Comparison of EndoSuture vs fenestrated aortic aneurysm repair in treatment of abdominal aortic aneurysms with unfavorable neck anatomy.

Hostile aortic neck anatomy is associated with loss of proximal seal and increased late reinterventions. Although both EndoSuture aneurysm repair (ESAR) and fenestrated endovascular aortic repair (FEVAR) are commercially available options for treatment of short neck aneurysms, branch vessel patency is a potential tradeoff for improved seal with FEVAR owing to the incorporation of renovisceral vessels. This study compares the performance of ESAR vs FEVAR in hostile aortic necks. Patients who underwent elective ESAR or FEVAR for hostile neck AAAs at a single center from 2012 to 2024 were reviewed retrospectively. Exclusion criteria included pararenal or thoracoabdominal aortic aneurysm, off-label modifications, and nonstandard FEVAR configurations. Propensity matching weights were generated based on age, year of operation, preoperative estimated glomerular filtration rate, neck length, neck diameter, and infrarenal angulation. Rates of survival, reintervention, dialysis, chronic kidney disease stage progression, type IA endoleak (EL), and sac regression (>5 mm) were assessed at latest follow-up. Of 391 patients, 60 with ESAR and 207 with FEVAR were included. FEVAR patients were younger (74.4 years vs 79.8 years; P < .001) with larger neck diameters (25.0 mm vs 23.6 mm; P = .016), shorter neck length (5.0 mm vs 9.8 mm; P < .001), and decreased infrarenal angulation (20° vs 40°; P < .001). After propensity score-adjusted regression (58 ESAR, 169 FEVAR), FEVAR, compared with ESAR, was associated with decreased IA EL (hazard ratio, 0.341; 95% confidence interval [CI], 0.061-0.72; P = .031) and increased sac regression (hazard ratio, 3.92; 95% CI, 1.25-5.14; P = .02). Notably, FEVAR was associated with increased 1-year aneurysm-related reintervention (odds ratio, 4.33; 95% CI, 1.12-10.54; P = .046). On Kaplan-Meier analysis, FEVAR was associated with reduced freedom from reinterventions at 3 years (71.8% [95% CI, 0.63-0.78] vs 93.5% [95% CI, 0.80-0.97]; log-rank P = .019) but a trend toward improved survival at 3 years (79.15% [95% CI, 0.70-0.85] vs 61.5% [95% CI, 0.44-0.74]; log-rank P = .095). There was no significant difference in new-onset chronic dialysis between ESAR and FEVAR at 3 years (94.2% [95% CI, 0.82-0.98] vs 97.4% [95% CI, 0.93-0.99]; log-rank P = .124). In the treatment of abdominal aortic aneurysms with hostile neck anatomy in this propensity-matched cohort, FEVAR was associated with fewer type IA ELs and greater sac regression compared with ESAR, with no detrimental impact on long-term renal function. There were more reinterventions, mostly branch related, in the FEVAR group. We await the results of the current randomized prospective trial comparing these strategies to further determine the impact of these clinical differences on aneurysm-related mortality.

Fereydooni A ，Satam K ，Dossabhoy S ，Trogolo-Franco C ，Sorondo S ，Arya S ，Ullery BW ，Lee JT ... -  《-》

Effect of narrow paravisceral aorta on target vessel instability after fenestrated and branched endovascular aortic repair.

To investigate the effect of narrow paravisceral aorta (NPA) on target vessel instability (TVI) after fenestrated-branched endovascular aortic repair. We conducted a single-center retrospective study (2014-2023) of patients treated by fenestrated-branched endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. The paravisceral aorta was defined as the aortic segment limited by the diaphragmatic hiatus proximally and the emergence of lower renal artery distally, and was considered "narrow" in case of a minimum inner diameter of <25 mm. The minimum aortic diameter, location, longitudinal extension, angulation, calcification, and thrombus thickness of NPA were evaluated at the preoperative computed tomography angiogram. End points were 30-day technical success and freedom from TVI. There were 142 patients with JRAA/pararenal aortic aneurysm (n = 85 [59%]) and extent IV (n = 24 [17%]) or extent I-III (n = 33 [23%]) TAAA, with 513 target arteries successfully incorporated through a fenestration (n = 294 [57%]) or directional branch (n = 219 [43%]). A NPA was present in 95 patients (70%), 73 (86%) treated by fenestrated endovascular aortic repair (FEVAR) and 22 (39%) by branched endovascular aortic repair (BEVAR). The overall 30-day mortality was 2% and technical success was 99%, without differences between NPA and non-NPA (P = .99). Kaplan-Meier estimated freedom from TVI at 4 years was 82%, 81% (95% CI, 75-95) in patients with a NPA and 80% (95% CI, 68-94) and in those without NPA (P = .220). The result was maintained for both FEVAR (NPA: 81% [95% CI, 62-88]; non-NPA: 76% [95% CI, 60-99]; P = .870) and BEVAR (NPA: 77% [95% CI, 69-99]; non-NPA: 80% [95% confidence interval (CI) 66-99]; P = .100). After multivariate analysis, the concomitant presence of a NPA <20 mm and angulation of >30° was significantly associated with TVI in FEVAR (HR, 3.21; 95% CI, 1.03-48.70; P = .036), being the result mostly driven by target vessel occlusion. In BEVAR, a NPA diameter of <25 mm was not associated with TVI (HR, 2.02; 95% CI, 0.59-5.23; P = .948); after multivariate analysis, the use of outer branches in case of a NPA longitudinal extension of >25 mm (hazard ratio [HR], 3.02; 95% CI, 1.01-36.33; P = .040) and NPA severe calcification (HR, 1.70; 95% CI, 1.00-22.42; P = .048) were associated with a higher chance for TVI. FEVAR and BEVAR are both feasible in cases of NPA and provide satisfactory target vessels durability. The use of outer branches should be avoided in cases with an inner aortic diameter of <25 mm with a longitudinal extension of >25 mm or moderate to severe NPA calcifications. In FEVAR, bridging stent patency may be negatively influenced by NPA of <20 mm in association with aortic angulation of >30°.

Piazza M ，Squizzato F ，Forcella E ，Bilato MJ ，Colacchio EC ，Grego F ，Antonello M ... -  《-》

Type IA Endoleak Correction With Fenestrated Devices After EVAR: Outcomes and Predictors of Secondary Failure.

Mesnard T ，Daher M ，Patterson BO ，Lebaz-Dubosq M ，Azzaoui R ，Pruvot L ，Haulon S ，Sobocinski J ... -  《-》

Endovascular vs open repair of ruptured abdominal aortic aneurysms with hostile neck anatomy.

Aneurysm neck anatomy in ruptured abdominal aortic aneurysms (rAAAs) is often complex, limiting the feasibility of endovascular repair (EVAR). The objective of this study was to compare the outcomes of EVAR and open surgical repair (OSR) for treatment of rAAAs in patients with hostile neck anatomy (HNA). The secondary aim was to review the clinical characteristics and anatomic risk factors predictive of mortality. A multi-center retrospective review was performed to identify patients with rAAAs and HNA between 2004 and 2021. HNA was defined as infrarenal aortic neck diameter >28 mm, infrarenal neck length <15 mm, or angulation >60 degrees. The primary end point was 30-day all-cause mortality. Secondary end points included 90-day, 1-year, and 5-year mortality. Preoperative computed tomography was analyzed using an Aquarius workstation. The Kaplan-Meier method was used to estimate survival, and univariate and multivariate Cox proportional hazard regression analysis was used to assess variables that influenced survival. A total of 137 patients with rAAAs and HNA underwent infrarenal EVAR or OSR. Overall mean age was 74 ± 10 years, and 72% were male. Eighty-five patients (62%) underwent infrarenal EVAR, and 52 (38%) underwent OSR. Mean aneurysm size at the time of rupture was 86 ± 22 mm. Patients who underwent OSR were more likely to present with a higher Garland preoperative risk score (P = .05), have a lower pH (P < .001), lower systolic blood pressure (P < .001), and higher lactate (P = .005). Patients with an infrarenal neck length <15 mm were more likely to undergo OSR (EVAR 64% vs OSR 87%; P = .004), and patients with an infrarenal neck angle >60 degrees were more likely to undergo EVAR (60% vs 39%; P = .01). EVAR was associated with lower 30-day (17% vs 27%; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3-1.2; P = .14) and 90-day (22% vs 33%; hazard ratio [HR], 0.6; 95% CI, 0.3-1.2; P = .17) all-cause mortality; however, this was not statistically significant. The overall median follow-up time was 19 months (range, 2-66 months). One-year survival for EVAR and OSR were 75% and 64% (log-rank P = .14), and 5-year survival for EVAR and OSR were 65% and 55% (log-rank P = .28). Hemoglobin (P = .009), increasing calcification score (P = .002), and infrarenal neck length <10 mm (P = .01) were associated with all-cause mortality at 30 days for EVAR on multivariate Cox regression analysis. Lactate (P < .001) was the only variable associated with all-cause mortality at 30 days for OSR on multivariate Cox analysis. Early and long-term survival favored EVAR in comparison to OSR in patients with rAAAs and HNA; however, this was not statistically significant. Calcification of the infrarenal neck and neck length <10 mm were associated with increased 30-day mortality for EVAR, whereas no anatomic variables were specifically associated with 30-day mortality for OSR.

Pitcher GS ，Sen I ，Newhall KS ，Stoner MC ，Mendes BC ，Mix D ... -  《-》

Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry.

Isernia G ，Simonte G ，Gallitto E ，Bertoglio L ，Fargion A ，Melissano G ，Chiesa R ，Lenti M ，Pratesi C ，Faggioli G ，Gargiulo M ，Italian Multicenter Fenestrated and Branched Study Group* ... -  《-》