Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians

Unsuspected Limitations of 3D Printed Model in Planning of Complex Aortic Aneurysm Endovascular Treatment

OBJECTIVE

Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning.

BACKGROUND

Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise.

METHODS

A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making.

RESULTS

The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation.

CONCLUSION

The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density.

Effect Of Fenestration Configuration On Renal Artery Outcomes During Fenestrated-Branched Endovascular Aortic Repair

OBJECTIVES

To evaluate the effect of fenestration configuration and fenestration gap on renal artery outcomes during fenestrated-branched endovascular aortic repair (F/BEVAR).

METHODS

A retrospective multicenter analysis was performed, including patients with complex aortic aneurysms treated with F/BEVAR that incorporated at least one small fenestration to a renal artery. The renal fenestrations were divided into groups 1 (8x6 mm) and 2 (6x6 mm). Primary patency, target vessel instability (TVI), freedom from secondary interventions (SIs), occurrence of type IIIc endoleak, all related to the renal arteries, were analyzed at 30-day, 1-year, and 5-year landmarks. The fenestration gap (FG) distance was analyzed as a modifier, and clustering was addressed at the patient level.

RESULTS

Seven hundred and ninety-six patients were included in this study, 71.7% male, with a mean age of 73.3±8.1 years. The mean follow-up was 30.0±20.6 months. Of the 1474 small renal fenestrations analyzed, 47.6% were 8x6, and 52.4% were 6x6mm. At the 30-day landmark, primary patency (99.9% vs 98.0%, p-value <0.001 for groups 1 and 2, respectively), freedom from TVI (99.6% vs 97.1%, p-value <0.001 for groups 1 and 2, respectively), and freedom from SI (99.8% vs 98.4%, p-value = .022 for groups 1 and 2, respectively) were higher in 8x6 compared to 6x6 fenestrations, and the incidence of AKI was similar across the groups (92.6% vs 92.7%, p-value = .953 for groups 1 and 2 respectively). The primary patency at 1 and 5 years was higher in 8x6 fenestrations (1-year: 98.8% vs 96.9%; 5-year: 97.8% vs 95.7%, for groups 1 and 2, respectively, p values = .010 and 0.021 for 1 and 5 year comparisons, respectively). The freedom from SIs was significantly higher among 6x6 fenestrations at 5 years (93.1% vs 96.4%, for groups 1 and 2, respectively, p value = .007). The groups were equally as likely to experience a type Ic endoleak (1.3 % and 1.6% for 8x6 and 6x6mm fenestrations, respectively, p = .689). The 6x6 fenestrations were associated with higher risk of kidney function deterioration (17.8%) when compared with 8x6 fenestrations (7.6%) at 5 years (p <.001). The risk of type IIIc endoleak was significantly higher among 8x6 fenestrations at 5 years (4.9% and 2% for 8x6 and 6x6 mm fenestrations, respectively, p= .005). A FG ≥5 mm negatively impacted the cumulative 5-year freedom from TVI (group 1: FG ≥5 mm = 0.714, FG <5 mm = 0.857, p<.001; group 2: FG ≥5 mm = 0.761, FG <5 mm = 0.929, p<.001) and the cumulative 5-year freedom from type IIIc endoleak (group 1: FG ≥5 mm = 0.759, FG <5 mm = 0.921, p=.034; group 2: FG ≥5 mm = 0.853, FG <5 mm = 0.979, p<.001) in both groups and the cumulative 5-year patency in group 2 (group 1: FG ≥5 mm = 0.963, FG <5 mm = 0.948, p=.572; group 2: FG ≥5 mm = 0.905, FG <5 mm = 0.938, p=.036).

CONCLUSIONS

Fenestration configuration for the renal arteries impacts outcomes. The 8x6 small fenestrations have better patency at 30-days, 1 year, and 5 years, while 6x6 small fenestrations are associated with lower rates of secondary interventions, primarily due to a lower incidence of type IIIc endoleaks. Fenestration gap ≥ 5 mm at the level of the renal arteries significantly impacts the freedom from TVI, freedom from type IIIc endoleak and 5-year patency independently of the fenestration size or vessel diameter.

Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair

OBJECTIVE

Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR.

METHODS

A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling.

RESULTS

Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05).

CONCLUSIONS

In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.

National trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms

INTRODUCTION

Custom-branched/fenestrated grafts are widely available in other countries, but in the United States, they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEGs). We therefore sought to determine how widespread the use of these grafts is.

METHODS

We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the Vascular Quality Initiative from 2014 to 2022 to examine temporal trends.

RESULTS

A total of 5826 repairs were performed during the study period: 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7 ± 0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256) and nearly twofold for juxtarenal repairs. In three-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFENs (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P < .001). The differences in PMEG use were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEGs and ZFENs. However, surgeons in the highest quartile of volume performed a median of 18 (interquartile range: 10-21) PMEGs/y, but only 1.6 (interquartile range: 0.8-3.4) ZFENs/y. The number of physician-sponsored investigational device exemption trials of PMEGs has expanded from 1 in 2012 to 8 currently enrolling. As those data are not included in the Vascular Quality Initiative, the true number of PMEGs is likely substantially higher.

CONCLUSIONS

PMEGs have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of investigational device exemptions. The field of endovascular aortic surgery and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes, and comparisons to custom-manufactured grafts.

Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair

OBJECTIVE

To examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians.

METHODS

A multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention.

RESULTS

A total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004).

CONCLUSIONS

Our findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, on par with other medical comorbidities and therefore age should be strict exclusion criterion for F/BEVAR procedures, rather age should be considered in the global context of patient's aortic anatomy, health, and functional status.

Long-term outcomes of chimney endovascular aneurysm repair procedure for complex abdominal aortic pathologies

OBJECTIVE

The aim of this study was to update our earlier experience and to evaluate long-term outcomes of chimney endovascular aortic repair performed for selected cases with complex abdominal aortic aneurysm.

METHODS

A single-center retrospective cohort study was conducted on 51 consecutive patients who underwent chimney endovascular aortic repair procedure, deemed unfit for open surgical repair and fenestrated endovascular aneurysm repair, from October 2009 to November 2019. Kaplan-Meier analyses were used to assess the estimated overall survival, freedom from aneurysm related mortality, freedom from reintervention, freedom from target vessel instability, and freedom from type Ia endoleaks.

RESULTS

Fifty-one patients (mean age, 77.1 ± 7.5 years) with a mean preoperative maximum aneurysm diameter of 74.2 ± 20.1 mm were included. Mean follow-up duration was 48.6 months (range, 0-136 months). Estimated overall survival at 5 and 7 years was 36.3% ± 7.1% and 18.3% ± 6.0%, respectively. Freedom from aneurysm-related mortality was 88.6% ± 4.9% at 7 years. Estimated freedom from type Ia endoleaks at 7 years was 91.8% ± 3.9%. A total of 21 late reinterventions were performed in 17 patients (33%). Most of them were performed to treat type II endoleaks with sac growth (47.6%; n = 10) and type Ib endoleak (23.8%; n = 5). Estimated freedom from reintervention at 7 years was 56.3% ± 7.9%. Estimated freedom from target vessel instability at 7 years was 91.5% ± 4.1%.

CONCLUSIONS

The 7-year results of chimney endovascular aortic repair procedures performed in our center confirm the long-term safety and effectiveness of this technique in a series of high-risk patients with large aneurysms. The present study has, to the best of our knowledge, the longest follow-up for patients treated with chimney endovascular aortic repair, and it provides data to the scarce literature on the long-term outcomes of this procedure, showing acceptable to good long-term results.

Systematic review of the results of fenestrated endovascular aortic repair in octogenarians

INTRODUCTION

With the increasing life expectancy of Western populations, more octogenarians are presenting with large abdominal aortic aneurysm (AAA). Endovascular repair offers a less invasive alternative and older patients who may not have been offered open repair in the past are now being considered for elective repair with this approach. Age in isolation may not be the only consideration in recommending elective aneurysm repair. We aimed to review the literature on complex endovascular AAA repairs (mainly fenestrated endovascular aortic repair [FEVAR]) in octogenarians.

METHODS

A literature search was conducted using the Ovid Medline®, Embase® and Cochrane Library databases for articles published up to January 2022. All English language publications from 1995 onwards were eligible for inclusion. Search terms included: "FEVAR", "F-EVAR", "fenestrated EVAR", "fenestrated endovascular aortic repair", "fenestrated endovascular aneurysm repair", "fenestrated AAA repair", "fenestrated endograft", "fenestrated stent graft", "fenestrated", "endograft", "EVAR", "octogenarian", "elderly", "above 80" and "over 80".

METHODS

The literature search identified 134 potential articles. Following qualitative assessment by two independent appraisers, this was refined to 11 studies, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement.

RESULTS

The primary outcome measure was 30-day mortality, which was highly variable, ranging from 0% to 9% in octogenarians and from 0% to 5% in non-octogenarians. However, these differences were only found to be statistically significant in two studies. The secondary outcome measures included technical success rates, major adverse events, reintervention rates, freedom from reintervention, target vessel patency, freedom from target branch instability, and length of hospital and intensive care unit stay. No statistically significant differences were found between octogenarians and non-octogenarians. Long-term survival was significantly lower for octogenarians in two studies.

CONCLUSIONS

The perioperative outcomes of FEVAR in octogenarians are comparable with those of younger patients. FEVAR therefore appears to be an acceptable option for complex endovascular aneurysm repairs in carefully selected octogenarians. Nevertheless, this review highlights the paucity of published data on the outcomes of endovascular repair of complex aneurysms in octogenarians.

Systematic Review of the Effect of Cerebrospinal Fluid Drainage on Outcomes After Endovascular Descending Thoracic/Thoraco-Abdominal Aortic Aneurysm Repair

OBJECTIVE

This study aimed to investigate whether prophylactic use of cerebrospinal fluid (CSF) drainage in endovascular descending thoracic aortic aneurysm (DTAA) and thoraco-abdominal aortic aneurysm (TAAA) repair contributes to a lower rate of post-operative spinal cord ischaemia (SCI).

DATA SOURCES

MEDLINE, Embase, and CINAHL.

REVIEW METHODS

A literature review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42021245893). Risk of bias was assessed through the Newcastle-Ottawa scale (NOS), and the certainty of evidence was graded using the GRADE approach. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI) of both early and late onset SCI. Pooled outcome estimates were calculated using the odds ratio (OR) and associated 95% CI. The primary outcome was SCI, both early and lateonset. Secondary outcomes were complications of CSF drainage, length of hospital stay, and peri-operative (30 day or in hospital) mortality rates.

RESULTS

Twenty-eight observational, retrospective studies were included, reporting 4 814 patients (2 599 patients with and 2 215 without CSF drainage). The NOS showed a moderate risk of bias. The incidence of SCI was similar in patients with CSF drainage (0.05, 95% CI 0.03 ‒ 0.08) and without CSF drainage (0.05, 95% CI 0.00 ‒ 0.14). No significant decrease in SCI was found when using CSF drainage (OR 0.67, 95% CI 0.29 ‒ 1.55, p = .35). The incidence rate of CSF drainage related complication was 0.10 (95% CI 0.04 ‒ 0.19). The 30 day and in hospital mortality rate with CSF drainage was 0.08 (95% CI 0.05 ‒ 0.12). The 30 day and in hospital mortality rate without CSF drainage and comparison with late mortality and length of hospital stay could not be determined due to lack of data. The quality of evidence was considered very low.

CONCLUSION

Pre-operative CSF drainage placement was not related to a favourable outcome regarding SCI rate in endovascular TAAA and DTAA repair. Due to the low quality of evidence, no clear recommendation on pre-operative use of CSF drainage placement can be made.

Severity of acute kidney injury is associated with decreased survival after fenestrated and branched endovascular aortic aneurysm repair

OBJECTIVE

Acute kidney injury (AKI) occurs frequently in complex aortic surgery and has been implicated in perioperative and long-term survival. This study sought to characterize the relationship between AKI severity and mortality after fenestrated and branched endovascular aortic aneurysm repair (F/B-EVAR).

METHODS

Consecutive patients enrolled by the US Aortic Research Consortium in 10, prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/B-EVAR, between 2005 and 2023, were included in this study. Perioperative AKI during hospitalization was defined by and staged using the 2012 Kidney Disease Improving Global Outcomes criteria. Determinants of AKI were evaluated with backward stepwise mixed effects multivariable ordinal logistic regression. Survival was analyzed with conditionally adjusted survival curves and backward stepwise mixed effects Cox proportional hazards modelling.

