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Multi-institutional Analysis Of Chimney Versus Fenestrated Endovascular Repair In The Treatment Of Juxtarenal Aortic Aneurysms
Clayton Brinster, MD1, Meghan Barber, MD
1, G. Ross Parkerson, MD
2, Giancarlo Speranza, MD
3, Thomas Maldonado, MD
3, Dillon Cheung, MD
4, Andrew Meltzer, MD, MBA
4, Joel Kruger, MD
5, Michael Stoner, MD
5, Samuel R. Money, MD, MBA
2.
1University of Chicago, Chicago, IL, USA,
2Ochsner Health, New Orleans, LA, USA,
3NYU Langone Medical Center, New York, NY, USA,
4Mayo Clinic, Scottsdale, AZ, USA,
5University of Rochester, Rochester, NY, USA.
OBJECTIVES:Fenestrated endovascular aortic repair (FEVAR) has demonstrated excellent outcomes following juxtarenal aneurysm repair but is limited by anatomic constraints and manufacturing time. Parallel grafting, or chimney EVAR (chEVAR), is an off-the-shelf alternative, but questions remain about associated long-term durability. This multi-institutional consortium aims to compare mid-term results with these two techniques.
METHODS:Five geographically distinct institutions with high-volume, complex aortic centers were included. Each center enrolled at least 25 consecutive cases of FEVAR and/or chEVAR with a minimum follow-up of 24 months. Ruptured aneurysms, thoracoabdominal aneurysms, and physician-modified cases were excluded. Data were combined and divided into index case category for analysis: FEVAR versus chEVAR.
RESULTS:130 cases were analyzed: 77 FEVAR, 53 chEVAR. Average age was 72 years in both cohorts. Average aneurysm diameter with FEVAR was 62mm versus 65mm with chEVAR (+3mm, P=.23). Technical success was achieved in 76/77 (99%) of FEVAR cases and 52/53 (98%) of chEVAR cases. (Table) Mean follow-up was 28 months. Significantly more (+20.2%, P<0.001) patients in the chEVAR group had persistent type I endoleak at one year (15/53, 28%) versus 6/77 (7.8%) following FEVAR. Ten reinterventions were required in 8/77 (10.4%) FEVAR patients versus 20 reinterventions in 16/53 (30.2%) chEVAR patients (+19.8, P<.001). Significant sac regression was seen at 12 months (55mm, -7mm, P=.002) and 24 months (51mm, -11mm, P<.001) following FEVAR. Sac regression was not significant at 12 months (59mm, -5mm, P=0.09) following chEVAR, and sac re-expansion was observed in this group between 12 and 24 months (59 to 63mm, +4mm).
CONCLUSIONS:This multi-institutional analysis demonstrates that while both FEVAR and chEVAR achieved excellent initial technical success, chEVAR was associated with significantly higher rates of type I endoleak and reintervention. FEVAR patients demonstrated significant sac regression, whereas chEVAR yielded a concerning trend of early sac regression followed by late re-expansion. With growing evidence linking stable or increasing sac size to late rupture and aneurysm-related mortality, our findings indicate that FEVAR could be a safer and more durable option in elective cases with suitable anatomy. Compared to previous single-center or registry-based series, data from this consortium offers potentially greater generalizability to real-world practice.
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