Outcomes Following Fenestrated/Branched Endovascular Aortic Repair for Failed Open Infrarenal Aortic Repair Compared with Primary Fenestrated/Branched Endovascular Aortic Repair.

Abstract

Objective: As aneurysmal disease is progressive, proximal disease progression and para-anastomotic aneurysms are complications experienced after open infrarenal abdominal aortic aneurysm repair (AAA). As such, fenestrated or branched endovascular repair (F/BEVAR) may be indicated in these patients. Data describing fenestrated endovascular aneurysm repair after prior open repair 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 open repair (OSR) compared with primary F/BEVAR using the Vascular Quality Initiative.

Methods: Using the VQI complex endovascular AAA module from 2014-2022, 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 one-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 Chi-squared analysis for categorical variables. Kaplan-Meier methods and Cox-regression were used to examine 5-year mortality.

Results: We identified 3,331 primary F/BEVAR patients and 102 prior OSR patients. Patients with prior OSR were more likely to have peripheral arterial disease (22% vs. 7.4%), prior smoking (67% vs 56%), undergo F/BEVAR with medium/high volume physicians (74% vs 62%), but less likely to be female (8.8% vs 23%) (all p<0.05). Patients with prior OSR were also more likely to have a more proximal aneurysm extent (median zone 7[6-8] vs. 8[7-8]), larger AAA diameters (62[56-66] mm vs 58[55-63] mm), receive a physician modified endograft (PMEG) vs commercial custom-made device (CCMD) (36% vs 20% PMEG), have longer surgery times (240[186-308] min vs. 206[155-272] min), and have a higher rate of celiac (51% vs 26%) and SMA (86% v 73%) artery involvement (all p < 0.05). 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<0.01). There was, however, no difference in perioperative mortality (2% vs. 2.9%; p = 0.78). They had similar one-year sac dynamics (48% vs. 50% regression; 12% vs 8% expansion, p>0.5) and 5-year mortality (23% vs 18%, HR: 1.44[0.89-2.31]; p=0.13).

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