Comparative outcomes of physician-modified fenestrated-branched endovascular repair of post-dissection and degenerative complex abdominal or thoracoabdominal aortic aneurysms

Contemporary Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair in the Endovascular Era

OBJECTIVES

Open thoracoabdominal aortic aneurysm (TAAA) repair has been associated with high morbidity and mortality prior to the endovascular era, when repair options were limited. Our institution developed a multidisciplinary protocol to standardize patient selection, operative technique and postoperative care to improve outcomes for open repairs. This study aimed to evaluate the protocol's preliminary benefits by comparing outcomes of open TAAA repair on vs off the protocol.

METHODS

A retrospective review of consecutive patients who underwent TAAA repair at a single institution from 2013-2023 was completed. Patients who underwent open repair were included and stratified by use of the protocol. The primary outcome was a composite of thoracoabdominal aortic aneurysm life-altering events (TALE) including in-hospital mortality, spinal cord ischemia with paraplegia, new onset of dialysis, or stroke. Secondary outcomes included each individual component, length of stay, and non-home discharge.

RESULTS

220 patients underwent TAAA repair at our institution during the study period - 190 endovascular and 30 open. There were 14 in the protocol group and 16 in the non-protocol group. Patient demographics were similar between groups with an overall mean age of 46-years-old. A connective tissue disorder was present in 64% and 50% (P=0.431) of protocol and non-protocol patients, respectively. The majority of the patients in both groups presented with extent II TAAA (64% vs 75%). The composite endpoint occurred in 0% of the protocol group vs 38% of the non-protocol group (P=0.010). Secondary outcomes were dialysis (0% vs 19%, P=0.23), paraplegia (0% vs 19%, P=0.232), stroke (0% vs 0%), in-hospital mortality (0% vs 13%, P=0.171), and non-home discharge (7% vs 50%, P=0.012). Median postoperative length of stay was 8 vs 15 days (P=0.038).

CONCLUSION

In the endovascular era, open TAAA repair can be performed with encouraging outcomes when particular attention is given to patient selection, surgical technique and postoperative care, with rates of mortality, paraplegia, renal failure, and length of stay that rival endovascular repair.

The Current State of Physician-Modified Endovascular Grafts in Complex Abdominal Aortic Aneurysms

Physician-modified endografts (PMEGs) for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms are a viable option. Other endovascular options include custom and off-the-shelf devices for fenestrated and branched endovascular aortic repair, parallel grafts, and in situ laser fenestration. The limitations of these devices include time to development, strict anatomic criteria, and durability regarding parallel grafts. PMEGs fill this void with perioperative and long-term outcomes similar to custom-made devices. Postdissection aneurysms also present a unique role for PMEGs given the added complexity with fixing these aneurysms and have been reported with good outcomes. Lastly, we discuss the approach to preoperative planning and the operative component of PMEGs in this brief review.

Three-year outcomes of off-the-shelf Gore thoracoabdominal multibranch endoprosthesis and physician-modified endografts for complex abdominal and thoracoabdominal aortic aneurysms

OBJECTIVE

Fenestrated-branched endovascular aortic repair (FB-EVAR) has shown favorable outcomes for repair of complex aneurysms and thoracoabdominal aortic aneurysms. Physician-modified endografting (PMEG) and the Gore thoracoabdominal multibranch endoprosthesis (TAMBE) provide custom and off-the-shelf devices for FB-EVAR, respectively. This study compares the outcomes of TAMBE and PMEG at a single institution.

METHODS

A retrospective review of patients who underwent TAMBE as part of the multicenter pivotal trial or PMEG as part of a prospective physician-sponsored investigational device exemption at a single institution between 2020 and 2022 were completed. Patient demographics, characteristics, and perioperative and midterm outcomes were compared.

RESULTS

A total of 68 patients were included, with 12 in the TAMBE group and 56 in the PMEG group. Baseline characteristics were comparable between groups. Aneurysm type was most often thoracoabdominal aortic aneurysm in both groups (58% TAMBE and 52% PMEG). TAMBE had a higher rate of upper extremity access (100% vs 63%; P = .013) and longer mean procedure time (247 ± 36 minutes vs 189 ± 49 minutes; P < .001). Other intraoperative metrics were similar between groups. Technical success was 100% in TAMBE and 95% in PMEG (P = .412). There was no 30-day mortality in either group. No major adverse events occurred with TAMBE, whereas in PMEG cases, 2% had respiratory failure, 2% required dialysis, and 4% experienced spinal cord ischemia. Although the overall endoleak rates were similar (50% of TAMBE vs 41% of PMEG; P = .57), type II endoleaks accounted for all of the endoleaks in the TAMBE group, whereas type I or III endoleaks were seen in 11% of PMEG patients. At a median follow-up of 26.7 months for the TAMBE group and 21.2 months for the PMEG group, target vessel instability was seen in 10.4% of TAMBE, and 6.9% of PMEG targeted branches (P = .401). Reintervention was required in 33% of TAMBE patients and 27% of PMEG patients (P = .646). Estimated freedom from reintervention rates at 3 years were similar (56% TAMBE vs 62% PMEG, log-rank P = .910). Freedom from visceral renal target vessel instability at 3 years was 89% for both groups (log-rank P = .459). The Kaplan-Meier 3-year estimated survival was 100% for patients in the TAMBE group and 77% for patients in the PMEG group (log-rank P = .157).

