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Introduction: Increasing experience with fenestrated/branched endovascular repair(F/B-EVAR) of acute visceral aortic disease has been reported due to the high risk of open repair, however durability remains unknown. The purpose of this analysis is to describe outcomes with F/B-EVAR for urgent or emergent presentations of visceral aortic disease in high risk surgical patients.
Methods: A single center retrospective review of all F/B-EVARs performed for urgent (repair <24h of admission) or emergent indications. Endografts were modified with fenestrations and/or directional graft branches based on centerline 3D CTA. Primary end-points included complications and mortality, and secondary end-points were reintervention, aneurysm diameter change and estimated glomerular filtration (eGFR) in follow-up. Life-tables were used to estimate freedom from events while mixed statistical models with random intercepts and slopes were used to demonstrate aneurysm diameter change.
Results: Between 2010-14, 37 patients (mean age±standard deviation, 67±10 years; 75% male) underwent urgent(N=27;73%) or emergent(N=10;27%) F/B-EVAR and median follow-up time was 6.3(range .5-31.4) months. Indications included thoracoabdominal aneurysm(N=24;65%), pararenal aneurysm(N=6;17%), post-surgical anastomotic pseudoaneurysm(N=3;8%), dissection(N=2;5%) and penetrating ulcer(N=2;5%). Mean preoperative aneurysm diameter was 7.3±1.8cm. All patients were ASA IV or IVE and 38%(N=14) had history of prior aortic repair. A total of 114 visceral vessels were revascularized (celiac, 26; superior mesenteric artery, 23; renal 65) and 25(68%) patients underwent 3 or 4-vessel repair. Technical success was 92%(N=33) with no intraoperative deaths and one conversion(3%).
Median LOS was 6(range 2-60) days and postoperative morbidity was 41%(N=15; neurologic 19%, pulmonary 13%, renal 14%, lower extremity ischemia 8%, cardiac 3%, bleeding 3%) with 30-day mortality of 19%(N=7; in-hospital 8%, N=3). Endoleak was detected at some point in follow-up in 27%(N=10). Six(16%) patients underwent reintervention and no late conversions occurred. Postoperative CT or duplex ultrasound was available in 25(68%) and 1 celiac fenestration lost patency at 12 months. One year branch vessel primary patency and freedom from reintervention was 98±6% and 70±9%, respectively. Estimated mean postoperative survival was 34.8 (95% CI 27.3-42.3) months. During the follow-up interval, aneurysm diameter decreased 0.5cm (95% CI -1.1, 0.2, P = .1) while preoperative eGFR compared to most recent follow-up value decreased on average by 2 mL/min/1.73m2.
Conclusion: F/B-EVAR for acute aortic pathology can be completed with a high degree of technical success, even in high-risk patients; however postoperative complications and mortality are significant. Despite the post-operative complications, given the overall complexity of patient comorbidities, their anatomy and mode of presentation, these results seem acceptable particularly if compared to historical open controls. Patients undergoing F/B-EVAR for acute visceral aortic disease can anticipate acceptable durability and long-term survival.