RESULTS

In the study period, 2413 patients with a median (interquartile range [IQR]) age of 74 years (IQR, 69-79 years) underwent F/B-EVAR. The median follow-up duration was 2.2 years (IQR, 0.7-3.7 years). The median baseline estimated glomerular filtration rate (eGFR) and creatinine were 68 mL/min/1.73 m2 (IQR, 53-84 mL/min/1.73 m2) and 1.1 mg/dL (IQR, 0.9-1.3 mg/dL), respectively. Stratification of AKI identified 316 patients (13%) with stage 1 injury, 42 (2%) with stage 2 injury, and 74 (3%) with stage 3 injury. Renal replacement therapy was initiated during the index hospitalization in 36 patients (1.5% of cohort, 49% of stage 3 injuries). Thirty-day major adverse events were associated with AKI severity (all P ≤ .0001). Multivariable predictors of AKI severity included baseline eGFR (proportional odds ratio, 0.9 per 10 mL/min/1.73 m2 [95% confidence interval (CI), 0.85-0.95 per 10 mL/min/1.73 m2]; P < .0001), baseline serum hematocrit (0.58 per 10% [95% CI, 0.48-0.71 per 10%]; P < .0001), renal artery technical failure during aneurysm repair (3 [95% CI,1.61-5.72]; P = .0006), and total operating time (1.05 per 10 minutes [95% CI, 1.04-1.07 per 10 minutes]; P < .0001). One-year unadjusted survivals for AKI severity strata were 91% (95% CI, 90%-92%) for no injury, 80% (95% CI, 76%-85%) for stage 1 injury, 72% (95% CI, 59-87%) for stage 2 injury, and 46% (95% CI, 35-59%) for stage 3 injury (P<.0001). Multivariable determinants of survival included AKI severity (stage 1, hazard ratio [HR], 1.6 [95% CI, 1.3-2]); stage 2, HR, 2.2 [95% CI, 1.4-3.4]); stage 3 HR, 4 [95% CI, 2.9-5.5]; P < .0001), decreased eGFR (HR, 1.1 [95% CI, 0.9-1.3]; P = .4), patient age (HR, 1.6 per 10 years [95% CI, 1.4-1.8 per 10 years]; P < .0001), baseline chronic obstructive pulmonary disease (HR, 1.5 [95% CI, 1.3-1.8]; P < .0001), baseline congestive heart failure (HR, 1.7 [95% CI, 1.6-2.1]; P < .0001), postoperative paraplegia (HR, 2.1 [95% CI, 1.1-4]; P = .02), and procedural technical success (HR, 0.6 [95% CI, 0.4-0.8]; P = .003).

CONCLUSIONS

AKI, as defined by the 2012 Kidney Disease Improving Global Outcomes criteria, occurred in 18% of patients after F/B-EVAR. Greater severity of AKI after F/B-EVAR was associated with decreased postoperative survival. The predictors of AKI severity identified in these analyses suggest a role for improved preoperative risk mitigation and staging of interventions in complex aortic repair.

The Effect of Age on Peri-Operative Outcomes after FEVAR

INTRODUCTION

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor.

METHODS

A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest.

RESULTS

During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest.

DISCUSSION

In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Predictors and Outcomes of Spinal Cord Injury following Complex Branched/Fenestrated Endovascular Aortic Repair in the US Aortic Research Consortium

OBJECTIVE

Spinal cord ischemia (SCI) is a well-known complication of thoracoabdominal aortic aneurysm (TAAA) repair and is associated with profound morbidity and mortality. The purpose of this study was to describe predictors for the development of SCI, as well as outcomes for patients who develop SCI, after branched/fenestrated endovascular aortic repair (FB-EVAR) in a large cohort of centers with adjudicated physician-sponsored investigational device exemption studies.

METHODS

We utilized a pooled dataset from 9 United States Aortic Research Consortium (US ARC) centers involved in investigational device exemption (IDE) trials for treatment of suprarenal and thoracoabdominal aortic aneurysms. SCI was defined as new transient weakness (paraparesis) or permanent paraplegia after repair without other potential neurologic etiologies. Multivariable analysis was performed to identify predictors of SCI, and life-table analysis and Kaplan-Meier methodology were used to evaluate survival differences.

