Fenestrated and Branched Endografting After Previous Open Infra-renal Aortic Aneurysm Repair

Abstract

Introduction - Proximal para-anastomotic aneurysms, or aneurysmal degenerations of the native aorta above a previous infra-renal aortic open repair (P-AAAs), are not rare challenging scenarios. The aim of this study was to report the early and mid-term outcomes following endovascular repair of P-AAAs with fenestrated and branched endografts (FB-EVAR) Methods - From 2006 to 2017, we prospectively collected and retrospectively analyzed pre, intra and postoperative data of patients undergoing FB-EVAR for P-AAAs at two European vascular surgery units. Early outcomes were: technical success (target visceral vessels cannulation and stenting, absence of Type I-III endoleak, iliac limb occlusion and 24-h mortality), spinal cord ischemia (SCI), and 30-day mortality. Mid-term outcomes were: survival, target visceral vessels (TVV) patency, and freedom from re-interventions. Fisher’s exact test, Kaplan Mayer and Log rank were used for the statistical analysis Results - During the study period, 108 patients (M:94%; age:71±4years; ASA 3-4:74%>26%) were enrolled. The previous aortic OR was a tubular aorto-aortic 63(58%), a bifurcated aorto bi-iliac 37(34%) or an aorto bi-femoral 8(8%) bypass. The OR was performed 10±2years prior to the FB-EVAR. A previous TEVAR had also been performed in 7 patients (6%). The aortic lesions at the time of FB-EVAR was a type I-III 69(64%) or type IV 39(36%) thoracoabdominal aneurysm according to the Crawford’s classification. The mean aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were perfused by endograft fenestrations (63;58%), branches (26;24%) or both fenestrations and branches (19;18%). Tubular, tri-modular or aorto-monoiliac implants were planned in 68 (63%), 38 (35%) and 2 (2%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass and iliac branch devices were planned adjunctive procedures in 41 (38%), 5 (5%) and 3 (3%) cases, respectively. Technical success was 93%. Technical failures included 5 TVV-loss (celiac trunk:1; renal arteries:4) and 3 deaths within 24 hours (cardiac aetiology). Post-operative SCI was diagnosed in 7 patients (7%), including 4 (4%) permanent. Type I-III TAAAs (p .04) and endograft incorporating both fenestrations and branches (p .04) were associated with SCI. Cardiac and pulmonary morbidity was 9% and 10%, respectively. Post-operative renal failure (GFR reduction >30% of baseline) was diagnosed in 22 patients (20%). Bowel ischemia was depicted in 3 (3%) patients. The 30-day mortality was 4%. Preoperative chronic renal failure (p .03), post-operative cardiac morbidity (p .04), and bowel ischemia (p .003) were associated with 30-day mortality. The mean follow-up was 38±18 months. Survival at 1, 3 and 5 years was 82%, 64% and 54%, respectively. There was no late aneurysm-related mortality. Survival during follow-up was significantly impacted by pre-operative chronic renal failure (p .005), post-operative cardiac morbidity (p .04), and SCI (p .04). Target visceral patency at 1, 3 and 5 years was 93%, 91% and 91%, respectively. New onset of hemodialysis was required in 4 patients (4%). Aneurysm enlargement (>5mm) was detected in 6 (5.5%) cases. Freedom from re-interventions at 1, 3 and 5 years was 89%, 77% and 74%, respectively Conclusion - Endovascular treatment of aortic aneurysmal evolution above a prior open AAA repair with FB-EVAR is safe and effective. If those promising results are confirmed during late follow-up, FB-EVAR should be considered as a therapeutic option, especially in high-risk patients