Extent Of Aneurysm Research Articles

Female Sex Portends Worse Long-Term Survival after Open Type I-III Thoracoabdominal Aneurysm Repair

Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in females, sex-specific differences in outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair are less clear. The goal of this study was to identify sex-based disparities in short- and long-term outcomes after open type I-III TAAA surgery. All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse events (MAEs), in-hospital death, and long-term survival. Univariate analysis was performed using the Fisher's exact test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Logistic regression was used for in-hospital end points; survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. Sensitivity analyses were performed for relevant multivariable models, one with ruptures removed and another evaluating only repairs performed before 2006 to account for any selection bias due to wider use of complex endovascular technology. Five-hundred sixteen patients underwent open type I-III TAAA repair during the study period. Females accounted for 54.3% (n=280) of the cohort. Women were older, less likely to have a chronic dissection etiology, more likely to present with a symptomatic/ruptured lesion, and had a lower admission creatinine than men. Perioperative death occurred in 23 men (9.8%) and 19 women (6.8%) (P=0.26); 133 women (47.3%) and 116 men (49.2%) suffered an MAE (P=0.72). Multivariable analyses revealed no sex-based difference in perioperative death (Female sex adjusted odds ratio (AOR): 0.72, 95% confidence interval (CI): 0.4-1.4, P=0.34) or MAE (AOR: 1.0 CI: 0.7-1.5, P=0.82). Unadjusted survival at five years was 50% for women and 67% for men (log-rank P<0.001). Female sex was an independent predictor of decreased survival (hazard ratio (HR): 1.5 95% CI: 1.2-1.9, P=0.001) when adjusted for age, aneurysm extent, creatinine, chronic obstructive pulmonary disease, and ruptures. After removing all ruptures, female sex remained nonpredictive of perioperative death (AOR: 1.1, 95% CI 0.5-2.5, P=0.75) or MAE (AOR: 1.2, CI: 0.8-1.9, P=0.31) and predictive of decreased long-term survival (HR: 1.5, 95% CI: 1.2-2.0, P=0.001). Those undergoing open type I-III TAAA repair have similar rates of perioperative mortality and MAEs, regardless of sex. However, female sex is an independent risk factor for decreased long-term survival.

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair

ObjectiveThe objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms. MethodsWe analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts. ResultsThere were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD. ConclusionsIntentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.

Early Limb Reperfusion Using Routinely Preloaded Fenestrated Stent-graft Designs for Complex Endovascular Aortic Procedures.

To evaluate the outcomes of the preloaded stent-graft design (PLD) in the routine treatment of pararenal and thoraco-abdominal aneurysms compared to the standard design (SND). Patients treated by fenestrated/branched endovascular aneurysm repair from 2013 were collected. Since 2017, PLD (23F delivery system) was implemented in our standard practice and the outcomes are reported. Primary outcome measurements were: technical success, 30-day adverse events, leg ischemia time, procedural time and radiation exposure. Secondary outcome measurements were: intraoperative urinary output, need of bicarbonate supplementation, postoperative biomarkers elevations and need for blood transfusions. A propensity 1:1 matching for graft design and aneurysm extent was performed with the SND (18F delivery system) cohort to highlight possible PLD advantages. A PLD was employed in 32 non-consecutive patients with a technical and clinical success rate of 100% and 81% respectively: no mortality was recorded. The Society for Vascular Surgery grade ≥ 1 adverse event was observed in 10 cases (31%): five temporary paraparesis were observed. Seventeen PLD patients were matched. The procedural time was shorter in PLD group (266 vs. 390min; p = 0.001) as well as fluoroscopy time (68 vs. 96min; p = 0.019) and contrast media used (180 vs. 382ml; p = 0.045). Contralateral limb ischemic time was significantly higher in SND group (0 vs. 70min; p = 0.042). The need for blood transfusion and the postoperative peak of creatine phosphokinase was lower in PLD group (151 vs. 449 U/l; p < 0.001). Preloaded stent-graft design allows a uni-femoral approach in the majority of the interventions reducing procedural times and the ischemia on the contralateral leg, leading to possible benefits.

Sex-related Outcomes After Fenestrated-Branched Endovascular Aneurysm Repair for Thoracoabdominal Aortic Aneurysms in the US Fenestrated and Branched Aortic Research Consortium

