Early and Long-term Efficacy of Fenestrated Endografting in the Treatment of Juxta-renal Aortic Aneurysms

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Introduction - Juxta-renal aneurysms (j-AAAs) are increasingly repaired by endovascular means with fenestrated endografts (FEVAR) worldwide, however long-term data are presently lacking. Aim of our study was therefore to evaluate late outcome of FEVAR in j-AAAs Methods - Between 2008 and 2017, all consecutive patients undergoing endovascular repair for j-AAAs (neck length ≤5mm) by FEVAR (Cook-Zenith platform) were prospectively collected. Preoperative clinical and morphological features, together with procedural and postoperative data were analyzed. Early endpoints were: technical success (TS: patency of target visceral vessels; TVVs, absence of type I-III endoleak; iliac leg stenosis/occlusion and 24-hour survival), renal function worsening (reduction of baseline GFR ≥30%) and 30-day mortality. Late endpoints were: survival, freedom from re-intervention (FFR), TVV-patency, j-AAA shrinkage (> 5mm) and renal function worsening. Results - During the study period, overall 181 cases underwent FB-EVAR repair. Sixty-six patients with j-AAA (M: 94%; age: 72±6years; ASA 3/4: 79/21%) were enrolled. The mean j-AAA diameter was 58±6mm. Endograft with 1, 2, 3 and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops (3.6±1 TVV/patient). Technical success was achieved in 65 cases (99%). The only failure occurred for a type III endoleak requiring renal artery relining on postoperative day 32. No TVVs were lost. Cardio and pulmonary morbidities were 5% and 6%, respectively. There were no cases of acute splanchnic ischemia. Renal function worsening occurred in 7 cases (10%): 4 returned to baseline within 30-day; 1 required hemodialysis and died within 30-day (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32 months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required re-interventions (sac embolization by trans-limb approach). Freedom from re-interventions at 1, 3 and 5 years was 97%, 93% and 88%, respectively. An asymptomatic celiac trunk occlusion occurred at 36-month in a case with asevere pre-operative stenosis - accommodated by a scallop. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 patients (8%) during follow-up (2 persisted from post-operative period and 3 with new onset). Survival at 1, 3 and 5 years was 92%, 86% and 67%, respectively, with no j-AAA related mortality. At the univariate analysis, COPD (p:.006), BMI >31 (p:.048), preoperative chronic renal failure (p:0.44) and late renal function worsening (p:.050) were risk factors for mortality. COPD was the only independent predictor for mortality at the multivariate analysis (p:.021; OR:5.3; 95%CI, 1.3-21.9) Conclusion - FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with the results of this series, FEVAR could be proposed as the first line treatment for j-AAAs in anatomically fit cases if performed in high volume centers. Long term survival is reduced in the presence of pre-operative COPD. The results of the present series should be taken in consideration when considering alternative open surgery technique in the treatment of J-AAAs