Application of off-the-shelf thoracoabdominal multibranch endoprosthesis for urgent repair of pararenal and thoracoabdominal aortic aneurysms with occluded target vessels

Abstract

The Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is a commercially available off-the-shelf four-vessel inner branched endograft for thoracoabdominal aortic aneurysms (TAAA) and pararenal abdominal aortic aneurysms (AAA). However, there is paucity of data on the use of TAMBE in repair of pararenal AAA and TAAA with occluded target vessels. Here, we present two cases demonstrating the feasibility of TAMBE for repair of pararenal AAA and TAAA in patients with occluded target vessels.

The Thoracoabdominal Multibranch Endoprosthesis (TAMBE; W.L. Gore & Associates) is the first dedicated off-the-shelf four-vessel branched endograft to receive commercial approval from the U.S. Food and Drug Administration, based on the excellent outcomes achieved in highly selected trial settings.^1,2 Beyond the pathologies included in the investigational device exemption studies, wider applicability of TAMBE is feasible such as in type 1A endoleak from previous infrarenal endovascular aortic repair (EVAR) devices.³ Fenestrated branched EVAR using off-the-shelf multibranch constructs has shown promising results as an option for urgent repair of contained rupture of thoracoabdominal aortic aneurysm (TAAA).⁴ However, no report exists where TAMBE was used for urgent repair of TAAA with occluded target vessels. Here, we present two cases demonstrating the feasibility of TAMBE used with Iliac Branch Endoprosthesis (IBE) (W.L. Gore & Associates) for urgent repair of patients with giant or symptomatic aneurysms and nonstandard anatomy including occluded target vessels and short common iliac arteries. Patients provided written consent for publication. Institutional review board approval was waived.

Cases/Technique

Case 1

A 72-year-old man with a history of stage IIIB chronic kidney disease, multiple strokes, hypertension, and smoking was transferred to our center for urgent repair of a symptomatic 8.5-cm pararenal AAA, after presenting to the outside hospital with abdominal pain. Computed tomography (CT) showed a break in the calcified wall of an 8.5-cm pararenal AAA and an atrophic right kidney concerning for possible contained rupture and chronic occlusion of the right renal artery (Fig 1, A and B), as well as short and aneurysmal bilateral common iliac arteries, measuring 3.3 cm and 3.9 cm in lengths (Fig 1, C-F). The right kidney measured 4.8 cm in length (Fig 1, G). Given the patient’s comorbidities, open repair was considered high risk. Thus, urgent total endovascular repair was planned.

Fig 1.

A 72-year-old patient with a symptomatic 8.5-cm pararenal abdominal aortic aneurysm (AAA) transferred to our institution for urgent repair. Computed tomography (CT) imaging showed a break (arrow) in the calcified wall of an 8.5-cm pararenal AAA and an atrophic right kidney concerning for possible contained rupture (A and B) and chronic occlusion of the right renal artery as well as short bilateral common iliac arteries (arrows) (C and D). The aneurysmal right common iliac artery measured 3.3 cm (E and F). The atrophic right kidney measured 4.8 cm (G).

The patient tolerated general anesthesia, and bilateral percutaneous femoral access and open left brachial access were obtained. We followed the standard TAMBE implantation steps, as previously described.¹ Under fusion guidance, a preloaded 37-mm TAMBE main body device was advanced with the portals above the target vessels (Fig 2, A). The celiac artery, superior mesenteric artery (SMA), and left renal artery were sequentially catheterized (Fig 2, B). After the second stage deployment of the TAMBE mainbody, bridging stents were placed sequentially using a 7 × 7.5 cm Viabahn relined with a 7 × 59 mm VBX for the left renal artery, 9 × 39 mm VBX for the celiac artery, and 8 × 59 mm VBX for the SMA (Fig 2, C). After full deployment of the TAMBE mainbody, the right renal portal was accessed using the preloaded wire, and the right hypogastric artery was accessed and bridged with two 7 mm × 10 cm Viabahns, reinforced with a 7 mm × 15 cm Viabahn and a 7 × 79 mm VBX across the portal to create a long directional branch to the right hypogastric artery (Fig 2, D). The bifurcated component was then deployed from the right femoral approach into the distal TAMBE mainbody. To reduce the length required for the left IBE (W.L. Gore & Associates), the left contralateral gate was extended with a 20 mm × 10 cm bell-bottom limb. Inside this, a 23 mm × 12 mm × 10 cm IBE (Fig 2, E) was deployed and bridged with an 8 × 79 mm VBX postdilated to 14 mm across the gate (Fig 2, F). Finally, a 12 mm × 14 cm limb was used to extend the seal into the right external iliac artery. Completion cone beam CT angiography showed no endoleak and patent branches. Total operative time was 308 minutes, with a fluoroscopy time of 43 minutes and 90 mL of contrast usage. Postoperative course was complicated by acute renal failure due to hypovolemia in the setting of the patient’s chronic right renal artery occlusion. Renal artery duplexes showed normal left renal artery perfusion. After a single session of hemodialysis, renal function stabilized, and the patient was discharged on postoperative day 6 off hemodialysis. The patient remains well with left renal artery patency on renal duplexes through 3-month follow-up, with CT scan showing no evidence of compression between the right internal iliac branch and the external iliac limb (Fig 3).

