Outcomes of patients treated with double-wide scallop vs fenestrations for celiac artery incorporation during repair of complex abdominal aortic aneurysms.

Abstract

Celiac artery (CA) incorporation during fenestrated-branched aortic aneurysm repair (FB-EVAR) for complex abdominal aortic aneurysms (cAAAs) is typically performed with fenestrations. Double-wide scallops (DWS) can be used when appropriate. We aimed to assess outcomes of patients treated with DWSs for the CA during FB-EVAR for cAAAs. This is a single-center retrospective review of patients enrolled in a prospective investigational device exemption trial undergoing FB-EVAR for cAAA from 2013 to 2020. The use of DWS or fenestrations for the management of the CA was selected to optimize seal. Patients with longer lengths of normal caliber aorta between the renal and celiac arteries, and without thoracic aortic ectasia or multifocal thoracic aortic aneurysms, were considered for DWS, whereas those with shorter visceral segment seal zones or thoracic aortic disease were preferentially treated with fenestrations for the CA. End points were morbidity, mortality, technical success, freedom from type IA endoleak, and target vessel instability (TVI). FB-EVAR with CA DWS or fenestration was performed in 131 patients, including 97 males (74%). DWSs were used in 68 patients (52%) and fenestrations in 63 (48%). The mean patient age was 75.0 ± 7.4 years in both groups. Demographics, cardiovascular risk factors, and mean aortic diameter (P = .382) were similar between groups. The median number of incorporated vessels was similar (4; P = .373) between groups. The median endovascular operative time (DWS = 118 minutes [interquartilr range (IQR), 98-154 minutes]; fenestration = 141 minutes [122-170 minutes]; P = .006) and fluoroscopy time (DWS = 64 minutes [IQR, 51-78 minutes]; fenestration = 70 minutes [IQR, 61-83 minutes]; P = .032) were shorter with DWS, with no difference in contrast volume (P = .204). Technical success was 96% with DWS and 100% with fenestrations (P = .096). Three patients with DWS had partial or complete CA coverage. Median aortic coverage (above CA) was higher with fenestrations (fenestration = 5.5 cm [IQR, 4.5-6.4 cm]; DWS = 3.8 cm [IQR, 3.5-4.2 cm]; P < .001). There was no difference in 30-day mortality (DWS = 0%, fenestration = 1.6%; P = .297) or major adverse events (DWS = 17.6% vs fenestration = 17.5%; P = .978). The median follow-up was 42 months [Q1, Q3, 25, 50]. There were no type IA endoleaks, aortic ruptures, or open conversions. There was no difference in sac regression (DWS = 60%, fenestration = 67%; P = .449), survival (P = .859), or CA TVI (P = .320). FB-EVAR with DWS and fenestrations show comparable perioperative and long-term outcomes without significant differences in technical success, TVI, or sac regression when used with precise device selection based on visceral segment seal zone lengths and risk for aortic degeneration. Device design should be determined by patient anatomy and seal zone given comparable outcomes.