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Physician-Modified Fenestrated Endovascular Aortic Aneurysm Repair After Failed EVAR Offers Promising Results Compared to Open Conversion
Trung Nguyen, Mackenzie Gittinger, Weiwei Liu, Cara L Grzybowski, Shane Grundy, Bruce Zwiebel, Murray Shames, Dean J Arnaoutakis
University of South Florida, Tampa, FL

Background: The incidence of EVAR failure from poor proximal seal, although uncommon, is occurring with greater frequency. Conversion to open repair (EVAR-c) is the gold standard treatment but is associated with significant technical and physiologic challenges. Endovascular salvage by obtaining a more proximal seal zone with a fenestrated/branched endovascular repair (F/BEVAR) is an alternative treatment option. F/BEVAR is limited due to a lack of commercially available custom-made devices and potential overlap issues between the F/BEVAR and the prior EVAR device. Physician-modified F/BEVAR (PM-F/BEVAR) addresses these issues by obtaining the necessary proximal seal and relining the entire prior endograft. However, there is no data directly comparing periprocedural and long-term results of EVAR-c and PM-F/BEVAR. The purpose of this study was to evaluate changes in our practice pattern over time and compare outcomes of EVAR-c and PM-F/BEVAR in patients with failed prior EVAR.
Methods: A prospective database of consecutive patients treated at a single-center with EVAR failure due to poor proximal seal between January 2015 and June 2023 was retrospectively reviewed. All EVAR failures due to infection or thrombosis were excluded (n=56). The cohort was stratified by treatment strategy, either EVAR-c or PM-F/BEVAR. Demographics, operative details, postoperative complications were compared between the groups using univariate analysis. Two-year overall survival was compared using Kaplan-Meier method.
Results: Seventy-six patients underwent treatment of failed EVAR, 41 undergoing EVAR-c and 35 undergoing PM-F/BEVAR. The total number of EVAR-c/year peaked in 2019 (n=11) with the average number EVAR-c/year decreasing by 50% since the inception of a PM-F/BEVAR program in March 2021. Patients who underwent EVAR-c had similar age, gender, and comorbid conditions compared to those who had PM-F/BEVAR (Table I). PM-F/BEVAR patients had more extensive aortic disease, but EVAR-c patients presented more urgently. For EVAR-c patients, crossclamp position was typically supraceliac (n=33[80%]) and crossclamp time was 2717minutes. For the PM-F/BEVAR group, 132 fenestrations/branches were constructed with an average of 3.80.6 target arteries per patient. Fluoroscopy time, radiation dose, contrast use, and technical success were 7840minutes, 3,1031,778mGy, 8025mL, and 100% respectively. Postoperative endoleak was identified in 5 patients (type II: n=4, type Ib: n=1). Blood resource utilization, length of stay, acute renal failure, respiratory complications, and discharge status were significantly better in the PM-F/BEVAR group (Table II). PM-F/BEVAR had significantly decreased 30-day mortality (n=6[15%] vs n=0[0%]; p=.03) but there was no difference in 2-year overall survival (EVAR-c=75% vs PM-F/BEVAR=74%; log-rank p=.73).
Conclusions: Endovascular salvage of failed prior EVAR due to poor proximal seal using a PM-F/BEVAR is safe and effective with significantly better perioperative outcomes compared to EVAR-c. Clinical management of these complex patients has evolved to a predominantly PM-F/BEVAR approach. A PM-F/BEVAR strategy should be strongly considered as first-line therapy in patients with failed EVAR.

Table I: Preoperative characteristics and aneurysm details
VariableTotal(n=76)PM-F/BEVAR (n=35)EVAR-c (n=41)P-value
Male gender64 (84)30 (86)34 (84)1.00
Age, years75.4 (7.1)75.3 (7.4)75.6 (7.0).85
Coronary artery disease42 (55)20 (57)22 (54).82
Congestive heart failure6 (8)4 (11)2 (5).41
Hypertension73 (96)32 (91)41 (100).09
Body mass index26.4 (4.7)25.7 (4.9)27.0 (4.4).20
Chronic renal insufficiencya15 (20)7 (20)8 (20)1.00
Chronic pulmonary disease28 (37)17 (49)11 (27).06
Moderate-to-severe chronic pulmonary disease13 (17)9 (26)4 (10).08
Diabetes mellitus12 (16)5 (14)7 (17)1.00
Aneurysm Extent.06
Infrarenal5 (7)0 (0)5 (12)
Juxtarenal13 (11)3 (9)10 (24)
Pararenal26 (34)13 (37)13 (32)
Extent I TAAA0 (0)0 (0)0 (0)
Extent II TAAA1 (1)1 (3)0 (0)
Extent III TAAA6 (8)3 (9)3 (7)
Extent IV TAAA24 (32)14 (40)10 (24)
Extent V TAAA1 (1)1 (3)0 (0)
Max aneurysm diameter, mm72.3 (17.0)68.2 (14.7)75.7 (18.3).053
Elective, intact61 (80)33 (94)28 (68)
Urgent, symptomatic7 (9)1 (3)6 (15)
Emergent, rupture8(11)1 (3)7 (17)

Table II: Perioperative outcomes
Table 2:Total(n=76)PM-FEVAR (n=35)EVAR-c (n=41)P-value
Procedure time, minutes246 (90)241 (111)250 (69).67
Spinal drain insertiona8 (11)8 (23)0 (0).001
Estimated blood loss1,956 (2,244)219 (142)3,439 (2,127)<.001
RBC transfusion, # units3.4 (4.3)0.7 (1.2)5.8 (4.6)<.001
Overall length of stay, days10.3 (10.3)6.2 (4.0)13.9 (12.6).001
ICU length of stay, days7.7 (10.0)4.8 (3.2)10.1 (12.8).02
Any postoperative complication38 (50)8 (23)30 (73)<.001
30-day mortality6 (8)0 (0)6 (15).03
Major strokea2 (3)0 (0)2 (5).50
Permanent spinal cord ischemia1 (1)1 (3)0 (0).72
Acute renal failurec28 (37)3 (9)25 (63)<.001
Renal replacement therapy8 (11)1 (3)7 (18).07
Bowel ischemia3 (4)0 (0)3 (8).24
Respiratory complicationd15 (20)3 (9)12 (30).02
Discharge to home59 (77)34 (97)25 (60).001
30-day Readmission11 (15)3 (9)11 (15).20

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