Adapting to a Total Endovascular Approach for Complex Aortic Aneurysm Repair: Outcomes Following Fenestrated and Branched Endovascular Aortic Repair

Abstract

Introduction - The use of fenestrated endovascular aneurysm repair (FEVAR) and branched endovascular aneurysm repair (BEVAR) has grown, and outcomes analyses from large centers of expertise have been favorable. An important question is whether these results can be replicated at other aortic centres.1,2 The objective of this analysis was to assess the mid-term outcomes of a total endovascular approach for treating complex aneurysms and thereby validate and guide other centres in considerations of adapting this approach. Methods - All patients treated for juxta/pararenal (J/PAAA) or thoracoabdominal aortic aneurysms (TAAAs), both elective and acute, as well as reoperations, from 2010-2015 were included. Treatment was either FEVAR or BEVAR, and outcomes were analyzed for technical success and mortality at 30- and 90 days, as well as Kaplan-Meier curve estimates at 3 years. Outcomes on target vessels were reported as freedom from branch instability in the follow-up period. Reinterventions, endoleaks and peri- and post-operative morbidities were analyzed. Results - A total of 71 patients were treated for J/PAAA (n=40) or TAAA (n=31); 14 type II, 4 type III, and 13 type IV. There were 47 FEVAR (including 2 physician-modified fenestrated grafts) and 24 BEVAR procedures performed. Four TAAAs were ruptured. There were no open repairs performed for these pathologies in this period. Mortality was 2 (2.8%) at 30 days. The 90-day mortality was 7 (9.9%). There was one late rupture in a patient whose treatment was a technical failure. Survival at 3 years was 77.9% ± 5.6% overall, 90.9% ±5.2% for J/PAAAs, and 60.7% ± 10.3% for TAAAs. Graft deployment was successful in 69/71 patients. There were 205/208 (98.6%) target vessels successfully revascularized; 51/51 superior mesenteric arteries (SMA), 27/27 celiac arteries, and 127/130 renal arteries. There were 131 fenestrated bridging stent grafts and 74 branched bridging stent grafts. Technical success was 68/71 (95.7%). There were nine cases of branch instability (5 BEVARs, 4 FEVARs) in 5 patients (7.0%). Seven vessels (5 renal arteries and 2 SMAs) underwent reintervention, 5 for stenoses, 1 for occlusion, and 1 for stent migration. Freedom from branch instability at three years was 92.7% ± 2.5% overall, 88.6% ± 6.4% for BEVAR, and 94.6% for FEVAR. Conclusion - The short- and mid-term results obtained here indicate that the benefits of a total endovascular treatment for complex aortic aneurysms, as demonstrated by large and multi-center studies, can be adapted and replicated at other centers with a dedicated aortic service. This may help guide future considerations of how to refer or treat this complex patient group.