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Effect Of Fenestration Configuration On Renal Artery Outcomes During Fenestrated-Branched Endovascular Aortic Repair
Vivian Carla Gomes1, F. Ezequiel Parodi1, Sydney E. Browder2, Matthew J. Eagleton3, Gustavo Oderich4, Bernardo Mendes5, Emanuel R. Tenorio4, Andrea Vacirca6, Jesse Chait5, Mark A. Farber1
1Division of Vascular and Endovascular Surgery, University of North Carolina, Chapel Hill, NC;2Department of Biostatistics, University of North Carolina, Chapel Hill, NC;3Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA;4Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center, Houston, TX;5Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN;6Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy

Background: The aim of this study was to evaluate the effect of fenestration configuration on renal artery outcomes during fenestrated-branched endovascular aortic repair (FB-EVAR).
Methods: A retrospective multicenter analysis of patients with thoracoabdominal aortic aneurysms (TAAA), pararenal, and short-neck infrarenal abdominal aneurysms treated with FB-EVAR including at least one small fenestration to a renal artery were included. The renal fenestrations were divided into group 1 (8x6 mm) and group 2 (6x6 mm). Primary patency, target vessel instability (TVI), and freedom from secondary interventions (SIs), all related to the renal arteries, were analyzed at 30-day, 1-year and 5-year landmarks. Size of fenestration gap (FG) was analyzed as a modifier and clustering was addressed at the patient level.
Results: There was 796 patients included in this study, 71.7% male, with a mean age of 73.38.1 years. The mean follow-up was 30.020.6 months. Of the 1474 small renal fenestrations analyzed, 47.6% were 8x6 and 52.4% were 6x6mm. Technical success related to the renal fenestrations was 99.6% and 99.2% in groups 1 and 2, respectively. At the 30-day landmark (Table 1), primary patency, freedom from TVI, and from SI were higher in group 1 (p=0.022, 0.043, and 0.007, respectively), and the incidence of AKI was the same across the groups (p=0.9383). The primary patency (Figure 1A) at 1 year and 5 years was higher in group 1 (p=0.001 and 0.032, respectively). The freedom from TVI at 1 year was not different between the groups (p=0.925), but significantly trended higher in group 2 at 5 years (p=0.036). The freedom from Sis was higher in group 2 at 1 and 5 years, although only significantly at 5 years (p=0.01). The groups were equally as likely to experience a type Ic endoleak or kidney function deterioration (p = 0.998 and 0.966 respectively). The risk of type IIIc endoleak trended higher in group1 at 30-day and 1 year, but the difference was only significant at 5 years. The presence of an FG larger than 5 mm negatively impacted the freedom from TVI (p<0.0001 for both, Figure 1B) and the freedom from type IIIc endoleak (p=0.034 and <0.0001 in groups 1 and 2, respectively, Figure 1C) in both groups and the 5-year patency in group 2 (p=0.036).
Conclusions: Fenestration configuration for the renal arteries impacts outcomes. The 8x6 small fenestrations have better patency at 30-days, 1 year, and 5 years, while 6x6 small fenestrations are associated with lower rates of secondary interventions, mostly due to a lower incidence of type IIIc endoleaks. Fenestration gap ≥5 mm at the level of the renal arteries significantly impacts the freedom from TVI, freedom from type IIIc endoleak in both groups and 5-year patency in group 2 independent of the fenestration size.


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