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Long-term Outcomes Of Patients With Failed Abdominal Aortic Aneurysm Repairs Rescued Using Fenestrated Stent-grafts At Centers Without Access To Custom-made Devices
Hamza Hanif, MD1, Muhammad Ali Rana, MD, FACS, FSVS
1, Rachel Danczyk, MD
1, LeAnn Chavez, MD, MBA
1, Ross Clark, MD, MBA, RPVI
1, Nedaa Skeik, MD
2, Jesse Manunga, MD, FACS
2.
1University of New Mexico, Albuquerque, NM, USA,
2Minneapolis Heart Institute at Abbott Northwestern Hospital Minneapolis, Minneapolis, MN, USA.
OBJECTIVE:Failed open or endovascular abdominal aortic aneurysm (AAA) repairs, due to disease progression, graft migration, or type Ia endoleaks, can be managed with graft explantation or fenestrated endovascular aneurysm repair (fEVAR). Endovascular rescue is challenging due to limited proximal landing zones and device overlap. This study reports outcomes of patients with failed AAA repairs treated with fEVAR.
METHODS:We retrospectively reviewed prospectively maintained databases of patients with failed AAA repairs rescued with fEVAR between 2013-2025 at two tertiary centers without access to custom-made devices (CMD), under senior author’s investigational device exemption (IDE). Primary endpoints were technical success (completion of fEVAR without open conversion, target vessel loss, or type Ia/b/III endoleak), device integrity, and vessel patency. Secondary endpoints were major adverse events (MAEs), mortality, and reintervention.
RESULTS:Sixty-nine patients (61 males; mean age 75±6 years) with prior failed repairs (62 EVARs, 4 fEVARs, 3 open) underwent fEVAR. ASA class was III in 50 (72%) and IV in 19 (28%). Failure was due to disease progression in 47 (68%), short initial neck in 12 (17%), and undetermined in 10 (14%). Four presented with contained rupture. A total of 249 vessels were targeted (130 renal, 68 superior mesenteric, 48 celiac) with 245 successful (98%). Entire aortoiliac relining was required in 35 (51%), while 34 (49%) achieved seal within prior grafts. Modifications included main body shortening (75%), bifurcated component shortening (57%), and inverted limbs (33%). Mean fluoroscopy time was 74±27 mins, radiation 3.2±2.1 Gy. Two renal arteries were lost intraoperatively. MAEs occurred in 7 patients (10.1%), including renal failure (n=6), mesenteric ischemia with death (n=1), compartment syndrome (n=1), and paralysis with death (n=2). Mean hospital stay was 3±2 and ICU stay 1±1 days. At 40±5 months follow-up, seven patients required reintervention, all for visceral stents. There was no aortic-related mortality, 100% device integrity, freedom from major endoleak, 98% primary patency, and 100% assisted patency.
CONCLUSION:Failed AAA repairs can be safely rescued with fEVAR at centers without CMDs, with high technical success and durable long-term outcomes. fEVAR should be considered as an alternative to open graft explantation in both high- and standard-risk patients.
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