Long-term results of elective endovascular repair of complex aortic aneurysms by custom-made fenestrated endografts.

Abstract

To report the outcomes of elective endovascular repair of complex aortic aneurysms (CAAAs) by custom-made fenestrated endografts (fenestrated endovascular aortic repair [FEVAR]). This single-center, retrospective analysis included all consecutive CAAAs (juxtarenal AAAs [JAAAs]; pararenal AAAs [PAAAs], and Crawford's extent IV thoracoabdominal AAAs [TAAAs]) managed electively by FEVAR (Cook Medical) from 2014 to 2024. Outcomes were reported according to the Society for Vascular Surgery reporting standards. Target arteries (TAs) loss, spinal cord ischemia, and 30-day/in-hospital mortality rates were assessed as early outcomes. Survival, freedom from reinterventions, TA instability, and aneurysm sac changes were assessed during follow-up. Of 457 advanced endovascular aortic procedures, FEVAR was electively performed in 255 (56%) CAAAs (juxtarenal AAAs, 145 [57%]; PAAAs, 65 [25%]; type IV TAAAs, 45 [18%]). Endograft with two or fewer, three, and four or more fenestrations were adopted in 42 (16%), 62 (24%), and 151 (60%) cases, respectively. Overall, 872 TAs were accommodated by 8 × 8 mm (378 [43%]) and 6 × 6 mm/6 × 8 mm (494 [57%]) fenestrations. Eight patients (3%) experienced loss within 30 days (8/872 TAs [1%]; renal arteries, 7; celiac trunk, 1). One case (0.4%) of spinal cord ischemia (permanent paraplegia in type IV TAAA) occurred. There were 6 deaths (2%) within 30 days or during a prolonged/complicated hospitalization. The mean follow-up was 65 ± 32 months. The estimated 5-year freedom from reinterventions and TA instability was 79% and 94%, respectively. Type IV TAAAs had lower freedom from TA instability than JAAAs/PAAAs at 5 years (type IV, 84% vs JAAAs/PAAAs, 89%; log-rank P ≤ .001) and it was confirmed as an independent risk factor on Cox regression analysis (P = .03; hazard ratio, 5.2; 95% confidence interval, 1.7-15.5). The estimated 5-year survival was 70%. Of 209 patients with available radiological follow-up at 1 year, aneurysm shrinkage, stability, and enlargement occurred in 117 (56%), 75 (36%), and 17 (8%) cases, respectively. Cases with shrinkage had higher follow-up survival at 5 years than cases without shrinkage (shrinkage, 75% vs no shrinkage, 61%; log-rank P = .04). Cases with TA instability had lower follow-up survival at 5 years than cases without TA instability (TA instability, 60% vs no TA instability, 70%; log-rank P = .004). TA instability was an independent risk factor for follow-up mortality on Cox regression analysis (P = .01; hazard ratio, 2.5; 95% confidence interval, 1.2-5.2). Elective endovascular repair of CAAAs by FEVAR is effective, with excellent early outcomes and satisfactory long-term results in terms of TA instability, reintervention, and survival. Type IV TAAA is a risk factor for TA instability, which is associated with lower late survival.