O-220 - TOTAL TRANSFEMORAL BRANCHED ENDOVASCULAR THORACOABDOMINAL AORTIC REPAIR (TORCH2) REGISTRY. A PHYSICIAN-INITIATED, NATIONAL, MULTICENTRE, AMBISPECTIVE, OBSERVATIONAL REGISTRY OF PATIENTS UNDERGOING BRANCHED ENDOVASCULAR AORTIC PROCEDURES WITH A TOTAL TRANS

TOPIC:
Thoraco-abdominal Aortic Disease
AUTHORS:
D'Oria M. (University Hospital of Trieste ASUGI ~ Trieste ~ Italy) , Pratesi G. (Ospedale Policlinico San Martino ~ Genova ~ Italy) , Grando B. (University Hospital of Trieste ASUGI ~ Trieste ~ Italy) , Parlani G. (S. Maria Misericordia Hospital ~ Perugia ~ Italy) , Giudice R. (S. Giovanni - Addolorata Hospital ~ Roma ~ Italy) , Gargiulo M. (DIMES-University of Bologna, IRCCS-University Hospital Policlinico S. Orsola ~ Bologna ~ Italy) , Mangialardi N. (San Camillo-Forlanini Hospital ~ Roma ~ Italy) , Chiesa R. (Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute ~ Milano ~ Italy) , Lepidi S. (University Hospital of Trieste ASUGI ~ Trieste ~ Italy) , Melloni A. (Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute ~ Milano ~ Italy) , Vena J. (Ospedale Policlinico San Martino ~ Genova ~ Italy) , Simonte G. (S. Maria Misericordia Hospital ~ Perugia ~ Italy) , Ferrer C. (S. Giovanni - Addolorata Hospital ~ Roma ~ Italy) , Gallitto E. (DIMES-University of Bologna, IRCCS-University Hospital Policlinico S. Orsola ~ Bologna ~ Italy) , Carbonaro A.R. (San Camillo-Forlanini Hospital ~ Roma ~ Italy) , Bertoglio L. (Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute ~ Milano ~ Italy)
Introduction:
Since the introduction of branched endovascular aortic repair (BEVAR) for treatment of thoracoabdominal aortic aneurysms (TAAA), upper extremity access has been considered mandatory for antegrade catheterization of side branches. However, the major drawback of this access has been the risk for peri-operative stroke. Recently, an alternative retrograde approach using transfemoral access (TFA) with steerable sheaths has been proposed to reduce the risk such neurologic complications. The aim of the present study was to report the outcomes of BEVAR with retrograde catheterization of antegrade branches using TFA from a multicenter experience.
Methods:
A physician-initiated, multicenter, ambispective, observational registry of patients undergoing BEVAR employing TFA for cannulation of side branches was designed (ClinicalTrials.gov Identifier: NCT04930172) to evaluate the peri-operative and mid-term outcomes of the technique. The registry included patients who underwent complex endovascular aortic procedures requiring a multibranched endograft via total transfemoral approach starting January 2018 until January 2022. Primary endpoints were technical success, peri-operative morbidity, and 1-year survival and branch stability (type I/III endoleaks, reinterventions, primary patency).
Results:
During the study timeframe, a total of 62 patients underwent BEVAR at seven participating institutions (range of included cases/center was one to twenty-seven). Mean age of the study cohort was 72 years and 65% were males. Based on SVS risk scoring tool, the study cohort could be stratified as follows: 29% score 0-3; 40% score 4-6; 23% score 7-9; 8% score 10 or higher. Most patients had Crawford extent II (39%) or extent IV (27%) TAAA, with mean aneurysm diameter at time of repair of 67 mm. Overall, 84% of the study subjects received BEVAR in elective setting, while 11% and 5% of the study cohort were treated for symptomatic and ruptured TAAA, respectively. Two thirds of the study cohort received BEVAR with an off-the-shelf device and 69% of the repairs were done in staged fashion. Routine policy and presence of hostile aortic arch anatomy were the main reasons for selecting TFA. Procedural parameters included mean operative and fluoroscopy times of 241 and 87 minutes, respectively; mean radiation dose and contrast volume were 323 mG/cm2 and 162 mL, respectively. A physician-made steerable sheath was used in 29% of the cases, and an additional guidewire was used to stabilize the steerable sheath in 37% of the procedures. In two thirds of the cases, the steerable sheath was inserted on the side of main stent-graft deployment, and a standard directional sheath was used coaxially to access the target vessels in 76% of the cases. The overall rate of technical success was 97%, and all target vessels were completed using TFA in 95% of the procedures. At thirty days, five deaths were observed (all in patients with ruptured aneurysms) and twenty-five patients experienced at least one major adverse event. The most common peri-operative complications included new-onset congestive heart failure (n=6), acute kidney injury (n=6), and spinal cord ischemia (n=9, of which three were showed neurologic damage). Access site-related major complications occurred in five cases. At one year, the following results were observed: all cause death in ten patients, reintervention in two patients, type I/III endoleaks in one patient, and loss of primary patency in six patients.
Conclusion:
BEVAR with retrograde catheterization of antegrade branches using TFA with steerable sheaths is safe and feasible, with low rates of neurologic complications. While longer follow-up is needed to ascertain durability of the technique, our preliminary results demonstrate comparable outcomes with those achieved using conventional upper extremity access. Further studies are needed to ascertain comparative effectiveness between TFA and upper extremity access.