Sequential Catheterization Amid Progressive Endograft Deployment for Fenestrated and Branched Endovascular Aortic Aneurysm Repair

Abstract

Fenestrated and branched endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms in high-risk patients. Unfortunately, patients with unfavorable anatomy are frequently denied FEVAR because of the risk of technical failure with loss of visceral arteries. The purpose of this study was to assess technical success of FEVAR using a sequential catheterization amid progressive endograft deployment (SCAPED) technique, particularly in patients with unfavorable anatomy. During a 12-month period, 39 high-risk patients (31 men and 8 women) underwent FEVAR using customized, physician-modified Zenith endografts that were fenestrated or branched using the SCAPED technique. The visceral vessels were sequentially catheterized through the fenestrations via left brachial artery access in a cranial-to-caudal direction as the endograft was progressively deployed. Each fenestration was deployed, aligned, and catheterized separately while the distal endograft was constrained within the delivery sheath. Technical success was defined as complete exclusion of the aneurysm sac with successful catheterization and patent fenestrated/branched visceral arteries. Median age was 74 years (interquartile range [IQR], 64-81 years). All patients were considered unfit for open repair and had a median Society for Vascular Surgery comorbidity score of 15 (IQR, 12-18). Median aneurysm size was 5.9 cm (IQR, 5.5-6.4 cm). Most aortic aneurysms were paravisceral (40%); 23% were thoracoabdominal aortic aneurysms and 37% were juxtarenal abdominal aortic aneurysms. Endografts were customized to include 102 fenestrations/branches (63 renal, 28 superior mesenteric, and 11 celiac arteries). Fourteen patients (36%) had complex aortic aneurysms with unfavorable anatomy because of severe suprarenal neck angulation (>45°) or tortuosity in five (13%), reverse taper configuration of the proximal neck in four (10%), and circumferential thrombus/atheroma above the renal arteries in five (13%). Severe preprocedural renal and visceral artery stenosis was present in five and four patients, respectively. Technical success for stenting of the fenestrated/branched arteries was 98% (100 of 102). In two patients with unfavorable anatomy, one renal artery was lost and the corresponding fenestration had to be sealed with a cuff or a vascular plug. No visceral arteries were lost. Median procedure time was 265 minutes (IQR, 168-348 minutes), and median fluoroscopy time was 73 minutes (IQR, 51-86 minutes). Median contrast load was 103 mL (IQR, 91-130 mL) and estimated blood loss 250 mL (IQR, 125-550 mL). Median procedure (272 vs 255) and fluoroscopy times (76 vs 72) were not significantly different between patients with and without unfavorable anatomy (P > .05). No 30-day mortality occurred. Median hospital stay was 6 days (IQR, 4-9 days). Blue toe syndrome because of embolization (3 patients), access vessel injury (2 patients), worsening renal insufficiency (2 patients), renal artery dissection (2 patients), and myocardial infarction (1 patient) were the more frequent procedure-related complications. No periprocedural paraplegia or strokes occurred. FEVAR using the SCAPED technique is safe and effective in the treatment of complex aortic aneurysms, even in patients with unfavorable anatomy.