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Aneurysm Sac Shrinkage at 1 Year after Fenestrated-branched Endovascular Aortic Repair of Complex Aortic Aneurysms Offers Mid-term Survival Advantage
Thomas Mesnard, MD1, Titia Sulzer1, Dora Babocs, MD1, Lucas Ruiter Kanamori, MD1, Andrea Vacirca, MD, PhD1, Aidin Baghbanioskouei, MD1, Safa Savadi Osgouei, MD1, Emanuel R. Tenorino, MD, PhD1, Aleem Mirza, MD1, Naveed U. Saqib, MD1, Ying Huang, MD, PhD1, Bernardo C. Mednez, MD2, Gustavo S. Oderich, MD1.
1McGovern Medical School, The University of Texas Health Science Center Memorial Hermann Heart and Vascular Institute, Houston, TX, USA, 2Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.

Objectives: To investigate the impact of early changes in aneurysm sac diameter on patient survival after fenestrated-branched endovascular repair (FB-EVAR) for complex abdominal (CAAA) or thoracoabdominal aortic aneurysms (TAAA).Methods: We reviewed the clinical data of patients enrolled in a prospective non-randomized study investigating FB-EVAR (2013-2022). Aneurysm sac diameters were measured from CT scans preoperatively and during follow-up. Maximum aortic diameter at 1-year (6-18 months) was compared to the early postoperative measure CTA (≤30 days). Patients were classified according to early sac dynamic into sac shrinkage (≥5mm) or failure to regress (<5mm or expansion). Primary endpoint was all cause survival, and secondary endpoints were cumulative incidences of aortic-related mortality (ARM), aneurysm rupture and aorta-related secondary intervention.Results: There were 549 patients treated by FB-EVAR. Of these, 463 patients (84%; 71% males; mean age 748 years-old) had > 1-year follow up (135 CAAAs, 328 TAAAs). Sac shrinkage at 1-year was observed in 270 patients (58%), sac expansion accounted for 4% of the entire cohort with no significant difference between patients with CAAAs and TAAAs (P>.05). Patients from both groups had similar cardiovascular risk factors, except for younger age among patients with sac shrinkage (738 vs. 758 years-old; p<.001). Median follow-up was 38 months (18-51). Survival estimates adjusted for confounders (age, chronic pulmonary disease, heart failure, dialysis, and aneurysm extent) revealed a higher hazard of late mortality in failure to regress patients (adjusted hazard ratio, 1.73; 95% Confidence Interval, 1.18-2.53; P=.005). Cumulative incidences of ARM (1.1% vs. 1.4%, p=.30) and aneurysm rupture (0.6% vs. 0.8%, p=.20) at 4-years were both comparable in patients with and without sac shrinkage. The sac behavior at 1 year had no predictive value for aorta-related secondary intervention (HR=3.84 95%CI (0.35-42.46); p=.259). The temporal trend of sac dynamic in both group is presented in Figure 1. Conclusions: Aneurysm sac shrinkage at 1-year is frequent after FB-EVAR and is associated with improved patient survival, while sac enlargement affects only a minority of patients. The low incidences of ARM and aneurysm rupture indicate that failure to regress is a surrogate marker for non-aortic causes of death.


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