Outcomes following fenestrated/branched endovascular aortic repair for failed open infrarenal aortic repair compared with primary fenestrated/branched endovascular aortic repair

Abstract

Objective

Because aneurysmal disease is progressive, proximal disease progression and para-anastomotic aneurysms are complications experienced after open infrarenal abdominal aortic aneurysm (AAA) repair. As such, fenestrated or branched endovascular repair (F/BEVAR) may be indicated in these patients. Data describing fenestrated endovascular aneurysm repair after prior open surgical repair (OSR) are limited to institutional databases. The aim of our study is to describe the safety and efficacy of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in patients with prior OSR compared with primary F/BEVAR using the Vascular Quality Initiative.

Methods

Using the VQI complex endovascular AAA module from 2014 to 2022, we identified all single-staged F/BEVAR repair in patients having prior OSR or no prior aortic surgery (primary F/BEVAR). The primary outcomes were perioperative mortality and completion endoleaks. Secondary outcomes were 5-year survival and 1-year sac dynamics. Between the two cohorts, differences in the primary and secondary outcomes were evaluated using Wilcoxon rank-sum tests for continuous variables and χ² analysis for categorical variables. Kaplan-Meier methods and Cox regression were used to examine 5-year mortality.

Results

We identified 3331 primary F/BEVAR patients and 102 prior OSR patients. Patients with prior OSR were more likely to have peripheral arterial disease (22.0% vs 7.4%), prior smoking (67% vs 56%), and undergo F/BEVAR with medium-/high-volume physicians (74% vs 62%), but less likely to be female (8.8% vs 23.0%) (all P < .05). Patients with prior OSR were also more likely to have a more proximal aneurysm extent (median zone 7 [interquartile range (IQR), zones 6-8] vs zone 8 [IQR, zones 7-8]), larger AAA diameters (62 mm [IQR, 56-66 mm] vs 58 mm [IQR, 55-63 mm]), receive a physician-modified endograft (PMEG) vs commercial custom-made device (36% vs 20% physician-modified endograft), have longer surgery times (240 minutes [IQR, 186-308 minutes] vs 206 minutes [IQR, 155-272 minutes]), and have a higher rate of celiac artery (51% vs 26%) and superior mesenteric artery (86% v 73%) artery involvement (all P < .05). Patients with prior OSR had lower rates of completion endoleaks (25% vs 36%), driven by lower rates of type II leaks (11% vs 20%) despite higher rates of indeterminate leaks (11% vs 5.1%) (all P < .01). There was, however, no difference in perioperative mortality (2% vs 2.9%; P = .78). They had similar 1-year sac dynamics (48% vs 50% regression; 12% vs 8% expansion; P > .5) and 5-year mortality (23% vs 18%; hazard ratio [HR], 1.44 [IQR, 0.89-2.31]; P = .13).

Conclusions

Based on VQI data, F/BEVAR after prior OSR seems to be well-tolerated and safe. Prior OSR patients also had lower rates of completion type II endoleaks and similar sac dynamics and 5-year mortality compared with primary F/BEVAR patients.