The Effect Of Supraceliac Versus Infraceliac Landing Zone On Outcomes Following Endovascular Aortic Repair Of Juxtarenal Aneurysms
Vinamr Rastogi, MD1, Nicole Kim1, Christina L. Marcarccio, MD MPH1, Priya B. Patel, MD MPH1, Aderike Anjorin, MPH1, Sara L. Zettervall, MD MPH2, Virendra I. Patel, MD MPH3, Jorg L. de Bruin, MD PhD4, Hence J.M. Verhagen, MD PhD4, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2University of Washington, Seattle, WA, USA, 3Columbia University Medical Center, New York, NY, USA, 4Erasmus University Medical Center, Rotterdam, Netherlands.
Objective: The optimal sealing zone for FEVAR in juxtarenal aortic aneurysms (JRAA) remains undefined. We assessed relative risks and benefits of supraceliac versus infraceliac sealing for FEVAR of JRAA using the Vascular Quality Initiative.
Methods: We identified all patients undergoing elective FEVAR (commercially available FEVAR and physician modified endografts, excluding any devices implanted under Investigational Device Exemption studies) for JRAA in the VQI between 2014 and 2021. Supraceliac sealing was defined as proximal sealing in aortic zones 5 or zone 6 with integration of the celiac trunk with scallop/fenestration/branch or occlusion. Primary outcomes were perioperative and 3-year mortality. Secondary outcomes included completion endoleaks, and in-hospital complications and reinterventions. To account for non-random treatment assignment, we calculated propensity scores and used inverse probability-weighted Cox/logistic regression to assess our primary and secondary outcomes, respectively.
Results: Among 1,402 patients identified, 1,180(84%) patients underwent infraceliac sealing and 222(16%) patients underwent supraceliac sealing. Of the supraceliac patients, 72(32%) scallops, 130(59%) fenestrations/branches, and 20(9.0%) occlusions (intentional or unintentional) were placed at the level of or in the celiac trunk. After risk-adjusted analyses, there was no difference in perioperative mortality (Supraceliac vs. Infraceliac: 2.3% vs. 2.5%; Hazard Ratio[HR]: 0.67[95%CI:0.26-1.77], p=.42) , and 3-year mortality (12% vs. 15%; HR: 0.89[95%CI 0.53-1.50]; p=.67)(Table) following supraceliac sealing compared with infraceliac sealing. However, supraceliac sealing was associated with higher odds of any complication (Supraceliac vs. Infraceliac:12% vs. 6.9%/Odds Ratio[OR]: 1.6[95%CI:1.01-2.49], p=.04), specifically cardiac complications (5.4% vs. 1.9%/OR: 2.6[95%CI:1.3-5.1]), lower-extremity ischemia (2.7% vs. 1.0%/OR: 3.2[95%CI:1.02-9.5]), and acute kidney injury (17% vs. 11%/OR: 1.6[95%CI:1.05-2.3]), but lower odds of type IA completion endoleaks (1.4% vs. 4.5%/OR: 0.24[95%CI: 0.05-0.67]). Between groups, there were no differences in spinal cord ischemia (2.3% vs. 0.9%/OR: 2.2[95%CI: 0.70-6.4]) or reintervention during index hospitalization (6.8% vs. 3.7%/OR: 1.5[95%CI:0.80-2.6]).
Conclusion: Following FEVAR for JRAA, proximal sealing at the supraceliac and infraceliac level have similar perioperative and mid-term survival. Nevertheless, supraceliac sealing is associated with higher perioperative complications, but lower rates of type IA endoleaks at completion compared with infraceliac sealing. Future studies with more granular and longer follow-up are required to demonstrate whether supraceliac sealing improves durability in FEVAR for JRAA.
| Table. Perioperative mortality and in-hospital complications following fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms | |||||
| Infraceliac Sealing zone(N=1180) | Supraceliac Sealing zone(N=222) | Infraceliac sealing vs. Supraceliac sealing Risk-adjusted outcomes | |||
| Adjusted Kaplan-Meier estimates | Hazards ratio | 95%-Confidence interval | p-value | ||
| Perioperative Mortality | 2.5% | 2.3% | 0.67 | 0.26-1.77 | .42 |
| 3-year Mortality | 12% | 15% | 0.89 | 0.53-1.50 | .67 |
| Unadjusted event rates | Odds ratio | 95%-Confidence interval | p-value | ||
| Type IA Endoleak at Completion | 4.5% | 1.4% | 0.24 | 0.05-0.67 | .021 |
| Any Complication | 6.9% | 12% | 1.6 | 1.01-2.49 | .041 |
| Pulmonary Complications | 2.5% | 3.6% | 1.27 | 0.57-2.59 | .54 |
| Cardiac Complication | 1.9% | 5.4% | 2.6 | 1.29-5.13 | .006 |
| Bowel Ischemia | 1.6% | 1.8% | 0.83 | 0.24-2.27 | .75 |
| Stroke | 0.6% | 0.5% | 0.47 | 0.02-2.65 | .48 |
| Leg Ischemia | 1.0% | 2.7% | 3.15 | 1.02-9.47 | .039 |
| AKI | 11% | 17% | 1.55 | 1.05-2.26 | .024 |
| Postoperative Dialysis | 0.8% | 1.4% | 1.09 | 0.23-3.70 | .90 |
| Spinal Cord Ischemia | 0.9% | 2.3% | 2.21 | 0.70-6.38 | .15 |
| Reintervention/Reoperation | 3.7% | 6.8% | 1.49 | 0.80-2.64 | .19 |
| This model was corrected for Age, Gender, Race, Diameter, Hypertension, Diabetes, Myocardial Infarction, Congestive Heart Failure (NYHAI/II / NYHAIII/IV), Smoking Status, Chronic Obstructive Pulmonary Disease, Obesity, Renal Dysfunction, Anemia, Prior Aortic Surgery, Aneurysm Extent (Zone 8/9), Repair type, Distal Sealing Zone, Low Center volume, Low Physician volume | |||||
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