Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology

Abstract

Objective: Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease.

Methods: A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change.

Results: Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5-31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ± 1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2-60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1-0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m(2).

Conclusions: F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients surviving the initial hospitalization for F/B-EVAR of acute aortic disease can anticipate good long-term survival.

Conflict of interest statement

Author conflict of interest: none.

Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Figures

Fig. 1

Example of a patient transferred from an outside hospital with a hemodynamically stable contained rupture of a thoracoabdominal aneurysm after a previous endovascular aneurysm repair (EVAR). A–C, Preoperative imaging of a ruptured Crawford extent III thoracoabdominal aortic aneurysm (TAAA) above a previous Medtronic Talent EVAR (A; red arrow). This patient had a chronically occluded celiac and left renal artery, necessitating a two-vessel fenestrated repair with inclusion of the superior mesenteric artery (SMA) and right renal artery (RRA). The contained rupture was adjacent to the left renal artery (B/C; yellow arrow), and the RRA was nearly occluded and appeared dissected at the origin (C; white arrow). D–F, The repair and postoperative three-dimensional reconstruction. D, The nearly occluded RRA, with successful revascularization through the graft fenestration (E). F, A 6-month postoperative computed tomography (CT) that demonstrated no endoleaks and continued perfusion of the RRA and SMA.

Fig. 2

Description of inpatient aortic referral volumes and annual elective, urgent, and emergent operative volumes for complex aortic disease at the University of Florida. A, The total number of inpatient aortic referrals that encompasses all potential patients with acute visceral aortic disease is depicted in this figure. Approximately 40% of cases were found to be nonurgent/emergent and subsequently managed in the outpatient setting. The remaining patients underwent open and/or endovascular operations involving the thoracic, thoracoabdominal, and abdominal aorta. B, The elective and ruptured pararenal and thoracoabdominal open and endovascular surgical volumes are highlighted in the graph. Notably, despite adoption of fenestrated/branched endovascular aortic repair (F/B-EVAR) for elective and acute visceral aortic disease in selected patients, no decrease in open operative volumes is noted, supporting the assertion that judicious application of the technology occurred during this time period. AAA, Abdominal aortic aneurysm. FEVAR, fenestrated endovascular aneurysm repair; OR, operating room; TAAA, thoracoabdominal aortic aneurysm.

Fig. 3

This Kaplan-Meier curve demonstrates the estimated midterm survival after urgent/emergent fenestrated/branched endovascular repair (F/B-EVAR). All reported intervals are less than 10% standard error of the mean. FEVAR, Fenestrated endovascular aneurysm repair.

Fig. 4

The freedom from reintervention after nonelective fenestrated/branched endovascular aortic repair (F/B-EVAR) is highlighted in the figure. Notably, six patients underwent remediation, and all were managed with endovascular techniques. All reported intervals are less than 10% standard error of the mean.

Fig. 5

There were 10 patients (27%) who survived initial hospitalization with an outpatient contrasted postoperative computed tomography (CT) scan during follow-up with evidence of endoleak. If patients were noted to have an intraoperative endoleak with graft implantation, this did not lead to higher likelihood of endoleak after hospitalization. Seventy percent of the posthospital discharge endoleaks were type II. The remaining endoleaks (type III; n = 3) all underwent successful endovascular remediation. All reported intervals are less than 10% standard error of the mean.

Fig. 6

The primary patency of all fenestrated/branched endografts in the series is displayed. Excellent 12-month patency is reported; however, one celiac fenestration was documented to have occluded at 12 months postoperatively. All reported intervals are less than 10% standard error of the mean.

Fig. 7

The overall trajectory of aortic diameter remodeling is demonstrated in this figure. Because repeated measures over time in the same patient are not independent, simple linear modeling is not appropriate. Mixed statistical models were applied to better understand the behavior of the aorta after nonelective fenestrated/branched endovascular aortic repair (F/B-EVAR). Notably, aortic diameter stabilization and/or regression were observed in the majority of patients with available postoperative imaging. CI, Confidence interval; FEVAR, fenestrated endovascular aneurysm repair.

Fig. 8

The posthospital discharged renal outcomes are significantly different for patients with pre-existing renal insufficiency. Specifically, patients with a preoperative estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 who survived initial hospitalization after urgent/emergent fenestrated/branched endovascular aortic repair (F/B-EVAR) had significantly worse renal function in short-term follow-up. These findings have significant implications on long-term survival, as well as surveillance and reintervention protocols. FEVAR, Fenestrated endovascular aneurysm repair; preop, preoperative.