Increasing Aortic Coverage Improves Branch Stability in Fenestrated Endovascular Aneurysm Repair

Abstract

Objective: During fenestrated endovascular aortic repair for complex visceral segment aneurysms, mesenteric vessels can be incorporated with a scallop or fenestration and reinforced with a bridging stent. The outcome of differences in visceral incorporation, specifically at the celiac axis, has not been previously contextualized to assess the cost/benefit of additional procedural complexity on patient outcomes perioperatively and at follow-up.Methods: A retrospective review of prospectively collected data from all patients who had undergone fenestrated endovascular aortic repair for degenerative juxtarenal and/or pararenal aneurysms from January 2015 to December 2019 at a single center (n ¼ 159) was performed to compare the primary outcomes of celiac instability during 5 years of follow-up and the type of celiac bridging strategy used. Secondarily, the "cost" of celiac stenting was measured, interrogating the procedural and perioperative complications and radiation exposure between the treatment groups.Results: The celiac axis of most patients was treated with a stented fenestration (n ¼ 74), followed by an unstented fenestration (n ¼ 59) and an unstented scallop (n ¼ 26). No differences were found between the groups in the procedural indication or anatomic aneurysm or celiac features, including no between-group differences in preoperative celiac stenosis. The fenestrated stented patients had a higher level of graft coverage above the celiac axis, had more often had a spinal drain placed, and, with the fenestrated unstented patients, had improved primary technical success compared with the scallop-only patients. During follow-up, the scallop-only patients were more likely to have developed an endoleak, although celiac instability was highest in the fenestrated unstented group. Celiac instability in the fenestrated unstented group was not associated with celiac reintervention, worse reintervention-free survival, or a difference in all-cause mortality. Regression analysis for any branch instability revealed significant predictors related to celiac scallop or nonstenting of the celiac, and diminished length of graft coverage above the celiac axis.Conclusions: Perioperatively, nonstenting of the celiac axis did not change radiation exposure or perioperative complication rates. At follow-up, nonstenting of the celiac axis was associated with clinically silent celiac instability. Increasing the length of graft coverage, regardless of the celiac bridging strategy, reduced any branch instability.