FEVAR With Chimney Grafting (FEVAR-ch) Produces Equivalent Outcomes To Standard FEVAR
Michael D. Sgroi, MD1, Celine Deslarzes-Dubuis, MD1, Graeme McFarland, MD2, Kenneth Tran, MD1, Jason T. Lee, MD1.
1Stanford University, Stanford, CA, USA, 2University of Alabama, Birmingham, AL, USA.
OBJECTIVES: To compare outcomes of planned chimney use with fenestrated endovascular aneurysm repair (FEVAR-ch) to standard FEVAR for elective treatment of juxtarenal aneurysms.
METHODS: A single center retrospective review of all patients that underwent fenestrated endovascular repair between 2012 and 2018. Clinical and perioperative outcomes were segregated among patients undergoing FEVAR with or without chimney grafts.
RESULTS: 140 patients (mean age 74 years, 83% male, mean AAA size 62mm) underwent elective FEVAR using the commercially available ZFEN device (see TABLE). The FEVAR-ch group included 34 patients with 116 target vessels (50 chimneys and 66 fenestrations/scallops) and the FEVAR group 106 patients with 297 target vessels, with a mean target vessel/patient ratio of 3.4 and 2.8 (p<0.01). Technical success was 97.1% (33/34) for the FEVAR-ch group and 97.2% (103/106) for the FEVAR group (p=0.97). 30-day mortality was 2.9% (1/34) and 2.8% (3/106), p=0.9. No difference in survival estimates was found between the groups at 36 months (69.1% vs. 79.5%, p=0.31). The FEVAR-ch strategy had a 23% (8/34) gutter endoleak rate seen on the first CT-A, with 75% (6/8) resolving without intervention at latest CT-A. For the total cohort, 34 reinterventions occurred in 30 patients (21.4%), and freedom from reintervention was 74.8% and 83.1% at 24 months for the FEVAR-ch and FEVAR group, respectively (p=0.98). There was no difference in target vessel estimated patency at 36 months between the groups (86.3% vs. 87.3%, p=0.26). The presence of a chimney graft did not influence the estimated patency of fenestrated renal branches compared to those in a FEVAR-only configuration (88.9% vs. 87.2%, p=0.47).
CONCLUSIONS: The chimney technique with FEVAR is a safe, effective way to overcome the design constraints of commercially available fenestrated endografts and provide further target vessel incorporation. Mid-term outcomes with ch-FEVAR are similar in terms of survival, branch patency, renal patency, and reintervention compared to standard FEVAR patients despite more complex interventions, although longer term follow-up is needed to confirm the durability of this strategy.
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