Fenestrated Endovascular Aneurysm Repair Research Articles

Initial experience of endovascular aneurysm repair at the Dr. Eduardo Liceaga General Hospital of Mexico

Background: Abdominal aortic aneurysm (AAA) is the permanent and irreversible dilation of the lower part of the aorta where the vessel expands, making it susceptible to rupture, which represents a high mortality incident. Methods: A review of clinical records was carried out from September 2021 to March 2023, patients who were diagnosed with aortic aneurysm were included in whom endovascular exclusion of abdominal and thoracic aortic aneurysm was performed at the General Hospital of Mexico by the angiology vascular and endovascular surgery department. Results: 18 endovascular repairs of aortic aneurysms were performed, of which 15.4% were female (n=6) and 84.6% male (n=12). The average proximal neck diameter in the thoracic aorta was 31 mm, average proximal neck diameter in infrarenal AAA 22.2 mm, average aneurysmal diameter in infrarenal segment 63.8 mm, thoracic 31 mm. Regarding the type of endovascular procedure, 11.1% were repaired with the fenestrated endovascular aneurysm repair (FEVAR) technique, and the same proportion with chimney endovascular aneurysm repair (ChEVAR), for a resolution with conventional EVAR of 77.7%. Complications occurred in 3 patients, 2 of which resulted in type 1a and 1b endoleaks that were reoperated and repaired with a proximal cuff, balloon angioplasty, and embolization of the aneurysmal sac with coils. Conclusions: Aortic aneurysm remains a major cause of death in adults because of aortic rupture despite advances over the past two decades that have been made in the endovascular management of large, symptomatic, and ruptured. Timely treatment is essential to prevent rupture and poor patient outcomes.

Adoption and clinical outcomes of fenestrated endovascular aneurysm repair in a regional, multistate community hospital system

ObjectiveComplex endovascular abdominal aortic aneurysm (AAA) repair techniques have evolved over the last decade, yet patterns of physician and hospital system adoption of fenestrated endovascular aneurysm repair (FEVAR) remain poorly defined. We investigated clinical outcomes, use trends, and surgeon and hospital experience for FEVAR in a large community hospital system. MethodsWe conducted a retrospective cohort study of all FEVAR procedures within our 5-state hospital system between April 2012 and June 2021. AAA repair volumes (open, EVAR, and FEVAR) were captured at the hospital and surgeon levels using Current Procedural Terminology and International Classification of Diseases codes. Clinical and outcomes data were collected for FEVAR patients. To consider if surgeon or hospital experience influenced outcomes, sequential case number was used to divide patients into surgeon experience and hospital experience groups. Inverse probability weighted and generalized linear mixed models, adjusted for demographics and comorbidities, were built to examine risk-adjusted outcomes for surgeon and hospital experience groups. ResultsOf 3850 patients treated with AAA procedures of any kind between 2012 and 2021, 160 (4.2%) underwent FEVAR. FEVAR procedures were performed by 34 different surgeons at 12 hospitals, with intraoperative complications and unplanned adjunctive procedures occurring in 18.8% (n = 30) and 19.4% (n = 31) of patients, respectively. Among FEVAR patients, in-hospital mortality was 1.3% (n = 2) and postoperative morbidity was 16.9% (n = 27). Renal function decline occurred postoperatively in 5.1% of patients. Early (<30 day) postoperative endoleaks occurred in 15.3% of patients (n = 21). Target vessel patency was 95.6% on initial postoperative imaging. Surgeon and hospital experience had a small positive impact on outcomes after the first one to three cases. Significant decreases in operative time, fluoroscopy time, and estimated blood loss were observed with increased surgeon experience, relative to a surgeon's first case (P < .05). There were lower odds of intraoperative complications after a surgeon's first case (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03-0.77, for cases 2-3) or after a hospital's first one to three cases (OR, 0.19; 95% CI, 0.04-0.89, for cases 4-8; OR, 0.12; 95% CI, 0.03-0.55 for cases 9-49). ConclusionsClinical outcomes of FEVAR across our hospital system compare favorably with previously published reports. Although system-wide FEVAR adoption increased 3-fold over the last decade, FEVAR continued to be performed by a minority of hospitals in our system. The results from this cohort demonstrate low rates of adverse events, high rates of technical efficiency, and a small impact of surgeon and hospital experience, thereby supporting this advanced endovascular technology as a safe, efficacious, and generalizable treatment alternative to open repair for patients with complex aortic anatomy.