Fenestrated-branched endovascular aneurysm repair (F-BEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Prior studies have demonstrated that women are less likely to be treated with routine endovascular aneurysm repair due to anatomic ineligibility and experience higher mortality following both infrarenal and thoracic aortic aneurysm repair. The purpose of this study was to describe sex-related outcomes after F-BEVAR for treatment of TAAA. A total of 886 patients with extent I to V TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective physician-sponsored investigational device exemption studies from 2007 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to US Food and Drug Administration oversight. All patients were treated with Cook manufactured patient-specific F-BEVAR devices or the Cook t-Branch off-the-shelf device. Of 886 patients who underwent F-BEVAR, 288 (33%) were women (Table I). Women had more extensive aneurysms, higher prevalence of diabetes, lower prevalence of coronary artery disease, and lower prevalence of prior endovascular aneurysm repair. Women had longer operative times, lower technical success (93 vs 98%; P = .002), and longer length of stay (Table II). Women were more commonly treated with low-profile devices and had smaller target vessels with no difference in access site complications. Thirty-day mortality was 2% in both men and women. Early outcomes were equivalent except women experienced increased risk of permanent paralysis 2.9% versus 0.9% (P < .05). Multivariable model adjusting for age, aneurysm extent, aneurysm size, urgent procedure and renal function demonstrated that patient sex was not an independent predictor of survival (hazard ratio, 0.9; 95% confidence interval, 0.53-1.53; P = .69). At 1 year, freedom from type I or III endoleak (92.5% vs 92.5%; P = .91), reintervention (82.8% vs 85.8%; P = .19), branch vessel instability (86.4% vs 89.7%; P = .54), and survival (89.9% vs 91.6%; P = .37) did not differ between men and women. Women experienced a higher incidence of postoperative sac expansion (13% vs 6.4%; P = .006). F-BEVAR performed on women demonstrate metrics of increased complexity and have a lower level of technical success. Women experienced a higher risk of perioperative spinal cord injury but no increase in 30-day mortality. Female sex is not associated with disadvantaged 1-year outcomes; however, they did experience twice the rate of sac expansion at last follow-up. These data demonstrate that F-BEVAR is safe and effective among women despite being slightly higher risk. Further efforts to improve outcome parity are indicated.Table IPatient demographicsWomen (n = 276)Men (n = 568)P valueAge74 (7.4)74 (7.4).98Medical comorbidities Coronary artery disease33%53%<.0001 Cerebrovascular disease23%19%.18 Hypertension89%91%.41 Hyperlipidemia66%71%.14 Diabetes mellitus33%26%.043 Chronic obstructive pulmonary disease35%35%.85 Renal failure requiring dialysis3%10%.56 Prior aortic surgery44%46%.68 Prior endovascular aneurysm repair7.6%16%<.001 Dissection5.7%7.5%.99 Smoking status87%89%.46TAAA extent<.0001 I9.4%7.2% II36%20% III25%18% IV28%53% V1%0.5%Aneurysm size (cm)6.4 (1.3)6.5 (1.1).20Symptomatic/urgent presentation2.3%1.4%.39TAAA, Thoracoabdominal aortic aneurysm.Data are reported as mean (standard deviation) or as percentage where indicated. Open table in a new tab Table IIDevice and operative detailsWomen (n = 276)Men (n = 568)P valueDevice design Target vessels3.4 (0.9)3.4 (0.9).50 t-Branch14%13%.58 No. of branches1.4 (1.6)1.2 (1.6).08 No. of fenestrations1.7 (1.6)2.0 (1.8).002 Low profile55%46%.034 Preloaded system26%23%.22 Distal landing zone in the infrarenal aorta42%24%<.0001 Distal landing zone in the iliac arteries58%76%<.0001 Celiac stent diameter, mm7.3 (1.9)7.1 (2.6).33 SMA stent diameter, mm7.5 (0.9)8.2 (1.1)<.0001 RRA stent diameter, mm5.9 (0.7)6.3 (0.8)<.0001 LRA stent diameter, mm5.9 (0.9)6.1 (1.1)<.0001Operative details Operative time, hours5.0 (1.8)4.6 (1.7)<.001 Examination dose, mGy1882 (2397)3606 (2418).10 Contrast volume, mL117 (56)111 (59).20 Technical success93%98%.002 ICU Length of stay, days3.8 (3.3)3.0 (3.5).004 Hospital length of stay, days9.5 (25)6.9 (18).14ICU, Intensive care unit; LRA, left renal artery; RRA, right renal artery; SMA, superior mesenteric artery.Data are reported as mean (standard deviation) or as percentage where indicated. Open table in a new tab

Preoperative Functional Status Predicts 2-year Mortality in Patients Undergoing Fenestrated/branched Endovascular Aneurysm Repair

Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is a minimally invasive alternative for patients at high risk for open repair of complex aortic aneurysms. Nearly all investigative study protocols evaluating F/BEVAR require a predicted life expectancy >2 years for study inclusion. However, accurate risk models for predicting 2-year survival in this patient population are lacking. We sought to identify preoperative predictors of 2-year survival in patients undergoing F/BEVAR. Prospectively collected data on all consecutive F/BEVAR procedures, performed in an institutional review board-approved registry and/or physician-sponsored investigational device exemption trial (IDE# G130210), were reviewed (November 2010 to February 2019). Forty-four preoperative patient characteristics, including comorbidities, preoperative functional status, and aneurysm/repair characteristics, were assessed. Preoperative functional status was defined as totally dependent (any impairment in activities of daily living (ADLs) or residence in a skilled nursing facility), partially dependent (any impairment in instrumental ADLs), or independent (no impairment of ADLs/instrumental ADLs). Based on a univariate screen (P < .2), a Cox proportional hazards model was constructed to identify independent predictors of 2-year all-cause mortality. Among 256 consecutive F/BEVARs (six [2.3%] common iliac, 94 [41%] juxtarenal, 35 [14%] pararenal, 119 [47%] thoracoabdominal, and 2 [0.8%] arch aneurysms), the 2-year mortality was 18%. On Cox modeling, the only independent preoperative predictor of 2-year mortality was functional status (totally dependent, hazard ratio [HR], 5.4 [95% CI, 1.8-16; P < .01]; partially dependent, HR, 4.7 [95% CI, 2.5-8.7; P < .01]). A history of coronary revascularization was protective (HR, 0.5, 95% CI, 0.2-0.9; P = .03). Factors such as age, congestive heart failure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, aneurysm extent, and prior aortic surgery were not significant. The 2-year mortality for the independent (n = 176 [69%]), partially dependent (n = 69 [27%]), and totally dependent groups (n = 10 [3.9%]), was 11%, 33%, and 40%, respectively (Fig). In patients undergoing F/BEVAR, decreased preoperative functional status is the strongest predictor of 2-year mortality, with totally dependent patients experiencing poor survival. Traditional risk factors were not independently significant, perhaps reflecting a high prevalence of severe chronic illness in these high-risk patients participating in an investigational device exemption trial. Given that 2-year survival in the independent group of this high-risk cohort is 89%, which mirrors that of infrarenal EVAR, expanding the indication for F/BEVAR to patients who are independent is reasonable for low-risk patients as well.

Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults

BackgroundSurgical portosystemic shunts are rare. We reviewed indications, operative details, and outcomes of patients undergoing surgical portosystemic shunt procedures. MethodsWe retrospectively reviewed clinical data of consecutive patients between 1997 and 2018 from a single institution. Clinical characteristics and outcomes were compared between two groups: patients with portomesenteric venous thrombosis (PMVT) vs those with cirrhosis. Endpoints included 30-day mortality, shunt-related complications, patency, and survival. ResultsThere were 99 patients, 45 male and 54 female, with a mean age of 46 ± 18 years, enrolled in the study. There were 63 patients (63%) with PMVT and 36 patients (36%) with cirrhosis. Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for more diabetes among those with cirrhosis (p < 0.05). There were no significant differences in procedural metrics and intra-procedure complications between groups, except that patients with PMVT underwent more non-selective shunts than those with cirrhosis (63% vs. 30%, p < 0.001). There were two 30-day deaths (2%), with no difference in mortality and MAEs between groups. On univariate analysis, cholangiopathy and PMVT were associated with graft thrombosis (HR = 9.22, 95% CI 1.22–70.27) while race, smoking, cardiac comorbidity, type of operative shunt, configuration of the shunt, and use of conduit were not (p > 0.05). Patients with PMVT had significantly lower 1-, 5-, and 10-year primary (77%, 71%, and 71% vs. 97%, p = 0.009) and secondary patency (88%, 76%, and 72% vs. 96%, p = 0.027) compared with those with cirrhosis. The 1-, 5-, and 10-year survival rates were 94%, 84%, and 61% for patients with PMVT compared with 88%, 58%, and 26% for those with cirrhosis (non-adjusted HR 0.40, 95% CI 0.19–0.84, p = 0.01, age-adjusted HR 0.51, 95% CI 0.24–1.09, p = 0.08). The survival of patients with PMVT without liver disease trended higher than those with liver disease; however, when adjusted for age, the survival gap narrowed, and the difference was not statistically significant (p = 0.19), survival being lowest for those with PMVT and liver disease. ConclusionsSurgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The odds of graft thrombosis is 9 times higher in patients with PMVT. Overall survival is similar in patients with PMVT or cirrhosis.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair

The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR). A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two≥5.0mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration. Twenty-four patients with 28<4.0mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288≥5.0mm incorporated RAs. Study group patients were significantly younger than controls (72±8 vs. 75±8 years, p=.04) and more often females (46% vs. 21%, p=.018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0mm and 99% for ≥5.0mm RA incorporation (p=.05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p=.009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p=.05). At one year, primary patency was 79±9% vs. 94±1% (p<.001) and secondary patency was 84±8% vs. 97±1% (p<.001) for study vs. control group; freedom from branch instability was 79±9% vs. 93±2% (p=.005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21±14 months. Incorporation of <4.0mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

Results of fenestrated and branched endovascular aortic aneurysm repair after failed infrarenal endovascular aortic aneurysm repair

