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Society For Clinical Vascular Surgery

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Use of the Zenith Fenestrated Graft for Complications Associated with Prior Endovascular or Open Repair Presents a Safe and Technically Feasible Approach in a Challenging Patient Population
S. Keisin Wang, MD, Ashley R. Gutwein, MD, Alok K. Gupta, MD, Gary W. Lemmon, MD, Michael C. Dalsing, MD, Raghu L. Motaganahalli, MD, Michael P. Murphy, MD, Andres Fajardo, MD.
Indiana University School of Medicine, Indianapolis, IN, USA.

Objective: For short-neck infrarenal and juxtarenal aneurysms, endovascular repair was not historically an option secondary to an inability to form a proximal seal. However, implantation of a fenestrated device (FEVAR) allows for extension into a healthy landing zone without encroaching on visceral arteries. The goal of this review was to determine our outcomes using the Zenith Fenestrated (ZFEN, Cook Medical) stent in reoperative and first-time aortas. Methods: A retrospective review of a prospectively maintained institutional database capturing all FEVARs with the ZFEN platform was performed. Procedures were classified as being a primary repair, reoperation in the setting of previous EVAR, or previous open surgical repair (OSR). Results: Between 2012 and 2017, 103 patients with inadequate proximal sealing zones for traditional EVAR received a ZFEN at our institution. Twelve patients were treated as a reoperation after previous EVAR (n=6) or OSR (n=6). The indications for reoperation were proximal disease progression (n=7) and type IA endoleak (n=5). Technical success was 97.8% and 100% in the primary and reoperative FEVARs, respectively (p=1.00). There was no difference in EBL (363 mL vs 500 mL, p=0.25) and contrast volume (97.3 mL vs 104.0 mL, p=0.55). However, we observed a disparity in fluoroscopy time (61.1 mins vs 79.8 mins, p=0.04), radiation dose (415.9 vs 606.3 RADs, p=0.02), and operative time (228.4 mins vs 287.6 mins, p=0.03). In the 30-day perioperative period, variations in mortality (2.2% vs 0%), major adverse cardiovascular events (5.5% vs 0%), and stent related complications (2.2% vs 0%) were not statistically significant. There were no differences in perioperative (5.5% vs 0%, p=1.0) or late reintervention (18.6% vs 25.0%, p=0.70) after average follow-up of 1.73 years. Conclusions: Treatment of disease progression after previous EVAR or OSR with a fenestrated graft is not associated with increased morbidity or mortality as compared to de novo repair of juxtarenal aortic aneurysms. These results provide practice guidelines for type I endoleaks or aortic dilatation after EVAR or OSR.

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