A New Ancillary Graft System For Salvage Of Failing Aortic Endografts: A Multicenter Survey

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Krishna Mannava, MD, Britt Tonnessen, MD, Rachael Price, PhD, W. Charles Sternbergh, III, MD, Samuel R. Money, MD.
Ochsner Clinic Foundation, New Orleans, LA, USA.

INTRODUCTION: Proximal endograft fixation failure leads to migration, increases the risk of type I endoleak, and may eventually cause aneurysm rupture. A new ancillary graft system was developed to treat proximal fixation failures of previously placed aortic endografts. There are 2 types of devices, a converter and a main body extension. The converter endograft system provides proximal suprarenal fixation and is used with a femoral-femoral bypass to convert the previously placed failing proximal endograft into an aorto-uniiliac system. The main body extension endograft system is a proximal cuff that provides suprarenal fixation to bridge the area between the renal artery and the failing primary endograft. Both of these devices have uncovered suprarenal stents with caudally oriented barbs. This abstract reviews the initial worldwide experience with this system for treatment of proximal endograft failure.
METHODS: A retrospective survey was sent to implanting physicians of custom-made predecessors to the ancillary endograft system. Seventy-five responses from physicians in 13 countries were returned and available for assessment. Of the 75 custom-made devices, 69 were reported to treat previously placed endografts, 4 to treat previously placed surgical grafts, 1 was deployed without a previously placed endograft, and 1 previously placed graft was unspecified. The focus of the following analysis is the 69 ancillary devices used to treat six different commercial endograft designs for primary proximal endograft failure.
RESULTS:
85.5% (59/69) previously placed grafts were treated with main body extensions, while 14.5% (10/69) were treated with converters.
Outcome # devices Time from device implant (mos)
Implant functional 55/69(79.7%) 26.3±10.7
Open conversion 5/69(7.2%)* 4.3±5.7
Patient expired 8/69(11.6%)† 10.1±13.5
Unknown 1/69(1.4%) 26
Two of the 5 surgical conversions occurred intra-operatively during ancillary graft placement. One was reportedly due to persistent endoleak and the other reason for conversion was not provided. Two delayed conversions occurred between 5 and 12 months post device implantation, while one conversion time was reported as unknown. All patients survived surgical conversion. 30-day mortality was 4.3% (3/69) from intra-operative cardiac death (n=1), sepsis (n=1), and one patient died before ancillary graft placement (included on intent-to-treat basis). In addition, one aneurysm ruptured 36 months post device placement reportedly due to a type II endoleak. The cause of death in the remaining patients was not aneurysm related. Thus, overall aneurysm related death rate was 4/69 (5.8%) in those patients with failed primary endografts and treated with custom-made ancillary graft devices.
CONCLUSIONS:
The use of the custom-made predecessors of the new aortic ancillary graft system to treat patients with proximal fixation failures of the primary endograft has been successful in a majority of patients with this difficult problem.