ObjectiveFailure of infrarenal endovascular aneurysm repair (EVAR) due to loss of proximal seal is increasingly common. Open surgical conversion can be challenging and has been associated with significant morbidity and mortality. The aim of this study was to evaluate the use of fenestrated-branched EVAR (F/BEVAR) for the treatment of patients with prior EVAR failure. MethodsConsecutive patients enrolled as part of the Aortic Research Consortium in six prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/BEVAR between 2012 and 2018 were included in this study. The cohort was stratified according to whether the F/BEVAR procedure was performed after EVAR failure. Demographics, operative details, perioperative complications, and length of stay were compared between groups. Postprocedural survival, type I or type III endoleak, target artery patency, target artery instability, and reintervention rates were calculated using Kaplan-Meier method and compared between groups. ResultsA total of 893 patients underwent F/BEVAR; 161 (18%) were treated after failed EVAR and 732 (82%) were treated without prior EVAR. Patients with failed EVAR were more often men (84% vs 66%; P < .01) with larger aneurysms (6.9 cm vs 6.4 cm; P < .01). There were no differences in aneurysm extent (P = .20) between groups; for the entire cohort, there were 19% juxtarenal, 9.2% suprarenal, and 72% thoracoabdominal aneurysms. The average number of targeted arteries per patient was 3.6 in both groups. The procedural technical success (99% vs 97%; P = .15) did not differ between groups, but radiation dose (4750 vs 2920 mGy; P = .02), dose-area product (154,572 vs 82,842 mGy·cm2; P < .01), and operative time (5.2 vs 4.6 hours; P < .01) were significantly higher in the failed EVAR group. Median intensive care unit length of stay (2.9 days) and total length of stay (6.3 days) did not differ between groups. The 30-day mortality rate (failed EVAR, 2.5%; no EVAR, 1.1%; P = .25) and 30-day major adverse event rates did not differ between groups. Kaplan-Meier estimates of freedom from type I or type III endoleak (91.9% vs 92.5%; P = .65), target artery patency (97.3% vs 97.0%; P = .91), freedom from target artery instability (86.3% vs 88.8%; P = .53), and freedom from reintervention at 1 year (84.7% vs 88.7%; P = .10) did not differ between the failed EVAR and no EVAR groups, respectively. One-year survival was decreased in the failed EVAR group (86.3% vs 91.9%; P = .02), but this effect did not persist on multivariable analysis (hazard ratio, 1.52; 95% confidence interval, 0.88-2.62; P = .14). ConclusionsIn this multicenter study, F/BEVAR was safe and effective in patients with prior failed EVAR, with nearly identical outcomes to those of patients without prior EVAR. However, differences in procedural metrics indicate higher level of technical challenge in performing F/BEVAR in patients with prior failed EVAR.

Impact of Intentional Coverage of Accessory Renal Arteries on Renal Function Among Patients Treated by Fenestrated-Branched Endografts

The objective of this study was to evaluate the impact of intentional accessory renal artery (ARA) coverage on renal function after fenestrated-branched endovascular aneurysm repair (F-BEVAR) for pararenal aneurysm or thoracoabdominal aortic aneurysm (TAAA). We analyzed the clinical data of 289 patients enrolled in a prospectively nonrandomized study to evaluate outcomes of F-BEVAR between 2013 and 2018. Thirty-two patients with solitary kidneys were excluded. Outcomes were analyzed in patients with intentional ARA coverage and controls who had preservation of all renal arteries, including patients with no ARAs and those who had preservation of ARAs. Acute kidney injury (AKI) was defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease), and renal function deterioration (RFD) was determined by >30% decline in estimated glomerular filtration rate. End points included 30-day mortality and major adverse events, AKI, and freedom from RFD. There were 257 patients (183 male; mean age, 75 ± 8 years) included in the study, 51 (20%) with ARA coverage (Ø = 2.6 ± 0.7 mm) and 206 controls (13 with ARA preservation; Ø = 3.5 ± 0.5 mm). There were no differences in demographics, cardiovascular risk factors, and aneurysm extent. Technical success was achieved in all patients with ARA coverage and in 99% of controls (P = 1.0). Neither of the two technical failures was attributed to the ARA incorporation. There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (35% vs 22%; P = .04) due to higher incidence of AKI (22% vs 10%; P = .03). None of the 13 patients who had ARA preservation developed AKI. Mean follow-up was 18 ± 15 months. At 3 years, there was no significant difference in freedom from RFD for ARA coverage and controls (65% ± 9% vs 73% ± 5%; P = .08), respectively. By multivariate analysis, ARA coverage (odds ratio [OR], 2.4; P = .03) was a predictor for AKI, and renal reintervention for stenosis (OR, 2.7; P = .007), extent II TAAA (OR, 3.3; P = .001), and postprocedure AKI (OR, 5.0; P < .001) were predictors for RFD. Intentional ARA covered during F-BEVAR was associated with twofold higher incidence of AKI, with a nonsignificant trend toward lower freedom from RFD. Factors associated with RFD included renal reinterventions for stenosis, extent II TAAA, and postprocedure AKI. Incorporation of ARAs during F-BEVAR, when technically feasible, may help decrease risk of AKI.

Fenestrated-branched endovascular aortic repair in patients with chronic kidney disease

