Outcomes Of Fenestrated And Branched Endovascular Repair Are Driven By Aneurysm Extent
Asma Mathlouthi, Maryam Ali Khan, Eugene Golts, Sukgu Han, Mahmoud B Malas, Andrew R Barleben
University of California, San Diego, San Diego, CA
INTRODUCTION: Fenestrated and branched endovascular aneurysm repair (F-BEVAR) have helped widen the range of thoracoabdominal (TAAAs) and pararenal aneurysms (PRAs) treated. While aneurysm extent has been shown to impact short and long-term outcomes after open repair, reports addressing its effect on endovascular repair are scarce with conflicting results. Thus, we sought to evaluate the impact of aneurysm extent on short and long-term outcomes following F-BEVAR. METHODS: We identified patients who underwent F-BEVAR for TAAA or PRA between January 2014 and December 2018 in the Vascular Quality Initiative-Medicare linked database. Patients with ruptured aneurysms were excluded. The remaining patients were divided into extensive (TAAA extent I-III) and non-extensive (TAAA IV, V and PRA) aneurysm groups. In-hospital outcomes included technical success, endoleak at completion imaging, stroke, spinal cord ischemia, bowel ischemia and mortality while long-term outcomes included 3-year freedom from reintervention, rupture and all-cause mortality (ACM). RESULTS: Over the study period, 2,545 F-BEVAR were performed for 1,517 (59.6%) extensive and 1,028 (40.4%) non-extensive aneurysms. Analysis of in-hospital outcomes showed significantly higher rates of stroke (2.9% vs. 1.2, P<0.001), spinal cord ischemia (5.2% vs. 1.7%, P<0.001) and mortality (4.9% vs. 2.5%, P<0.001) in the extensive group. At 3 years, the non-extensive group achieved higher rates of freedom from reintervention (79.5% vs. 70.5%), freedom from rupture (90.6% vs. 84.2%) and freedom from ACM (68.7% vs. 62.1%) (All P<0.05). After adjustment, F-BEVAR for extensive TAAAs was associated with a 47% increase in the risk of death [aHR(95%CI):1.47(1.2-1.8)], an 82% increase in the risk of rupture [aHR(95%CI):1.82(1.3-2.6)] and a 2-fold increase in the risk of reintervention [aHR(95%CI):2(1.6-2.5)] at 3 years (All P<0.05).
CONCLUSIONS: Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair exhibited worse short and long-term outcomes. The extent of disease and length of coverage likely contributes to these differences. Further prospective research evaluating new devices that may be more effective in the treatment of extensive TAAA is warranted. 
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