title: Geometry and respiratory-induced deformation of abdominal branch vessels and stents after complex endovascular aneurysm repair.
abstract: OBJECTIVE
  This study quantified the geometry and respiration-induced deformation of abdominal branch vessels and stents after fenestrated (F-) and snorkel (Sn-) endovascular aneurysm repair (EVAR).
  
  
  METHODS
  Twenty patients (80% male; mean age, 75.2 ± 7.4 years; mean aneurysm diameter, 6.2 ± 1.8 cm) underwent computed tomography angiography during inspiratory and expiratory breath hold protocols after F-EVAR (n = 11) or Sn-EVAR (n = 9). Centerlines for the aorta and visceral vessels were extracted from three-dimensional models. Branch angles were computed relative to the orthogonal plane at the branch ostia, and end-stent angles of the left renal artery (LRA) and right renal artery (RRA) were computed relative to the distal stent orientation. The radius of peak curvature was defined by the circumscribed circle at the highest curvature.
  
  
  RESULTS
  Sn-renal branches were more downward-angled than F-renal branches (P < .04). At the distal ends of the RRA stents, Sn-RRAs were angled greater than F-RRAs (P < .03) and had a smaller radius of peak curvature (P < .03). With expiration, the end-stent angle of Sn-LRAs increased by 4° ± 4° (P < .02) and exhibited a significant reduction of radius of curvature (P < .04). The unstented celiac arteries were more downward-angled (P < .02, inspiration), with a smaller radius of curvature (P < .00001), than the unstented superior mesenteric arteries. With expiration, the celiac arteries angled upwards by 9° ± 9° (P < .0005), which was greater than the superior mesenteric arteries (P < .03). At a median postoperative follow-up of 12.6 months (range, 1.0-37.1 months), branch vessel patency was 100%, serum creatinine levels remained stable, and one reintervention was required for a type III endoleak at the main body-LRA stent interface.
  
  
  CONCLUSIONS
  Sn-renals were angled more inferiorly at the branch and more angulated at the stent end than F-renals due to stent placement strategies. Sn-LRAs exhibited a significant change in end-stent angle and curvature during respiration, a finding that may compromise long-term durability for parallel stent graft configurations. Further investigation is warranted to better optimize anatomic, patient, and branch vessel stent selection between fenestrated and snorkel strategies and their relationship to long-term patency.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif. Electronic address: ullery@gmail.com.
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif.
authors.forename: Ga-Young
authors.initials: GY
authors.lastname: Suh
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Lee
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif.
authors.forename: Brian
authors.initials: B
authors.lastname: Liu
authors.affiliation: Department of Chemistry, Stanford University, Stanford, Calif.
authors.forename: Robert
authors.initials: R
authors.lastname: Stineman
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Dalman
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cheng
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011474:Prosthesis Design; D012077:Renal Artery / Q000503:physiopathology / Q000601:surgery; D012119:Respiration; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency