Outcomes of fenestrated and branched endovascular aneurysm repair with an inverted contralateral limb.
To report technical success and evaluate clinical outcomes of fenestrated and branched endovascular aortic repair (F/B-EVAR) incorporating a contralateral inverted limb.
Patients who underwent F/B-EVAR with a custom-made bifurcated device containing an inverted limb between January 2010 and September 2023 were retrospectively analyzed. Time-to-event data were analyzed using the Kaplan-Meier method.
A total of 32 patients (26 men; mean age 77±6.2 years) were included in the analysis. Technical success was achieved in 28 patients (87.5%). Two technical failures resulted from misplaced contralateral limbs in patients with previous endovascular aortic repair (EVAR), necessitating one open conversion due to a type 3b endoleak, and one femoro-femoral crossover bypass after occlusion of a misplaced contralateral limb. Additionally, two technical failures were attributed to a type 3c endoleak and a type 1c endoleak, originating from a fenestrated device at the level of the left and right renal artery, respectively. One patient (3.1%) died <30 days post-operatively due to a subdural hemorrhage. Estimated patient survival after 1 and 2 years was 92.7%±5.1%, and 74.3%±10.1%, respectively. No aneurysm-related deaths were observed. During the median follow-up of 13 months, one (3.1%) inverted limb occluded, in addition to the occlusion resulting from a misplaced contralateral limb, and was treated with a femoro-femoral crossover bypass. One target vessel (right renal artery) occluded (0.9%), resulting in a permanent, significantly reduced renal function. Freedom from overall reintervention after 1 and 2 years was 73.5%±8.0% and 68.3%±9.0%, respectively. An additional four patients (12.5%) presented with a type 3c endoleak during follow-up scans, three of which originated from fenestrations at the level of the renal stents. There were no junctional problems between the inverted limb device and the main endograft, and no significant correlation was found between the one-sealing-stent inverted limb device design and the onset of type 3 endoleak (log-rank P=.064).
F/B-EVAR incorporating an inverted limb can be a viable endovascular option to manage complex aneurysms with a short renal artery to bifurcation distance. However, using the inverted limb presents a notable technical challenge and could be associated with a higher need for reintervention. Carefully confirming correct cannulation of the inverted limb is warranted.
Huistra EWM
，Tielliu IFJ
，de Vries JPM
，Zeebregts CJ
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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
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