Effects of Preoperative Visceral Artery Stenosis on Target Artery Outcomes after Fenestrated/Branched Endovascular Aortic Aneurysm Repair (F-BEVAR)
Carla K Scott, David E Timaran, Marilisa Soto Gonzalez, Fatemeh Malekpour Ghorbani, Melissa L Kirkwood, Carlos H Timaran
UT Southwestern Medical Center, Dallas, TX
Objective: Visceral artery stenosis is among the exclusion criteria for F-BEVAR trials. Whether branch stability is affected by preoperative stenosis is unknown. The aim of this study was to assess the effects of preoperative stenosis of the celiac and superior mesenteric artery (SMA) on target artery outcomes after F-BEVAR.
Methods: During a 4-year period, 287 consecutive patients, 204 men (71%) and 83 women (29%), underwent F-BEVAR using branched (6%), fenestrated (36%), off-the-shelf t-Branch (9%) and fenestrated/branched devices (49%). Preoperative SMA and celiac artery significant stenosis was defined as a CTA-based intraluminal diameter reduction > 50%. Primary endpoints included primary patency, freedom from branch instability and patient survival.
Results: Median age was 71 years (interquartile range [IQR], 67-77 years). Suprarenal (61%) and thoracoabdominal aortic aneurysms (39%) were treated. Technical success was 99%. 30-day survival was 97%. Among 981 stented vessels, 139 (14%) were celiac arteries and 270 (27.5%) were SMAs. Significant preoperative celiac artery stenosis was identified in 49 patients (17%) and SMA stenosis in 24 (8.3%). The median follow-up was 29.9 months. Primary patency rates at 12, 36 and 60 months were 98%, 92% and 92% for the celiac artery and 99%, 98% and 98% for the SMA, respectively. Primary patency was significantly lower in patients with previous significant celiac artery stenosis than in those without stenosis (76%, 76% and 76% vs. 100%, 97% and 97% at 12, 36 and 60 months, respectively; p<0.01). Freedom from celiac branch instability was also significantly lower among patients with significant stenosis (76%, 76% and 76% vs. 100%, 93% and 93% at 12, 36 and 60 months; p<0.01). Significant SMA stenosis did not affect either primary patency (99%, 98% and 98% vs. 100%, 100% and 100% among patients with and without stenosis at 12, 36 and 60 months, respectively; p=0.1) or freedom from branch instability (98%, 98% and 98%, vs. 100%, 100% and 100% among patients with and without stenosis at 12, 36 and 60 months, respectively; p=0.5). Overall survival rate was 91%, 84% and 84% at 12, 36 and 60 months, respectively. Survival rates at 12, 36, and 60 months were significantly lower in patients with celiac artery stenosis than in those without stenosis (70%, 64% and 43% vs. 92%, 84% and 84%, respectively; p<0.01). Similarly, lower survival rates were observed in patients with significant SMA stenosis (78%, 52% and 52%, vs. 89%, 81% and 81% at 12, 36 and 60 months, respectively; p=0.04).
Conclusion: F-BEVAR is associated with overall primary patency rates higher than 90% for the celiac artery and SMA. Preoperative celiac artery stenosis is associated with lower primary patency and freedom from branch instability. Conversely, neither SMA branch primary patency nor freedom from branch instability was affected by preoperative SMA stenosis. Of importance, visceral artery stenosis is a marker of atherosclerosis burden associated with reduced mid- and long-term patient survival.
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