Role of open surgery as an adjunct or bailout in visceral and renal artery incorporation for fenestrated/branched endovascular aortic repair.

Abstract

To describe indications and outcomes of open surgery performed for visceral and renal artery (RA) incorporation and revascularization before, during, or after fenestrated/branched endovascular aortic repair (F/BEVAR). Retrospective review of patients who underwent F/BEVAR for complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms between 2007 and 2024 was conducted. Patients who underwent open surgical revascularization for the superior mesenteric artery (SMA), celiac artery, and/or RA as part of a planned or bailout procedure to the F/BEVAR were included. Access-related procedures, such as open surgical conduits, were excluded. Descriptive analysis was done to illustrate indications and outcomes of these hybrid procedures. A total of 861 patients underwent F/BEVAR during the study period, of whom 22 (2.5%) had a hybrid procedure and were included. The average age was 76 ± 6 years (range, 63-89 years), and 13 patients were male (59%). Most of the hybrid repairs were done in patients with thoracoabdominal aortic aneurysms (n = 17 [77%]) and electively (n = 20 [91%]). Three interventions (14%) were performed preoperatively, and 19 were performed intraoperatively (n = 3 [14%]) or postoperatively (n = 16 [72%]). Preoperative hybrid interventions included iliorenal bypass with syndactylization owing to multiple small accessory RA diameter in two patients, and ilio-SMA bypass for chronic mesenteric ischemia in one. Indication for post-F/BEVAR interventions included an inability to cannulate target arteries (n = 13 [59%]), complications from target artery dissection (n = 3 [14%]) or thrombosis (n = 2 [9%]), and complicated endoleak (n = 1 [4.5%]). Most of these interventions were done during the index admission (n = 15 [68%]), and included RA bypasses (n = 6 [27%]), retrograde SMA stenting (n = 5 [23%]), retrograde RA access and stenting (n = 4 [18%]), hepatic artery bypasses (n = 3 [14%]), and celiac artery ligation owing to complex endoleak in one patient (4.5%). Technical success was achieved in all cases, with one patient experiencing a postoperative complication (retroperitoneal hematoma requiring evacuation). The mean postoperative hospital length of stay was 15 ± 13 days. At a mean follow-up of 22 months (range, 0-93 months), primary patency rates of bypass grafts and stented target arteries via hybrid approach were 100% and 95%, respectively. Overall freedom from target-artery related reintervention was 95%, with only one patient requiring RA restenting. Freedom from aortic-related mortality was 100%. Finally, among 12 patients who had hybrid RA intervention, one patient with a solitary kidney who underwent retrograde access required permanent dialysis. Open surgical intervention is rarely necessary before, during, or after F/BEVAR. Nevertheless, when performed, it proves to be a useful adjunct to incorporate difficult anatomy and as a bailout procedure providing satisfactory long-term target artery patency with minimal risk.