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Midterm Results After Endovascular Repair of Complex Aortic Aneurysms Using Inverted Limb Bifurcated Devices
Jesus Porras Colon, Khalil H Chamseddin, Carla K Scott, Felipe Pavarino, Marilisa Soto Gonzalez, Mirza S Baig, Carlos H Timaran
UT Southwestern Medical Center, Dallas, TX

Background: Fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR) is a less invasive treatment method of complex aortic aneurysms with acceptable long-term results. Similarly, F-BEVAR has demonstrated to be an adequate alternative for the rescue of prior failed EVAR with type Ia endoleaks or recurrent aneurysms after prior open aortoiliac repair. However, patients with a short distance between the renal arteries and the aortic bifurcation can be challenging for endovascular treatment using standard bifurcated devices. The use of an inverted limb bifurcated device may overcome these anatomic limitations. The purpose of this study was to evaluate the mid-term outcomes of patients treated with inverted iliac limb bifurcated devices used in conjunction with fenestrated-branched stent-grafts.
Methods: A retrospective analysis of a prospectively maintained database of 268 patients undergoing F-BEVAR between March 2015 and August 2021 was performed. Patients that received a customized distal inverted iliac limb bifurcated device to dock the contralateral gate as part of a physician-sponsored investigational device exemption study were included. End points were technical success, 3-year survival, type I or III endoleaks, limb occlusion, and secondary reintervention. 
Results: A total of 65 patients (84% male, mean age 77 years) received an inverted limb device; 47 (72%) were used with fenestrated devices, five (8%) with branched devices and 13 (20%) with fenestrated-branched devices. Forty-four (67%) patients had prior EVAR with a type Ia endoleak, six (9%) prior open abdominal aortic repair and 15 (23%) demonstrated short distance between the native lowest renal artery and aortic bifurcation. Technical success was 100 % and 3-year survival was 86%. No deaths were related to the inverted limb device. The mean distance between the lowest renal to the aortic bifurcation was 6528 mm. The mean device diameter was 240.7 mm. At a mean follow-up of 40 months, three patients developed endoleaks, one type IIIa, one type IIIb and one type Ib from an iliac limb. Two patients developed inverted limb occlusions. All were successfully treated by angioplasty and restenting.
Conclusion: The use of an inverted limb bifurcated device during F-BEVAR is safe and with satisfactory mid-term outcomes. Inverted limb devices provide an optimal alternative for the endovascular treatment in patients with a short distance between the renal arteries and aortic bifurcation that prevents the use of standard bifurcated components.


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