Outcomes of Elective and Non-elective Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms
Gustavo S. Oderich*1, Tomasz Jakimowicz2, Mark Farber3, Tilo Kolbel4, Jonathan Sobocinski5, Warren Gaper6, Mauro Gargiulo7, Luca Bertoglio8, On behalf of The International Aortic Research Consortium1
1Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX; 2Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland; 3Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, NC; 4Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center Hamburg, Hamburg, Germany; 5Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM, Lille, France; 6Department of Surgery, University of California, San Francisco, San Francisco, CA; 7Vascular Surgery, University of Bologna, IRCCS-University Hospital Policlinico S. Orsola, Bologna, Italy; 8Division of Vascular Surgery, San Raffaele Hospital, Milan, Italy
Purpose: The aim of this study was to describe outcomes of elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms (TAAAs).
Methods: We reviewed the clinical data of consecutive patients treated by FB-EVAR for Extent I to IV TAAAs in 24 international centers (2006-2021). All patients received manufactured patient-specific or off-the-shelf fenestrated-branched stent grafts. Endpoints were analyzed in patients who had elective or non-elective repair for ruptured and symptomatic TAAAs, including 30-day/in-hospital mortality, major adverse events (MAEs), patient survival and freedom from aortic-related mortality (ARM).
Results: There were 2603 patients (69% male; mean age 72±10 years-old) treated by FB-EVAR for Extent I (7%), II (35%), III (33%) and IV (25%) TAAAs. Elective repair was indicated in 2187 patients (84%) and non-elective repair in 416 patients (16%.) who presented with contained ruptured or symptomatic TAAAs. Patients who had elective repair were more often males (69% v 64%, p=.037), had lower incidence of congestive heart failure (15% v 21%, p=.001), peripheral arterial disease (23% v 43%, p<.001), chronic pulmonary obstructive disease (24% vs 33%, p<.001), chronic post dissection TAAAs (43% v 51%, p=.002), and had smaller aneurysm diameter (median [interquartile range] 63.0 [11.2] v 70.0 [24.6], p<.001). Use of multi-branch stent grafts (45% v 86%, p<.001) and upper extremity access was less frequent among patients who had elective repair (72% v 84%, p<.001). Mortality and MAEs at 30-day/in-hospital stay was significantly lower for elective compared to non-elective procedures (5% and 20% v 17% and 34%, p<.001). Median follow up was 20 months. Patient survival at 1-, 3- and 5-years was significantly higher for elective compared to non-elective repair (86±1%, 70±1% and 52±2% and 66±3%, 50±4% and 44±5% ,p<.001). Freedom from ARM was 94±1%, 93±1% and 90±1% % for elective and 81±2%, 77±3% and 74±3% for non-elective repair (p<.001). After adjustment for baseline and procedural variables, non-elective repair was associated with a two-fold increase in the risk of all-cause mortality (Hazard ratio (HR), 1.915; 95% Confidence Interval [CI], 1.502-2.440) and ARM (HR 2.431; 95% CI 1.631-3.623).
Conclusion: Elective FB-EVAR was associated with low mortality and rate of MAEs and low rate of aneurysm-related mortality at 5-years in this multi-center experience. Patients treated by non-elective FB-EVAR have more medical comorbities, larger aneurysms and a two-fold increase in all-cause mortality and risk of aneurysm-related death.
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