Editor's Choice – Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) – Peri-operative and Midterm Outcomes

Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments vs. OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR). All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 - 4 mm, 5 - 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts). Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; p= .001) and FEVAR (2.2%; p= .001) than OSR (4.5%). In standard risk patients with a 0 - 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR vs. 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 - 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR. FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 - 4 mm neck length), with comparable midterm survival. For patients with short neck (5 - 9 mm) and complex neck (≥10mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.

Outcome of the Be Graft Bridging Stent in Fenestrated Endovascular Aortic Repair in a High-Volume Single Center and an Overview of Current Evidence.

Fenestrated endovascular aneurysm repair (FEVAR) has become one of the standard treatment options for complex abdominal aortic aneurysms (cAAAs) and thoraco-abdominal aortic aneurysms (TAAAs). Despite technological advances in the main endograft design, the lack of dedicated bridging stent-grafts (BSGs) is still the Achilles heel of the procedure. The aim of this study was to evaluate the mid-term outcomes of the BeGraft stent-graft as a dedicated bridging stent for FEVAR and to review the current evidence in literature. Retrospective single center study, including all consecutive FEVARs performed between September 2018 and December 2022 for the treatment of cAAAs and TAAAs with implantation of at least one BeGraft peripheral as the main BSG in one of the target vessels (TVs). Primary endpoints were technical success and TV instability of TV bridged with a BeGraft stent, as well as 30-day mortality and re-intervention rates. Secondary endpoints were follow-up TV instability, re-interventions, and mortality. A total of 113 patients (93 male, mean age 71.1±9.7) and 440 TV (14 scallops and 426 fenestrations) were included. Of the 440 TV, 406 received primary stenting. Be Grafts were used in 88.9% of these (n=361; celiac trunk [CT]=67, superior mesenteric artery [SMA]=98, right renal artery [RRA]=97, and left renal artery [LRA]=99). The technical success rate was 99.4% (359/361). The 30-day TV instability rate was 0.27% (1/361) with one early renal artery occlusion. During a median follow-up of 20 months (6-32), TV instability rate was 0.8% (3/361). Freedom from TV instability was 99.3%, 98.8%, and 98.8% at 1, 2, and 3 years, respectively. Early-term and mid-term results regarding TV instability are satisfactory and support the use of BeGraft as BSG in FEVAR for cAAAs and TAAAs. The findings of the current study show that the use of the BeGraft stent graft as bridging stent in FEVAR is associated with a high technical success and low early and mid-term instability rate and support the standard use as a bridging stent in fenestrated aneurysm repair.

Systematic Review and Meta-analysis of Fenestrated and Chimney/Snorkel Techniques for Endovascular Repair of Juxtarenal Aortic Aneurysms.

Comparative effectiveness of fenestrated endovascular aneurysm repair (FEVAR) and chimney graft endovascular aneurysm repair (ChEVAR) for juxtarenal aortic aneurysms (JAAs) remains unclear. Our objective was to identify and analyze the current body of evidence comparing the effectiveness of both techniques for JAA. We performed a systematic review and meta-analysis comparing the effectiveness of FEVAR and ChEVAR for JAA repair. We searched MEDLINE, EMBASE, and Cochrane Register for Controlled Trials from January 1, 1990, for randomized and non-randomized studies assessing outcomes of FEVAR and ChEVAR for JAA repair. Screening, data extraction, risk of bias assessment, and GRADE (Grading of Recommendations, Assessments, Development, and Evaluations) certainty of evidence were performed in duplicate. Data were pooled statistically where possible. Nine retrospective cohort studies comparing the use of FEVAR and ChEVAR for juxtarenal aneurysm were included for meta-analysis. The FEVAR and ChEVAR arms of the meta-analysis consisted of 726 participants and 518 participants, respectively. There were 598 (86.8%) and 332 (81.6%) men in each arm. The mean diameter was larger in the ChEVAR arm (59 mm vs 52.5 mm). Both techniques had similar rates of postoperative 30-day mortality, 3.38% (8/237) versus 3.52% (8/227), acute kidney injury, 16.76% (31/185) versus 17.31% (18/104), and major adverse cardiac events, 7.30% (46/630) versus 6.60% (22/333). The meta-analysis supported the use of FEVAR for most outcomes, with significant advantage for technical success (odds ratio [OR]: 3.24, 95% CI: 1.24-8.42) and avoidance of type 1 endoleak (OR: 5.76, 95% CI: 1.94-17.08), but a disadvantage for spinal cord ischemia (OR: 10.21, 95% CI: 1.21-86.11), which had a very low number of events. The quality of evidence was "moderate" for most outcomes. Both endovascular techniques had good safety profiles. The evidence does not support superiority of either FEVAR or ChEVAR for JAA. While lack of equipoise has hampered the design of randomised trials of open versus endovascular repair of juxtarenal aortic aneurysms, concern about the durability of endovascular repair highlights the need for stronger evidence of the comparative efficacy of endovascular techniques. This review performed meta-analysis and evidence appraisal of recent data from large observational studies comparing fenestrated and chimney techniques, using a comprehensive outcome set. Superiority of either intervention could not be established due to differences in participants' baseline risk in each study arm. However, data suggests that both techniques are safe and suitable for use when indicated.

