Intraoperative adverse events and early outcomes of custom-made fenestrated stent grafts and physician-modified stent grafts for complex aortic aneurysms

Jean Nicolas Sénémaud, Iannis Ben Abdallah, Paul de Boissieu, Joseph Touma, Hicham Kobeiter, Pascal Desgranges, Jean-Pierre Becquemin, Frédéric Cochennec, Jean Nicolas Sénémaud, Iannis Ben Abdallah, Paul de Boissieu, Joseph Touma, Hicham Kobeiter, Pascal Desgranges, Jean-Pierre Becquemin, Frédéric Cochennec

Abstract

Objective: Physician-modified fenestrated stent grafts (PMSGs) are a useful option for urgent or semiurgent treatment of complex abdominal aortic aneurysms (CAAAs). The aim of this study was to describe in-hospital outcomes of custom-made fenestrated stent grafts (CMSGs) and PMSGs for the treatment of CAAAs and thoracoabdominal aortic aneurysms (TAAAs).

Methods: In this single-center, retrospective study, all consecutives patients with CAAAs or TAAAs undergoing endovascular repair using Zenith CMSGs (Cook Medical, Bloomington, Ind) or PMSGs between January 2012 and November 2017 were included. End points were intraoperative adverse events, in-hospital mortality, postoperative complications, reinterventions, target vessel patency, and endoleaks.

Results: Ninety-seven patients were included (CMSGs, n = 69; PMSGs, n = 28). The PMSG group included more patients assigned to American Society of Anesthesiologists class 4 (n = 14 [50%] vs n = 16 [23%]; P = .006) and more TAAAs (n = 17 [61%] vs n = 10 [15%]; P < .0001). Intraoperative adverse events were recorded in eight (11%) patients in the CMSG group vs six (21%) patients in the PMSG group. No intraoperative death or open conversion occurred. In-hospital mortality rates were of 4% (n = 3) in the CMSG group and 14% in the PMSG group (n = 4). Chronic renal failure was an independent preoperative risk factor of postoperative death or complications (odds ratio, 4.88; 95% confidence interval, 1.65-14.43; P = .004). Rates of postoperative complications were 22% (n = 15) and 25% (n = 7) in the CMSG and PMSG groups. Spinal cord ischemia rates were 4% (n = 3) and 7% (n = 2) in the CMSG and PMSG groups. Reintervention rates were 16% (n = 11) in the CMSG group and 32% (n = 9) in the PMSG group. At discharge, target vessel patency rate in CMSGs was 98% (n = 207/210). All target vessels (n = 98) were patent in the PMSG group. Endoleaks at discharge were observed in 24% of the CMSG group (n = 16) vs 8% of the PMSG group (n = 2).

Conclusions: Our study showed clinically relevant differences of several important in-hospital outcomes in the CMSG and PMSG groups. Larger cohorts and longer follow-up are needed to allow direct comparison. PMSGs may offer acceptable in-hospital results in patients requiring urgent interventions when CMSGs are not available or possible.

Keywords: Complex abdominal aortic aneurysm; Custom-made stent graft; Early results; Physician-modified stent graft; Thoracoabdominal aortic aneurysm.

Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Figures

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Fig
A-C, Computed tomography (CT) angiography scan performed 8 days after cervical debranching and thoracic stent grafting for an intramural hematoma with persisting thoracic pain despite medical therapy. Postoperatively, the patient presented with persisting thoracic and abdominal pain. Three-dimensional reconstructions and axial view showed new onset of ulcer-like projections that we decided to treat with a four-fenestration physician-modified stent graft (PMSG). D-F, CT angiography scan performed after PMSG implantation showed satisfactory exclusion of the aortic disease and target vessel patency.

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