RESULTS

A total of 1,681 patients underwent FB-EVAR over the period 2005-2020. The overall rate of SCI was 7.1% (3% transient and 4.1% permanent). Predictors of SCI on multivariable analysis were Crawford Extent I, II, and III distribution of aortic disease (OR 4.79 95% CI 4.77- 4.81, P<.001), age ≥70 (OR 1.64, 95% CI, 1.63-1.64, P=.029), packed red blood cell transfusion (OR 2.00, 95% CI, 1.99-2.00, P=.001), and history of PVD (OR 1.65, 95% CI, 1.64-1.65, P=.034). Median survival was significantly worse for patients with any degree of SCI compared to those without SCI (any SCI - 40.4 vs no SCI - 60.3 months, Log Rank <.001), and also worse in those with a permanent deficit (24.1 months) vs. those with a transient deficit (62.4 months) (Log Rank <0.001). One year survival for patients who developed no SCI was 90.8%, compared to 73.9% in patients who developed any SCI. When stratified by degree of deficit, survival was 84.8% at one year for those who developed paraparesis, and 66.2% for those who developed permanent deficits.

CONCLUSIONS

The overall rates of any SCI at 7.1% and permanent deficit at 4.1% observed in this study compare favorably to those reported in contemporary literature. Our findings confirm that increased length of aortic disease is associated with SCI and those with Crawford Extent I-III TAAAs are at highest risk. The long-term impact on patient mortality underscores the importance of preventive measures and rapid implementation of rescue protocols if and when deficits develop.

Outcomes in octogenarians after thoracoabdominal and juxtarenal aortic aneurysm repair using fenestrated-branched devices justifies treatment

OBJECTIVE

To compare outcomes between octogenarians and nonoctogenarians undergoing thoracoabdominal aortic aneurysm repair and juxtarenal aortic aneurysm repair using branched and/or fenestrated endovascular devices (F/BEVAR) and compare octogenarian survival to population survival statistics from Ontario, Canada.

METHODS

Patients who underwent F/BEVAR at a single institution between 2007 and 2020 were retrospectively reviewed with a median follow-up of 3.3 years (interquartile range, 1.6-5.3). The median survival of an average 84-year-old Ontarian from Canada, adjusted for a male:female ratio of 4:1, was retrieved from publicly available Statistics Canada data.

RESULTS

In total, 68 octogenarians (25.8%) and 196 nonoctogenarians (74.2%) were included (mean age, 83.5 ± 3.0 vs 71.9 ± 5.8 years; P ≤ .001). The maximum aneurysm size was significantly larger in octogenarians (68.9 ± 11.4 mm vs 65.4 ± 10.0 mm; P = .017). No differences in the number of thoracoabdominal aortic aneurysm repairs (29.4% vs 38.3%; P = .19) or operative technical success (92.6% vs 85.7%; P = .136) were observed between the two cohorts. Postoperatively, no significant differences in overall in-hospital mortality (7.3% vs 5.1%; P = .49), elective in-hospital mortality (6.1% vs 4.4%; P = .49), stroke (1.5% vs 3.6%; P = .384), or spinal cord ischemia (2.9% vs 9.2%; P = .094) were seen between octogenarians and nonoctogenarians. There was no difference in survival at 4 years between the two cohorts (62.9% vs 71.1%; P = .22), however, survival at 6 years was significantly lower for octogenarians (44.5% vs 64.1%; hazard ratio, 1.96; P = .02). The cumulative rate of reintervention (44.1% vs 41.3%; P = .84) and freedom from branch instability (67.6% vs 73.5%; P = .33) at 6 years were not different between the two groups. When comparing octogenarians who survived to discharge from index hospitalization after F/BEVAR with 84-year-old Ontarians unmatched for comorbidities, a survival difference of 4.8% and 11.1% was noted at 4 and 6 years, respectively.

CONCLUSIONS

F/BEVAR in octogenarians is associated with no differences in technical success or postoperative adverse outcomes when compared with their younger counterparts. Octogenarians had increased mortality after 4 years and their survival at 4 years was comparable with that of an 84-year-old Ontarian. F/BEVAR was safe and effective in octogenarians deemed fit for intervention. Further research into preoperative patient selection and improving perioperative outcomes is needed.

