The Impact of Suprarenal Fixation on Complex Aneurysm Morphology
Alex Sher, BS, Rami Tadros, MD, FACS, RPVI, Martin Kang, BS, Melissa Tardiff, Ageliki Vouyouka, MD, Daniel Han, MD, Rajiv Chander, MD, Sung Yup Kim, MD, Michael Marin, MD, Peter L. Faries, MD.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.
INTRODUCTION AND OBJECTIVES: In endovascular aortic aneurysm repair (EVAR), stent-grafts with suprarenal fixation are used to enhance fixation and theoretically lower rates of graft migration. The aim of this study is to investigate the impact of suprarenal fixation on outcomes in patients with complex morphology. METHODS: 564 of 1581 consecutive patients were stratified into two groups, infrarenal fixation and suprarenal fixation. Demographics, comorbidities, anatomical features, and outcomes were analyzed using T-tests, Chi-squared tests, and logistic regression. RESULTS: Of the 564 patients, 271 (219 male; mean age 75.2 +/- 8.3 years at time of surgery) received implants with suprarenal fixation and 293 (242 male; mean age 74.4 +/- 9.0 years at time of surgery) received implants with infrarenal fixation. Patients in the suprarenal fixation group had significantly shorter follow up time (38.2 +/- 29.5 vs. 46.8 +/- 33.3 months; p<0.004). Of note, patients in the suprarenal fixation group had more complex aneurysms with more hostile necks. In particular, these patients had significantly larger aneurysm diameters (59.7 +/- 10.7mm vs. 55.4 +/- 9.8mm), infrarenal neck diameters (26.4 +/- 5.4mm vs. 23.3 +/- 3.0mm), and shorter aortic neck lengths (23.3 +/- 14.9mm vs. 28.4 +/- 14.3mm; p<0.0001 for all). This corresponded with higher rates of AAA-related death (4% vs. 1%; p=0.03), rupture (3% vs. 0.3%; p=0.01), and reintervention (24.34% vs. 11.07%; p<0.0001). The major reasons for reintervention in the suprarenal fixation group were endoleak/sac enlargement (48%), renal (15%), and flow/obstruction management (9%). There was no difference in rates of endoleak or sac enlargement between the two groups. For favorable necks with 15mm in length, the results were similar between groups with no significant difference in reintervention, endoleak, sac growth, AAA-related-death, or rupture. CONCLUSIONS: In cases of hostile infrarenal neck morphology, suprarenal fixation may be useful. However, further research is needed to evaluate more optimal treatment options such as fenestrated EVAR and endovascular adjuncts such as Aptus when dealing with high-risk anatomical characteristics.
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