Society For Clinical Vascular Surgery

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Impact of Secondary Interventions on Mortality after Fenestrated Branched Endovascular Aortic Aneurysm Repair
Kristina A. Giles, MD1, Salvatore T. Scali, MD1, Thomas S. Huber, MD,MPH1, Scott A. Berceli, MD,MPH1, Javairiah Fatima, MD1, Adam W. Beck, MD2.

Objectives: Fenestrated and branched endovascular aortic repair(F/BEVAR) is increasingly used to manage pararenal and thoracoabdominal aortic disease(TAAA). Device related re-intervention after F/BEVAR is common, but little is known about the impact on post-operative mortality. The purpose of this analysis was to describe aortic and branch-vessel related re-intervention and determine the impact on patient survival.
Methods: A single center review was performed of all consecutive F/BEVARs performed from 2010-16. Primary end-points were incidence of secondary aortic or branch related re-intervention and survival. Re-interventions were categorized as minor endovascular(branch re-stenting, access vessel treatment, or percutaneous coil embolization), major endovascular(new aortic graft placement), or open surgical repair. Multivariable analysis was used to identify predictors of re-intervention.
Results: There were 308 F/BEVAR procedures performed[75%-physician modified;18%-custom;7%-Zfen], with 1022 vessels revascularized[celiac- 228;sma-263;renal-525]. There were 115(38%) Extent I-III TAAA, 130(43%) Extent IV TAAA/4-vessel pararenal, and 54(18%) <4-vessel pararenal repairs performed. Re-interventions occurred in 21%(65) of patients over a mean follow-up of 1516months. The majority of re-interventions were endovascular[minor-54%(35); major-29%(19)], while 14%(9) were open and 3%(2) hybrid. Indications included: 19(29%) branch-related endoleaks(1c or III), 13(20%)aortic device Type III endoleak/loss of overlap, 10(15%)proximal or distal aortic degeneration, 6(9%)branch thrombosis, 5(8%) acute postoperative event(bleeding or thrombosis), 3(5%)Type II endoleak, 2(3%)graft infection, and 7(11%) other. A majority of the re-interventions were elective(61%;n=39) with the remainder occurring for emergent(28%;n=18) or for symptoms/urgent indications(11%;n=7). Compared to endovascular remediation, open re-interventions were more likely to be emergent(66%-6 of 9;p=.039). Freedom from re-intervention was 823% and 625% at 1 and 3 years, respectively. One and 5-year survival with or without re-intervention was:1-year-832% vs. 855%; 5-year-704% vs. 707%(log-rank p=.75). There was no survival difference based upon method of re-intervention, even when including additional, non-aortic related procedures such as exploratory laparotomy for bowel ischemia(Figure). Extent I-III TAAA (HR 1.5;95%CI 1.1-2.2;p=.02) and number of branches(HR 1.3-per branch;95%CI 1.2-2.7;p=.037) revascularized were predictive of re-intervention.
Conclusions: Re-interventions after F/BEVAR are common, most frequently involving branch vessel or aortic device remediation, but do not impact survival. Close monitoring and well planned secondary interventions are important to ensure overall durability of the repair.

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