This document discusses total endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) using fenestrated and branched endovascular aneurysm repair (F-EVAR/B-EVAR) techniques. It summarizes outcomes from 86 high-risk patients treated with F-EVAR/B-EVAR for TAAA between 2007-2014, finding a 30-day mortality of 2.3%, 1-year survival of 91%, and 3-year survival of 88%. The use of staged procedures was associated with reducing spinal cord ischemia from 10% to 0%. The conclusion is that F-EVAR/B-EVAR provides good outcomes for high-risk TAAA patients when

1. Donald AdamDonald Adam
Consultant Vascular and Endovascular SurgeonConsultant Vascular and Endovascular Surgeon
Total endovascular repairTotal endovascular repair
of thoracoabdominal aorticof thoracoabdominal aortic
aneurysmsaneurysms

2. Disclosure
Preceptor for Cook Medical's fenestrated,Preceptor for Cook Medical's fenestrated,
TAAA branch and t-branch EVAR devicesTAAA branch and t-branch EVAR devices
Unrestricted research funding from Cook MedicalUnrestricted research funding from Cook Medical

4. Current status of TAAA repairCurrent status of TAAA repair
Open repairOpen repair
Performed in small number of hospitalsPerformed in small number of hospitals
Low-risk patients (extent IV, young, CTD)Low-risk patients (extent IV, young, CTD)
High turn-down rateHigh turn-down rate
Endovascular repairEndovascular repair
Performed in small number of hospitalsPerformed in small number of hospitals
Hybrid visceral debranching and TEVARHybrid visceral debranching and TEVAR
Fenestrated / Branch EVARFenestrated / Branch EVAR
High-risk (unfit) patientsHigh-risk (unfit) patients

5. Fenestrated EVARFenestrated EVAR Branch EVARBranch EVAR

9. TBRANCH-34-18-202TBRANCH-34-18-202
3 proximal sealing stents3 proximal sealing stents
4 branches at 1:00, 12:00, 3:00, 10:004 branches at 1:00, 12:00, 3:00, 10:00
Tick, anterior and branch markersTick, anterior and branch markers
Diameter-reducing tiesDiameter-reducing ties
22 Fr, 60 cm Flexor22 Fr, 60 cm Flexor®®
introducerintroducer
Distal bodyDistal body
UNIBODY-22-81, 22-98, 22-115, 22-132UNIBODY-22-81, 22-98, 22-115, 22-132
20 Fr, 40 cm Flexor20 Fr, 40 cm Flexor®®
introducerintroducer
34 mm
18 mm
202 mm
81, 98, 115,
132 mm
22 mm

11. F-EVAR / B-EVAR for TAAA
220 patients
Mean diameter = 7cm
Mean age = 75 yrs
50% extent IV TAAA
40% previous aortic surgery
50% coronary artery disease
50% COPD
25% renal failure

12. F-EVAR / B-EVAR for TAAA
30-day mortality 8%
Spinal cord ischaemia 9%
Renal failure 5.8% (50% RRT)
Mean ITU stay 3 days
Mean post-op stay 6.5 days
Branch patency 95% @ 12m

13. _____________________________________________________________________
Chuter 1 100% 0% -
Anderson 4 75% 25% 75%
Simi 1 100% - -
Roselli 73 93% 5% 81%
Chuter 22 100% 9% 77%
Gilling-Smith 6 100% 0% 100%
Ferreira 11 - 24% 76%
Bicknell 8 100% 0% -
Verhoeven 30 93% 7% 76%
Haulon 33 94% 9% 82%
Clough 31 100% 10% 80%
_____________________________________________________
F-EVAR / B-EVAR for TAAA
N= Technical success 30d mortality 1-yr survival
c. 80% 1-year survival

14. F-EVAR / B-EVAR for TAAA
406 patients
54% extent IV TAAA
30-day mortality 4%
Estimated 2-year survival 75%
JTCS 2010;140:S171-8JTCS 2010;140:S171-8
CCF 2006 - 2010

15. Birmingham TAAA EVAR program
Commenced June 2007
High-risk patients unsuitable for OR due to
physiological or anatomical factors
Exclusions from this analysis:
65 FEVAR / BEVAR for juxtarenal AAA
10 surgeon-modified FEVAR for acute TAAA
45 FEVAR / BEVAR proctored in other hospitals

