Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology

Abstract

Objective Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease. Methods A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change. Results Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5–31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ±1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2–60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1–0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m2. Conclusions F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients survi...

Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative

“…However, it is evident that EVAR-c confers higher risk in the nonelective situation and may justify our bias to attempt endovascular salvage techniques in selected patients to reduce mortality similarly to how EVAR has begun to supplant open repair of native ruptured AAA. 32,33 Further, preoperative identification of the clinical and procedure-specific predictors may provide important risk stratification for clinicians that can inform operative decision making and patient and family counseling. Decisions regarding aortic cross-clamp placement and the effect on renal/visceral ischemia time can be factored into the operative plan when possible to reduce postoperative morbidity and mortality.…”

Fenestrated aortic endograft branching with Gore VBX poses failure risk from delayed-onset branch kinking

“…Uncovered stent branches exhibit higher rates of problems than covered stent branches, mostly from in-stent stenosis 5 ; however, no particular stent graft has been shown to be more effective or durable as a branch device than others. The failure modes of branches include stent kinking, stent fracture, device migration, material fatigue, thrombosis, and neointimal hyperplasia 6, 7. A retrospective study of fenestrated aortic endografts reported that 34% of grafts experienced either proximal or distal migration, but there was no significant association between graft migration and kinking or component fractures 8 .…”

Commentary: Physician-Modified Fenestrated/Branched EVAR and Hybrid Techniques for Acute Thoracoabdominal Aortic Pathologies: Inequality When Comparing Alternative Options With Different Philosophies Does Not Equal Lower Quality

“…3,8 In a previous systematic review of 23 reports containing 308 patients treated between 1999 and 2015 for complex aortic aneurysm, outcomes overall were similar for off-the-shelf fenestrated/branched stent-grafts and PMEGs, including technical success of 95% and 91%, mortality of 1.1% vs 3.5%, and target vessel patency of 98% vs 97%, respectively. 9 Since that review, many additional studies (those with ≥10 cases) citing the use of PMEGs have been published, [1][2][3][4][5]7,8,[10][11][12][13][14][15] though some updated earlier populations within investigation device exemption (IDE) protocols 2,3,13 or earlier single-center reports. 4,5,7,10 Excluding 4 duplicate studies (103 cases) 8,[13][14][15] and another 101 patients presented earlier, 9 375 new cases not incorporated in the previous review were identified since March 31, 2015 (a 100% increase), even though in some qualified centers the use of PMEGs declined from 66% between 2011 and 2013 to 4% between 2014 and 2016.…”

“…Overall, 9 additional single-center studies were found (Table 1), [1][2][3][4][5]7,[10][11][12] 3 of them conducted within an IDE trial, 2,3,12 with a total of 476 patients (339 men, 71.2%). Few of these compared outcomes between PMEGs and company-manufactured devices 3,5,7 and hybrid techniques.…”