ObjectiveRenal function impairment is a common complication after open repair of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). The purpose of this study was to assess renal perioperative outcomes and renal function deterioration after fenestrated-branched endovascular aneurysm repair (F/BEVAR) in patients with chronic kidney disease (CKD). MethodsThe study included 186 patients who underwent F/BEVAR between 2013 and 2018 for suprarenal, juxtarenal, and type I to type IV TAAAs. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Postoperative acute kidney injury (AKI) and CKD were defined using RIFLE criteria (Risk, Injury, Failure, Loss, and End-stage renal disease) and CKD staging system (stage ≥3, GFR <60 mL/min/1.73 m2), respectively. For those without baseline CKD, renal decline was defined as a drop in GFR <60 mL/min/1.73 m2 (ie, progression to CKD stage 3 or higher). For patients with baseline renal dysfunction, GFR decline ≥20% or progression in CKD stage (ie, from stage 3 to stage 4) was considered renal decline. ResultsCKD was present in 83 patients (44.6%). Postoperative AKI was diagnosed in 27 patients (14.5%); 13 (48.1%) had history of CKD and 14 (51.9%) had adequate renal function preoperatively (P = .8). None of these patients required permanent renal replacement therapy. Intraoperative technical success was 100%. Overall 30-day mortality was 1.1%. There was no difference in 30-day mortality in patients with (1.2%) and without (1.0%) CKD (P = .5). During a median follow-up time of 12 months (interquartile range, 6-23 months), renal decline was observed in 21 patients (25.3%) with previous CKD and in 11 patients (10.6%) without CKD (P = .01). Among patients with previous CKD, 18 patients (9%) progressed from stage 3 CKD to stage 4. In patients with progression in CKD stage, two (5%) had renal stent stenosis requiring restenting. Among patients with renal decline, 13 had juxtarenal aneurysms (21.3%), 27 had suprarenal aneurysms (44.3%), and 21 had TAAAs (34.3%; P = .4). Subset analysis of patients who developed AKI in the immediate postoperative period found that patients with a history of CKD were less likely to experience freedom from renal decline. ConclusionsF/BEVAR is an effective and safe procedure for patients with complex abdominal aortic aneurysms and TAAAs, even among patients with CKD. The frequency of AKI was not affected by pre-existing CKD. Midterm outcomes demonstrated that progression of CKD was more frequent among patients with pre-existing CKD, but permanent renal replacement therapy was not required. Anatomic extent of aneurysms did not affect CKD progression. CKD patients are susceptible to renal decline over time if they experience AKI in the postoperative period. Therefore, preventing AKI in the postoperative period should be regarded as a priority. Long-term effects of CKD after F/BEVAR remain to be elucidated.

Outcomes of fenestrated-branched endovascular aortic repair in patients with a solitary functional kidney

ObjectiveThe aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal abdominal aortic aneurysms or thoracoabdominal aortic aneurysms (TAAAs) in patients with a solitary functional kidney (SFK). MethodsWe analyzed the outcomes of 287 consecutive patients (206 male; mean age, 74 ± 8 years old) enrolled in a prospective nonrandomized study to investigate use of F-BEVAR for treatment of patients with pararenal abdominal aortic aneurysms or TAAAs between 2013 and 2018. Outcomes were analyzed in patients with solitary kidney (functional or congenital) and compared with control patients who had two functioning kidneys. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease criteria, and renal function deterioration (RFD) was defined by a decline in estimated glomerular filtration the estimated glomerular filtration rate of more than 30% from baseline. End points included 30-day mortality and major adverse events, AKI, freedom from RFD, and patient survival. ResultsThere where 30 patients (10%) with a SFK and 257 patients with two functioning kidneys. Patients with a SFK were younger and had significantly (P < .05) higher baseline creatinine (+0.3 mg/dL), lower estimated glomerular filtration rate (−16 mL/minute/1.73 m2) and more often had stage III to V chronic kidney disease (73% vs 43%). There were no differences in cardiovascular risk factors and aneurysm extent. Technical success was achieved in 98.9% of patients with SFK and in 99.8% of controls (P = .10). At 30 days, there was no significant differences in mortality (0% vs 1%) and major adverse events (40% vs 24%; P = .08), including rates of AKI (20% vs 12%) and new-onset dialysis (3% vs 1%) between patients with a SFK and the control group, respectively. Mean follow-up was 18 ± 15 months. At 2 years, there was no difference (P = .36) in patient survival (92 ± 5% vs 84 ± 3%) and freedom from RFD (100 ± 0% vs 84 ± 3%) for patients with SFK and controls, respectively. Presence of a SFK was not a predictor for AKI or RFD. By multivariable analysis, estimated blood loss of more than 1 L (odds ratio [OR], 2.9; P = .04) and total fluoroscopy time (OR, 1.8; P = .05) were predictors for AKI, and postoperative AKI (OR, 4.9; P < .001), renal branch occlusion/stenosis (OR, 3.1; P = .001), and Crawford extent II TAAA (OR, 2.4; P = .007) were predictors for RFD. ConclusionsDespite the worse baseline renal function, F-BEVAR is safe and effective with nearly identical outcomes in patients with a SFK as compared with patients with two functioning kidneys. Development of postoperative AKI is the most important predictor for RFD.

Preoperative Psoas Muscle Size and Radiodensity Predict Mid-term Survival and Quality of Life After Fenestrated-branched Endovascular Aortic Repair