Midterm Outcomes and Aneurysm Sac Dynamics Following Fenestrated Endovascular Aneurysm Repair after Previous Endovascular Aneurysm Repair

Fenestrated endovascular aneurysm repair (FEVAR) represents a feasible option for aortic repair after endovascular aneurysm repair (EVAR), due to improved peri-operative outcomes compared with open conversion. However, little is known regarding the durability of FEVAR as treatment of failed EVARs. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine mid-term outcomes and aneurysm sac dynamics of FEVAR after prior EVAR. Patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two hospitals in The Netherlands were included. Patients were categorised into primary FEVAR and FEVAR after EVAR. Outcomes included five year mortality, one year aneurysm sac dynamics (regression/stable/expansion), sac dynamics over time, and five year aortic related procedures. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, chi-square tests, and linear mixed effect models. In total, 196 patients with FEVAR were identified, of whom 27% (n = 53) had a prior EVAR. Patients with prior EVAR were significantly older (78 ± 6.7 years vs. 73 ± 5.9 years, p < .001). There were no significant differences in mortality. FEVAR after EVAR was associated with higher risk of aortic related procedures within five years (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.1 - 6.5, p = .037). Sac dynamics were assessed in 154 patients with available imaging. Patients with a prior EVAR showed lower rates of sac regression and higher rates of sac expansion at one year compared with primary FEVAR (sac expansion 48%, n = 21/44, vs. 8%, n = 9/110, p < .001)). Sac dynamics over time showed similar results, sac growth for FEVAR after EVAR, and sac shrinkage for primary FEVAR (p < .001). FEVAR after EVAR showed high rates of sac expansion and needed more secondary procedures than patients with primary FEVAR, although this did not affect mid-term survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention, and the underlying process that drives aneurysm sac growth following successful FEVAR after EVAR.

Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair

BackgroundEndovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR. MethodsPatients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups. ResultsPatient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (−5.2% vs +2.0%; P < .0001) and peak pressure (−3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs −31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR. ConclusionsbEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies. Clinical RelevanceThis study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.

An Analysis of Cost-Effectiveness and Clinical Outcomes of a Comprehensive Aortic Service in a Tertiary Center over One Year

ObjectivesEndovascular aortic repair (EVAR) is an established and attractive alternative to open surgical repair (OSR) of abdominal aortic aneurysms (AAA) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness.We compared the total yearly cost of running endovascular and OSR services in a single tertiary centre, to determine whether fenestrated EVAR (FEVAR) represents a clinically efficacious, affordable treatment option. Design and MethodsA single centre retrospective review was performed on 109 patients undergoing a procedure related to index or previous abdominal aortic repair, with one year follow up. Data was collected from the National Vascular Registry and hospital records. The primary outcome was cost per QALY. Secondary outcomes included 30-day mortality and morbidity, re-intervention rates, length of hospital stay, aneurysm and all-cause mortality at one year for elective index procedures. ResultsThe average cost per patient of all FEVAR was £16,041.53 (+/-8,857.54), £13,893.51 (+/-£21,425.25) for standard EVAR, and £15,357.22 (+/-£15,904.49) for OSR (FEVAR vs EVAR p=.55, FEVAR vs OSR p=.83, OSR vs EVAR p=.76). Of the secondary outcomes, significant findings included increased length of stay and respiratory morbidity for patients undergoing open versus endovascular repair. There was no significant difference in 30-day or one-year mortality between groups. ConclusionFEVAR, EVAR and OSR all represent cost-effective options for aortic repair, with similar outcomes. Our data highlights the potential for FEVAR to present a viable alternative to open repair, particularly in higher risk groups, when performed in specialist centres.

Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair

Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0years, P=0.04), had increased preoperative creatinine (1.6 vs. 0.9mg/dL, P<0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P=0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228ml, P=0.01), longer operative times (186 vs. 162min, P=0.04), and longer length of stay (3 vs. 2days, P<0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P<0.01 and 55.4% vs. 70.8%, P=0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1year (94.4% vs. 100%, P=0.015) and 5years (84.7% vs. 100%, P<0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P=0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scansbetween groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P=0.17). On multivariable modeling, age (hazardratio 1.05, 95% confidence interval 1.01-1.09, P=0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P<0.01) were independently associated with mortality. Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.

Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms.

Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair. This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test. A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I-IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05). There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison.

Endovascular Solutions for Abdominal Aortic Aneurysms: Fenestrated, Branched and Custom-Made Devices.

Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities.

Aneurysm Sac Dynamics and Mid-term Outcomes Following Fenestrated Endovascular Aneurysm Repair After Previous Endovascular Aneurysm Repair

Research has shown that fenestrated endovascular aneurysm repair (FEVAR) represents a feasible option for aortic repair after prior EVAR, owing to improved perioperative outcomes. However, little is known regarding the durability of FEVAR as rescue of failure. Since aneurysm sac evolution is an important marker for success after endovascular aneurysm repair, the aim of our study was to examine aneurysm sac dynamics of FEVAR after prior EVAR as well as mid-term outcomes. We included all consecutive patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two large hospitals in the Netherlands. FEVARs after open aortic repair were excluded, and patients were subsequently categorized into primary FEVAR and FEVAR after EVAR. Outcomes included 5-year secondary aneurysm-related procedures and mortality. One-year aneurysm sac dynamics (regression/stable/expansion, based upon 5% change compared with 30-day volume), and sac dynamics over time were evaluated between the groups with imaging data. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, χ2 tests, and linear mixed effect models. We identified 196 FEVAR patients of which 27% patients (n = 53) had a prior EVAR. Patients with a prior EVAR were significantly older (78.0 ± 6.7 years vs 73.0 ± 5.9 years; P < .001). FEVAR after EVAR was associated with higher risk of developing secondary aneurysm-related procedures within 5 years (hazard ratio, 2.62; 95% confidence interval, 1.06-6.50; P = .04) compared to primary FEVAR. Moreover, patients with a prior EVAR showed significantly lower rates of sac regression and higher rates of sac expansion at 1 year compared to primary FEVAR patients (42% sac expansion vs 5% sac expansion; P < .001). Sac dynamics over time showed the same results, sac growth for FEVAR after EVAR and sac shrinkage for primary FEVAR (P < .001) (Figure). Finally, there were no significant differences in f-year mortality between the groups (hazard ratio, 0.67; 95% confidence interval, 0.30-1.49; P = .33). Despite successful proximal extension and relining, FEVAR after EVAR patients had higher rates of sac expansion at one-year and needed more secondary procedures than primary FEVAR patients although this did not seem to effect survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention following failed infrarenal EVAR, and the underlying process that drives aneurysm sac growth after successful FEVAR after EVAR.

Reinterventions and Sac Dynamics After Fenestrated EVAR With Physician-modified Endografts for Index Aneurysm Repair and Following Prior EVAR

Reinterventions and Sac Dynamics After Fenestrated EVAR With Physician-modified Endografts for Index Aneurysm Repair and Following Prior EVAR

A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.

Editor's Choice – Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms

The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre. Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed. A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088). Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.

