Comparison of Intraoperative Outcomes and Initial Results of Antegrade Laser Fenestration Versus Company-Manufactured Stent Grafts in Fenestrated Endovascular Aortic Aneurysm Repair

Abstract

Introduction: Laser fenestrated endografting (LfEVAR) has been recently described as a potential alternative in patients presenting with complex (CAAAs) or thoracoabdominal aortic aneurysms (TAAAs) or type I endoleaks (T1ELs) who could not benefit from a company-manufactured stent graft (CM). The aim of this study was to compare the initial outcomes of LfEVAR and CM for the treatment of CAAAs, TAAAs and T1ELs. Methods: A single-institution retrospective review of all LfEVAR and Zenith (Cook) CM was performed. The cohort was analyzed by device type (LfEVAR and CM) after matching of cases using the following criteria: number of target vessels, extend of the aneurysm, aneurysm diameter, ASA score and age. Patients were deemed for open or hybrid repair by a multidisciplinary staff. The LfEVAR procedures were performed under fusion technique using a steerable sheath positioned inside the stent graft in front of each target vessel ostium. After graft puncture, fenestrations were dilated and bringing stents were placed and flared. Preoperative features, postoperative outcomes and reinterventions were compared. Outcomes at 6 months were estimated using the Kaplan-Meier method. Results: Between January 2012 and December 2018, 54 patients were identified and matched using a 2:1 ratio. The cohort included 18 LfEVAR and 36 CM who underwent repair of 43 CAAAs (LfEVAR, 11; CM, 32; p=.03), five TAAAs (LfEVAR, 1; CM, 4; p=.65) and six T1Els (LfEVAR, 6, CM, 0; p=< .0001). Indications of LfEVAR included painful aneurysms (n=3), > 65mm aneurysms (n=6), anatomical constrains and/or presence of previous renal stents (n=7) or cases declined by manufacturer planning center (n=2). The number of target vessel per patient was of 2.89 in the LfEVAR group and 2.83 in the CM group (p=.77). The median ischaemic time was of 35 minutes for the superior mesenteric artery, 66 and 67 minutes for the renal arteries and 81.5 minutes for the celiac artery. Intraoperative adverse events were recorded in 50% of cases (n=9) in the LfEVAR group vs 5.5% (n=2) in the CM group (p< .0001). Rates of in-hospital mortality and postoperative complications were respectively of 6% (n=1) in the LfEVAR group vs 3% in the CM group (p=1) and 44% (n=8) vs 30% (n=11) in the CM group (p=.37). The follow-up duration was respectively of 14 +- 11 months in the LfEVAR group and 36 +-20 months in the CM group. The estimate of global survival, freedom from reintervention and target vessel patency at 6 months were respectively of 94% in the LfEVAR group vs 92% in the CM group (p=.65), 58% in the LfEVAR group vs 83% in the CM group (p=.11) and 94.4% in the LfEVAR group vs 94.3% in the CM group (p=.98). Conclusion: In our study, the differences between LfEVAR and CM related to intraoperative adverse events with a trend to more early reinterventions in the LfEVAR group. Despite study low power and short follow-up duration, our initial results of LfEVAR offer acceptable early results compared to CM devices in cases where a CM device is not available or possible, at the cost of frequent reinterventions. Disclosure: Nothing to disclose