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National Use of Chimney and Fenestrated EVAR for the Endovascular Repair of Complex Abdominal Aortic Aneurysms
Sarah E. Deery, MD, MPH1, Thomas F.X. O'Donnell, MD1, Laura T. Boitano, MD1, Robert T. Lancaster, MD, MPH1, Salvatore T. Scali, MD2, Adam W. Beck, MD3, Marc L. Schermerhorn, MD4, Virendra I. Patel, MD, MPH1.
1Massachusetts General Hospital, Boston, MA, USA, 2University of Florida, Gainesville, FL, USA, 3University of Alabama Birmingham, Birmingham, AL, USA, 4Beth Israel Deaconess Medical Center, Boston, MA, USA.

OBJECTIVES: Currently, there are few studies that compare outcomes of chimney (c-EVAR) and fenestrated endovascular aneurysm repair (FEVAR) of complex abdominal aortic aneurysms. The purpose of this analysis was to evaluate the utilization and postoperative outcomes following c-EVAR and FEVAR within a national registry.
METHODS: We identified all c-EVAR and FEVAR for intact, complex (supravisceral, suprarenal, or juxtarenal) abdominal aortic aneurysms from 2012-2016 in the VQI. Surgeon volume accounted for their prior year of c-EVAR or FEVAR volume, but separate hospital and surgeon volume measures accounted for all c-EVAR, FEVAR, TEVAR, and EVAR volume.
RESULTS: A total of 487 patients underwent complex EVAR, of whom 88% (n=427) received FEVAR and 12% (n=60) c-EVAR. Preoperative demographics and comorbidities were similar, although c-EVAR patients more often had a history of AAA repair (17% vs. 6.9%, P = .02). Surgeons performing FEVAR had higher annual case volume (median FEVAR: 5/year, IQR: 2-11) compared to surgeons performing c-EVAR (median cEVAR: 1/year, IQR: 1-2; P < .01). Only 102 surgeons performed FEVAR, with 10 surgeons performing >50% of cases; 38 surgeons performed c-EVAR, with only 14 surgeons performing >1 case/year. Only 21 of 119 surgeons performed both procedures, of whom only five performed >1 case/year of each. Patients undergoing c-EVAR had larger aneurysms (61 vs. 58 mm, P = .07) that were more often symptomatic (23% vs. 6.4%, P < .001) and repaired non-electively (18% vs. 3.8%, P < .001). FEVAR patients had more branch vessels revascularized (mean 2.6 vs. 1.9, P < .001), suggesting more complex aneurysms. Procedure time, fluoroscopy time, and blood loss were similar; however, c-EVAR patients more frequently received intraoperative transfusion (43% vs. 20%, P < .001). There was no difference in 30-day mortality on unadjusted (c-EVAR: 3.3%, FEVAR: 2.9%, P = .69) or adjusted analyses (c-FEVAR OR 1.2, 95% CI: 0.2-7.0). Similarly, no significant differences in major complications including colitis, acute kidney injury, or in-hospital reintervention were observed. One-year survival was similar between groups (c-EVAR: 93%, FEVAR: 91%, log-rank P = .61).
CONCLUSIONS: While c-EVAR tends to be performed more frequently by lower-volume surgeons in more urgent settings, perioperative outcomes following chimney and fenestrated EVAR are comparable. Further analyses are warranted to understand late outcomes, especially reintervention and rupture, following chimney and fenestrated EVAR.


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