Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms

Abstract

Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71±11 vs. 74±7years, P=0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P=0.02) and had a different race distribution compared to the elective cohort (P<0.01). Thirty-day mortality was 4% (n=6) in elective repairs and 7% (n=3) in nonelective repairs. One-year mortality was 13% (n=22) in elective repairs and 18% (n=8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P=0.40) or1-year mortality (P=0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P<0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P<0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P<0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P>0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P=0.03). Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.