Comparison of Fenestrated Stentgrafts and Open Repair for Juxtarenal Aortic Aneurysms Using A Propensity Score Matching

Abstract

Introduction: The purpose of this study is to compare the short- and mid-term results of fenestrated stentgrafts (FEVAR) and open repair (OR) for juxtarenal aortic aneurysms (JRAA). Methods: This cohort study was conducted in two tertiary centers between 2005 and 2017. Preoperative CT scans of patients who underwent FEVAR for complex abdominal AAA in both centers were reviewed by two experienced surgeons to select JRAA and exclude suprarenal and thoracoabdominal aneurysms. JRAA were defined as requiring suprarenal cross clamping but infrarenal proximal suture if treated by OR. Patients with JRAA treated by FEVAR were compared to patients with JRAA treated by OR using a propensity score matching. Propensity score was calculated on age, sex, smoking, diabetes, obesity, coronary artery disease, heart/renal/respiratory failure, ASA score, history of aortic surgery, aneurysm diameter and center. Results: Of 277 patients with JRAA, 102 (36,8%) received FEVAR and 175 (63,2%) received OR. Before propensity score matching, 30-day, in-hospital, 12 months and 36 months mortality rates were 5,9% / 5,9% / 17,5% / 27,8% (n= 6/n=6/n=17/n=27) in the FEVAR group and 1,7%/4%/6,5%/9,4% (n=3/n=7/n=11/n=16) in the OR group, respectively. After propensity score matching, 102 FEVAR patients (66,7%) and 51 OR patients (33,3%) were included in the analysis. 30-day and in-hospital mortality rates were 5.9% (N = 6) in the FEVAR group vs. 3,9% (N=2) / 7,8% (N=4) in the OR group (p=0,61 / p=0,64). The median follow-up period was 40 months (range: 0,2-112) in the FEVAR group and 41 months (range: 1-149) in the OR group. During follow-up, overall mortality at 12 months was similar in both groups (FEVAR: 17,7% vs. OR: 12 %, p = 0,31). At 36 months, there was a non-significant trend towards higher overall mortality rates in the FEVAR group (27,1% vs. 14,0%, p = 0,07). FEVAR- patients experienced significantly fewer moderate to severe complications (FEVAR group: n=19, 18,8%; OR group: n=21, 41,2%, Odd Ratio = 0,32; 95% CI: 0.15-0.71; p = 0,05), especially renal (18,0% vs. 26,0%; p = 0,005) and respiratory (4,9% vs. 17,7%; p = 0,029). In total, twenty-five patients required reintervention (16,4%), with no difference between the two groups (FEVAR: 16,7% vs. OR: 15,7%, p = 0,88). In the FEVAR group, two aortic ruptures occurred during follow-up. Persistent endoleak was observed in 17 patients (16,7%) in the FEVAR group (3 type IA, 13 type II and 1 unclassified). Conclusion: This comparative study did not show a significant difference in mid-term mortality, although a trend towards higher mortality rates was observed at 36 months in the FEVAR group. Moderate to severe complications, especially renal and respiratory, were more frequent in the OR group. Propensity score matching mainly selected the most fragile patients in the OR group. This study highlights the need for a randomized study to compare FEVAR and OR for juxtarenal AAA. Disclosure: Frederic Cochennec is a proctor for Cook MEdical