Midterm Results of Supraceliac vs Infraceliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

Abstract

The complexity of fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms has increased over time including a more proximal sealing zone despite a similar disease extent. Prior studies demonstrated that supraceliac sealing is associated with higher perioperative morbidity, although mortality seems to be similar. Durability of sealing at a supra celiac level vs an infraceliac level remains unknown. The aim of our study was to examine outcomes of FEVAR for juxtarenal abdominal aortic aneurysms comparing a supraceliac vs an infraceliac sealing zone. We included patients undergoing elective juxtarenal FEVAR from 2008 to 2021 at two large hospitals in the Netherlands. The definition of a supraceliac sealing zone was incorporation of the celiac trunk by either a scallop or fenestration. The primary outcome was 5-year aneurysm-related procedures. Secondary outcomes included perioperative complications, 5-year mortality and 1-year aneurysm sac dynamics. These outcomes were analyzed using t tests, Kaplan-Meier methods, multivariable Cox regression analysis, and χ2 tests. One-year aneurysm sac dynamics were evaluated between the groups with imaging data (sac regression/stable sac/sac expansion, based upon 5% volume change compared with 30-day volume). Among 173 patients identified, 114 (66%) had a supraceliac and 59 (34%) had an infraceliac sealing zone. Patients with supraceliac sealing more often had prior EVAR (26.3% vs 12%; P = .045). Furthermore, supraceliac sealing had similar rates of perioperative complications and mortality. No differences were found in one-year aneurysm sac dynamics. Supraceliac sealing was associated with significantly lower risks of secondary aneurysm-related procedures at 5 years compared to use of infraceliac sealing (25% vs 45%; hazard ratio, 0.37; 95% confidence interval, 0.17-0.79; P = .012) (Figure). Finally, supraceliac sealing had similar risks of 5-year mortality compared with infraceliac sealing (hazard ratio, 0.93; 95% confidence interval, 0.49-1.74; P = .813). FEVAR with supraceliac sealing is more durable with less secondary aneurysm-related procedures as compared to infraceliac sealing for juxtarenal aneurysms. Future research has to examine whether supraceliac sealing should be the standard for juxtarenal aneurysms.