Analysis of Results after Ch-EVAR for Patients with Less Than a Five Millimeter Proximal Neck.
Brian M. Rapp, A. Carson Milner, Andrew B. Giggey, M. Zachary Arko, Charles S. Briggs, Stephen G. Lalka, Frank R Arko, III
Sanger Heart and Vascular Institute, Charlotte, NC
Introduction: Ch-EVAR is becoming increasingly used to repair aneurysms that extend into the visceral segment of the aorta (renal, superior mesenteric and celiac arteries) in patients with a disadvantaged proximal neck. The purpose of this study is to examine and quantify the long-term outcomes of Ch-EVAR at a large tertiary referral center, in patients in whom the proximal neck was less than 5 mm.
Methods: Between 2011 and 2015, 463 patients underwent EVAR at a single institute. A total of 89 Ch-EVAR were performed. Of those 89 patients, 168 visceral or renal arteries were stented [9 Celiac (5%), 36 SMA (22%), 61 Right Renal (36%), 62 Left Renal (37%)]. Patients underwent Ch-EVAR for a proximal neck of less than 5mm, with a neck diameter of 32 mm or less in the 5 mm zone. Follow-up including post-operative CTA’s at 1 month, 6 month, 1 year, and then yearly after were performed. Further imaging was performed if there was the presence of an endoleak. Follow-up evaluation included AAA size, presence of a endoleak, need for re-intervention at 1 year, 2 year and 3 year post-operation, vessel patency, need for dialysis, 30 day mortality rate, and long-term survival 1 year, 2 year and 3 year post-operation.
Results: Thirty-day mortality rate was 2.3% (2 out of 89) with an 18% morbidity rate. Mean follow-up was 9 months (range, 1 to 36 months). Ch-EVAR resulted in a statistically significant decrease in aneurysm size from pre-operation to post-operation follow-up CTA scans [58.09+/- 10.82 mm versus 55.72+/- 13 mm (p=0.01)]. Endoleak was present in 11 patients (12.3%), with 7 (7.8%) being a type II and 4 (4.4%) being a type I. Freedom from re-intervention was 86%, 84%, and 80% at 1 year, 2 years, and 3 years, respectively. This procedure resulted in 2 (2.3%) patients being put on dialysis (34 and 39 days post) with patency rate of chimney vessels being 97.4% (164 of 168). Survival rate at 1 year, 2 years, and 3 years was 91%, 82%, and 82% respectively and freedom from aneurysm related death at 1 year, 2 years, and 3 years was 98%, 96%, and 96%, respectively.
Conclusion: Ch-EVAR is a reasonable procedure that is associated with excellent perioperative morality rates. Sac regression is clearly seen in the majority of the patients treated with neck lengths less than 5 mm. Patency of chimney vessels long term is excellent at 97.4 percent. Long-term survival is reasonable and long-term from aneurysm-related mortality is superb. Continued follow-up will be required, but Ch-EVAR appears safe and effective in this, the largest reported Ch-EVAR series published.
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