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PC082 Effect of Stent Design on Branch Vessel Outcomes in Fenestrated Endografting of Complex Aortic Aneurysms
Journal of Vascular Surgery
Abstracts
161S
Volume 65, Number 6S Methods: A retrospective chart review over a 16-month period identified patients undergoing ultrasound-guided scalene block. Injectate consisted of local anesthetic (0.25% bupivacaine) combined with steroid (20 mg triamcinolone) into the anterior and middle scalene muscles. Successful block included intramuscular needle placement and medication delivery (Fig). Positive diagnostic outcome was defined as pain relief and/ or improvement in function. Results: Forty-two procedures (71.4% women; range, 20-56 years; mode age, 33) were identified. Technical success was achieved in all procedures. Average pain intensity (visual analog scale 1-10) was rated 6 6 2.02 before injection and 2.7 6 2.22 at 10 minutes after injection. No complications were reported. A total of 41 patient encounters (97.6%) had a positive outcome. One patient (2.4%) complained of subacute pain 3 weeks following injection without neurologic or vascular sequela. Computed tomography (CT)-guided scalene blocks were not performed at our institution during the reviewed time frame. Such injections routinely average continuous radiation exposure times of 25 seconds per procedure. Conclusions: Neurogenic thoracic outlet syndrome (NTOS) is more commonly diagnosed in women, often within childbearing age. CT-guided local anesthetic injection of the scalene muscles has been the standard for confirming diagnosis and guiding NTOS treatment. The disadvantage is exposure to ionizing radiation and thyroid sensitivity, which is significantly greater at younger ages. Our study demonstrates that ultrasound-guided techniques can be used safely and effectively for NTOS diagnosis and treatment without exposure to radiation. In all cases, no nerve injury, vascular puncture, hematoma, infection, local hemodynamic consequence, or pneumothorax occurred. While CT-guided scalene injections are accurate and effective, this study supports that ultrasound guided techniques have low complication rates without radiation. This provides a significant benefit to improving maternal and fetal safety as women are four times as likely to present for NTOS management and may require multiple injections to achieve sustained pain relief. References: 1. Christo PJ, Christo DK, Carinci AJ, Freischlag JA. Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med 2010;11:504-11. 2. Mashayekh A, Christo PJ, Yousem DM, Pillai JJ. CT-guided injection of the anterior and middle scalene muscles: technique and complications. AJNR Am J Neuroradiol 2011;32:495-500. 3. Freischlag J, Orion K. Understanding Thoracic Outlet Syndrome. Scientifica (Cairo) 2014;2014:248163. 4. Lum YW, Brooke BS, Likes K, Modi M, Grunebach H, Christo PJ, et al. Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2012;55:1370-5. 5. Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using a ultrasound-guided approach. Skeletal Radiol 2010;39:973-80.
PC082. Effect of Stent Design on Branch Vessel Outcomes in Fenestrated Endografting of Complex Aortic Aneurysms Behzad S. Farivar, Agenor Dias, Corey S. Brier, Yuki Kuramochi, Federico Ezequiel. Parodi, Matthew J. Eagleton. Cleveland Clinic, Cleveland, OH Objectives: The ideal mating stent for target vessel revascularization in fenestrated/branched endograft (F/B-EVAR) repair of juxtarenal aortic aneurysm (JRAA) and thoracoabdominal aortic aneurysms (TAAA) remains unknown. The objective of this study was to assess the impact and complications associated with use of different stent types and configurations mated with reinforced fenestrations during F/B-EVAR. Methods: Clinical data from patients undergoing F/B-EVAR for JRAA/ TAAA in a prospective physician-sponsored investigational device exemption trial were analyzed. Outcomes for two different balloonexpandable covered stents (BECS) mated with reinforced fenestrations along with the effect of placement of an additional self-expanding stent (SES) were assessed. Primary patency, type III endoleaks, and overall per-patient reintervention rates were calculated. The Cox proportional hazards model was used for time-to-event analysis. Results: From 2003 to 2015, 918 patients underwent F/B-EVAR of complex aortic aneurysms. A total of 1604 renal arteries (RAs) and 714 superior mesenteric arteries (SMAs) were mated with reinforced fenestrations using JOSTENT (n ¼ 1790; Abbott Vascular, Abbott Park, Ill) or iCAST (n ¼ 528; Atrium Medical, Hudson, NH). The type of BECS did not impact primary patency at 5 years (97.5% JOSTENT vs 97.1% iCAST; P > .05). A total of 85% (605 of 714) of SMAs and 25% (402 of 1604) of RAs had an additional distal SES at the index operation. There was a trend towards higher hazard of occlusion for addition of distal SES to RAs (hazard ratio [HR], 1.935; 95% confidence interval [CI], 0.96-3.88; P ¼ .0631) but not for SMA (HR, 0.5856; 95% CI, 0.18-1.95; P ¼ .3824). Time to first reintervention in patients (HR, 1.191; 95% CI, 0.86-1.64; P ¼ .2851) or type III endoleaks (HR, 1.086; 95% CI, 0.6-1.95; P ¼ .783) with different BECS were not significantly different. Conclusions: BECS choice does not appear to affect branch durability following F/B-EVAR. Selective distal SES placement in vulnerable RAs may provide a safeguard against a primary occlusive event. Routine addition of distal SES does not improve SMA fenestration stability. Stent design does not impact primary patency and overall reintervention rates in patients with fenestrated endograft repair of aortic aneurysm.
