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Long-term Results: Comparing Outcomes Of Open Vs. Endovascular Complex Aortic Aneurysm Repairs At Centers Without Access To Custom Made Devices In The Fenestrated/branched Stent-graft Era
Jesse Manunga, Jr., MD1, Hamza Hanif, MD
2, Ellen Cravero, MS
3, Elliot Stephenson, MD
1, Ross M. Clark, MD
4, Nedaa Skeik, MD
1, Muhammad Ali Rana, MD
5.
1Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA, 2University of New Mexico Health Sciences Center, Albuquerque, NM, USA, 3Minneapolis Heart Institute Foundation, Minneapolis, MN, USA, 4University of New Mexico Health Sciences, Albuquerque, NM, USA, 5University of New Mexico Health Sciences, Alburquerque, NM, USA.
Objective: To compare long-term outcomes of complex aortic aneurysms (cAAs) treated with open surgical repair (OSR) or fenestrated/branched endovascular aneurysm repair (f/b-EVAR) between 2010 and 2023 at two institutions.
Methods: This retrospective analysis compared outcomes of patients with cAAs treated by OSR vs. f/b-EVAR at two centers with no access to custom made devices. cAA was defined as those requiring a suprarenal or higher clamp (OR) or unsuitable for commercially available infrarenal endografts. Primary endpoints were technical success and major adverse events (MAEs); secondary endpoints included target vessel patency, re-intervention rate, and long-term survival. MAEs encompassed in-hospital death, stroke, MI, paraplegia, renal insufficiency, target vessel loss, and conversion to open repair.
Results: 507 patients (OSR:157; f/b-EVAR:350) underwent cAA repair. Majority were male with a median age of 74 years. F/b-EVAR patients were older and had higher comorbidities (p>0.001). Clamp site was suprarenal in 71%, supra-mesenteric/celiac in 20% and intra-thoracic in 9% patients. Complications were higher (p>0.001) in patients requiring supra-mesenteric/celiac or intra-thoracic clamp. In the f/b-EVAR group, 34% patients underwent ≤ 3 vessel repair while 66% underwent ≥ 4 vessel repair. In this group, 1486 vessels were targeted and 99.5% successfully incorporated. Completion angiography revealed 16 types Ia,b,c or III endoleaks. Overall technical success was 97% (OR:100%; f/b-EVAR: 96%). Thirty-day mortality was 3% (f/b-EVAR: 3.4%; OR: 2.0%) and MAEs occurred in 19% (f/b-EVAR: 20%; OR: 15%, p=0.13) patients. Paraplegia rate (1.7%) was clinically higher in the f/b-EVAR group. However, operating room time, estimated blood loss, transfusion requirement, pneumonia, intensive care unit and hospital length of stay were higher in the OR group (p<0.001). Acute kidney injury was higher in the f/b-EVAR group (16% vs 10%, p<0.001). Incisional complications were higher (p<0.001) in the OSR group. At a median follow-up of 32 months, re-intervention rates were similar (OSR: 5%, f/b-EVAR: 7%, p=0.3) including 13 (2.6%) late endoleaks in the f/b-EVAR group - type Ib (9), type Ic (2) and type III (10) - requiring reintervention. One and five-year survival were 95% (OR:97%; f/b-EVAR:94%) and 78% (OR: 83%; f/b-EVAR: 75%), respectively.
Conclusion: Both approaches demonstrated remarkable safety and effectiveness for cAA treatment with equivalent incidence of MAEs, short and long-term mortality. F/b-EVAR reveals advantages of faster convalescence with shorter hospital and ICU stays.
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