Physician-modified endograft using three-dimensional model-assisted planning

Objective

Case-specific and true-to-scale three-dimensional (3D) models have become increasingly useful tools for physician-modified endovascular grafting. This study aimed to validate the use of 3D model-assisted planning for fenestration design.

Methods

Thirty-two consecutive patients (2019-2021) presenting with pararenal or juxtarenal abdominal aortic aneurysm (n = 16), paravisceral abdominal and Crawford's extent IV thoracoabdominal aortic aneurysm (n = 12), and type I endoleak after endovascular repair (n = 4) were analyzed retrospectively. All cases were planned manually with a standard method using curved planar reconstruction stretch images and multiplanar images perpendicular to the centerlines. The design was finalized by intraoperative 3D model-assisted planning. Intermethod agreements were assessed for geometrical relationships (separation heights and angles) between the superior mesenteric and renal arteries. The datasets from 55 double measurements of the entire cohort in this series were used to assess measurement discrepancies (≥3 mm separation height or ≥15° angle difference) and fenestration mismatches (≥3 mm separation between the manually planned and 3D model-assisted-planned renal arterial centers on the device surface) between manual and 3D model-assisted planning. Statistical analyses were performed to test the impact of anatomical factors on the discrepancies and mismatches. The imposition accuracy of 3D model-assisted planning and short-term clinical results of the 32 cases were also evaluated.

Results

Fourteen fenestration measurement discrepancies were detected. The size of the stent graft (P = .0381), the aortic angle (P = .0008), and the prior existence of stent graft (P = .0123) were found to have a statistically significant impact on the measurement discrepancy, using single logistic and Fisher's exact tests. Twelve fenestration mismatches were observed and found to be significantly affected (P = .0039) by aortic angle. A cutoff value for fenestration mismatch was found to be 36.5°, with a sensitivity and specificity of 69.2% and 80.5%, respectively, using receiver operating characteristic analysis (area under the curve, 0.782 ± 0.081; P = .0023). A high level of branch preservation (100%) was achieved. During the observation period (1.3 years on average; range, 0.5-2.5 years), no patient experienced complications related to fenestration.

Conclusions

The differences between the planning methods were non-negligible. However, 3D model-assisted planning increased the precision of the fenestration design when the conformation of the stent graft to the aortic anatomy is taken into account.

Reintervention Does Not Impact Long-term Survival After Fenestrated Endovascular Aneurysm Repair

OBJECTIVES

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 if REIs impact long-term survival after FEVAR.

METHODS

A single-institution retrospective review of all Cook ZFEN repairs was performed. Patients with ≥6 months 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 by early (<30 days) or late (≥30 days), indication (branch, endoleak, limb, access-related, or other), and target branch/device component. Patients were stratified into REI vs No REI and Branch REI vs Non-Branch REI.

RESULTS

Of 219 consecutive ZFEN from 2012-2021, 158 patients met inclusion criteria. Forty-one (26%) patients underwent a total of 51 REIs (10 early, 41 late) over a mean follow-up of 33.9 months. The most common indication for REI was branch-related 61% (31/51), with the renal arteries most frequently affected 51% (26/51). The only differences found in baseline, aneurysm, or device characteristics were a higher mean SVS comorbidity score (9.6 vs 7.9, P=.04) and larger suprarenal neck angle (23.3 vs 17.1 degrees, P=.04) in No REI, while REI had larger mean proximal seal zone diameter (26.3 vs 25.1 mm, P=.03) and device diameter (31.9 vs 30.0 mm, P=.002) than No REI. Technical success and operative characteristics were similar between groups, except for longer mean fluoroscopy time (74.9 vs 60.8 min, P=.01) and longer median length of stay (2 vs 2 days, P=.006) in REI. While the rate of early major adverse events (<30 days) was higher in REI (24.4% vs 6.0%, P=.001), 30-day mortality was not statistically different (4.9% vs 0.9%, P=.10). On Kaplan-Meier analysis, freedom from REI at 1- and 5-years was 85.7% and 62.6%, respectively, in the overall cohort. There was no difference in estimated 5-year survival between REI and No REI (62.8% vs 63.5%, log-rank P=.87) and Branch REI and Non-Branch REI (71.8% vs 49.9%, log-rank P=.16). In multivariate analysis, REI did not predict mortality; age, the SVS comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (HR 1.07 95% 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).