Fig 2.

The Thoracoabdominal Multibranch Endoprosthesis (TAMBE) mainbody device was advanced (A). The celiac artery, superior mesenteric artery (SMA), and left renal artery were sequentially catheterized (B). After second-stage deployment of the TAMBE mainbody, bridging stents (arrow) were placed (C). After full deployment of the TAMBE mainbody, the right renal portal was accessed and bridged into the right hypogastric artery with Viabahns, creating a long directional branch (arrow) (D). The distal bifurcated component was then deployed, and the contralateral bell-bottom limb was deployed and extended with a left Iliac Branch Endoprosthesis (IBE) (arrow) (E). Illustration showing aortic reconstruction with no evidence of endoleak (F).

Fig 3.

The patient remains well postoperatively with no compression (arrow) between the internal iliac branch and the external iliac as demonstrated on computed tomography (CT) imaging (A and B).

Case 2

A 67-year-old man with a history of hypertension, atrial fibrillation, pulmonary embolism, and previous total arch repair with staged thoracic endovascular aortic repair and celiac artery coil embolization was transferred to our center for urgent repair of a symptomatic 9.7-cm extent II postdissection TAAA (Fig 4, A and B). The patient was also found to have a 3-cm left iliac artery aneurysm with near obliteration of the true lumen (Fig 4, C). Open repair was considered. However, the patient strongly desired to avoid open aortic repair because of the prolonged recovery after the previous open arch repair, and, therefore, a staged endovascular repair was planned. Staging was elected, given the very compressed true lumen of the left common iliac artery, perfusing the internal iliac artery, as well as unavailability of the surgeon who was trained in the TAMBE device when the patient initially presented.

Fig 4.

A 67-year-old patient with a symptomatic 9.7-cm extent II postdissection thoracoabdominal aortic aneurysm (TAAA) transferred to our institution for urgent repair. Computed tomography (CT) angiography showed aneurysmal dilation of an extensive thoracoabdominal aortic dissection (A and B). The patient was also found to have a 3-cm left iliac aneurysm with a nearly occluded true lumen (C). The patient underwent first-stage left Iliac Branch Endoprosthesis (IBE) (arrow) for the left iliac artery aneurysm without complication (D). Four days later, the patient underwent second-stage Thoracoabdominal Multibranch Endoprosthesis (TAMBE) implantation using a preloaded 37-mm TAMBE mainbody. The superior mesenteric artery (SMA) and bilateral renal arteries were catheterized, and after second-stage deployment of the TAMBE mainbody, bridging stents (arrow) were placed (E). Then, an 8 × 79 mm VBX was placed across the unused celiac portal extending higher into the planned overlap zone of the bridging GORE Conformable TAG Thoracic Endoprosthesis (cTAG) (F). Repair was completed with an IBE (arrow) as the distal bifurcated device, sealing into the left IBE with a 27-mm iliac limb (G).

The first stage used an IBE for left iliac artery aneurysm repair to maintain internal iliac artery patency and create an adequate distal landing zone. For this, the true lumen was cannulated with intravascular ultrasound guidance and angioplastied for the deployment of the IBE (Fig 4, D). Four days later, the second stage repair was performed using TAMBE. Lumbar drain was placed preoperatively. Under general anesthesia, bilateral percutaneous femoral access was obtained. A preloaded 37-mm TAMBE mainbody was advanced with the portals above the target vessels and deployed through the second stage. Using the transfemoral technique previously described, the SMA and bilateral renal arteries were sequentially catheterized and stented using fusion guidance (Fig 4, E). A 7 × 59 mm VBX with a distal extension of an 8 × 39 mm VBX and the 10 × 59 mm VBX for the SMA were used to bridge the renal and the SMA. An 8 × 79 mm VBX was then placed across the celiac portal from the ipsilateral femoral approach, extending cephalad into the planned overlap zone of the bridging 40 mm × 10 cm GORE Conformable TAG Thoracic Endoprosthesis (cTAG) (Fig 4, F). By extending the celiac into the overlap zone of the TAMBE and bridging thoracic endovascular aortic repair, flow through the unused celiac portal was eliminated. The repair was completed with an IBE as the distal bifurcated device, sealing into the stage 1 left IBE using a 27-mm iliac excluder limb (Fig 4, G). The total operative time was 408 minutes with a fluoroscopy time of 54 minutes and 135 mL of contrast usage. The patient had an unremarkable postoperative recovery with removal of lumbar drain on post-TAMBE day 2 and was discharged on post-TAMBE day 3. The patient remains well at 1-month follow-up with no complications, and CT imaging showed no evidence of endoleak (Fig 5).

