PC022. Renal Artery Outcomes With Selective Use of Fenestrations and Branches for Endovascular Repair of Pararenal and Thoracoabdominal Aortic Aneurysms

Abstract

To describe anatomic factors affecting selection of fenestrations or branches for renal artery incorporation and branch-related outcomes of this selective approach during fenestrated-branched endovascular repair of pararenal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). We reviewed the clinical data and imaging of 386 consecutive patients (74% male; mean age, 75 ± 8 years old) treated by fenestrated-branched endovascular repair between 2007 and 2017. Anatomic analysis of 689 incorporated renal arteries included aneurysm extent, inner aortic diameter, aortic-renal (AR) angulation, and target vessel diameter (Fig 1). End points were technical success, renal artery patency and branch instability (occlusion, in-stent stenosis, stent compression/kink, and type I or III endoleak). There were 386 patients treated by fenestrated-branched endovascular repair (74% male; mean age 75 ± 8 years old) with 689 renal arteries incorporated using 612 fenestrations (89%) and 74 directional branches (11%). Compared with directional branches, fenestrations were used more often (P < .001) for pararenal aortic aneurysms (98% vs 1%), extent IV TAAAs (93% vs 7%), and in patients with narrower inner aortic diameters (25.3 ± 6.0 mm vs 33.6 ± 9.6 mm). Directional branches (85% vs 15%) were used preferentially (P < .001) for extent I to III TAAAs, where selection was affected by wider inner aortic diameters (33.1 ± 9.0 mm vs 27.6 ± 6.1 mm; P = .003) and downgoing AR angulation (−25.3° ± 19.6° vs −16.7° ± 20.8°; P = .004) when compared with fenestrations. There was no difference in AR angulation (−24.7° ± 20.4° vs −26.1° ± 20.9°) or renal artery diameter (5.7 ± 0.8 mm vs 5.8 ± 0.9 mm) between fenestrations and directional branches, respectively. Technical success of renal artery incorporation was achieved in 99.3% of all vessels, with no difference between fenestrations (99.5%) and directional branches (97.3%). After a median follow-up of 18 months (interquartile range, 6.4-36 months; maximum of 106 months), 57 renal artery targets (8%) had instability, including 12 occlusions (2%), 22 in-stent stenosis (3%), 5 stent compression/kink (1%), and 18 type I/III endoleaks (3%). At 2 years, primary and secondary patency was 95% ± 1.1% and 99% ± 0.6% for fenestrations and 92% ± 4.1% and 97% ± 2.5% for directional branches, respectively (P = NS). Freedom from any renal artery instability was 92% for fenestrations and 88% for directional branches, at the same interval. Anatomic variables associated with more common selection of fenestrations compared with branches were pararenal aortic aneurysms and TAAA as well as narrower aortic diameter (Fig 2). Renal instability was not significantly different for fenestrations compared with branches.Fig 2Selection of fenestrations or branches for renal artery incorporation based on anatomic factors including inner aortic diameter and aortic renal angulation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)