Finding Favor with Fenestration for Complex Aortic Repair
James C. Iannuzzi, MD. MPH., Laura T. Boitano, MD, Michol A. Cooper, MD PhD, Jahan Mohebali, MD. MPH, W. Darrin Clouse, MD, Mark F. Conrad, MD MSSc, Virendra I. Patel, MD. MPH., R. Todd Lancaster, MD. MPH..
Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVES: Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:8.0pt; mso-para-margin-left:0in; line-height:107%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri",sans-serif; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} Fenestrated aortic repair(FEVAR) has shifted the aortic repair; however, it remains unclear how this technically challenging procedure performs in comparison to other approaches including complicated endovascular aortic repair with adjuncts(CEVAR) and open aortic repair(OAR). This study evaluated 30-day outcomes following aortic repair for FEVAR compared to CEVAR and OAR.
METHODS: The National Surgical Quality Improvement Program Vascular Procedure Targeted Database was evaluated for elective aortic repair using FEVAR as defined by prefabricated fenestrated main body device use, CEVAR (defined by extension, renal, or visceral stenting) and juxtarenal to proximal OAR. Analysis was stratified by proximal aneurysm extent. 30-day outcomes were assessed using standard statistical analysis.
RESULTS: In total 234 FEVAR, 1,056 CEVAR and 908 OAR cases were evaluated. A majority of cases were male (FEVAR=82.9%, CEVAR=78.6%, OAR=69.5%, p<0.01) and mean age was 73.4(±8.7) years (FEVAR=74±8.3, CEVAR=74.8±9.0, OAR=71.5±8.0, p<0.01). When stratified by proximal aneurysm extent, mortality was greater for CEVAR compared to FEVAR in juxtarenal cases[FEVAR=3.1%(n=3/98) CEVAR=10.1%(n=9/89),p=0.05], but otherwise there were no significant mortality differences between endovascular repair groups. Compared to endovascular repair(CEVAR/FEVAR combined), OAR was associated with increased length of stay(OAR=11.1±9.5, CEVAR/FEVAR=3.8±5.6 days, p<0.01), major complications [OAR=28.4% CEVAR/FEVAR=10.6%(n=137/1290), OR=3.3,CI:2.7-4.2, p<0.01], ischemic colitis[OAR=6.0%(n=54/908) CEVAR/FEVAR=1.5%(n=19/1290),OR=4.2, CI:2.5-7.2,p<0.01)]. Mortality was greatest following OAR[OAR=7.2%(n=65) FEVAR=2.6%(n=6) CEVAR=2.9%(n=31), p<0.01]. On multivariable analysis OAR had 2.7 times the odds for death compared to CEVAR/FEVAR[OR=2.7,CI:1.7-4.1, p<0.01(Table 1)]. CONCLUSIONS: FEVAR is associated with a mortality benefit for juxtarenal cases compared to CEVAR suggesting surgeons properly equipped to perform FEVAR should preferentially be treating juxtarenal aneurysms. Furthermore, this study demonstrated improved 30-day outcomes for FEVAR/CEVAR compared to OAR suggesting it is a viable and important tool for aneurysm repair in appropriately selected cases.
| Covariate | Odds Ratio | 95% Confidence Interval | p-Value |
| OAR | 2.7 | 1.7-4.1 | <0.01 |
| Age>75 | 1.7 | 1.1-2.5 | 0.01 |
| ASA Class>3 | 2.1 | 1.4-3.2 | <0.01 |
| Female | 1.8 | 1.2-2.8 | 0.01 |
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