Fig 5.

The patient remains well with no complications at 1-month follow-up with computed tomography (CT) imaging with three-dimensional reconstruction (A) showing no endoleak (B-D).

Discussion

Off-the-shelf multibranched thoracoabdominal stent grafts such as TAMBE have shown promising results for urgent repair of pararenal AAA and TAAA.^5,6 However, limited literature exists regarding the suitability of TAMBE in occluded target vessels and short distal iliac seal zones. As reported by Cambiaghi et al,⁷ the TAMBE device can be applicable to approximately 50% of the patients with pararenal AAA and TAAA. Our report adds to the literature by demonstrating the feasibility of using TAMBE with IBE to urgently repair giant or symptomatic pararenal AAA and TAAA with occluded target vessels and short common iliac arteries.

Despite promising results, access to custom-manufactured fenestrated branched endografts has been limited in the United States.⁴ To fill this gap, physician-modified endografts (PMEG) have been adopted in many centers with a recent multicenter international study showing acceptable outcomes with high technical success in both elective and urgent settings.⁸ TAMBE is the first four-vessel multibranched endograft to obtain Food and Drug Administration approval for pararenal AAA and TAAA. As such, centers including ours are rapidly accumulating experience with TAMBE, often used beyond the anatomical boundaries included in the trials. Previous reports on expanded TAMBE usage include failed infrarenal EVARs with type IA endoleak and failed four-vessel PMEG with fabric tear.^3,9 As demonstrated by Manesh et al,⁹ the TAMBE design offers significant advantages in navigating challenging anatomy. This report expands on this concept by demonstrating the feasibility of urgent TAMBE in patients with pararenal AAA and TAAA with occluded target vessels, presenting with symptomatic or giant aneurysms.

The concept of off-the-shelf multibranch endograft in urgent cases has been demonstrated using the t-Branch device (Cook Medical).^10,11 Hongku et al¹² described t-Branch use in ruptured, symptomatic TAAA for 11 consecutive patients. Technical success rate was 64% (7/11) and 30-day mortality was 27% (3/11) with the only early reintervention for type IA endoleak. The t-Branch device has also been applied to patients with occluded target vessels. Tenorio et al¹³ reported 100 cases of t-Branch used in patients with chronic occlusion of one of the target vessels by occluding the corresponding branch cuff. Although availability of t-Branch remains limited in the United States, TAMBE provides similar off-the-shelf solution with the added feature of a preloaded wire system. As an alternative to the techniques described here, simple occlusion of the branch portal is an option. However, TAMBE portals are 1 cm long, shorter than the t-Branch side arm branch cuffs that are 2.1 cm or 1.8 cm long. Stable plug occlusion through the TAMBE portal likely requires a branch stent extension. Therefore, in the first case, we elected to use the portal to bridge into the right hypogastric artery, eliminating the need for a plug and IBE on one side in the first case. A similar construct has been previously described using PMEG.¹⁴ The choice of self-expanding Viabahn stents was based on their flexibility and long length, reducing the risk of kinking and type III endoleaks. Long-term patency for such configurations warrants continued observation. Nevertheless, gradual stenosis and late branch occlusion may be better tolerated. Methods such as branch cuff or portal extension with covered stents and plug embolization or the use of micro-plugs are viable options.¹⁵ Here, we present an alternative solution to achieve the portal occlusion without the use of plugs.

Conclusions

TAMBE can be applied to urgent repair of patients presenting with TAAA with occluded target vessels. Further, follow-up to assess aortic remodeling and long-term durability of these constructs is planned. Prospective multicenter registry of commercial TAMBE can further elucidate the wider applicability of TAMBE and its impact on the outcomes.

Funding

None.

Disclosures

S.M.H. is a consultant for W.L. Gore and Associates (all honoraria paid to the institution with no personal income), Cook Medical, Terumo, and Vestek, and is on the scientific advisory board for W.L. Gore and Associates and Vestek. A.J.P. is a consultant for W.L. Gore and Associates. The remaining author reports no conflicts.