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The State of Complex Endovascular Aneurysm Repairs in the Vascular Quality Initiative
Thomas FX O'Donnell, MD1, Virendra I. Patel, MD, MPH1, Sarah E. Deery, MD2, Chun Li, MD3, Nicholas J. Swerdlow, MD3, Patric Liang, MD3, Adam W. Beck, MD4, Marc L. Schermerhorn, MD3.
1New York Presbyterian/Columbia University Medical Center, New York, NY, USA, 2Massachusetts General Hospital, Boston, MA, USA, 3Beth Israel Deaconess Medical Center, Boston, MA, USA, 4University of Alabama at Birmingham, Birmingham, AL, USA.

OBJECTIVES: Endovascular repair of complex abdominal aortic aneurysms (cAAA) has become increasingly common, but reports have been mostly limited to single centers and single devices.
METHODS: We studied all endovascular repairs of cAAA from 2014-2018 in the VQI. This included all commercially available fenestrated (FEVAR), chimney/snorkel repairs, and physician-modified devices (PMEG), exclusive of Investigational Device Exemptions (IDEs) and clinical trial devices. We used inverse probability weighted, multilevel logistic regression to compare rates of perioperative outcomes, and Cox regression for long-term mortality.
RESULTS: During the study period, surgeons performed 1396 endovascular cAAA repairs; 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized: 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. PMEGs were used to treat more extensive aneurysms, and involved more renal/visceral arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast. Rates of perioperative death (FEVAR: 3.4% vs PMEG: 2.7% vs Chimney/Snorkel: 6.1%, P = .13), and AKI (17% vs 18% vs 19%, P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%, P = .03), and MACE (6.1% vs 5.4% vs 11.7%, P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (OR 7.3 [1.5 - 36.4], P = .015), MI (OR 18.7 [2.6 - 136.8], P = .004), and MACE (OR 11.1 [2.1 - 58.9], P = .005). Overall survival following elective repair was 91% at one year and 88% at three years, with no difference between repair types in crude or adjusted analysis. CONCLUSIONS:The VQI provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher following chimney/snorkel repair, but further study is needed to confirm these findings and establish the durability of these novel technologies.


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