Author Disclosures: C. S. Brier: Nothing to disclose; A. Dias: Nothing to disclose; M. J. Eagleton: Nothing to disclose; B. S. Farivar: Nothing to disclose; Y. Kuramochi: Nothing to disclose; F. Ezequiel. Parodi: Nothing to disclose.
PC084. Natural History and Management of Splanchnic Artery Aneurysms in a Single Tertiary Referral Center Young Erben,1 Adam J. Brownstein,1 Sareh Rajaee,1 Yupeng Li,2 John Rizzo,2 Hamid Mojibian,1 Bulat Ziganshin,1 John Elefteriades1. 1Yale University School of Medicine, New Haven, Conn; 2Stony Brook University Medical Center, Stony Brook, NY
Fig. Author Disclosures: C. DeMesa: Nothing to disclose; S. Fishman: Nothing to disclose; J. Freischlag: Nothing to disclose; M. D. Humphries: Nothing to disclose; K. A. Price: Nothing to disclose; S. Sheth: Nothing to disclose.
Objectives: Splanchnic artery aneurysms (SAA) are rare, and little is known about their natural history and management. We reviewed our single-center experience managing this patient population. Methods: A retrospective review of the Yale radiology database from January 1999 to December 2016 was performed. Only patients with a SAA and a computed tomography (CT) scan of the abdomen were selected for review. Patient demographics, aneurysm characteristics,
Abstracts
161S
Volume 65, Number 6S Methods: A retrospective chart review over a 16-month period identified patients undergoing ultrasound-guided scalene block. Injectate consisted of local anesthetic (0.25% bupivacaine) combined with steroid (20 mg triamcinolone) into the anterior and middle scalene muscles. Successful block included intramuscular needle placement and medication delivery (Fig). Positive diagnostic outcome was defined as pain relief and/ or improvement in function. Results: Forty-two procedures (71.4% women; range, 20-56 years; mode age, 33) were identified. Technical success was achieved in all procedures. Average pain intensity (visual analog scale 1-10) was rated 6 6 2.02 before injection and 2.7 6 2.22 at 10 minutes after injection. No complications were reported. A total of 41 patient encounters (97.6%) had a positive outcome. One patient (2.4%) complained of subacute pain 3 weeks following injection without neurologic or vascular sequela. Computed tomography (CT)-guided scalene blocks were not performed at our institution during the reviewed time frame. Such injections routinely average continuous radiation exposure times of 25 seconds per procedure. Conclusions: Neurogenic thoracic outlet syndrome (NTOS) is more commonly diagnosed in women, often within childbearing age. CT-guided local anesthetic injection of the scalene muscles has been the standard for confirming diagnosis and guiding NTOS treatment. The disadvantage is exposure to ionizing radiation and thyroid sensitivity, which is significantly greater at younger ages. Our study demonstrates that ultrasound-guided techniques can be used safely and effectively for NTOS diagnosis and treatment without exposure to radiation. In all cases, no nerve injury, vascular puncture, hematoma, infection, local hemodynamic consequence, or pneumothorax occurred. While CT-guided scalene injections are accurate and effective, this study supports that ultrasound guided techniques have low complication rates without radiation. This provides a significant benefit to improving maternal and fetal safety as women are four times as likely to present for NTOS management and may require multiple injections to achieve sustained pain relief. References: 1. Christo PJ, Christo DK, Carinci AJ, Freischlag JA. Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med 2010;11:504-11. 2. Mashayekh A, Christo PJ, Yousem DM, Pillai JJ. CT-guided injection of the anterior and middle scalene muscles: technique and complications. AJNR Am J Neuroradiol 2011;32:495-500. 3. Freischlag J, Orion K. Understanding Thoracic Outlet Syndrome. Scientifica (Cairo) 2014;2014:248163. 4. Lum YW, Brooke BS, Likes K, Modi M, Grunebach H, Christo PJ, et al. Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2012;55:1370-5. 5. Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using a ultrasound-guided approach. Skeletal Radiol 2010;39:973-80.