Introduction: Age alone is a relatively poor predictor of survival due to the discrepancy between biological and chronological age. We need better predictors of clinical outcomes and life expectancy in elderly patients considered for endovascular repair of complex aortic aneurysms. Sarcopenia may be a key determinant of survival in elderly people. Psoas muscle area (PMA) measured at L3-level has been shown to be a reproducible and reliable surrogate for sarcopenia. However, the association of PMA with survival has been inconsistent in previous studies involving patients treated for infrarenal abdominal aortic aneurysms (1-7). PMA alone does not take the muscle quality over quantity into account. Decreased radiodensity, on the other hand, could indicate fatty infiltration of skeletal muscle (myesteatosis) that is associated with frailty and sarcopenia. The aim of this study was to investigate the association of PMA and psoas muscle density (PMD) with survival and quality of life (QOL) after fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. Methods: The study included 244 consecutive patients enrolled in a prospective study to investigate outcomes of F-BEVAR. Preoperative computed tomography angiography was used to measure PMA (cm2) and PMD (Hounsfield unit, HU) from a single axial slice at L3-level. Lean psoas muscle area (LPMA) was calculated (LPMA = PMA×PMD). Patients were divided into two groups using LPMA cut-point based on Cox hazard model (Figure 1). Group A was defined as LPMA ≥ 350 (n=79) and group B as LPMA < 350 cm2×HU (n=165). QOL was assessed at baseline and 12 months using SF-36 survey. Results: Patients in Group A were younger (mean age, 72±8 vs 76±7 years, P< .001), more often males (95% vs 59%, P< .001) and had higher body mass index (30±6 vs 27±5 kg/m2, P=.001). There were no major differences in comorbidities, aneurysm extent and procedural measures between the groups. Thirty-day mortality (0% vs 0.6%, P=1.00) and major adverse event rates (15% vs 24%, P=.18) were similar in Group A and B. At 3 years, patient survival was 94±3% in Group A and 75±4% in Group B (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.07-0.56, P=.002, Figure 2). The 3-year survival difference was even more prominent in patients aged ≥75 years: 100% for Group A and 72±5% for Group B (HR 0.12, 95% CI 0.02-0.86, P=.035). Group A patients had significantly higher QOL scores at baseline and 12 months. Out of all preoperative variables, LPMA was the strongest independent predictor of survival during the follow-up in multivariable analysis (adjusted HR 0.59 per one standard deviation, 95% CI 0.40-0.87, P=.008), whereas PMA alone was not a significant predictor. Conclusion: A high LPMA was independently and strongly associated with better mid-term survival and quality of life after F-BEVAR. LPMA can be used to identify suitable candidates for F-BEVAR among elderly patients. The measurement of psoas muscle radiodensity should be included in future studies assessing CT parameters as predictors of survival in patients undergoing vascular surgical procedures.Figure 2Kaplan-Meier survival estimates, dotted line adjusted for age, gender and BMI.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: The last author has received consulting fees and grants from Cook Medical, W. L. Gore, and GE Healthcare (all paid to the affiliated institution with no personal income).

Pre-operative Psoas Muscle Size Combined With Radiodensity Predicts Mid-Term Survival and Quality of Life After Fenestrated-Branched Endovascular Aortic Repair

To investigate the association between psoas muscle area (PMA) and density (PMD) with survival and quality of life (QoL) after fenestrated-branched endovascular aortic repair (F-BEVAR). The study included 244 consecutive patients enrolled in a prospective study to investigate outcomes of F-BEVAR. Pre-operative computed tomography angiography was used to measure PMA (cm2) and PMD (Hounsfield unit [HU]) at the L3 level. Lean PMA (LPMA) was calculated (PMA×PMD). Patients were divided into two groups using the LPMA cut off point based on a Cox hazard model. Group A was defined as LPMA ≥350 (n=79) and group B as LPMA<350cm2×HU (n=165). QoL was assessed at baseline and at 12 months using the Short Form-36. Patients in group A were younger (mean age 72±8 vs. 76±7 years; p<.001), more often male (95% vs. 59%; p<.001), and had higher body mass index (30±6 vs. 27±5kg/m2; p=.001). There were no major differences in comorbidities, aneurysm extent, or procedural measures between the groups. Thirty day mortality (0% vs. 0.6%; p=1.0) and major adverse event rates (15% vs. 24%; p=.18) were similar in groups A and B. At three years, patient survival was 94%±3% in group A and 75%±4% in group B (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.07-0.56; p=.002). The three-year survival difference was even more prominent in patients aged ≥75 years: 100% for group A and 72%±5% for group B (HR 0.12, 95% CI 0.02-0.86; p=.035). Patients in group A had significantly higher QoL scores at baseline and at 12 months. LPMA was the strongest independent predictor of survival during follow up in multivariable analysis (adjusted HR 0.59 per 1 standard deviation, 95% CI 0.40-0.87; p=.008). A high LPMA was independently and strongly associated with better mid term survival and QoL after F-BEVAR. LPMA may help to identify the best candidates for F-BEVAR among elderly patients.

Predictors of enucleation in Coats disease: analysis of 259 eyes of 259 patients at a single center

To evaluate the effects of clinical features associated with enucleation in eyes with Coats disease. The medical records of all patients with Coats disease at the Ocular Oncology, Wills Eye Hospital from November 1, 1973, to July 31, 2018, were reviewed retrospectively. The clinical features pertaining to need for ultimate enucleation and time to enucleation were compared. The records of 351 eyes were reviewed, of which 259 had follow-up at our center and 32 (12%) were managed with enucleation. Reasons for enucleation included neovascular glaucoma (n=24 [75%]), possible tumor (6 [19%]), and phthisis bulbi (2 [6%]). Compared to nonenucleated eyes, enucleated eyes had more extensive clock hour involvement of telangiectasia (P<0.001), light bulb aneurysms (P<0.001), exudation (P<0.001), and subretinal fluid (P<0.001). On adjusted analysis by binomial logistic regression, variables predictive of enucleation included presence of iris neovascularization (P=0.01), ultrasonographic retinal detachment (P=0.004), open-funnel retinal detachment (P=0.04), closed-funnel retinal detachment (P=0.01), ultrasonographic elevation of subretinal fluid by millimeters (P=0.001), and angiographic extent of light bulb aneurysms by clock hours (P=0.02). By Kaplan-Meier analysis of 4-year cumulative risk of enucleation, risk factors for enucleation included presence of iris neovascularization (hazard ratio [HR] 31.0; P<0.001), ultrasonographic retinal detachment (HR 56.2; P<0.001), open-funnel retinal detachment (HR 2.7; P=0.01), and closed-funnel retinal detachment (HR 4.5; P<0.001). Clinical features that predict risk of and time to enucleation in eyes with Coats disease include iris neovascularization, ultrasonographic presence and millimeter-elevation of retinal detachment, and angiographic extent of light bulb aneurysms.

