Differences in procedural metrics and clinical outcomes among patients treated by fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms using infrarenal aortic versus iliac sealing zones.

Abstract

PURPOSE\nThe purpose of this study was to assess outcomes of fenestrated branched endovascular aortic repair (FB-EVAR) using infrarenal aortic versus iliac sealing zones.\n\n\nMETHODS\nWe reviewed the clinical data of 430 consecutive patients enrolled in a prospective non-randomized study to evaluate FB-EVAR between 2013 and 2020. Outcomes were analyzed in patients with Extent I-IV TAAAs who underwent FB-EVAR with distal implantation in the native infrarenal aorta. Minimum anatomical criteria for use of infrarenal aortic seal was >3-cm length of parallel aorta with diameter of 18-32 mm without excessive thrombus or calcification. A control group matched for extent of aortic disease with iliac arteries seal was used to compare end-points including 30-day mortality, major adverse events (MAEs), freedom from Type Ib endoleak (TIbE), freedom from secondary interventions and changes in infra-renal aortic diameter.\n\n\nRESULTS\nThere were 110 patients (55 males, mean age 73±8 years old) included in the study, 55 with infrarenal aortic distal seal and 55 with iliac arteries as sealing zone. Both groups had similar clinical characteristics, aneurysm extent and diameter, except for more male patients and higher serum creatinine among those who had iliac seal. Technical success was obtained in 106 patients (96%) and it was higher for iliac sealing zone (100% vs 93%; p 0.04). Infrarenal aortic sealing zone was associated with shorter endovascular (148±56 vs 191±61 min, p <0.001) and fluoroscopy time (76±28 vs 96±32 min, p <0.001), lower cumulative air kerma (1.4±1.4 vs 2.1±2.0 Gy, p 0.02) and dose area product (147±75 vs 208±102 Gy.cm2, p 0.006). There was one (1%) 30-day mortality. There was no difference in MAEs among patients treated with infrarenal aortic vs iliac sealing zones (22% vs 18%, p 0.63), including any spinal cord injury (13% vs 9%, p 0.54) and grade 3 spinal cord injury (7% vs 7%, p 1.0). Mean clinical follow up was 24±18 months. TIbE occurred in one patient in each group (p 1.0). Freedom from TIbE and freedom from secondary intervention was 98±2% and 67±8% for patients with infrarenal aortic seal and 97±3% and 67±8% for those who had iliac seal at 3-years, respectively (p NS). Among patients treated with infrarenal aortic sealing zones, the mean enlargement of infrarenal aortic diameter was 5±3.2 mm at 3 years. There were no late TIbE due to progression of disease in the infrarenal aorta.\n\n\nCONCLUSION\nInfrarenal aortic and iliac artery seal zone are safe and effective during FB-EVAR, provided patients have suitable segments. The use of infrarenal aortic sealing zone has modest procedural advantages such as shorter endovascular and fluoroscopy time and lower radiation exposure. There was no difference in clinical outcomes and TIbEs.