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Aortic Neck Remodeling After Fenestrated EVAR
Marc Salhanick, MD, David Timaran, MD, Mark Levin, MD, Carlos Timaran, MD.
UT Southwestern, Dallas, TX, USA.

Aortic neck expansion after endovascular aortic aneurysm repair (EVAR) is a well described phenomenon that may increase the risk of type I endoleak. Fenestrated EVAR (FEVAR) has been proposed as both treatment and prophylaxis for this remodeling. Data about proximal neck changes after FEVAR remains sparse. We aimed to assess differences in remodeling of the aortic neck between the Zenith fenestrated AAA stent-graft (ZFEN) vs. premanufactured custom-made devices (CMD) with higher sealing zones.
Aortic imaging of 53 patients undergoing FEVAR (29 ZFENs and 24 CMDs) was analyzed. Devices were designed to attain a proximal sealing zone length of at least 2 cm. All premanufactured CMDs were used under a physician-sponsored investigational device exemption. Aortic outer-wall areas at the level of the celiac, superior mesenteric artery (SMA), and renal arteries as well as the proximal seal zone 1 and 2 centimeters proximal to the edge of the endograft were measured using TeraRecon software.
The median follow-up period was 12 months (interquartile range[IQR], 2 - 23 months). Aortic area changes after FEVAR are included in the Table. The rates of change were comparable for ZFENs and CMDs proximally, but CMDs revealed further decreasing size at the level of the renal arteries. The right renal aortic area regressed -0.15 (IQR, -4.38 - 0.37) cm²/yr after FEVAR with CMDs, as opposed to an aortic expansion of 0.55 (IQR 0.07-1.5) cm²/yr for ZFENs (p = 0.005). The left renal aortic area also shrank -0.73 (IQR (-5.48 - 0.37) cm²/yr for CMDs vs. 0.55 (IQR 0.07-1.4) cm²/yr for ZFENs (p = .002). Although aortic area changes at the level of the proximal sealing zone were similar, at the level of the SMA and renal arteries, ZFENs revealed aortic area expansion >10%, whereas CMDs revealed a regression in aortic area up to 9% (p<.05).
After FEVAR, CMDs revealed significant regression in aortic size at the level of the renal arteries whereas ZFENs revealed an expansion >10%. No significant changes occurred proximally. Aortic area changes after FEVAR were lower than previously reported after EVAR at all levels of proximal fixation and the visceral aorta.

Rates of change
ZFEN (IQR cm²/yr)CMD (IQR cm²/yr)P value
2cm Proximal0.2 (0.004-0.5)0.29 (-0.15 - 0.62)0.9
1cm Proximal0.29 (0.04-0.62)0.15 (-0.37 - 0.73)0.5
Furthest Proximal Extent of Graft0.18 (-0.11-0.69)0.26 (-0.37 - 1.1)0.8
Celiac0.44 (0.07-0.84)0.73 (-0.73 - 2.19)0.8
SMA0.51 (0.18-1.61)0.37 (-0.73 - 2.19)1
Right Renal0.55 (0.07-1.5)-0.15 (-4.38 - 0.37)0.005
Left Renal0.55 (0.07-1.4)-0.73 (-5.48 - 0.37)0.002
Right Renal (Percent Change IQR)12% (0 - 29%)-2% (-19 - 3%)0.002
Left Renal (Percent Change IQR)12% (0 - 24%)-9% (-25 - 5%)0.0002

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