafts improves 30-day outcomes for complex aortic aneurysms compared with open repair. Ann Vasc Surg 2013; 27: 267-273 DOI: 10.1016/j.avsg.2012.05.022.
• 6 Ricotta 2nd JJ, Tsilimparis N. Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patients. J Vasc Surg 2012; 56: 1535-1542 DOI: 10.1016/j.jvs.2012.05.096.
• 7 Georgiadis GS, Koutsoumpelis A, Tsilimparis N. Commentary: Physician-Modified Fenestrated/Branched EVAR and Hybrid Techniques for Acute Thoracoabdominal Aortic Pathologies: Inequality When Comparing Alternative Options With Different Philosophies Does Not Equal Lower Quality. J Endovasc Ther 2020; 27: 757-763 DOI: 10.1177/1526602820934469.
• 8 Konstantinou N, Antonopoulos CN, Jerkku T. et al. Systematic review and meta-analysis of published studies on endovascular repair of thoracoabdominal aortic aneurysms with the t-Branch off-the-shelf multibranched endograft. J Vasc Surg 2020; 72: 716-725.e1 DOI: 10.1016/j.jvs.2020.01.049.
• 9 Spanos K, Kölbel T, Theodorakopoulou M. et al. Early Outcomes of the t-Branch Off-the-shelf Multibranched Stent-Graft in Urgent Thoracoabdominal Aortic Aneurysm Repair. J Endovasc Ther 2018; 25: 31-39 DOI: 10.1177/1526602817747282.
• 10 Mendes BC, Rathore A, Ribeiro MS. et al. Off-the-shelf fenestrated and branched stent graft designs for abdominal aortic aneurysm repair. Semin Vasc Surg 2016; 29: 74-83 DOI: 10.1053/j.semvascsurg.2016.06.005.
• 11 Mendes BC, Oderich GS, Macedo TA. et al. Anatomic feasibility of off-the-shelf fenestrated stent grafts to treat juxtarenal and pararenal abdominal aortic aneurysms. J Vasc Surg 2014; 60: 839-847 DOI: 10.1016/j.jvs.2014.04.038. discussion 847–848
• 12 Sweet MP, Hiramoto JS, Park KH. et al. A standardized multi-branched thoracoabdominal stent-graft for endovascular aneurysm repair. J Endovasc Ther 2009; 16: 359-364 DOI: 10.1583/09-2734.1.
• 13 Kristmundsson T, Sveinsson M, Björses K. et al. Suitability of the Zenith p-Branch Standard Fenestrated Endovascular Graft for Treatment of Ruptured Abdominal Aortic Aneurysms. J Endovasc Ther 2015; 22: 760-764 DOI: 10.1177/1526602815601096.
• 14 Bertoglio L, Grandi A, Carta N. et al. Comparison of anatomical feasibility of three different multibranched off-the-shelf stent-grafts designed for thoracoabdominal aortic aneurysms. J Vasc Surg 2021; DOI: 10.1016/j.jvs.2021.04.066.
• 15 Starnes BW. Physician-modified endovascular grafts for the treatment of elective, symptomatic, or ruptured juxtarenal aortic aneurysms. J Vasc Surg 2012; 56: 601-607 DOI: 10.1016/j.jvs.2012.02.011.
• 16 Uflacker R, Robison JD, Schonholz C. et al. Clinical experience with a customized fenestrated endograft for juxtarenal abdominal aortic aneurysm repair. J Vasc Interv Radiol 2006; 17: 1935-1942 DOI: 10.1097/01.RVI.0000248828.92093.1A.
• 17 Oderich GS, Ricotta 2nd JJ. Modified fenestrated stent grafts: device design, modifications, implantation, and current applications. Perspect Vasc Surg Endovasc Ther 2009; 21: 157-167 DOI: 10.1177/1531003509351594.
• 18 Oderich GS, Farber MA, Sanchez LA. Urgent endovascular treatment of symptomatic or contained ruptured aneurysms with modified stent grafts. Perspect Vasc Surg Endovasc Ther 2011; 23: 186-194 DOI: 10.1177/1531003511408341.
• 19 Georgiadis GS, van Herwaarden JA, Antoniou GA. et al. Systematic Review of Off-the-shelf or Physician-Modified Fenestrated and Branched Endografts. J Endovasc Ther 2016; 23: 98-109 DOI: 10.1177/1526602815611887.
• 20 Canonge J, Jayet J, Heim F. et al. Comprehensive Review of Physician Modified Aortic Stent Grafts: Technical and Clinical Outcomes. Eur J Vasc Endovasc Surg 2021; 61: 560-569 DOI: 10.1016/j.ejvs.2021.01.019.
• 21 Scali ST, Neal D, Sollanek V. et al. Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology. J Vasc Surg 2015; 62: 1148-1159.e2 DOI: 10.1016/j.jvs.2015.06.133.
• 22 Juszczak MT, Vezzosi M, Khan M. et al. Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts. J Vasc Surg 2020; 72: 435-444 DOI: 10.1016/j.jvs.2019.10.056.
• 23 Tsilimparis N, Heidemann F, Rohlffs F. et al. Outcome of Surgeon-Modified Fenestrated/Branched Stent-Grafts for Symptomatic Complex Aortic Pathologies or Contained Rupture. J Endovasc Ther 2017; 24: 825-832 DOI: 10.1177/1526602817729673.
• 24 Hongku K, Sonesson B, Björses K. et al. Mid-term Outcomes of Endovascular Repair of Ruptured Thoraco-abdominal Aortic Aneurysms with Off the Shelf Branched Stent Grafts. Eur J Vasc Endovasc Surg 2018; 55: 377-384 DOI: 10.1016/j.ejvs.2017.11.021.
• 25 Scheerbaum M, Kölbel T, Rohlffs F. et al. Back-Table Surgeon Modification of a t-Branch. Ann Vasc Surg 2017; 45: 330-335 DOI: 10.1016/j.avsg.2017.07.011.
• 26 Oderich GS. Commentary: Physician-Modified vs. Off-the-shelf Fenestrated and Branched Endografts: Is This a Fair Comparison?. J Endovasc Ther 2016; 23: 110-114 DOI: 10.1177/1526602815613520.