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Physician-modified Fenestrated Endovascular Aortic Aneurysm Repair After Failed Evar Offers Promising Results Compared To Open Conversion
Trung Nguyen, DO, Mackenzie Gittinger, BS, Weiwei Liu, BS, Cara L. Grzybowski, MMD, Shane Grundy, MD, Bruce Zwiebel, MD, Murray Shames, MD, Dean J. Arnaoutakis, MD, MBA.
University of South Florida, Tampa, FL, USA.

Objective: Conversion to open repair (EVAR-c) is the gold standard treatment for EVAR failure from poor proximal seal but is associated with significant challenges. Endovascular salvage with fenestrated/branched endovascular repair (F/BEVAR) is an alternative option but is limited option due to lack of commercially available custom-made devices and potential overlap issues between the F/BEVAR and prior EVAR device. Physician-modified F/BEVAR (PM-F/BEVAR) addresses these issues by obtaining the necessary proximal seal and relining the entire prior endograft. The purpose of this study was to evaluate changes in our longitudinal practice pattern and compare outcomes of EVAR-c and PM-F/BEVAR in patients with failed prior EVAR.
Methods: A prospective database of consecutive patients treated at a single-center with EVAR failure due to poor proximal seal between 1/2015 and 6/2023 was retrospectively reviewed. All EVAR failures due to infection/thrombosis were excluded (n=56). The cohort was stratified by treatment strategy (EVAR-c vs PM-F/BEVAR). Demographics and perioperative details were compared between the groups using univariate analysis. Two-year overall survival was compared using Kaplan-Meier method.
Results: Seventy-six patients underwent treatment of failed EVAR, 41 undergoing EVAR-c and 35 undergoing PM-F/BEVAR. The total number of EVAR-c/year peaked in 2019 (n=11) with the average number EVAR-c/year decreasing by 50% since the inception of a PM-F/BEVAR program in March 2021. Patients who underwent EVAR-c had similar age, gender, and comorbidities compared to PM-F/BEVAR. For EVAR-c patients, crossclamp position was typically supraceliac (n=33[80%]). For the PM-F/BEVAR group, 132 fenestrations/branches were constructed averaging 3.80.6 target arteries/patient. Fluoroscopy time, radiation dose,
contrast use, and technical success were 7840minutes, 3,1031,778mGy, 8025mL, and 100%, respectively. Blood transfusion, length of stay, acute renal failure, respiratory complications, and discharge status were significantly better in the PM-F/BEVAR group (Table). PM-F/BEVAR had significantly decreased 30-day mortality (n=6[15%] vs n=0[0%]; p=.03) but there was no difference in 2-year overall survival (EVAR-c=75% vs PM-F/BEVAR=74%; log-rank p=.73).
Conclusions: Endovascular salvage of failed prior EVAR using a PM-F/BEVAR is effective with significantly better perioperative outcomes compared to EVAR-c. Management of these complex patients has evolved to a predominantly PM-F/BEVAR approach, which should be strongly considered as first-line therapy in patients with failed EVAR.

Perioperative outcomes
Total(n=76)PM-FEVAR (n=35)EVAR-c (n=41)P-value
Procedure time, minutes246 (90)241 (111)250 (69).67
Estimated blood loss1,956 (2,244)219 (142)3,439 (2,127)<.001
RBC transfusion, # units3.4 (4.3)0.7 (1.2)5.8 (4.6)<.001
Overall length of stay, days10.3 (10.3)6.2 (4.0)13.9 (12.6).001
ICU length of stay, days7.7 (10.0)4.8 (3.2)10.1 (12.8).02
Any postoperative complication38 (50)8 (23)30 (73)<.001
30-day mortality6 (8)0 (0)6 (15).03
Major strokea2 (3)0 (0)2 (5).50
Permanent spinal cord ischemia1 (1)1 (3)0 (0).72
Acute renal failurec28 (37)3 (9)25 (63)<.001
Renal replacement therapy8 (11)1 (3)7 (18).07
Bowel ischemia3 (4)0 (0)3 (8).24
Respiratory complicationd15 (20)3 (9)12 (30).02
Discharge to home59 (77)34 (97)25 (60).001
30-day Readmission11 (15)3 (9)11 (15).20


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