Surgeon-modified Stentgrafts für komplexe Aortenrekonstruktionen – was ist möglich?

Zusammenfassung

Hintergrund Die enge anatomische Beziehung zu den Viszeralgefäßen macht die Behandlung der komplexen thorakoabdominellen Aortenpathologien zu einer Herausforderung. Im Notfall stehen zu ihrer endovaskulären Behandlung Off-the-Shelf-Prothesen und parallele Techniken zur Verfügung, alternativ kann für komplexe Aortenanatomien die Modifizierung herkömmlicher Stentgrafts durch die behandelnden Chirurginnen und Chirurgen erfolgen, im Sinne eines Surgeon-modified Stentgrafts (SMSG). Ziel der vorliegenden Publikation ist die Darstellung der Möglichkeiten und Ergebnisse, die dieses Verfahren bietet.

Ergebnisse Die Planung der Fenestrierungen des SMSG kann mittels manueller Messungen in Centerline of Flow-Rekonstruktionen der aortalen Computertomografie-Angiografie erfolgen. Vereinfacht und standardisiert wird die Planung des SMSG durch die Erstellung von personalisierten 3-D-Aortenmodellen und die Entwicklung von Algorithmen zur automatisierten Ermittlung der idealen Fenestrierungspositionen. Zur Herstellung des SMSG können die meisten zugelassenen Stentgrafts verwendet werden. Für die Anfertigung selbst sind unterschiedliche Techniken beschrieben. Außer der einfachen Fenestrierung ist auch die Erstellung von Mini-Cuffs, Directional Branches und Inner Branches beschrieben, weiterhin die Ergänzung von Diameter reducing Ties und das Vorladen von Führungsdrähten zur Erleichterung der Implantation. Die Behandlung mit SMSG zeigt gute Ergebnisse mit hohen technischen Erfolgsraten um 90–100% und niedriger 30-Tage-Mortalität, vor allem im Vergleich zur offen-chirurgischen Behandlung ähnlicher PatientInnen. Auch die Rate an Endoleaks ist mit 0–14% akzeptabel. Langzeitergebnisse zur Nachhaltigkeit der modifizierten Stentgrafts sind bislang noch nicht verfügbar.

Schlussfolgerung Die Surgeon-modified Stentgrafts stellen eine sichere und machbare Ergänzung der Palette endovaskulärer Behandlungsoptionen für PatientInnen mit dringlichen komplexen thorakoabdominellen Aortenpathologien dar. Sie können im Rahmen eines individuellen Heilversuches eingesetzt werden und zeigen in der Literatur vielversprechende Ergebnisse.

Abstract

Background The close anatomical relationship to the visceral vessels renders the treatment of complex throacoabdominal aortic pathologies challenging. In emergent cases, off-the-shelf stent grafts and parallel techniques are feasible treatment options. Alternatively, the treating surgeon can alter a conventional stent graft, creating a so-called surgeon-modified stent graft (SMSG) to adapt it to the complex aortic pathology. The aim of this publication is to present the possibilities and results of this method.

Results The location of SMSG’s fenestrations can be determined after manual measurements of the centerline of flow reconstructions of the aortic computed tomography-angiography. The planning of the SMSG can be simplified and standardized by creating personalized 3D aortic models, and by using algorithms for the automated determination of the ideal fenestration positions. Most approved stent grafts can be used as platforms for SMSG. Different manufacturing techniques have been described. In addition to simple fenestrations, mini-cuffs, directional branches, and inner branches are used. Furthermore, diameter reducing ties and preloaded catheters could facilitate the implantation. The treatment of complex aortic pathologies using SMSG has achieved good results, with high technical success rate of 90–100%, and low 30-day mortality, especially when compared to open surgical treatment of similar patients. The rate of endoleak of 0–14% was also acceptable. Long-term durability results after treatment with SMSG are not yet available.

Conclusion Surgeon-modified stent grafts are safe and feasible for the endovascular treatment of patients with urgent complex thoracoabdominal aortic pathologies. They represent compassionate use and show promising results in the published literature.

