Impact Of Preoperative Risk Factors On 5-year Survival After Fenestrated/Branched Endovascular Aortic Repair

Abstract

To investigate which preoperative factors most impact the 5-year survival of patients undergoing fenestrated/branched endovascular aortic repair (F/BEVAR) and to identify modifiable elements that, if time allows, should be actively managed and adequately controlled preoperatively. Patients treated for aortic aneurysms with complex anatomy using either a patient-specific company manufactured or an off-the-shelf F/BEVAR devices were included. The exposure of interest was aneurysm type (group I: types I-III thoracoabdominal aneurysms (TAAA) vs group II: type IV TAAA vs group III: juxtarenal or suprarenal aneurysms) and the primary outcome was 5-year risk of all-cause mortality. Generalized linear models were used to estimate each group's crude 5-year risk of death and the 5-year risk of death across groups. Each preoperative factor was added to the model individually and a change in estimate was calculated between the new risks and the crude risk. Preoperative factors with a change of estimate of ≥10% were utilized to create an inverse probability of treatment weights for multivariable analysis. Results: 408 F/BEVAR patients were included, who were 71.6% male (mean age: 72.0±7.9 years). Eleven of the 22 preoperative factors analyzed had a change in estimate ≥10%. The greatest changes in estimates were observed for history of congestive heart failure (CHF), arrhythmia, overweight, obesity, COPD. Almost 60% of patients with CHF in group I died within 5 years. Current smoking or overweight at the time of F/BEVAR increases the 5-year risk of death more significantly than having a history of myocardial infarction. After adjustment, patients in group I had a significantly higher risk of 5-year all-cause mortality compared to those in group III (log-rank p-value=0.0082). The present findings suggest that cardiac arrhythmias, CHF, overweight, obesity, COPD, and aneurysm diameter above 7 cm are the most relevant preoperative elements that impact the 5-year survival post F/BEVAR. More specifically, CHF and arrhythmias should be used to alter patient selection and identify those individuals more likely to benefit from repair. Moreover, modifiable risk factors such as weight loss and smoking cessation during the surveillance period before the F/BEVAR procedure, might improve survival in this population. Considering that preoperatively, many patients are periodically evaluated by a vascular surgery team until the aneurysm diameter meets criteria for repair, a multidisciplinary approach that could address these modifiable risk factors might be an impactful strategy.