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively

ObjectiveA rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy. MethodsWe used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival. ResultsAssessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men. ConclusionsWomen and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

Preloaded Catheters and Guide-Wire Systems to Facilitate Catheterization During Fenestrated and Branched Endovascular Aortic Repair.

The aim of this study was to review the clinical outcomes for patients treated for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs) by fenestrated-branched endovascular aortic repair (F-BEVAR) using preloaded systems (PLS). We reviewed clinical data of 83 patients (64 male, mean age 75 ± 7years) enrolled in a prospective study to investigate F-BEVAR. All patients had PLS, which included two catheters or two through-and-through guide wires with 12-Fr trans-brachial sheaths positioned in the descending thoracic aorta. Outcome measurements were technical success defined as successful deployment of the main fenestrated stent graft and cannulation of all target vessels, total endovascular time, total lower extremity ischemia time and complications, 30-day mortality, and major adverse events (MAEs). Aneurysm extent was PRA in 27 patients and TAAA in 56 (35 extent IV and 21 extent I-III). A total of 333 target vessels were incorporated with an average of 4 ± 0.4 vessels per patient. Technical success was 99.7%. Total endovascular time was 160 ± 51min. Sixty-five (78%) patients had motor and somatosensory evoked potentials monitoring, and lower extremity ischemia time was 115 ± 42min. There were no 30-day mortalities. Fifteen patients (18%) had MAEs, including three (3.6%) minor ischemic strokes. There were no upper extremity complications. All ischemic strokes occurred in female patients (3.6% vs. 0%, P = .001). One (1.2%) patient had paraplegia. This study shows high technical success and early lower limb reperfusion using PLS with trans-brachial access. The risk of stroke, especially in female patients, should be carefully assessed by review of preoperative arch imaging.

Evolution of Fenestrated/Branched Aortic Aneurysm Repair Complexity and Outcomes at an Organized Center for the Treatment of Complex Aortic Disease

Fenestrated/branched endovascular aneurysm repair (F/BEVAR) volume has increased rapidly, with favorable outcomes at centers of excellence. We evaluated changes over time in F/BEVAR complexity and associated outcomes at a single-center complex aortic disease program. Prospectively collected data of all F/BEVAR procedures (definition: requiring one or more fenestrations or branches) in an Institutional Review Board-approved registry or physician-sponsored investigational device exemption trial (#G130210) were reviewed (November 2010-February 2019). Patients were stratified by surgery date: early experience, mid experience, and recent experience. Patient/operative characteristics, aneurysm morphology, device types, and perioperative and midterm outcomes (survival, freedom from type I or type III endoleak, target artery patency, freedom from reintervention) were compared. For 252 consecutive F/BEVARs (early experience, n = 84; mid experience, n = 84; recent experience, n = 84), 194 (77%) company-manufactured custom-made devices, 11 (4.4%) company-manufactured off-the-shelf devices, and 47 (19%) physician-modified devices were used to treat 5 (2.0%) common iliac, 97 (39%) juxtarenal, 31 (12%) pararenal, 116 (46%) thoracoabdominal, and 2 (0.8%) arch aneurysms. All patients had follow-up for 30-day events (Fig). Mean follow-up was 589 days (interquartile range, 149-813 days). On 1-year Kaplan-Meier analysis, survival was 88%, freedom from type I or type III endoleak was 91%, and target vessel patency was 92%. When stratified by time period, significant differences included aneurysm extent (thoracoabdominal: 64% recent experience, 40% mid experience, and 33% early experience; P < .001) and target vessels per case (four-vessel case: 67% recent experience, 39% mid experience, and 31% early experience; P < .0001). There was no difference but a trend toward improvement in composite 30-day events (early experience, 39%; mid experience, 23%; recent experience, 27%; P = .05). On Kaplan-Meier analysis, there was no difference in survival (P = .19) or target artery patency (P = .6). There were differences in freedom from reintervention (P < .01) and from type I or type III endoleak (P = .02), with more reinterventions in the early experience, and more endoleaks in the recent period. Despite increasing repair complexity, there has been no significant change in perioperative complications, overall survival, or target artery patency, with favorable outcomes overall. Freedom from reintervention has improved over time, but type I or type III endoleaks have not and remain a significant limitation in need of further innovation.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9days, P=0.012), operative room time (262 vs. 209, P=0.040), and perioperative mortality (28.6% vs. 4.1%, P=0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P=0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

