Long-term Results of Endovascular Aneurysm Sealing in Treatment of Infrarenal Abdominal Aortic Aneurysm With Unfavourable Morphology

Abstract

Introduction: Endovascular aneurysm repair (EVAR) is a less invasive alternative of treatment of patients with abdominal aortic aneurysm (AAA). Its applicability however is limited by the AAA anatomy. Endovascular aneurysm sealing originally emerged as an endovascular solution for AAA repair with very promising early results. The purpose of this study was to report long-term results of EVAS of AAAs with unfavourable anatomy for EVAR. Methods: A prospectively maintained database of 42 patients with EVAR-unfavourable anatomy treated by EVAS was analysed. The median age of the patients was 74 (IQR 67-80) years. The median diameter of AAA was 61 (IQR 56-71) mm. The EVAS consisted of implantation of two balloon expandable aorto-iliac stent-grafts surrounded by polymer filled endobags. In case of proximal AAA neck shorter than 5 mm chimney grafts were implanted. The final angiographic result, intra- and early post-operative complications were noted. A follow-up included a clinical assessment angio-CT 4-6 weeks and 12 months after the procedure and duplex Doppler at 12 months intervals thereafter. In case of any abnormalities detected in either clinical or duplex Doppler examination an angio-CT was performed. Patency of the aorto-iliac stents and chimney grafts, occurrence of graft failure and all additional interventions and/or events were noted in the database. The graft failure was defined as AAA growth of more than 5mm, type I endoleak, occlusion of the stent-graft or chimney graft or aneurysm rupture. All-cause mortality (ACM) and aneurysm related mortality (ARM) were analysed with Kaplan-Meier estimates. Results: The procedure was completed in all patients. Twenty-eight chimney grafts were implanted in 19 patients. There were two intraoperative ruptures, one of an aortic neck that required conversion to an open repair and one of an external iliac artery that was successfully treated with implantation of a self-expandible covered stent. One patient died in an early postoperative period. The median follow-up period was 24 (IQR 12-34) months. The cumulative ACM was 15, 21 and 35% at 12, 24 and 36 months respectively and the cumulative ARM was 8, 11 and 27% at 12, 24 and 36 months respectively. Three out of five aneurysm related deaths were due to a secondary aorto-duodenal fistula. The cumulative incidence of graft failure was 20, 27 and 42% at 12, 24 and 36 months, respectively. Cumulative incidence of endoleak was 5, 9 and 23% at 12, 24 and 36 months, respectively.The graft failure increased significantly both ACM (p = 0,012) and ARM (p = 0,00003). The implantation of chimney grafts at the initial procedure increased significantly ARM (p=0,008). The presence of endoleak did not have any significant influence on ACM and ARM. Conclusion: Patients treated with EVAS for AAA with EVAR-unfavourable anatomy, especially those with chimney grafts, have a high risk of graft failure and subsequent death. These patients require more rigorous monitoring than patient after standard EVAR. Disclosure: Nothing to disclose