Comparative Outcomes of Open, Hybrid, and Fenestrated Branched Endovascular Repair of Extent II and III Thoracoabdominal Aortic Aneurysms
Dean J. Arnaoutakis, M.D., M.B.A.1, Salvatore T. Scali, M.D.1, Adam W. Beck, M.D.2, Kristina A. Giles, M.D.1, Thomas S. Huber, M.D., Ph.D.1, Gilbert R. Upchurch, M.D.1.
1University of Florida-Gainesville, Gainesville, FL, USA, 2University of Alabama-Birmingham, Gainesville, FL, USA.
OBJECTIVES: The benefits of different operative approaches to manage extent II and II thoracoabdominal aortic aneurysms(TAAA) remain unclear. The purpose of this study was to compare outcomes of three different operative strategies to manage extent II/III TAAA.
METHODS: All patients undergoing extent II/III TAAA repair(2002-2018) for non-mycotic, degenerative or dissection-related aneurysm at a single institution were reviewed. The primary end-point was 30-day mortality. Secondary end-points included incidence of spinal cord ischemia(SCI), complications, unplanned reoperation/readmission, and survival. Propensity analysis was used to match patients to mitigate impact of covariate imbalance and selection bias.
RESULTS: 198 patients(FEVAR=92, Hybrid=40, Open=66) underwent extent II/III TAAA repair. Seven(18%) Hybrid patients failed to undergo the 2nd stage operation(death=5;lost follow-up=2). The unadjusted 30-day mortality and complication risks(combined elective/non-elective) were: 30-day mortality, FEVAR-4%, Hybrid-13%, Open-12%(p=0.01);complications, FEVAR-36%, Hybrid-33%, Open-50%(p=0.11)[Permanent SCI: FEVAR-3%, Hybrid-3%, Open-6%(p=0.64)%]. In adjusted analysis, 30-day mortality risk was significantly greater for Open vs. FEVAR[HR 3.6, 95%CI 1.4-9.2, p=.008] with no difference for Hybrid vs. Open or Hybrid vs. FEVAR. There was significantly lower risk of any SCI for FEVAR patients compared to Open(Open:FEVAR, 3.4, 1.0-11.3, p=.04); however, there was no difference overall in the risk of permanent SCI. There was no difference in risk of major complications or unplanned reoperation but Hybrid patients had greater risk of unplanned 90-day readmission compared to FEVAR/Open subjects. There was a time varying effect of procedure type on survival probability between 30 and 90 days with Open repair having greater mortality risk. This led to a significant 1-year but not 5-year survival disadvantage compared to Hybrid/FEVAR subjects(1 and 5-year survival: FEVAR, 86±3%, 55±8%; Hybrid, 86±5%, 60±11%; Open 69±7%, 59±8%; Cox-model p=0.03;Figure)
CONCLUSIONS: Extent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity. FEVAR is associated with the lowest 30-day mortality risk compared to Hybrid and Open repair when patients are matched based upon preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients, especially when presenting electively. 
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