CONCLUSIONS

Following ZFEN, 26% of patients required a total of 51 REIs with most occurring ≥30 days and 61% being branch-related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs do not influence 5-year post-procedural survival.

Effect of patient frailty status on outcomes of fenestrated-branched endovascular aortic repair for complex abdominal and thoracoabdominal aortic aneurysms

OBJECTIVE

In the present study, we assessed the effects of patient frailty status on the early outcomes and late survival after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal and thoracoabdominal aortic aneurysms.

METHODS

We retrospectively reviewed the clinical data and outcomes of consecutive patients who had undergone elective FB-EVAR from 2007 to 2019 in a single institution. A previously validated 11-item modified frailty index (mFI-11) was derived from the comorbidity and preoperative functional status data. An mFI-11 <0.3 was defined as low risk, 0.3 to 0.5 as medium risk, and >0.5 as high risk. The studied outcomes were 90-day mortality, major adverse events (MAE), and long-term survival. Multivariate analyses were performed to identify the independent predictors of these outcomes.

RESULTS

A total of 592 patients (155 women, mean age, 75 ± 8 years) had undergone FB-EVAR. Using the mFI-11, 310 patients (52%) were included in the low-risk, 199 (34%) in the medium-risk, and 83 (14%) in the high-risk group. The 90-day mortality was significantly higher in the high-risk group than in the medium- and low-risk groups (13%, 4%, and 3%, respectively; P < .01). The corresponding MAE rates were 27%, 18%, and 19% (P = .23). As a subgroup, 44 patients in the high-risk group had had chronic kidney disease (CKD). The 90-day mortality for these patients was as high as 23%, and 32% had experienced MAE. On multivariable analysis, the independent risk factors for 90-day mortality were CKD, respiratory disease, and a high mFI-11. The independent risk factors for MAE were female sex, CKD, larger aneurysm diameter, and the high-risk subgroup with CKD. The independent risk factors for long-term mortality were age, a low body mass index, CKD, larger aneurysm diameter, extent I-III thoracoabdominal aortic aneurysm, respiratory disease, congestive heart failure, a history of cerebrovascular problems, and higher mFI-11. The estimated survival at 1 year was 91% ± 2% in the low-risk, 88% ± 2% in the medium-risk, and 78% ± 5% in the high-risk group (P < .001). The corresponding 5-year survival estimates were 60% ± 4%, 52% ± 5%, and 32% ± 6%. The mean follow-up time was 2.9 ± 2.3 years. The patients treated during the first quartile of the study period were significantly more frail than were those in the later quartiles. Also, the outcomes of FB-EVAR had improved over time.

CONCLUSIONS

Greater frailty was significantly associated with early mortality. Together with CKD, frailty was also associated with MAE and lower patient survival after FB-EVAR. The mFI-11 represents the accumulation of comorbidities and can be used to assist in better patient selection for FB-EVAR.

Physician-modified endografts are associated with a survival benefit over parallel grafting in thoracoabdominal aneurysms

OBJECTIVE

Physician-modified endografts (PMEG) and parallel grafting (PG) are important techniques for endovascular repair of complex aortic aneurysms using off-the-shelf devices. However, there is little data regarding the relative efficacy and outcomes of these techniques in thoracoabdominal extent aneurysms. This study sought to compare outcomes of PG and PMEG across different extents of thoracoabdominal aneurysms to which they can be employed.

METHODS

The SVS VQI TEVAR/Complex EVAR module was queried for all patients undergoing repair of an unruptured, thoracoabdominal aneurysm (TAAA, Extents I-IV) years 2012-2020; aneurysm types were defined by repair extent as determined by proximal and distal seal zones. Patients were differentiated based on whether they received repair with a physician-modified endograft (PMEG) or parallel grafting technique (PG). The primary outcomes for this study were overall survival and freedom from aneurysm/procedure-related mortality at 1-year determined via Kaplan-Meier analysis, with Cox hazard regression analysis conducted to examine the independent association of repair modality with primary outcomes.

