Outcomes from the Real-World Multicenter Laser In-Situ Fenestrated Endovascular Repair (LIFE) Registry for Complex Thoracoabdominal and Pararenovisceral Aortic Pathology.

Abstract

Laser in-situ fenestrated endovascular (LIFE) repair allows fenestrated endovascular aortic repair in complex and challenging cases, including urgent and emergency presentations and patients with prior aortic repairs. The real-world multicenter LIFE Registry reports the results of this unique approach for thoracoabdominal and pararenovisceral (TAAA/PAA) pathologies. All patients (2017-2022) undergoing LIFE for TAAA/PAA were identified at nine high-volume institutions and collected in a retrospective multicenter registry database. Descriptive statistics and Kaplan-Meier analysis were used. The primary outcomes were technical success and target vessel instability. Secondary outcomes included mortality, stroke, paraplegia, and reinterventions. 210 patients undergoing LIFE were included (mean age 72.3, 27% female, 83% white). Notable demographics included previous stroke in 14%, COPD in 26%, renal insufficiency in 27% (dialysis 3%) and previous aortic repair in 55% of patients. Indications for repair included fusiform aneurysm in 69%, Type Ia endoleak in 21%, saccular aneurysm in 10% and aortic dissection in 7%. Repair was performed for symptomatic/ruptured pathologies in 39%. Thirty-day deaths were seen in 17 patients overall (8%) with 15 deaths in symptomatic/ruptured patients and 2 deaths in asymptomatic patients (p<.0001). Proximal seal was achieved in Zone 2 (1%), Zone 3 (5%), Zone 4 (10%), Zone 5 (34%), Zone 6 (14%), Zone 7 (16%) and Zone 8 (17%). A total of 529 target vessels were incorporated (one vessel 18%, two vessel 26%, three vessel 29%, four vessel 24%, NR 3%) with a mean of 2.5 target vessels per patient. Technical success for LIFE repair was 95%. Fifteen of those deaths occurred in 77 symptomatic/ruptured patients (19%). There were six strokes (2.9%) and permanent paraplegia in four patients (2%). At mean follow-up of 9 months (range 1-35), there were twelve additional deaths (5.7%), four of which were aneurysm-related (2%). Kaplan-Meier survival for the overall cohort at 36 months was 70% with 80% freedom from bridging stent reintervention at 24 months (both SE < 10%) (Figure 1). By group, asymptomatic patients experienced higher overall survival (82% vs. 63%, p=.0007) at 20 months and freedom from bridging stent reintervention (88% vs. 77%; p=.0005) at 21 months than symptomatic/ruptured patients (SE < 10%). Overall reinterventions were performed in 45 patients (21%) with additional aortic stent graft in 21 patients (10%), bridging stent reintervention to 24 target vessels (4.5%), coil embolization in four patients for Type II endoleak and to the false lumen of a dissection (2%) and other surgical procedures in three patients (1.4%). The LIFE registry represents the largest multicenter experience with the laser in-situ fenestrated endovascular (LIFE) technique to date. Perioperative and mid-term outcomes are reasonable in a cohort with a significant proportion of symptomatic and ruptured patients. There was a higher-than-expected need for aortic stent graft reinterventions, which may be related to the learning curve with the technique and is higher than described for physician-modified endografts or fenestrated/branched EVAR. These data suggest that LIFE repair is a viable treatment option when no commercially-available solution exists, particularly among patients presenting with symptomatic or ruptured thoracoabdominal and pararenovisceral aortic pathologies. The need for longer-term evaluation of durability and reintervention rate is of paramount importance to fully assess the applicability of this technique.