Renal Disease And Congestive Heart Failure Are Risk Factors For Urgent Endovascular Repair In Patients Under Active Surveillance For Thoracic And Thoracobdominal Aortic Aneurysms

Outcomes after urgent thoracic endovascular aortic repair (TEVAR) and/or fenestrated-EVAR (FEVAR) are worse compared to elective intervention. We described demographic factors associated with urgent TEVAR and/or FEVAR, with further analysis of patients presenting urgently despite active aneurysm surveillance.

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm.

The aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA). All patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared. The median AAA diameter was 54mm (interquartile range [IQR], 52-61mm) versus 58mm (IQR, 53-63mm) with a median neck length of 8mm (IQR, 6-12mm) vs 10mm (IQR, 6-13mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138mm (IQR, 113-182mm) vs 240mm (IQR, 199-293mm) ( P< .001) and the median length of stay was 2days (IQR, 2-3days) vs 7days (IQR, 6-7days) (P< .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23months (IQR, 19-33months) vs 36months (IQR, 22-57months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P= .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P= .23). ESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.

The effect of supraceliac versus infraceliac landing zone on outcomes following fenestrated endovascular repair of juxta-/pararenal aortic aneurysms.

With increasing experience in fenestrated endovascular aneurysm repair (FEVAR) over time, devices designed to treat juxta-/pararenal aortic aneurysms have evolved in complexity to extend to more proximal landing zones and incorporate more target vessels. We assessed perioperative outcomes in patients who underwent juxta-/pararenal FEVAR with supraceliac vs infraceliac sealing in the Vascular Quality Initiative. We identified all patients who underwent elective FEVAR (commercially available FEVAR and physician-modified endografts) for juxta-/pararenal aortic aneurysms in the Vascular Quality Initiative between 2014 and 2021. Supraceliac sealing was defined as proximal sealing in aortic zone 5, or zone 6 with a celiac scallop/fenestration/branch or celiac occlusion. Primary outcomes were perioperative and 3-year mortality. Secondary outcomes included completion endoleaks, in-hospital complications, and factors associated with 3-year mortality. We calculated propensity scores and used inverse probability-weighted Cox regression and logistic regression modeling to assess outcomes. Among 1486 patients identified, 1246 patients (84%) underwent infraceliac sealing, and 240 patients (16%) underwent supraceliac sealing. Of the supraceliac patients, 74 (31%) had a celiac scallop, 144 (60%) had a celiac fenestration/branch, and 22 (9.2%) had a celiac occlusion (intentional or unintentional). After risk-adjusted analyses, there were no differences in perioperative mortality following supraceliac sealing compared with infraceliac sealing (2.3% vs 2.5%; hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.26-1.8; P= .42), or 3-year mortality (12% vs 15%; HR, 0.89; 95% CI, 0.53-1.5; P= .67). Compared with infraceliac sealing, supraceliac sealing was associated with lower odds of type-IA completion endoleaks (odds ratio [OR], 0.24; 95% CI, 0.05-0.67), but higher odds of any complication (12% vs 6.9%; OR, 1.6; 95% CI, 1.01-2.5) including cardiac complications (5.5% vs 1.9%; OR, 2.6; 95% CI, 1.3-5.1), lower extremity ischemia (3.0% vs 0.9%; OR, 3.2; 95% CI, 1.02-9.5), and acute kidney injury (16% vs 11%; OR, 1.6; 95% CI, 1.05-2.3). Though non-significant, there was a trend towards higher risk of spinal cord ischemia following supraceliac sealing compared with infraceliac sealing (1.7% vs 0.8%; OR, 2.2; 95% CI, 0.70-6.4). There were no differences in bowel ischemia between groups (1.7% vs 1.5%; OR, 0.83; 95% CI, 0.24-1.23). A more proximal aneurysm disease extent was associated with higher 3-year mortality (HR zone 8 vs 9, 1.7; 95% CI, 1.1-2.5), whereas procedural characteristics had no influence. Compared with sealing at an infraceliac level, supraceliac sealing was associated with lower risk of type IA endoleaks and similar mortality. However, clinicians should be aware that supraceliac sealing was associated with higher perioperative morbidity. Future studies with longer follow-up are needed to adequately assess durability differences to comprehensively weigh the risks and benefits of utilizing a higher sealing zone within the visceral aorta for juxta-/pararenal FEVAR.

