Endovascular Treatment of Para-Visceral Penetrating Aortic Ulcers Using Fenestrated/Branched Endografts

Introduction - Para-Visceral Penetrating Aortic Ulcer (PV-PAU) is a rare lesion of the abdominal aorta. Its treatment is challenging with endovascular or open surgical repair (OR). Implantation of Fenestrated/Branched Endografts (F-BEVAR) is a treatment option. The aim of this study was to report the experience of two European University Vascular Surgery Units in the endovascular treatment of PV-PAU using F-BEVAR. Methods - Since January 2011, all patients with PV-PAU and treated by F-BEVAR in two European University Vascular Surgery Units were enrolled in a prospective database and retrospectively evaluated; clinical, morphological, intra-operative and post-operative data were collected. Primary end-points of the study were technical success (TS: successful F-BEVAR main body deployment, complete and effective revascularization of all target visceral vessels -TVV, no evidence of type I-III endoleak at the end of the procedure, no conversion to open repair and 24-hour survival) and clinical success (CS: 30-day survival, freedom from 30-day operative related post-operative complications). Secondary end-points were short and mid-term survival and freedom from aortic-related reintervention. Results - Between January 2011 and December 2016 eighteen patients with PV-PAU were treated with F-BEVAR (male: 83.3%; mean age 72.8±8.2; ASA III/IV 77.8%/11.1%). Eight PV-PAU were localized in the para-celiac aorta and 10 in the para-renal aorta. Mean PAU’s neck, length, depth and diameter were respectively 21.7 mm, 48.9 mm, 24.8 mm and 53.7 mm. Three patients (16.6%) had a history of aortic aneurysm treatment, 1 (5.5%) was symptomatic. Sixty-seven visceral vessels (32 renal arteries, 18 superior mesenteric arteries and 17 celiac trunks) were revascularized with 58 fenestrations, 8 scallops and 1 branch. Custom made fenestrated/branched endografts were manufactured in all cases. Technical success, 30-day mortality and 30-day visceral vessel patency were respectively 100%, 0% and 100%. Clinical success was 94.4% (one surgical revision for para-rectal surgical access wound dehiscence in a case requiring an iliac conduit). Mean follow-up was 19.7 months (range: 1- 72.5); no patients died and no TVV occlusion were depicted during follow-up. Re-interventions were performed in 4 patients: 1 embolization for a type II endoleak, 2 TVV relining for endoleak and stenosis, 1 iliac extension for a type Ib endoleak). No conversion, type Ia or III endoleaks and no AAA related mortality occurred during follow-up. Conclusion - Our experience suggests that endovascular exclusion of PV-PAU with F-BEVAR is a safe and effective treatment. References1.Taher F, Assadian A, Strassegger J, Duschek N, Koulas S, Senekowitsch C et al. Pararenal aortic ulcer repair. Eur J Vasc Surg. 2016 Apr;51(4):504-10.2.Ferro C, Rossi UG, Petrocelli F, Seitun S, Robaldo A, Mazzei R. Penetrating atherosclerotic ulcer of the abdominal aorta involving the celiac trunk origin and superior mesenteric artery occlusion: endovascular treatment. Cardiovasc Intervent Radiol. 2011 34:S40-S43.3.Gargiulo M, Gallitto E, Freyrie A, Stella A. Endovascular treatment of penetrating ulcers of the paraceliac aorta using fenestrated endograft. Ann Vasc Surg. 2014 Apr;28(3):738.4.Nathan DP, Boonn W, Lai E, Wang GJ, Desai N, Woo WY et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg 2012 Jan;55(1):10-5.5.Gallitto E, Gargiulo M, Freyrie A, Mascoli C, Bianchini Massoni C, Ancetti S et al. The endovascular treatment of juxta-renal abdominal aortic aneurysm using fenestrated endograft: early and mid-term results. J Cardiovasc Surg (Torino). 2015 Sep 29.