American Surgical Association

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Analysis of the Learning Curve and Patient Outcomes of Endovascular Repair of Thoracoabdominal Aortic Aneurysms Using Fenestrated and Branched Endografts
Darren B. Schneider*, Sharif H. Ellozy*, Peter H. Connolly*, Andrew J. Meltzer*, Ashley R. Graham*, Fabrizio Michelassi
Weill Cornell Medicine and NewYork-Presbyterian Hospital, New York, NY

OBJECTIVE(S): Endovascular aneurysm repair has reduced morbidity and mortality compared to open surgical repair. However, application to thoracoabdominal aneurysm repair remains limited by procedural complexity and device availability. Our objective was to evaluate the learning curve of fenestrated and branched endovascular repair (F/BEVAR) of thoracoabdominal aneurysms.
METHODS: 50 consecutive patients treated in a prospective, nonrandomized, single-center IDE study (NCT02323581) between January, 2014 and July, 2017 were analyzed. Patients (mean age 75.67.5 years; mean aneurysm diameter 67.39.8 mm) underwent F/BEVAR of thoracoabdominal aneurysms (58% type IV; 42% type I-III) using custom-manufactured endografts. The experience was divided into 3 cohorts (Early: 1-17; Mid: 18-34; Late: 35-50) to evaluate learning curve effects on key process measures.
RESULTS: F/BEVAR included 194 visceral branches (average 3.9 per patient). Technical success was 99.5% (193/194 targeted branches). 30-d MAEs included 3(6%) deaths, 1(2%) new-onset dialysis, 3(6%) paraparesis/paraplegia, and 2(4%) strokes. 1-year survival was 797% with no late aneurysm-related deaths. Comparison of Early and Late groups revealed reductions in procedure time (45274 min vs. 36253 min; P=0.0001), fluoroscopy time 13040 min vs. 9927 min; P=0.016), contrast administration (15773 ml vs. 10838 ml; P=0.028), and EBL (1003933 ml vs. 481317 ml; P=0.042). ICU and total LOS decreased from 43 days to 21 days and 76 days to 52 days, respectively, but was not statistically significant.
CONCLUSIONS: Use of F/BEVAR for treatment of thoracoabdominal aneurysms is safe and effective. During this early experience there was significant improvement in key process measures reflecting improvements in technique and physician learning over time.

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