title: Endovascular Management of Proximal Fixation Loss Using Parallel Stent Grafting Techniques to Preserve Visceral Flow.
abstract: BACKGROUND
  Proximal fixation loss following endovascular aortic aneurysm repair (EVAR) creates a clinical dilemma. Typically, endovascular salvage requires adequate aortic neck below the renal arteries, in cases with no infrarenal neck proximal extension into the paravisceral aorta using parallel grafts provides an alternative to open graft explant. We present our experience at a tertiary care center with endovascular management of proximal fixation loss following EVAR using parallel stent grafting techniques to preserve renal and visceral branches.
  
  
  METHODS
  We conducted a retrospective review of our type I endoleak database. Of 135 patients, 19 patients were identified that required Ch-EVAR as a salvage procedure for loss of proximal fixation or seal after a previous EVAR. Data from all procedures, as well as the entire hospital course, and documented follow-up were captured and analyzed.
  
  
  RESULTS
  The average age of the cohort was 83 (78-88) years. The average time from original EVAR to secondary treatment was 6.05 years. The most common primary endograft treated was the AneuRx stent graft at 37% (n = 7). Ninety-five percent of patients were treated for an expanding aneurysm sac with 21% of patients being symptomatic at the time of treatment. Open femoral access was used more commonly than a percutaneous approach (n = 14 vs. 5). Adjunctive proximal arterial access was required in 58% of cases; open axillary exposure (n = 4), percutaneous brachial (n = 4), and open brachial (n = 3) access. Eighteen patients received proximal cuffs in addition to parallel stent grafts, whereas 1 patient required an entire endograft relining in addition to the parallel visceral stents. Twenty-nine total parallel stent grafts were placed, most commonly in a single renal artery (n = 27). Primary technical success was achieved in 100% of cases with exclusion of all type IA endoleaks. Reintervention was required for 1 patient for a new type III endoleak. There was an average follow-up time of 520.5 days with 100% snorkel patency.
  
  
  CONCLUSIONS
  Although technically challenging, endovascular salvage of proximal fixation failure after EVAR is possible with extension to the paravisceral aorta using parallel graft techniques. Parallel chimney stent treatment for proximal fixation failure following EVAR can be performed with high technical success, low need for reintervention, and excellent midterm patency rates. Given these findings, chimney stent treatment should be considered the primary mode of therapy for those patients with limited life span and extensive medical comorbidities.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL. Electronic address: atanious@health.usf.edu.
authors.forename: Adam
authors.initials: A
authors.lastname: Tanious
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL.
authors.forename: Mathew
authors.initials: M
authors.lastname: Wooster
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL.
authors.forename: Andrew
authors.initials: A
authors.lastname: Jung
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL.
authors.forename: Peter R
authors.initials: PR
authors.lastname: Nelson
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL.
authors.forename: Martin R
authors.initials: MR
authors.lastname: Back
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida Health Morsani School of Medicine, Tampa, FL.
authors.forename: Murray L
authors.initials: ML
authors.lastname: Shames
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005431:Florida; D006801:Humans; D008297:Male; D012039:Regional Blood Flow; D012189:Retrospective Studies; D015607:Stents; D062606:Tertiary Care Centers; D013997:Time Factors; D017211:Treatment Failure; D014781:Viscera / Q000098:blood supply*