Invited commentary

Abstract

In light of the current enthusiasm for the expanded use of branched and fenestrated endovascular aneurysm repair (F/B-EVAR) of complex aortic aneurysms, we are fortunate that Dr Schanzer and his colleagues have given us some insight into the high reintervention rate of patients after F/B-EVAR. The 26% need for at least one re intervention is probably understated in this study, given the inclusion of a small number of iliac branched devices and the significant number of commercially available Cook Zenith fenestrated renal branch devices (arguably the low-hanging fruit of F/B-EVAR grafts). Furthermore, the authors can expect even further reinterventions, given the relatively short-term follow-up of 25 months and the fact that reintervention rates seem to increase rather than to decrease over time. Several points are worth emphasizing. First of all, it is reassuring to see that the great majority of problems requiring reintervention after F/B-EVAR can be successfully managed (most often through an endovascular approach). Second, these devices were placed under the auspices of a physician-sponsored investigational device exemption trial. As such, patients were carefully selected to ensure anatomic suitability for a successful repair. This senior author knows better than most the poor results that can result when the limits of anatomic acceptability are stretched to expand the application of endovascular technology.1Schanzer A. Greenberg R.K. Hevelone N. Robinson W.P. Eslami M.H. Goldberg R.J. et al.Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.Circulation. 2011; 123: 2848-2855Crossref PubMed Scopus (576) Google Scholar Analogous to the application of EVAR, we can anticipate even higher rates of failure, reintervention, and poor outcomes as this technology proliferates to less selective surgeons. Third, the authors demonstrate a significantly higher reintervention rate in physician-modified endografts (PMEGs) compared with company-manufactured devices (CMDs). They note that there is still a role for PMEGs in urgent cases. By inference, CMDs are preferred for elective cases. Given that CMDs are restricted to only a small number of centers nationwide, the implications for surgeons using PMEGs for elective repair are important. Finally, patients with complex aneurysms repaired with F/B-EVAR should be considered to have a chronic disease with vigilant continued follow-up and anticipated reinterventions. Reinterventions after fenestrated or branched endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 68Issue 3PreviewReinterventions after fenestrated or branched endovascular aneurysm repair (F/B-EVAR) are sometimes necessary to maintain aneurysm exclusion or endograft and target artery patency. These reinterventions are nontrivial, potentially associated with morbidity, mortality, and resource utilization. Whereas rates, types, and outcomes of reintervention after infrarenal EVAR have been well described, they have not been well described for F/B-EVAR. We sought to characterize the morbidity, mortality, and resource utilization due to reinterventions after F/B-EVAR. Full-Text PDF Open Archive