The Impact of Reinterventions on Survival After Fenestrated and Branched Endovascular Aneurysm Repair

Abstract

Fenestrated and branched endografting techniques are widely accepted for treatment of juxtarenal and pararenal abdominal aortic aneurysms (AAAs) and thoracoabdominal aortic aneurysms (TAAAs) in patients at high surgical risk. However, long-term results are largely unknown, particularly in terms of reintervention rate and subsequent impact on overall outcome. The aim of this study was therefore to evaluate early and midterm reinterventions after fenestrated-branched endovascular aneurysm repair (F/B-EVAR) for juxtarenal and pararenal AAAs and TAAAs and their impact on follow-up survival. Between 2006 and 2019, all consecutive patients undergoing F/B-EVAR for juxtarenal and pararenal AAAs or TAAAs were prospectively enrolled. Cases requiring reinterventions were clustered and retrospectively analyzed. Reinterventions were classified as access related (R1), aortoiliac related (R2), and target visceral vessel related (R3). Reinterventions and survival were assessed by Kaplan-Meier analysis; Cox regression was used to determined their predictors. Overall, 221 F/B-EVAR procedures were performed for 111 (50.3%) juxtarenal and pararenal AAAs and 110 (49.7%) TAAAs in an elective (182 [82%]) or urgent (39 [18%]) setting. At 30 days, 27 (12%) patients needed reinterventions: R1, 9 (4%); R2, 4 (2%); and R3, 14 (6%). The mean follow-up was 29 ± 15 months. Forty-one (19%) patients underwent reinterventions (single, 30 [14%]; multiple, 11 [5%]) for a total of 52 reinterventions: R1, 18 (35%); R2, 6 (12%); and R3, 28 (53%). Eight (15%) reinterventions were performed in an urgent setting. Endovascular and open reinterventions were performed in 32 (62%) and 20 (38%) cases, respectively. Open reinterventions were frequently access related (R1, 16; R2 + R3, 4; P < .001). Technical success was 95% (39 patients); failures consisted of one splenic artery rupture and one renal artery loss. Patients undergoing reinterventions more frequently had a primary urgent F/B-EVAR procedure (urgent, 12 [39%]; elective, 29/182 [16%]; P < .001) and TAAAs (TAAAs, 34/41 [83%]; juxtarenal and pararenal AAAs, 7/41 [17%]; P < .001). TAAAs had a higher incidence of R3 (TAAAs, 26/28 [93%]; juxtarenal and pararenal AAA, 2/28 [7%]; P < .001) and multiple reinterventions (TAAAs, 9/11 [82%]; juxtarenal and pararenal AAAs, 2/11 [18%]; P = .03) compared with juxtarenal and pararenal AAAs. Survival at 1 year and 3 years was 88% and 75%, and freedom from reintervention was 88% and 75% at 1 year and 3 years, respectively. Patients who underwent reinterventions had lower 3-year survival (reinterventions, 61%; no reinterventions, 77%; P = .02), but this was not confirmed by the multivariate analysis, in which TAAAs (hazard ratio, 2.3; 95% confidence interval, 1.1-4.8; P = .03) and urgent primary F/B-EVAR procedures (hazard ratio, 2.5; 95% confidence interval, 1.2-4.9; P = .01) were the only independent predictors of late mortality. Reinterventions after F/B-EVAR are not uncommon and are related to target visceral vessels in only half of cases. Most reinterventions can be performed by endovascular techniques and in an elective setting, and they are more frequent after urgent primary F/B-EVAR and TAAA procedures. Their technical success rate is excellent (95%) and does not have an impact on survival, which is conversely dependent on TAAA and urgent primary F/B-EVAR repair.