PC082. Effect of Stent Design on Branch Vessel Outcomes in Fenestrated Endografting of Complex Aortic Aneurysms Behzad S. Farivar, Agenor Dias, Corey S. Brier, Yuki Kuramochi, Federico Ezequiel. Parodi, Matthew J. Eagleton. Cleveland Clinic, Cleveland, OH Objectives: The ideal mating stent for target vessel revascularization in fenestrated/branched endograft (F/B-EVAR) repair of juxtarenal aortic aneurysm (JRAA) and thoracoabdominal aortic aneurysms (TAAA) remains unknown. The objective of this study was to assess the impact and complications associated with use of different stent types and configurations mated with reinforced fenestrations during F/B-EVAR. Methods: Clinical data from patients undergoing F/B-EVAR for JRAA/ TAAA in a prospective physician-sponsored investigational device exemption trial were analyzed. Outcomes for two different balloonexpandable covered stents (BECS) mated with reinforced fenestrations along with the effect of placement of an additional self-expanding stent (SES) were assessed. Primary patency, type III endoleaks, and overall per-patient reintervention rates were calculated. The Cox proportional hazards model was used for time-to-event analysis. Results: From 2003 to 2015, 918 patients underwent F/B-EVAR of complex aortic aneurysms. A total of 1604 renal arteries (RAs) and 714 superior mesenteric arteries (SMAs) were mated with reinforced fenestrations using JOSTENT (n ¼ 1790; Abbott Vascular, Abbott Park, Ill) or iCAST (n ¼ 528; Atrium Medical, Hudson, NH). The type of BECS did not impact primary patency at 5 years (97.5% JOSTENT vs 97.1% iCAST; P > .05). A total of 85% (605 of 714) of SMAs and 25% (402 of 1604) of RAs had an additional distal SES at the index operation. There was a trend towards higher hazard of occlusion for addition of distal SES to RAs (hazard ratio [HR], 1.935; 95% confidence interval [CI], 0.96-3.88; P ¼ .0631) but not for SMA (HR, 0.5856; 95% CI, 0.18-1.95; P ¼ .3824). Time to first reintervention in patients (HR, 1.191; 95% CI, 0.86-1.64; P ¼ .2851) or type III endoleaks (HR, 1.086; 95% CI, 0.6-1.95; P ¼ .783) with different BECS were not significantly different. Conclusions: BECS choice does not appear to affect branch durability following F/B-EVAR. Selective distal SES placement in vulnerable RAs may provide a safeguard against a primary occlusive event. Routine addition of distal SES does not improve SMA fenestration stability. Stent design does not impact primary patency and overall reintervention rates in patients with fenestrated endograft repair of aortic aneurysm.
Author Disclosures: C. S. Brier: Nothing to disclose; A. Dias: Nothing to disclose; M. J. Eagleton: Nothing to disclose; B. S. Farivar: Nothing to disclose; Y. Kuramochi: Nothing to disclose; F. Ezequiel. Parodi: Nothing to disclose.
PC084. Natural History and Management of Splanchnic Artery Aneurysms in a Single Tertiary Referral Center Young Erben,1 Adam J. Brownstein,1 Sareh Rajaee,1 Yupeng Li,2 John Rizzo,2 Hamid Mojibian,1 Bulat Ziganshin,1 John Elefteriades1. 1Yale University School of Medicine, New Haven, Conn; 2Stony Brook University Medical Center, Stony Brook, NY
Fig. Author Disclosures: C. DeMesa: Nothing to disclose; S. Fishman: Nothing to disclose; J. Freischlag: Nothing to disclose; M. D. Humphries: Nothing to disclose; K. A. Price: Nothing to disclose; S. Sheth: Nothing to disclose.
Objectives: Splanchnic artery aneurysms (SAA) are rare, and little is known about their natural history and management. We reviewed our single-center experience managing this patient population. Methods: A retrospective review of the Yale radiology database from January 1999 to December 2016 was performed. Only patients with a SAA and a computed tomography (CT) scan of the abdomen were selected for review. Patient demographics, aneurysm characteristics,