Impact Of Aortoiliac Tortuosity In Outcomes Of Fenestrated Endovascular Aortic Repairs
Nallely Saldana-Ruiz, MD MPH, Audrey Mossman, BS, Randy Cure, MHS, Ayumi Tachida, MS, Benjamin W. Starnes, MD, Sara L. Zettervall, MD MPH.
University of Washington, Seattle, WA, USA.
Objective: Anatomy plays a key role in suitability and outcomes for endovascular aortic repair of abdominal aneurysms. Angulation of the proximal aneurysm neck has been associated with adverse events following endovascular repair, including endoleaks, stent migration and secondary interventions. Still, information on the impact of aortoiliac tortuosity in fenestrated repairs of aortic aneurysms remains limited. We aimed to quantify effects of aorto-iliac tortuosity on outcomes in complex endovascular aortic repairs.
Methods: Patients who underwent a physician-modified endovascular repair (PMEG) for treatment of juxtarenal aortic aneurysms at a single center, under a physician-sponsored investigation device exemption study, from 2011-2021 were reviewed. Centerluminal lines and geometric distances were obtained using TeraRecon software. A tortuosity index (TI) was calculated. Aortic and iliac tortuosity were assessed independently and stratified into low (<1.15) and high (>1.15) using SVS aortic tortuosity reporting standards. Univariable and multivariable analyses were applied.
Results: 108 patients were identified including 72 with low and 36 with high aortic tortuosity, and 65 with low and 42 with high iliac tortuosity. Patients with high aortic tortuosity were older (76 vs 79yrs, p=0.03), more commonly female (35 vs 78, p=0.03). On univariable analysis, high aortic tortuosity index was associated with increased fluoroscopy time (30 vs 40min, p=0.02), however no differences were noted in outcomes (Table). When iliac tortuosity was assessed, a high tortuosity index was associated with an increased risk of type I or III endoleak (30 vs 23, p=.0001), as well as reinterventions (20 vs 16, p=0.04) (Table). In multivariable analysis, higher iliac tortuosity was again associated with secondary interventions (OR 2.8, 95% CI 1.1-7.2), including those for type I or type III endoleaks (OR 4.0, 95% CI 1.2-1.6).
Conclusion: Among patients treated with PMEG for juxtarenal aneurysms, iliac tortuosity but not aortic, is associated with increased reinterventions and type I or III endoleaks. Long term follow-up is particularly critical for patients with high iliac tortuosity to ensure these high risk endoleaks are identified and treated early to avoid the risk of rupture.
| Aortic Tortuosity | Iliac Tortuosity | |||||
| Variables | Lown=72 (%) | Highn=36 (%) | P-value | Lown=65 (%) | Highn=42 (%) | P-value |
| Adverse Events (Any) | 12 (17) | 12 (33) | 0.09 | 18 (28) | 6 (14) | 0.15 |
| Death <30 days | 2 (3) | 3 (8) | 0.33 | 4 (6) | 1 (2) | 0.65 |
| Endoleak (any) | 39 (54) | 15 (42) | 0.31 | 30 (85) | 23 (55) | 0.43 |
| Type I / Type III endoleak | 3 (4) | 12 (33) | 0.38 | 3 (5) | 12 (29) | 0.001 |
| Type Ia | 3(4) | 2(6) | 1.00 | 3 (5) | 2 (5) | 1.00 |
| Type Ib | 2 (3) | 1 (3) | 1.00 | 1 (2) | 2 (5) | 1.00 |
| Type Ic | 0 (0) | 1 (3) | 1.00 | 1 (2) | 0 (0) | 1.00 |
| Technical Success | 71 (99) | 34 (94) | 0.26 | 63 (97) | 41 (98) | 1.00 |
| Reintervention (any) | 23 (32) | 12 (33) | 1.00 | 20 (48) | 16 (25) | 0.04 |
| Reintervention for Endoleak | 10 (14) | 5 (14) | 1.00 | 5 (8) | 10 (24) | 0.02 |
| Pulmonary Complications | 3 (4) | 0 (0) | 0.55 | 3 (5) | 0(0) | 0.28 |
| Myocardial infarction | 3 (4) | 2 (6) | 1.00 | 5 (8) | 0(0) | 0.15 |
| Acute Renal Failure | 1 (1) | 3 (8) | 0.11 | 3 (5) | 1 (2) | 1.00 |
| Mesenteric ischemia | 2 (3) | 0 (0) | 0.55 | 2 (3) | 0 (0) | 0.52 |
| Stroke | 0 (0) | 1 (3) | 0.33 | 1 (2) | 0 (0) | 1.00 |
| Spinal Cord Ischemia | 0 (0) | 2 (6) | 0.11 | 2 (3) | 0 (0) | 0.52 |
| Hospital Length of Stay (days) | 3.9 +/- 5.0 | 2.5 +/- 2.0 | 0.68 | 3.7 +/- 4.8 | 2.9 +/- 3.0 | 0.58 |
| ICU length of stay (days) | 1.5 +/- 0.8 | 2.0 +/- 2.7 | 0.06 | 1.3 +/- 0.7 | 2.1 +/- 2.6 | 0.06 |
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