Stenting Of Superior Mesenteric Artery Fenestrations Facilitates Fenestrated Endovascular Repair Of Pararenal/suprarenal Aneurysms
Momodou Jammeh, MD, John W. Ohman, Luis Sanchez.
Washington University in St Louis, St Louis, MO, USA.
OBJECTIVES: According to instructions for use, fenestrated aneurysm repair (FEVAR) with the Cook Zenith fenestrated endograft (ZFEN) requires at least 4 mm of non-aneurysmal infrarenal neck length and superior mesenteric artery (SMA) stenting is optional. This study evaluates the outcomes of FEVAR with SMA stenting relative to SMA scallops or unstented fenestrations and anatomical differences there-in. METHODS: Single-institution retrospective analysis of patients who underwent FEVAR with SMA scallop, SMA fenestration with and without stenting from May 2012 to December 2019 following Institutional Review Board approval. RESULTS: Of 203 aneurysms repaired with ZFENs, 127 were included in our analysis: 55 stented SMA fenestrations, 38 unstented SMA fenestrations and 34 SMA scallops. Technical success was achieved in all patients. Operative times were longer (335.5 ± 16.4 vs 265.0 ± 12.8 vs 269.0 ± 12.7 mins, p <0.001 ) and transfusion rates were higher (33% vs 8% vs 18%, p = 0.01) in the SMA stent group but fluoroscopy time (65.4 ± 3.76 vs 58.3 ± 3.94 vs 51.4 ± 4.75 mins, p = 0.05) and contrast volume (92.2 ± 5.17 vs 87.1 ± 6.73 vs 93.1 ± 5.89 mL, p = 0.84) were not significantly different. Anatomically, patients that underwent ZFEN with SMA stenting had less infrarenal neck (1.73 ± 1.18 vs 4.92 ± 1.16 vs 6.28 ± 1.42 mm, p =0.03) and shorter SMA to aneurysm start length (16.9 ± 1.39 vs 23.9 ± 1.24 vs 26.8 ± 1.67 mm, p <0.001). In the SMA stent group, 1 had small bowel necrosis after intra-operative embolization of a perforated, bleeding jejunal branch and 2 had colonic ischemia of unclear etiology with patent SMA stents on imaging post-operatively. In addition, type 3 endoleak (6% vs 0% vs 3%, p =0.45) and re-intervention (20% vs 18% vs 12%, p =0.60) rates were similar across all groups. Mean follow-up duration was longer in the SMA scallop group but 82% of these occurred in the first half of the study period. The rate of mortality <30-days post-operatively (5% vs 0% vs 3%, p =0.80) was relatively similar. CONCLUSIONS: Despite the added technical complexity, SMA stenting enables FEVAR for pararenal and suprarenal aneurysms with high rates of technical success and no increased risk of mortality, type 3 endoleak, or re-intervention.
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