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Supra-renal Versus Infra-renal Graft Fixation Does Not Affect Outcomes After Endovascular Aortic Aneurysm Repair In Patients With Favorable Neck Anatomy
Molly Ratner, MD1, Caron Rockman, MD1, William Johnson, MD1, Todd Berland, MD1, Thomas Maldonado, MD1, Neal Cayne, Md1, Virendra Patel, MD2, Jeffrey J. Siracuse, MD MBA3, Glenn Jacobowitz, MD1, Bhama Ramkhelawon, PhD1, Heepeel Chang, MD4, Karan Garg, MD1.
1New York University Langone Hospital, New York, NY, USA, 2New York Presbyterian/Columbia University Medical Center, New York, NY, USA, 3Boston Medical Center, Boston, MA, USA, 4Westchester Medical Center, New York, NY, USA.

OBJECTIVES: The choice of supra-renal (SR) fixation for the treatment of aortic aneurysm remains debatable. SR fixation enhances stable proximal sealing but comes at the cost of placing struts across the renal artery ostia. To date, literature has focused on the risk of SR fixation on renal function. This study aims to assess the effect of graft fixation on other postoperative-operative outcomes, as well as renal function.
METHODS: The Vascular Quality Initiative database was queried from to 2012-2022 for patients undergoing EVAR for infra-renal aortic aneurysms. Patients with hostile neck anatomy were excluded. Patients were stratified based on SR versus infra-renal (IR) graft fixation. Primary outcomes were post-operative complications and reintervention.
RESULTS: Of the patients identified, 2,357 (21.1%) and 8,837 (78.9%) underwent SR versus IF graft fixation. Patients who underwent SR graft fixation were more likely to be on aspirin (68.1% vs 63.5%, p <.001) or beta-blocker (52.1% vs 49.5%, p = 0.026). Otherwise, the frequency of standard pre-operative comorbidities and medications was similar between the two cohorts. SR grafts were more likely to be performed electively (90.5% vs 88.2%, p = .002). On completion angiogram, the SR cohort were more likely to have an endoleak (27.8% vs 21.8%, p <.001), but were not more likely to have a type 1a (p=NS). At one year, there was a higher re-intervention rate among the SR cohort (5.2% vs 3.5%, p = .003), but no difference in the frequency of interventions performed for type 1a endoleak. Although there was a higher rate of renal artery coverage in the SR cohort (2.8% vs 1.8%, p = .001), there was no difference in rate of re-intervention for renal artery stenosis/occlusion (p=NS) or in degree of creatinine elevation at follow-up (p=NS).
CONCLUSIONS: Patients who underwent EVAR with SR graft fixation were more likely to have an endoleak, but there was no difference in rate of type 1a endoleak. As such, higher rates of re-intervention in the SR cohort were not driven by proximal leaks. Although renal artery coverage was more commonly observed after SR fixation, there was no difference in degree creatinine elevation or dialysis dependence at 1-year follow-up. As such, surgeon preference and experience should dictate the use SR vs IR fixation in patients with favorable neck anatomy.
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