Fenestrated and branched endovascular aortic repair (FB-EVAR) is widely used to treat thoracoabdominal aortic aneurysms (TAAAs) with satisfactory early and midterm outcomes (1). Chronic post-dissection TAAAs (PD-TAAAs) present a unique set of technical challenges, such as more difficult vessel catheterisation due to compression of the true lumen or extension of the dissection flap into target arteries (2). This multicentre international study aimed to analyse outcomes of FB-EVAR for treatment of PD-TAAAs.

We reviewed the clinical data of consecutive patients treated by FB-EVAR for Extent I-IV PD- TAAAs in 15 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events (MAEs) at 30-days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12Fr sheath) and major (open or >12Fr sheath) secondary interventions, and patient survival and freedom from aortic-related mortality (ARM).

A total of 246 patients (76% male; median age 67 years [IQR 61-73]) were treated for Extent I (7%), Extent II (57%), Extent III (24%) and Extent IV (11%) PD- TAAAs (Median aneurysm diameter, 65mm [IQR 59-73]) by FB-EVAR. 18 patients (7%) were octogenarians, 212 (86%) were American Society of Anaesthesiologists (ASA) class 3 and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 577 fenestrations (63%) and 356 directional branches (37%), with a mean of 3.7 vessels/patient. Technical success was 99%. The 30-day mortality was 3% and MAEs occurred in 28%, including acute kidney injury in 8%, new-onset dialysis in 1%, major stroke in 1%, spinal cord injury in 7% and permanent paraplegia in 2%. Median follow-up was 14 months (IQR 3.5 - 37.3). Patient survival and freedom from ARM were 67±6% and 96±3% at 5 years, respectively (Fig 1). Secondary interventions were needed in 93 patients (38%), including minor procedures in 68 (28%) and major in 30 (12%). There was 1 conversion to open repair (<1%). Freedom from any secondary intervention was 47±5% at 5-years (Fig 2). The 5-year primary and secondary patency and freedom from TA instability were 94±2%, 98±1% and 82±3%, respectively.

FB-EVAR was associated with high technical success and low mortality (3%), new-onset dialysis (1%) and permanent paraplegia rates (2%) in patients with chronic PD-TAAAs. Although the procedure is effective against ARM, patient survival was low at 5-years (67%) likely due to advanced age and significant comorbidities. Freedom from secondary interventions at 5-years was 47%, although most were minor procedures and conversion to open repair was needed in only 1 patient. This study highlights the need for continued follow-up surveillance.

1) Oderich GS, Farber MA, Schneider D, Makaroun M, Sanchez LA, Schanzer A, et al. Final 5-year results of the United States Zenith Fenestrated prospective multicenter study for juxtarenal abdominal aortic aneurysms. Journal of Vascular Surgery. 2021;73(4):1128-38.e2. 2) Oikonomou K, Katsargyris, A., Ritter, W., Spinelli, D., Seto, Y., Verhoeven, E. L. Endovascular management of chronic post-dissection aneurysms. Ann Cardiothorac Surg. 2014;3(3):307-13.