SS2. Fenestrated and Branched Endovascular Aneurysm Repair (F/B-EVAR) Outcomes for Type II and III Thoracoabdominal Aortic Aneurysms (TAAAs)

Abstract

The aim of this study was to evaluate technical and clinical outcomes of fenestrated(F)/branched (B) endovascular aneurysm repair (EVAR) for extensive thoracoabdominal aortic aneurysms (TAAAs). Data from 354 high-risk patients (Table) enrolled in a physician sponsored-investigational device exemption trial (2004-2013) undergoing F/B-EVAR for type II and III TAAA were evaluated. Technical success, perioperative clinical outcomes, and midterm outcomes (36 months) for branch patency, reintervention, aneurysm-related death, and all-cause mortality were analyzed. Data are presented as mean ± standard deviation and assessed using Kaplan-Meier, univariate, and multivariable analysis. F/B-EVARs incorporating 1305 fenestration/branches were implanted, with 96% of target vessels successfully stented. On completion aortography, 3.7% patients had a type I or III endoleak (EL). Procedure duration (6.0 ± 1.7 vs 5.5 ± 1.6 hours, P < .01) and hospital stay (13.1 ± 10.1 vs 10.2 ± 7.4 days, P < .01) were longer for type II TAAA. Perioperative mortality trended higher in type II repairs (7.0% vs 3.5%, P = .14). Permanent spinal cord ischemia and renal failure requiring hemodialysis occurred in 4.0% and 2.8% of patients, respectively. Eighteen branches required reintervention for stenosis; and celiac, superior mesenteric artery and renal artery patency at 36 months was 97% (95% confidence interval [CI], 0.94%-0.99%), 99% (95% CI, 0.97%-1.0%), and 96% (95% CI, 0.94%-0.99%), respectively. Forty-two patients required reintervention for a branch-related EL, four for type Ia EL, and three for type Ib EL. At 36 months, freedom from aneurysm-related death was 91% (95% CI, 0.88%-0.95%), and freedom from all-cause mortality was 57% (95% CI, 0.50%-0.63%). Aneurysm extent (P < .01), age (P < .01), and chronic obstructive pulmonary disease (P < .05) negatively affected survival. F/B-EVAR is a robust treatment option for patients at increased risk for conventional repair of extensive TAAAs. Technical success and branch patency are excellent, but several patients will require reintervention for branch-related endoleak. Aneurysm extent portends higher risk of perioperative and long-term morbidity and mortality. Additional efforts are needed to improve outcomes and understand the utility of this treatment option in the general TAAA population.TableDemographics of patients undergoing type 2 and 3 thoracoabdominal aortic aneurysm (TAAA) repairTotal (N = 354)Type2 (n = 128)Type 3 (n = 226)P valueMale gender270 (76.3%)82 (64.1%)188 (83.2%)<.001Age (years)73.5 ± 8.471.9 ± 8.074.4 ± 8.4.003Smoking status.765 Never27 (8.1%)11 (9.2%)16 (7.5%) Former248 (74.5%)90 (75.0%)158 (74.2%) Current58 (17.4%)19 (15.8%)39 (18.3%)Cardiac disease155 (43.8%)43 (33.6%)112 (49.6%).004Diabetes52 (14.7%)14 (10.9%)38 (16.8%).133Renal failure.459 Hemodialysis9 (2.5%)2 (1.6%)7 (3.1%) CRI66 (18.6%)21 (16.4%)45 (19.9%)COPD109 (30.8%)42 (32.8%)67 (29.6%).535Prior aneurysmSurgery153 (43.2)58 (45.3%)95 (42%).55 EVAR18 (5.1%)2 (1.6%)16 (7.1%).023 TEVAR25 (7.1%)21 (16.4%)4 (1.8%)<.001 AAA95 (26.8%)30 (23.4%)65 (28.8%).277 TAA27 (7.6%)14 (10.9%)13 (5.8%).077AAA, Abdominal aortic aneurysm; CRI, chronic renal insufficiency (creatinine >2.0); EVAR, endovascular abdominal aortic aneurysm repair; TAAA, thoracic aortic aneurysm; TEVAR, thoracic endovascular aortic aneurysm repair. Open table in a new tab