Abstract
OBJECTIVE
Secondary interventions are common following endovascular repair of aortic aneurysms. However, the frequency and procedural details of secondary intervention following fenestrated and branched repairs (F/BEVAR) have been less well described, and the impact on long-term survival and aneurysm-related mortality is unknown.
METHODS
Consecutive patients enrolled as part of a multicenter research consortium in nine independent physician-sponsored investigational device exemption studies from 2005-2020 were evaluated. All secondary interventions performed after the initial procedure were classified as open or percutaneous and as major or minor, as per SVS reporting standards. Secondary interventions were further classified as high or low magnitude according to the physiologic impact of the intervention. Demographics, procedural details, and perioperative outcomes were compared for those who underwent secondary interventions and those who did not. Kaplan-Meier and Cox Proportional Hazard Ratio analysis were utilized to evaluate long-term survival.
RESULTS
Of 1681 patients who underwent F/BEVAR, 385 (23%) underwent secondary intervention at any point in follow-up. Freedom from reintervention was 82% at 1-year and 59% at 5-year follow up. Mean follow-up was 23 months. The majority of secondary interventions were percutaneous (84%), minor (70%), and low magnitude (81%). Renal stenting (30%) and access related procedures (24%) were the most frequent percutaneous and open procedures, respectively. High magnitude operations were performed in 19% of patients. Technical success was achieved for 94% of secondary interventions and mortality from secondary intervention was less than 1%. Secondary interventions as a whole were associated with improved long-term survival (Hazard Ratio: 0.6 95% Confidence Interval: 0.5-0.7). In subgroup analysis, major (HR: 0.6, 95% CI 0.4-0.8), minor (HR: 0.6, 95% CI: 0.5-0.8), low magnitude (HR 0.5, 95% CI: 0.4-0.7), and percutaneous (HR: 0.6, 95% CI: 0.5-0.7) secondary interventions were associated with improved survival; however high magnitude (HR: 1.0, 95% CI: 0.7-1.5) and open secondary interventions (HR: 1.0, 95% CI: 0.7-1.5) were not. Similarly, when aneurysm-related survival was specifically assessed, low magnitude secondary interventions were found to improve survival (HR: 0.3, 95% CI: 0.1-0.7), while high magnitude secondary interventions (HR: 2.8, 95% CI: 1.4-5.8) and open secondary interventions (HR: 2.7, 95% CI: 1.3-5.5) were associated with increased mortality.
CONCLUSIONS
Secondary interventions after F/BEVAR are frequent and are typically percutaneous, minor, and low magnitude procedures. While uncommon, high magnitude and open secondary interventions are associated with decreased long-term survival and increased aneurysm-related mortality. These data highlight the importance of close, life-long surveillance, and suggest that a significant rate of secondary intervention should be anticipated, but these do not negatively impact survival.
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