IF08. Fate of the Unstented Superior Mesenteric Artery in Fenestrated Endovascular Aortic Aneurysm Repair

Abstract

The objective of this study was to evaluate the patency of the unstented superior mesenteric artery (SMA) after fenestrated EVAR (F-EVAR) using duplex ultrasound (DUS) and computed tomography angiography (CTA). Patients with SMA fenestrations or crossing struts were identified from a database of patients who underwent F-EVAR at our institution between 2011 and 2017 as part of an investigational device exemption clinical trial (NCT01538056). Mesenteric DUS and CTA data were obtained at baseline and at 30 days, 6 months, and annually out to 5 years. The DUS parameter of SMA peak systolic velocity (PSV) of 275 cm/s was used to detect 70% SMA stenosis. CTA was used to evaluate the patency of the SMA when DUS PSV was elevated or if DUS was not performed. There were 107 patients who underwent endograft placement involving the SMA in association with F-EVAR. There were 87 SMA fenestrations and 20 bare-metal struts crossing the SMA; 79 patients had baseline and at least 30-day follow-up DUS SMA PSV measurements (64 fenestrations, 15 struts). Mean follow-up was 18.6 months (range, 30 days-5 years). SMA PSVs are listed in the Table. Mean PSVs remained well below the threshold velocity of 275 cm/s for native atherosclerotic 70% SMA stenosis. Nine patients had at least one SMA PSV >275 cm/s during follow-up. All were observed and showed no subsequent clinical sequelae. All patients had at least 30-day follow-up with CTA, and all had widely patent SMAs at last follow-up. Mean total seal zone length was 41.4 mm. There was a single secondary intervention for asymptomatic SMA stenosis requiring stent placement 1 year after F-EVAR. There were no Type IA endoleaks and no endoleaks related to SMA fenestrations. Five patients of the entire cohort (4.7%) required SMA stenting at the index procedure. Three of these patients had prior EVAR (n =2) or open repair (n = 1), One patient had a pre-existing critical SMA stenosis and underwent planned SMA stenting, and in one patient, the graft was deployed imprecisely and low, and the SMA was successfully stented from a brachial approach. The unstented SMA in association with F-EVAR remains widely patent in the presence of fenestrations or struts and is not associated with endoleaks. The need for adjunctive SMA stenting may be related to prior aortic intervention and case complexity. Follow-up DUS and CTA surveillance confirms that SMA patency remains in the normal or <70% stenosis range after F-EVAR regardless of whether it is encompassed by a large fenestration or crossing struts.TableSuperior mesenteric artery (SMA) peak systolic velocity (PSV)Fenestrations (n = 64)Struts (n = 15)Overall mean PSV (N = 79)Baseline128 ± 57153 ± 41133 ± 5530 Days115 ± 56155 ± 63123± 596 Months121 ± 80128 ± 82122 ± 801 Year131 ± 7799 ± 55124 ± 732 Years138 ± 89124 ± 58134 ± 813 Years145 ± 11399 ± 63129 ± 1004 Years134 ± 112120 ± 61129 ± 965 Years96 ± 61191 ±147122 ± 90Values are reported as mean ± standard deviation. Open table in a new tab