RESULTS

813 patients met inclusion criteria (TAAA I-III 362, TAAA IV 451; 426 PG, 387 PMEG). PMEG repairs were performed at centers with a nearly 2-3-fold higher annual volume of endovascular TAAA repairs. Type Ia endoleaks were reduced with PMEG repair, most significantly in TAAA IV (TAAA I-III: 2.2% PMEG vs. 10% PG, p = 0.2; TAAA IV: 1.2% PMEG vs. 21.6% PG, p <0.001). Thoracoabdominal repairs demonstrated improved survival at 1-year with PMEG devices, significant for TAAA I-III repairs (TAAA I-III: PMEG 85% vs. PG 74%, p = 0.01; TAAA IV: 84% PMEG vs. PG 78%, p = 0.08). Freedom from aneurysm/procedure-related mortality was also improved with PMEG repairs, remaining significant at 1-year in the case of TAAA IV (TAAA I-III: PMEG 94% vs. PG 86%, p = 0.06; TAAA IV: PMEG 94% vs. PG 88%, p = 0.02). PMEG demonstrated reductions in several measures of post-operative morbidity, including stroke/death, MACE, and post-operative complications. In multivariate analysis, repair modality was not associated with either primary outcome, rather, several perioperative complications conveyed the greatest hazard for both primary outcomes across repair extents.

CONCLUSIONS

Survival after endovascular TAAA repair is improved with the use of PMEG compared to PG. Several key factors of this study demonstrate the shortcomings of parallel grafting in complex aneurysm repair, namely high rates of critical endoleaks, the need for adjunctive access sites, and an increase in perioperative complications that influence longer-term outcomes.

Impact of gap distance between fenestration and aortic wall on target artery instability following fenestrated-branched endovascular aortic repair

OBJECTIVE

Target artery (TA) instability is the most frequent indication for secondary intervention following fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to evaluate the impact of gap distance between the endograft reinforced fenestration and TA origin at the aortic wall (fenestration gap, FG) on target-related outcomes following FB-EVAR.

METHODS

Clinical data and imaging of 430 patients enrolled in a prospective, non-randomized study to evaluate FB-EVAR using manufactured stent-grafts were reviewed. Three hundred and forty patients (79%) had >1 vessel incorporated by fenestration. FG distance was retrospectively measured on postoperative imaging and classified into three groups: no gap (FG=0 mm), FG distance 1-4 mm, and FG≥5 mm. Primary outcome was freedom from TA instability. Secondary endpoints included TA-related endoleak, TA secondary intervention, and TA patency.

RESULTS

A total of 1558 renal-mesenteric TAs were incorporated by 1104 reinforced fenestrations and 454 directional branches (DBs), with a mean of 3.9±0.5 vessels per patient. Mean FG distance was 2.8±4.5mm with FG distance of 0mm for 646 TAs, 1-4mm for 209 TAs, and ≥5mm for 249 TAs. FG distance ≥5mm was associated with significantly lower (p<.001) freedom from TA instability, type IC/IIIC endoleak, and secondary interventions at 5-years. As compared to DBs, fenestrations with FG ≥5mm had similar primary patency and freedom from TA instability, but significantly lower freedom from type IC/IIIC endoleak (91±2 vs 95±1%, log rank=0.02) and secondary interventions (87±3% vs 93±2%, log rank=0.02) at 5-years. Independent predictors of TA instability included post-dissection TAAAs (HR 2.5; 95% CI 1.2-5.4) and FG distance ≥5mm (HR 1.6; 95% CI 1.2-1.8). TAs incorporated by reinforced fenestrations had higher primary (99±0.8% vs 97±1.0%, p=.039) and secondary patency rates (100% vs 98±1.0%, p=.012) at 5-years compared DBs, with the lowest primary patency observed for renal DBs (80±6% v 92±2% p=.008).

CONCLUSION

FG distance ≥5mm was independently associated with increased risk of TA instability, type IC/IIIC endoleaks, and secondary interventions in patients treated by FB-EVAR using fenestrated designs. Targets incorporated by DBs have lower 5-year primary and secondary patency as compared to those with reinforced fenestrations, with the lowest 5-year patency of 80% for renal branches. As compared to DBs, fenestrations with FG ≥5mm carried higher risk of type IC/IIIC endoleak and secondary interventions. Independent predictors of TA instability included post-dissection TAAAs and greater FG distance, whereas dual antiplatelet therapy and larger TA diameters were protective.

Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.

How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study

OBJECTIVE

There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort.

METHODS

This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes.

RESULTS

In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay.

CONCLUSION

In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.