Suprarenal vs Infrarenal Graft Fixation Does Not Affect Outcomes After Endovascular Aortic Aneurysm Repair in Patients with Favorable Neck Anatomy

Abstract

The decision to choose an endograft with or without suprarenal fixation for the treatment of aortic aneurysm remains highly debatable. Literature to date has focused on quantifying the risk of suprarenal graft fixation on renal function. This study aims to assess the effect of graft fixation on renal function as well as other intra- and postoperative outcomes. The Vascular Quality Initiative was queried from 2012 to 2022 to identify patients undergoing EVAR for infrarenal aortic aneurysms. Patients with hostile neck were excluded (aortic neck diameter >28 mm, neck length <15, angulation >60°). Patients were stratified on suprarenal vs infrarenal graft fixation. Primary outcomes were postoperative complications and aortic reintervention. Of the patients identified, 2357 (21.1%) and 8837 (78.9%) underwent suprarenal vs infrarenal graft fixation, respectively. Patients who underwent suprarenal graft fixation were more likely to be on an aspirin (68.1% vs 63.5%; P < .001) or a beta-blocker (52.1% vs 49.5%; P = .026). Otherwise, comorbidities and medications were similar between the cohorts (Table). Suprarenal grafts were more likely to be performed electively (90.5% vs 88.2%; P = .002). On completion angiogram, suprarenal, as compared to infrarenal, graft fixation was associated with endoleak (27.8% vs 21.8%; P < .001), but there was no difference in type Ia endoleaks (2.0% vs 2.1%; P = .760). At 1 year, there was a higher reintervention rate among the suprarenal cohort (5.2% vs 3.5%; P = .003); however, there was no difference in interventions for type Ia endoleak. There was a higher rate of renal artery coverage in the suprarenal cohort (2.8% vs 1.8%; P = .001), but no difference in rate of re-intervention for renal artery stenosis/occlusion (0.4% vs 0.2%; P = .170) or difference in creatinine elevation at follow-up (0.08 ± 0.67 vs 0.06 ± 0.51; P = .43). Patients who underwent EVAR with suprarenal graft fixation were more likely to have an endoleak on completion angiogram, however, there was no difference in type Ia endoleak. As such, higher rates of reintervention seen in the suprarenal graft fixation group was not found to be driven by proximal leaks. Although renal artery encroachment and/or coverage was more commonly observed after suprarenal graft fixation, there was no significant difference in creatinine elevation, reintervention rates for renal artery occlusion or dialysis dependence. Given the equivalent outcomes, surgeon preference and experience should dictate decision to use suprarenal or infrarenal fixation in patients with favorable neck anatomy.TableDemographics and comorbiditiesVariableInfrarenal graftSuprarenal graftP valueMale7320 (82.8)1941 (82.4).581Age, years72.9 ± 8.873.8 ± 8.8.859Current smoker2725 (30.8)683 (29).082Hypertension7226 (81.8)1912 (81.1).469Diabetes1769 (20)465 (19.7).753Coronary artery disease2569 (29.1)689 (29.3).870Congestive heart failure1053 (11.9)262 (11.1).286Hemodialysis76 (0.9)15 (0.6).283Preoperative aspirin5605 (63.5)1604 (68.1)<.001Preoperative P2Y inhibitor1145 (13)288 (12.2).344Preoperative statin6214 (70.3)1704 (72.4).052Preoperative beta-blocker4373 (49.5)1223 (52.1).026Preoperative angiotensin-converting enzyme inhibitor4047 (45.8)1070 (45.5).744Preoperative anticoagulant1250 (14.1)312 (13.2).262Values are mean ± standard deviation or number (%). Open table in a new tab