RR12. Changes in AAA Neck Morphology and Loss of Anatomic Suitability for EVAR during Surveillance: Does the ”Window of Opportunity” Close for Some Small AAAs?

Abstract

Objectives:To compare the outcomes of surgeon-modified fenestrated-branched stent grafts (mFBSG) and abdominal debranching (AD) in patients unfit for conventional open repair of complex abdominal (AAA) and thoracoabdominal aortic aneurysms (TAAA).Methods: We reviewed the outcomes of 35 high-risk patients (30 male, 5 female; median age 75 years) treated for large (7.2Ϯ1 cm) complex AAA and TAAA between 2006 and 2008. Fifteen patients had AD of 43 vessels (26 mesenteric, 17 renal) with aortic stent grafting. Twenty patients had 1 to 4-vessel mFBSG with branch artery stenting of 52 vessels (32 renal, 18 mesenteric, 2 hypogastric). End-points were mortality, morbidity, patency, endoleak and re-intervention rates.Results: mFBSG patients had higher comorbidity scores (16Ϯ5 vs 12Ϯ3; PϽ.03) and more (PϽ.05) stress-induced cardiac ischemia (60% vs 27%), renal insufficiency (65% vs 20%) and trans-renal aneurysm extension (100% vs 67%). The number of target vessels per patient (2.8Ϯ1) was similar in both groups, but AD patients had more thoracic extension (80% vs 32%; PϽ.05). Technical success for branch artery stenting was 98% (51/52). mFBSG required more (PϽ.05) fluoroscopy time (ϩ135Ϯ20 min) and contrast dose (ϩ105Ϯ89 ml), but less operative time (Ϫ151Ϯ49 min), blood loss (Ϫ1Ϯ0.8 L) and fluid requirement (Ϫ7Ϯ2 L). There was 1 (5%) operative death after mFBSG and 3 (20%) after AD (Pϭ0.19). Patients treated with mFBSG had less complications (40% vs 73%; PϽ.05), similar paraplegia rate (5% vs 13%; Pϭ.39) and decreased hospital stay (Ϫ10Ϯ7 days; PϽ.05). Type I endoleak was noted in 3 mFBSG (2 resolved) and in 4 AD patients (1 resolved). There was no difference in 1-year freedom from endoleak (83Ϯ9% vs 74Ϯ9%), re-intervention (83Ϯ9% vs 58Ϯ9%), target vessel patency (95Ϯ9% vs 98Ϯ2%) and survival (72Ϯ8% vs 71Ϯ9%) in mFBSG vs AD patients. Sac shrinkage (Ͼ 5mm) was noted in 7 of 9 (78%) mFBSG patients with Ͼ6 months follow up, and in none of the AD patients (PϽ.02). There were no migrations, component separations, fractures, or aneurysm ruptures after mFBSG.Conclusion: Surgeon-modified fenestrated and branched stent grafts can be performed with high procedural success in high-risk patients with complex AAA and TAAA. This study supports the use of mFBSG as an alternative to AD in patients who are suitable candidates for both techniques.Background: Growth of small abdominal aortic aneurysms (AAAs) is frequently associated with aortic neck and iliac artery (IA) changes during surveillance. The purpose of this study was to determine the effects of aortic neck and IA changes on anatomic suitability for endovascular aortic aneurysm repair (EVAR ) during long-term follow-up, particularly of small AAAs with marginal neck morphology (length Ͻ 15 mm and diameter Ͼ28 mm).Methods: We studied 62 patients with small AAAs (diameter, 4 cm to 5.4 cm) under surveillance with long-term follow-up by CT angiography and 3D reconstructions. The mean follow-up duration was 36 months (interquartile range [IQR], 16-53 months). AAA morphology and changes w...