Effect of Aortic Angulation on the Outcomes of Fenestrated-Branched Endovascular Aortic Repair.

Abstract

OBJECTIVE\nTo investigate the effect of aortic angulation on the early and mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) for thoracoabdominal (TAAA) or pararenal (PRAA) aortic aneurysms.\n\n\nMETHODS\nWe retrospectively reviewed the data of consecutive patients enrolled in a prospective non-randomized physician-sponsored investigational device exemption study (2013-2018). The infrarenal, suprarenal, and supraceliac aortic angles were measured on 3-dimensional reconstructions of the pre-operative computed tomography angiogram; a 45° cutoff was used for the analysis. Endpoints were technical success, freedom from endograft-related complications (defined by type IA/IB/IIIA/IIIB/IIID endoleaks, and limb thrombosis); and freedom from target vessel instability (defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak or disconnection). Cox proportional hazard multivariable regression analyses were preformed to assess impact of covariates.\n\n\nRESULTS\nThere were 298 patients treated for 102 (34%) PRAAs and 196 (66%) TAAAs (78 Extent IV, 118 Extent I-III) with 1156 renal-mesenteric vessels incorporated. Angulation >45° was present in the infrarenal aortic axis in 94 (32%) patients, suprarenal axis in 39 (13%) and supraceliac axis in 93 (31%). A supraceliac angle >45° was more common with Extent I-III TAAAs (P=.01). Technical success was 97%, and was not significantly related to aortic angulation; total operating time and fluoroscopy time were significantly longer in patients with any aortic angulation >45°. Freedom from endograft-related complications was 93% (95%CI 90-97) at 42 months, and was not associated with infrarenal (HR 1.0, 95%CI 0.4-2.9; P=.976), suprarenal (HR 1.7, 95%CI 0.5-1.8; P=.428) or supraceliac (HR 0.9, 95%CI 0.3-2.6; P=.886) aortic angles >45°. Overall freedom from target vessel instability was 92% (95%CI 90-94) at 42 months. By multivariable analysis, target vessel instability was not affected by infrarenal angle >45° (HR 1.5, 95%CI 0.9-2.4); P=.135) and supraceliac angle>45° (HR 0.9, 95%CI 0.5-1.5; P=.627), but was associated with suprarenal angle >45° (HR 5.6, 95%CI 3.5-9.1; P<.001) even after adjustment for aneurysm extent and type of bridging stent. In this subgroup of patients, the use of directional branch versus fenestration (P=.10) and the type of bridging stent (P=.10) did not significantly impact target vessel instability.\n\n\nCONCLUSION\nF-BEVAR can achieve excellent early and mid-term results among patients with aortic angulation >45°, with no increase in rates of graft-related complications. However, increased aortic angulation was associated with longer operative and fluoroscopy time. Suprarenal aortic angle was the most important determinant of more target vessel events, independent of stent design or which bridging stent was selected.