Reintervention does not affect long-term survival after fenestrated endovascular aneurysm repair.

Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine whether REI affects long-term survival after FEVAR. A single-institution retrospective review of all Cook Zenith fenestrated (ZFEN; Cook Medical, Inc, Bloomington, IN) repairs was performed. Patients with ≥6months of follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized as early (<30days) or late (≥30days), by indication (ie, branch, endoleak, limb related, access related, other), and by target branch or device components. Patients were stratified into REI vs no REI groups and branch REI vs non-branch REI groups. Of 219 consecutive ZFEN repairs from 2012 to 2021, 158 patients met the inclusion criteria. Of these 158 patients, 41 (26%) required a total of 51 REIs (10 early and 41 late) during a mean follow-up of 33.9months. The most common indication for REI was branch-related (31 of 51; 61%), with the renal arteries the most frequently affected (26 of 51; 51%). The only differences found in baseline, aneurysm, and device characteristics were a higher mean Society for Vascular Surgery comorbidity score (9.6 vs 7.9; P= .04) and larger suprarenal neck angle (23.3° vs 17.1°; P= .04) in the no REI group. In contrast, the REI group had a larger mean proximal seal zone diameter (26.3mm vs 25.1mm; P= .03) and device diameter (31.9mm vs 30.0mm; P= .002) compared with the no REI group. Technical success and operative characteristics were similar between the groups, except for a longer mean fluoroscopy time (74.9minutes vs 60.8minutes; P= .01) and longer median length of stay (2 vs 2days; P= .006) for the REI group. Although the rate of early (<30days) major adverse events was greater for the REI group (24.4% vs 6.0%; P= .001), the difference in 30-day mortality was not statistically significant (4.9% vs 0.9%; P= .10). On Kaplan-Meier analysis, freedom from REI at 1 and 5years was 85.7% and 62.6%, respectively, for the overall cohort. No difference was found in the estimated 5-year survival between the REI and no REI groups (62.8% vs 63.5%; log-rank, P= .87) and branch REI and non-branch REI groups (71.8% vs 49.9%; log-rank, P= .16). On multivariate analysis, REI was not an independent predictor for mortality. However, age, Society for Vascular Surgery comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.02-1.12 [P= .007]; HR, 1.10; 95% CI, 1.01-1.18 [P= .02]; HR, 1.05; 95% CI, 1.02-1.08 [P= .003], respectively). After ZFEN, 41 patients (26%) had required a total of 51 REIs, with most occurring ≥30days after the index procedure, and 61% were branch related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. The use of FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs did not influence 5-year postprocedural survival.

Comparative clinical study of short-term outcomes between table fenestrated and chimney endovascular aneurysm repair for hostile neck aneurysms.

Hostile neck abdominal aortic aneurysm (AAA) is challenging for standard endovascular aneurysm repair (EVAR). We sought to compare fenestrated endovascular aneurysm repair (fEVAR) and chimney endovascular aneurysm repair (chEVAR) for hostile neck AAA. Patients were identified retrospectively. Hostile neck anatomy was defined as a proximal neck length of <15mm or angulation >60°. The choice of fEVAR or chEVAR was based on neck anatomy and physician preference. Type I endoleak (T1EL) was the primary outcome. Other outcomes included type III endoleak (T3EL), visceral stent occlusion, renal insufficiency, reintervention, and mortality. A total of 84 patients were included from April 2012 to December 2021. fEVAR and chEVAR patients were 48 and 36 cases, respectively. Both groups showed similar rate of T1EL, T3EL, visceral stent occlusion, renal insufficiency, reintervention, and mortality. However, chEVAR patients had a more tortuous neck (61.1% vs. 16.7%, p < 0.001), while fEVAR patients had a greater neck size (29.5 ± 6.3mm vs. 24.5 ± 4.8mm, p < 0.001) and more reconstructing target arteries (2.2 ± 1.1 vs 1.3 ± 0.6, p < 0.001). fEVAR and chEVAR show similar safe and effective outcomes in well-selected hostile neck. fEVAR might be able to reconstruct multiple visceral arteries, and chEVAR seems justified in patients with poor anatomical suitability for fEVAR.