Early and Mid-Term Outcomes of Open Repair, Fenestrated Stent Graft and Chimney Graft in Juxtarenal Abdominal Aortic Aneurysms

Abstract

Introduction - Juxtarenal abdominal aortic aneurysm (JAAA) is defined as an infrarenal AAA that is adjacent to or involving the lower margin of the renal artery origins1. Recently, promising results have been reported in peer reviewed journals after fenestrated and chimney graft approaches to repair of JAAA2,3. Open repair, fenestrated endovascular aneurysm repair (FEVAR) and chimney endovascular aneurysm repair (Ch-EVAR) are effective methods to treat this condition, but the comparative effectiveness of these treatment modalities is unclear4. Upon completion of a hybrid vascular intervention room at our institution and careful planning and sizing, we started a prospective registry of all JAAA cases performed. Here we present our retrospectively analyzed results, including short and midterm follow-up results in patients with JAAA treated using either endovascular or open repair. Methods - We retrospectively reviewed patients with JAAA (n= 75) who underwent chimney grafts (Ch-EVAR, n = 23), fenestrated stent grafts (FEVAR, n = 20) or open repair (OR, n = 32) between January 2011 and December 2016 at a single institution. Our primary endpoint was peri-operative mortality. Secondary endpoints included renal function impairment, new-onset dialysis, procedural details and postoperative complications. Descriptive statistics are reported as mean ± standard deviation for continuous data and categorical data are presented as number and percentage. Kaplan-Meier analysis was used to estimate freedom from late re-intervention, primary patency of targeted vessel stent grafts and overall survival. Results - There were no statistically significant differences in baseline characteristics among the three groups. Perioperative mortality was not significantly different between groups: 4.3% (1/23) in the Ch-EVAR group, 0% in the FEVAR group and 3.1% (1/32) in the OR group(p = 0.532). Mean follow up time was 36.7 months. There were no statistically significant differences among the three groups in secondary endpoints, except for increased blood loss in the open repair group when compared to the endovascular groups. There were no statistically significant differences in overall survival among groups (p=0.282). Estimated targeted vessel stent patency at 1 and 4 years were 89.5% and 89.5% in the Ch-EVAR group and 93.8% and 93.8% in the FEVAR group, respectively. There were no statistically significant differences in estimated freedom from late re-intervention among groups (82.3% in the Ch-EVAR group, 77.2% in the FEVAR group and 96.4% in the OR group) Conclusion - We were unable to show a ststistically significant difference in outcomes among the treatment options for JAAA repair, which may be due to the size of our series. Nevertheless, our results show that after careful patient selection, we are able to offer our patients good results with fenestrated and chimney graft techniques that are comparable to open surgical procedures, but with a much faster recovery time. All three approaches (Ch-EVAR, FEVAR and open surgery) are effective treatment options for JAAA repair and have comparable short and mid-term outcomes in well-selected patients. Long term follow-up results are needed to determine the optimal management of JAAA. References·Jongkind V, Yeung KK, Akkersdijk GJ, Heidsieck D, Reitsma JB, Tangelder GJ, Wisselink W. Juxtarenal aortic aneurysm repair. J Vasc Surg. 2010;52:760-767·Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ, Prins TR, Bracale UM, van den Dungen JJ. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: An 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39:529-536·Donas KP, Torsello GB, Piccoli G, Pitoulias GA, Torsello GF, Bisdas T, Austermann M, Gasparini D. The protagoras study to evaluate the performance of the endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique. J Vasc Surg. 2016;63:1-7·Katsargyris A, Oikonomou K, Klonaris C, Topel I, Verhoeven EL. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: Are we ready for a paradigm shift? J Endovasc Ther. 2013;20:159-169