Role of In Situ Fenestration as the Technique of Choice for Endovascular Repair of Ruptured Thoracoabdominal and Suprarenal Aortic Aneurysms at a Regional Aortic Center

Abstract

Emergent endovascular repair of suprarenal aortic aneurysms (SRAAs) and thoracoabdominal aortic aneurysms (TAAA) poses a significant challenge owing to branch vessel incorporation, time constraints, and the lack of dedicated devices. At our center, techniques to incorporate branch vessels have included parallel grafting, physician modified endografts, double-barrel/reversed iliac branch endoprosthesis, and in situ fenestration (ISF; Fig 1). We have described our experience using these techniques to repair ruptured SRAAs and TAAAs and their associated outcomes. A retrospective review of patients who had undergone endovascular repair of ruptured SRAAs and TAAAs from 2014 to 2021 with branch vessel incorporation was performed. The clinical presentations, intraoperative details, and postoperative outcomes of ISF were compared against the other techniques. Forty-two patients had undergone endovascular repair for ruptured SRAAs and TAAAs, 18 of whom had undergone ISF. Of the 18 ISF patients, 72% were hypotensive before surgery compared with the patients (58%) who had received the other techniques (ie, physician modified endografts, parallel grafting, double-barrel/reversed iliac branch endoprosthesis). The procedural times, fluoroscopy times, and interval from admission to surgery were similar between the two groups despite ISF incorporating more branch vessels than the other techniques (3.1 vs 2.2 per patient). The rate of serious complications was 57% across all techniques, with postoperative renal dysfunction the most frequent. In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. In-hospital mortality was the lowest with ISF (11% vs 25%), and this advantage was more pronounced for the patients with hypotension (8% vs 45%). Later in the study period, ISF became more commonly used owing to the improved outcomes for patients with ruptured aneurysms (Fig 2). Although emergent endovascular repair of SRAAs and TAAAs remains a challenge, a number of techniques are available for expeditious treatment. Of these, ISF has become an attractive technique owing to the improved mortality and the ability to rapidly achieve hemorrhage control before branch vessel incorporation. These advantages were especially apparent for ruptures with hypotension. Further experience is required to validate these encouraging initial results and assess the durability of ISF repair.Fig 2Endovascular techniques used for ruptured thoracoabdominal aortic aneurysm (TAAA) and suprarenal aortic aneurysm (SRAA) over time. DB/rIBE, Double barrel excluded/reversed iliac branch endoprosthesis; ISF, in situ fenestration; PG, parallel grafting; PMEG, physician modified endograft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)