1
|
Sulzer TAL, de Bruin JL, Rastogi V, Boer GJ, Mesnard T, Fioole B, Rijn MJV, Schermerhorn ML, Oderich GS, Verhagen HJM. Midterm Outcomes and Aneurysm Sac Dynamics Following Fenestrated Endovascular Aneurysm Repair after Previous Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:886-893. [PMID: 38301871 DOI: 10.1016/j.ejvs.2024.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is 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 a treatment for failed EVAR. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine midterm outcomes and aneurysm sac dynamics of FEVAR after prior EVAR. METHODS 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 rate, 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. RESULTS One hundred and ninety-six patients with FEVAR were identified, of whom 27% (n = 53) had 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 rate. FEVAR after EVAR was associated with a 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). CONCLUSION There were high rates of sac expansion and a need for more secondary procedures in FEVAR after EVAR than primary FEVAR patients, although this did not affect midterm 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.
Collapse
Affiliation(s)
- Titia A L Sulzer
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Thomas Mesnard
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Gustavo S Oderich
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
2
|
Karelis A, Dias NV. Navigating the Twist and Turn: Deciphering Misalignment in FEVAR. Eur J Vasc Endovasc Surg 2024; 67:775-776. [PMID: 37952632 DOI: 10.1016/j.ejvs.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Angelos Karelis
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Sweden.
| | - Nuno V Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Sweden
| |
Collapse
|
3
|
Koleilat I, Dalmia V, Batarseh P, Rai A, Carnevale M, Phair J, Indes J. Large-Diameter Fenestrated Endograft Repair of Abdominal Aortic Aneurysms Is Not Associated With Medium-Term Outcomes. J Surg Res 2024; 296:516-522. [PMID: 38330677 DOI: 10.1016/j.jss.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Recent data suggests that infrarenal abdominal aortic aneurysm (AAA) endovascular repair (EVAR) with large diameter grafts (LGs) may have a higher risk of endoleak and reintervention. However, this has not been studied extensively for fenestrated endovascular aneurysm repair (fEVAR). We, therefore, sought to evaluate the outcomes of patients undergoing fEVAR with large-diameter endografts. METHODS Patients from the national Vascular Quality Initiative registry who underwent fEVAR for intact juxtarenal AAA were identified. Patients with genetic causes for aneurysms, those with prior aortic surgery, and those undergoing repair for symptomatic or ruptured aneurysms were excluded. Rates of endoleaks and reintervention at periprocedural and long-term follow-up timepoints (9-22 mo) were analyzed in grafts 32 mm or larger (LG) and were compared to those smaller than 32 mm (small diameter graft). RESULTS A total of 693 patients (22.8% LG) were identified. Overall, demographic variables were comparable except LG exhibited a more frequent history of coronary artery disease (32.9% versus 25.4%, P = 0.037). There were no significant differences in the rates of endoleak at procedural completion. Overall survival at 5 y was no different. The rate of reintervention at 1 y was also no different (log-rank P = 0.86). CONCLUSIONS While graft size appears to have an association with outcomes in infrarenal aneurysm repair, the same does not appear to be true for fEVAR. Further studies should evaluate the long-term outcomes associated with LG which could alter the approach to repair of AAA with large neck diameters traditionally treated with standard infrarenal EVAR.
Collapse
Affiliation(s)
- Issam Koleilat
- Department of Surgery, Community Medical Center, RWJ/Barnabas Health, Toms River, New Jersey.
| | - Varun Dalmia
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Paola Batarseh
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anvit Rai
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Matthew Carnevale
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - John Phair
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeff Indes
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
4
|
Haulon S, Steinmetz E, Feugier P, Magnan PE, Maurel B, Fabre D, Geng B, Doyle M, Twesigye I, Sobocinski J. Two-Year Results on Real-World Fenestrated or Branched Endovascular Repair for Complex Aortic Abdominal Aneurysm in France. J Endovasc Ther 2023:15266028231208653. [PMID: 37902436 DOI: 10.1177/15266028231208653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
PURPOSE To describe and compare mid-term outcomes from 2 real-world data collection efforts on fenestrated and branched endovascular aortic repair (fbEVAR) for complex abdominal aortic aneurysms (AAAs) in France and to evaluate the potential of health care databases for long-term post-market surveillance (PMS) and continued reimbursement approval. METHODS Two real-world studies were conducted in France: a retrospective health care database study (SNDS) and a prospective clinical study. In the SNDS study, data from implantation and/or hospital stays occurring during follow-up were extracted for all patients treated with the study devices from April 2012 to December 2018. In the clinical study, high-risk patients undergoing fbEVAR with the study devices were enrolled consecutively at 15 sites in France from December 2016 to November 2018. RESULTS Data from 1073 patients were extracted from SNDS and compared with analogous variables from 186 patients in the clinical study. Most demographic details were similar between studies (SNDS vs clinical: mean age, 71.9 vs 71.8 years; men, 91.0% vs 89.8%), as was 30-day mortality (SNDS: 5.5%, clinical: 4.3%). Patients received custom-made fenestrated or branched devices (SNDS: 80.7%, clinical: 96.2%) or CE-marked Zenith Fenestrated devices (SNDS: 19.3%, clinical: 3.8%). Initial or technical success was above 94% for both studies. Two-year freedom from all-cause mortality was 80.0% (SNDS) and 85.1% (clinical study). Two-year freedom from aneurysm-related mortality was 93.8% (SNDS) and 94.6% (clinical study). Detailed imaging outcomes were not captured within SNDS; however, information on secondary procedures to restore patency was available and used as a surrogate measure for secondary interventions. Two-year freedom from secondary interventions was 73% for the SNDS study. In the clinical study, at 2 years, aneurysm stability or shrinkage was observed in 92.3% of patients, freedom from target vessel primary patency loss was above 95% for all visceral target vessels, and freedom from secondary interventions was 79.1%. CONCLUSION Real-world outcomes from the SNDS and clinical study suggest positive mid-term outcomes in high-risk populations following fbEVAR for complex AAAs. The similarities between these studies suggest that the use of health care databases may be an alternative to prospective clinical studies for long-term follow-up and PMS. CLINICAL IMPACT Positive results following endovascular repair of complex abdominal aortic aneurysms are observed from data extracted from both the French health care database and a post-market clinical study despite initial high-risk patient status and diverse center experience. These outcomes parallel more rigorously designed studies and suggest that with careful study design, real-world data collections have high translatable value to add to the clinical understanding of fenestrated and branched endovascular aortic repair (fbEVAR).
Collapse
Affiliation(s)
- Stéphan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | | | | | | | | | - Dominique Fabre
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Bo Geng
- Cook Research Incorporated, West Lafayette, IN, USA
| | | | | | | |
Collapse
|
5
|
Rastogi V, Marcaccio CL, Kim NH, Patel PB, Anjorin AC, Zettervall SL, Patel VI, de Bruin JL, Verhagen HJM, Schermerhorn ML. The effect of supraceliac versus infraceliac landing zone on outcomes following fenestrated endovascular repair of juxta-/pararenal aortic aneurysms. J Vasc Surg 2023; 77:9-19.e2. [PMID: 35981657 PMCID: PMC9789162 DOI: 10.1016/j.jvs.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicole H Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aderike C Anjorin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|