CONCLUSIONS

At experienced centers, FB-EVAR can be completed with PMEG or TAMBE with comparable, excellent perioperative and midterm outcomes. Reinterventions are frequently needed for both TAMBE and PMEG.

Modified deployment technique of off-the-shelf Gore thoracoabdominal multibranch endoprosthesis for post-dissection thoracoabdominal aortic aneurysm repair

The Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is a commercially available off-the-shelf four-vessel inner branched endograft for complex abdominal and thoracoabdominal aortic aneurysms. As post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) were excluded from the pivotal trials, there is paucity of data on the use of TAMBE in PD-TAAAs. Here, we present a case demonstrating the feasibility of TAMBE in conjunction with iliac branch endoprosthesis to repair PD-TAAAs, with focus on the deployment technique specific to PD-TAAAs.

The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases

INTRODUCTION

Physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for the aortic arch provides a minimally invasive treatment option for patients who are too high-risk for open repair. Improvements in technique are gained with ongoing experience with these complex repairs. This study aims to describe outcomes of arch PM-FBEVAR and technical lessons.

MATERIALS AND METHODS

A retrospective review of consecutive patients who underwent PM-FBEVAR with zone 0 proximal sealing at a single institution between January 2019 and July 2023 was performed. Cases completed using initial techniques (early technique) were compared with cases using the current techniques (current technique). Modification technique changed to include a self-orienting spine trigger wire and anatomically specific fenestrations or inner branches in the current group. The primary outcome was in-hospital mortality. Secondary outcomes included technical success and 30 day stroke.

RESULTS

A total of 21 patients underwent arch PM-FBEVAR, with 7 in the early group and 14 in the current group. Severe comorbidities were present in both groups including chronic obstructive pulmonary disease (COPD) (43% vs 36%), prior open ascending aortic repair (57% vs 43%), and prior stroke (86% vs 21%), respectively. Technical success was the same (86% vs 86%, p=1.0). Fluoroscopy time (56 vs 24 min, p=0.012) and in-hospital death (43% vs 0%, p=0.026) were significantly lower in the current group. A 30 day stroke rate (29% vs 7%, p=0.247) was non-significantly decreased in the current group. All-cause mortality was 100% vs 7% during median follow-up of 8 and 6 months (p<0.001). Three deaths in the early group were related to their aortic arch repair including aortic rupture during endograft advancement and 2 postoperative strokes.

CONCLUSION

There is a significant learning curve associated with aortic arch PM-FBEVAR. This study suggests that gained experience, use of the spine trigger wire technique, and precise creation of fenestrations or inner branches can lead to a shorter procedure time and lower complications.

CLINICAL IMPACT

Physician modified fenestrated branched endografting is feasible for the aortic arch. The high rate of stroke and perioperative mortality was reduced with incorporation of self-orienting spine trigger wire and anatomically specific inner branch creation.

A Systematic Review and an Updated Meta-Analysis of Fenestrated/Branched Endovascular Aortic Repair of Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms

The objective of this study is to present the current outcomes of fenestrated/branched endovascular repair (F/BEVAR) for post-dissection thoracoabdominal aortic aneurysms (PDTAAAs). A systematic review of the literature according to PRISMA guidelines up to October 2023 was conducted (protocol CRD42023473403). Studies were included if ≥10 patients were reported and at least one of the major outcomes was stated. A total of 10 studies with 585 patients overall were included. The pooled estimate for technical success was 94.3% (95% CI 91.4% to 96.2%). Permanent paraplegia developed with a pooled rate of 2.5% (95% CI 1.5% to 4.3%), whereas a cerebrovascular event developed with a pooled rate of 1.6% (95% CI 0.8% to 3.0%). An acute renal function impairment requiring new-onset dialysis occurred with a pooled rate of 2.0% (95% CI 1.0% to 3.8%). Postoperative respiratory failure was observed with a pooled estimate of 5.5% (95% CI 3.8% to 8.1%). The pooled estimate for 12-month overall survival was 90% (95% CI 85% to 93.5%), and the pooled estimates for 24-month and 36-month survival were 87.8% (95% CI 80.9% to 92.5%) and 85.5% (95% CI 76.5% to 91.5%), respectively. Freedom from reintervention was estimated at 83.9% (95% CI 75.9% to 89.6%) for 12 months, 82.8% (95% CI 68.7% to 91.4%) for 24 months and 76.1% (95% CI 60.6% to 86.8%) for 36 months. According to the present findings, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results.