SS03. Results of Fenestrated and Branched Endovascular Aortic Aneurysm Repair After Failed Infrarenal Endovascular Aortic Aneurysm Repair

Failure of infrarenal endovascular aortic aneurysm repair (EVAR) owing to loss of proximal seal is increasingly common. Open surgical conversion is challenging and associated with significant morbidity/mortality. The aim of this study was to evaluate the use of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of patients with prior EVAR failure. Consecutive patients enrolled in six, prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/BEVAR between 2012 and 2018, were included in this study. The cohort was stratified according to whether the F/BEVAR procedure was performed after EVAR failure. Demographics, operative details, perioperative complications, and length of stay were compared between groups. Patient survival, type I or type III endoleak, target artery patency, and reintervention rates were calculated using Kaplan-Meier method and compared between groups. A total of 893 patients underwent F/BEVAR; 161 (18%) were treated after failed EVAR and 732 (82%) were treated without prior EVAR. Patients with failed EVAR were more often men (84% vs 66%; P < .01) with larger aneurysms (6.9 cm vs 6.4 cm; P < .01). There were no differences in aneurysm extent (P = .20) between the groups: 19% juxtarenal, 9.2% suprarenal, and 72% thoracoabdominal. The average number of targeted arteries per patient was 3.6 in both groups. The procedural technical success (99% vs 97%; P = .15) did not differ between groups, but radiation dose (4753 mGy vs 2924 mGy; P = .02), dose area product (154,572 mGy cm2 vs 82,842 mGy cm2; P < .01), and operative time (5.2 hours vs 4.6 hours; P < .01), were significantly higher in the failed EVAR group. Median intensive care length of stay (2.9 days) and total length of stay (6.3 days) did not differ between groups. The 30-day mortality rate (failed EVAR, 2.5%; no EVAR, 1.1%; P = .25) and 30-day major adverse event rate (Fig 1) did not differ between groups. Kaplan-Meier estimates of freedom from death (88.3% vs 92.5%; P = .10; Fig 2), type I or type III endoleak (91.9% vs 92.5%; P = .65), target artery occlusion (97.3% vs 97.0%; P = .91), and reintervention at 1 year (84.7% vs 88.7%; P = .10) did not differ between the failed EVAR and no EVAR group, respectively. In this multicenter study, F/BEVAR was safe and effective in patients with prior failed EVAR, with nearly identical outcomes as compared with patients without prior EVAR. However, differences in procedural metrics indicate higher level of technical challenge when performing F/BEVAR in patients with prior failed EVAR.Fig 2Kaplan-Meier estimates of freedom from death. EVAR, Endovascular aortic aneurysm repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Elective Fenestrated and Branched Endovascular Thoraco-abdominal Aortic Repair with Supracoeliac Sealing Zones and without Prophylactic Cerebrospinal Fluid Drainage: Early and Medium-term Outcomes

To report the outcome of elective fenestrated and branch (FEVAR-BEVAR) endovascular aortic repair with supracoeliac (SC) sealing zones and the impact of staged repair without prophylactic cerebrospinal fluid (CSF) drainage on the incidence of spinal cord ischaemia (SCI). Two hundred and seventy consecutive patients (217 men; mean [SD] age, 72.8±6.3 years; median (IQR) diameter 65mm [62-75mm]) with juxtarenal (JRAAA) (n=69) or thoraco-abdominal aortic aneurysms (TAAAs) (n=201) underwent elective FEVAR (n=192) or BEVAR (n=78) with renovisceral stent grafting, proximal SC (Zones 1-5; <40mm [n=83]; ≥40mm [n=187]) and distal infrarenal aorto-iliac sealing zone (Zones 9-11) between December 2008 and September 2017. A spinal cord protection protocol (SCPP) including staging without prophylactic CSF drainage was introduced in September 2012. A total of 1026 renovisceral vessels (mean 3.8±0.5 per patient) were targeted for preservation. One patient (0.4%) died in the institution within 30 days and 31 (11.4%) developed 36 major non-fatal complications including unplanned permanent dialysis (n=1, 0.4%) and non-ambulatory SCI (n=6, 2.2%). In patients with <40mm SC coverage, none were staged or had prophylactic CSF drains and none developed SCI. In patients with ≥40mm SC coverage, SCI occurred in 3.3% (pre-SCPP: 4/20 [20%; none staged, 13 prophylactic CSF drains] vs. post-SCPP: 2/167 [1.2%; 89 staged, no prophylactic CSF drains]; p=.001 [OR=19.9]). Estimated survival (±SE) at one, two and three years was 92.6%±1.6%, 86.5%±2.4%, and 73.8%±3.5%, respectively, with no significant difference comparing extent of aneurysm or SC coverage. Forty-three (15.9%) patients required late re-intervention. Estimated freedom from re-intervention at one, two and three years was 91.9%±1.8%, 85.1%±2.5%, and 79.5%±3.2%, respectively. Elective endovascular thoraco-abdominal aortic repair with SC sealing zones can be performed with low peri-operative risk and good medium-term outcomes. Selective staging without prophylactic CSF drainage contributed to a significant reduction in the incidence of SCI.