16. Patients
June 2007 - February 2014June 2007 - February 2014
8686 high-risk patientshigh-risk patients
[73 men; median 73 (range 54-84) years][73 men; median 73 (range 54-84) years]
Asymptomatic (n=81), acute symptomatic (n=5)Asymptomatic (n=81), acute symptomatic (n=5)
Crawford extent I-III (n=43), extent IV (n=43)Crawford extent I-III (n=43), extent IV (n=43)
Fenestrated (n=49), branch EVAR (n=37)Fenestrated (n=49), branch EVAR (n=37)

17. Patients
Crawford Extent I 4 (5%)
Extent II 9 (10%)
Extent III 30 (35%)
Extent IV 43 (50%)
Previous aortic surgery * 26 (30%)
Thoracic aortic surgery 3 (3%)
Thoracic EVAR 1 (1%)
Abdominal aortic surgery 19 (22%)
Abdominal EVAR 5 (6%)
* 1 pt – open AAA + TEVAR; 1pt – open AAA + TAAA repair* 1 pt – open AAA + TEVAR; 1pt – open AAA + TAAA repair

20. Procedures
320 target vessels320 target vessels
coeliac axis (71), superior mesenteric (83), renal (154),
arch branches (7), internal iliac artery (4)
scallops (16), branches (102), fenestrations (202)
297 stent-grafted target vessels297 stent-grafted target vessels
coeliac axis (55), superior mesenteric (81), renal (151),
arch branches (6), internal iliac artery (4)
4 target vessels occluded intra-operatively4 target vessels occluded intra-operatively
coeliac axis (1), renal (3)
no clinical consequences

21. Early outcome
Outcome Total (n=86) I-III (n=43) IV (n=43)
30-day mortality 2 (2.3%) 1 (2.3%) 1 (2.3%)
Spinal cord ischaemia * 4 (4.7%) 3 (7%) 1 (2.3%)
Unplanned permanent RRT 0 (0%) 0 (0%) 0 (0%)
Non-fatal CVA 2 (2.3%) 0 (0%) 2 (4.7%)
Myocardial infarction 1 (1.2%) 0 (0%) 1 (2.3%)
Early re-operation 3 (3.5%) 1 (2.3%) 2 (4.7%)

22. Spinal cord ischaemia
First 40 procedures
SCI = 4 (10%)
Staged procedures introduced for extent I-III
Spinal cord protection protocol without CSF drainage
Next 46 procedures
27 extent I-III
SCI = 0

23. Spinal cord protection protocol
Preserve spinal cord collaterals (LSA, IIA)Preserve spinal cord collaterals (LSA, IIA)
Minimize embolisationMinimize embolisation
Staged procedures for extent I-III TAAAStaged procedures for extent I-III TAAA
Stop anti-hypertensives 3 days pre-operativelyStop anti-hypertensives 3 days pre-operatively
HDU care for at least 36 hours post-operativelyHDU care for at least 36 hours post-operatively
Maintain MAPMaintain MAP >> 80mmHg80mmHg
Maintain patient lying at 30 degrees for 36 hrsMaintain patient lying at 30 degrees for 36 hrs
Maintain CVP < 15mmHgMaintain CVP < 15mmHg
Maintain oxygen delivery (Hb > 10, pOMaintain oxygen delivery (Hb > 10, pO22 > 9, SaO> 9, SaO22 > 95%)> 95%)

24. Staged proceduresStaged procedures
Stage 1: Complete SMA and RA branchesStage 1: Complete SMA and RA branches
Stage 2: Complete CA branchStage 2: Complete CA branch
Stage 1: Deploy proximal device landing above CAStage 1: Deploy proximal device landing above CA
Stage 2: Complete FEVAR/BEVARStage 2: Complete FEVAR/BEVAR
Stage 1: Complete proximal FEVAR / BEVARStage 1: Complete proximal FEVAR / BEVAR
Stage 2: Complete distal repair / limb extensionStage 2: Complete distal repair / limb extension
Allow remodelling of spinal collateralsAllow remodelling of spinal collaterals

26. Mid-term outcome
Patient survivalPatient survival
1 year = 91%1 year = 91%
3 years = 88%3 years = 88%
5 years = 81%5 years = 81%
Freedom from re-interventionFreedom from re-intervention
3 years = 95%3 years = 95%
Late target vessel occlusion = 2Late target vessel occlusion = 2

27. Conclusions
Fenestrated / branch EVAR is associated with good
early and medium-term outcomes in high-risk
patients with TAAA
Staged procedures have contributed to a significant
reduction in spinal cord ischaemic injury
Patients with TAAA should be evaluated by
multidisciplinary teams who are capable of offering
open and endovascular repair