Evolution of Fenestrated/Branched Aortic Aneurysm Repair Complexity and Outcomes at an Organized Center for the Treatment of Complex Aortic Disease

Abstract

Fenestrated/branched endovascular aneurysm repair (F/BEVAR) volume has increased rapidly, with favorable outcomes at centers of excellence. We evaluated changes over time in F/BEVAR complexity and associated outcomes at a single-center complex aortic disease program. Prospectively collected data of all F/BEVAR procedures (definition: requiring one or more fenestrations or branches) in an Institutional Review Board-approved registry or physician-sponsored investigational device exemption trial (#G130210) were reviewed (November 2010-February 2019). Patients were stratified by surgery date: early experience, mid experience, and recent experience. Patient/operative characteristics, aneurysm morphology, device types, and perioperative and midterm outcomes (survival, freedom from type I or type III endoleak, target artery patency, freedom from reintervention) were compared. For 252 consecutive F/BEVARs (early experience, n = 84; mid experience, n = 84; recent experience, n = 84), 194 (77%) company-manufactured custom-made devices, 11 (4.4%) company-manufactured off-the-shelf devices, and 47 (19%) physician-modified devices were used to treat 5 (2.0%) common iliac, 97 (39%) juxtarenal, 31 (12%) pararenal, 116 (46%) thoracoabdominal, and 2 (0.8%) arch aneurysms. All patients had follow-up for 30-day events (Fig). Mean follow-up was 589 days (interquartile range, 149-813 days). On 1-year Kaplan-Meier analysis, survival was 88%, freedom from type I or type III endoleak was 91%, and target vessel patency was 92%. When stratified by time period, significant differences included aneurysm extent (thoracoabdominal: 64% recent experience, 40% mid experience, and 33% early experience; P < .001) and target vessels per case (four-vessel case: 67% recent experience, 39% mid experience, and 31% early experience; P < .0001). There was no difference but a trend toward improvement in composite 30-day events (early experience, 39%; mid experience, 23%; recent experience, 27%; P = .05). On Kaplan-Meier analysis, there was no difference in survival (P = .19) or target artery patency (P = .6). There were differences in freedom from reintervention (P < .01) and from type I or type III endoleak (P = .02), with more reinterventions in the early experience, and more endoleaks in the recent period. Despite increasing repair complexity, there has been no significant change in perioperative complications, overall survival, or target artery patency, with favorable outcomes overall. Freedom from reintervention has improved over time, but type I or type III endoleaks have not and remain a significant limitation in need of further innovation.