Long-term comparison of physician-modified endografts with and without low-profile fabric designs for repair of complex abdominal and thoracoabdominal aortic aneurysms.

Abstract

After commercial approval, our institution began using the Cook Zenith Alpha low-profile stent graft (LPSG) for physician-modified endograft (PMEG) repair of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAA) owing to its smaller sheath size and wider apex-to-apex stent distances, allowing for better accommodation of modifications. We aimed to compare outcomes of PMEGs using LPSGs and the standard-profile stent graft (SPSG), Zenith TX2. We reviewed clinical data and outcomes of patients treated using PMEGs for CAAAs (short-neck infrarenal, juxtarenal, and pararenal AAAs) and TAAAs between 2007 and 2024. End points included 30-day mortality and major adverse events, patient survival, freedom from reintervention, freedom from target artery instability, and freedom from type III endoleak. Of 317 patients treated with PMEGs, 228 (72%) were men with a mean age of 74 ± 9 years. SPSGs were used in 174 patients (55%) and LPSGs were used in 143 patients (45%). Patients treated with LPSGs were mostly treated for TAAAs (69% vs 48%) and subsequently had more incorporated TAs per patient (3.7 ± 0.6 vs 3.1 ± 1.0) compared with the SPSG cohort (P ≤ .001). LPSGs were used more frequently with percutaneous femoral access (91% vs 36%; P ≤ .001) and less frequently with upper extremity access (41% vs 75%; P ≤ .001) and iliofemoral conduits (6% vs 21%; P ≤ .001). Technical success rates were similar between the two groups (89% LPSG vs 93% SPSG; P ≤ .001), with shorter operating time (257 ± 89 minutes vs 296 ± 107 minutes), and lower estimated blood loss (383 ± 464 mL vs 1063 ± 1221 mL) compared with the SPSG cohort (P ≤ .001). Early (30-day) mortality (5% SPSG vs 4% LPSG) and any major adverse events (30 SPSG vs 23 LPSG) were similar between two groups; however, patients in the SPSG cohort were more likely to undergo early aortic or side-branch-related reintervention (13% vs 6%; P ≤ .035). There were no significant differences in 4-year overall survival, freedom from target artery instability, freedom from reintervention, or freedom from type III endoleak rates between the two groups. Repair of CAAAs and TAAAs with PMEGs using devices with low-profile fabric has similar perioperative and long-term outcomes compared with standard-profile endografts, including no difference in endoleak or issues with device integrity. Confounding factors in this comparison include learning curve, improved surveillance, and treatment of more complex aneurysms.