Schlüsselwörter

Aortenstentprothese - Notfalleingriff - rupturiertes Bauchaortenaneurysma - 3D-Druck - surgeon-modified Stentgraft

Keywords

aortic aneurysm - aortic rupture - aortic stent prosthesis - 3D printing - surgeon-modified Stentgraft

• Literatur

• 1 Johnston KW, Rutherford RB, Tilson MD. et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991; 13: 452-458
• 2 Ulug P, Hinchliffe RJ, Sweeting MJ. et al. Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT. Health Technol Assess 2018; 22: 1-122
• 3 Wanhainen A, Verzini F, van Herzeele I. et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57: 8-93
• 4 Volodos NL, Karpovich IP, Shekhanin VE. et al. A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm. Grudn Khir 1988; 84-86
• 5 Ferrer C, Cao P, De Rango P. et al. A propensity-matched comparison for endovascular and open repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2016; 63: 1201-1207
• 6 Chuter T, Greenberg RK. Standardized off-the-shelf components for multibranched endovascular repair of thoracoabdominal aortic aneurysms. Perspect Vasc Surg Endovasc Ther 2011; 23: 195-201
• 7 Katsargyris A, Uthayakumar V, Marques de Marino P. et al. Aneurysm Rupture and Mortality During the Waiting Time for a Customised Fenestrated/Branched Stent Graft in Complex Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2020; 60: 44-48
• 8 Li Y, Hu Z, Bai C. et al. Fenestrated and Chimney Technique for Juxtarenal Aortic Aneurysm: A Systematic Review and Pooled Data Analysis. Sci Rep 2016; 6: 20497
• 9 Starnes BW. Physician-modified endovascular grafts for the treatment of elective, symptomatic, or ruptured juxtarenal aortic aneurysms. J Vasc Surg 2012; 56: 601-607
• 10 Koleilat I, Jaeggli M, Ewing JA. et al. Interobserver variability in physician-modified endograft planning by comparison with a three-dimensional printed aortic model. J Vasc Surg 2016; 64: 1789-1796
• 11 Starnes BW, Tatum B. Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts. J Vasc Surg 2013; 58: 311-317
• 12 Leotta DF, Starnes BW. Custom fenestration templates for endovascular repair of juxtarenal aortic aneurysms. J Vasc Surg 2015; 61: 1637-1641
• 13 Branzan D, Winkler D, Schmidt A. et al. 3-Dimensional Aortic Model to Create a Fenestrated Stent Graft for the Urgent Treatment of a Paravisceral Penetrating Aortic Ulcer. JACC Cardiovasc Interv 2019; 12: 793-795
• 14 Barón V, Guevara R. Three-dimensional printing-guided fenestrated endovascular aortic aneurysm repair using open source software and physician-modified devices. J Vasc Surg Cases Innov Tech 2019; 5: 566-571
• 15 Branzan D, Geisler A, Grunert R. et al. The Influence of 3D Printed Aortic Models on the Evolution of Physician Modified Stent Grafts for the Urgent Treatment of Thoraco-abdominal and Pararenal Aortic Pathologies. Eur J Vasc Endovasc Surg 2021; 61: 407-412
• 16 Coles-Black J, Barber T, Chuen J. A Flexible 3D Printed Template to Assist with Physician Modified Endografts for FEVAR. Eur J Vasc Endovasc Surg 2021; 61: 699-700
• 17 Starnes BW, Tatum B, Singh N. Procedural and perioperative results in patients treated with fenestrated endovascular aneurysm repair planned by automated software in a physician-sponsored investigational device exemption trial of physician-modified endografts. J Vasc Surg 2018; 68: 1297-1307
• 18 Canonge J, Jayet J, Heim F. et al. Comprehensive Review of Physician Modified Aortic Stent Grafts: Technical and Clinical Outcomes. Eur J Vasc Endovasc Surg 2021; 61: 560-569
• 19 Lopez-Pena G, Garcia-Alva R, Laparra-Escareno H. et al. Physician-Modified Endovascular Gore Excluder Graft (Handmade Modified) for Complex Abdominal Aortic Aneurysm: A Step-by-Step Approach. Vasc Endovascular Surg 2020; 54: 656-659
• 20 Oderich GS, Fatima J, Gloviczki P. Stent graft modification with mini-cuff reinforced fenestrations for urgent repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2011; 54: 1522-1526
• 21 Oderich GS, Mendes BC, Correa MP. Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm using a physician-modified branched stent graft. J Vasc Surg 2014; 59: 1168-1173
• 22 D’Oria M, Mirza AK, Tenorio ER. et al. Physician-Modified Endograft With Double Inner Branches for Urgent Repair of Supraceliac Para-Anastomotic Pseudoaneurysm. J Endovasc Ther 2020; 27: 124-129
• 23 Oderich GS. Technique of adding a diameter-reducing wire to the modified TX2 fenestrated stent graft. Vascular 2010; 18: 350-355
• 24 Manning BJ, Harris PL, Hartley DE. et al. Preloaded fenestrated stent-grafts for the treatment of juxtarenal aortic aneurysms. J Endovasc Ther 2010; 17: 449-455
• 25 Uflacker R, Robison JD, Schonholz C. et al. Clinical experience with a customized fenestrated endograft for juxtarenal abdominal aortic aneurysm repair. J Vasc Interv Radiol 2006; 17: 1935-1942