O-224 - SYSTEMATIC REVIEW AND META-ANALYSIS OF PHYSICIAN MODIFIED ENDOGRAFTS FOR TREATMENT OF THORACO-ABDOMINAL AND COMPLEX ABDOMINAL AORTIC ANEURYSMS.

TOPIC:
Thoraco-abdominal Aortic Disease
AUTHORS:
Gouveia E Melo R. (Ludwig Maximilian University Hospital ~ Munich ~ Germany) , Fernández Prendes C. (Ludwig Maximilian University Hospital ~ Munich ~ Germany) , Caldeira D. (Centro Hospitlar Universitários Lisboa Norte ~ Lisbon ~ Portugal) , Stana J. (Ludwig Maximilian University Hospital ~ Munich ~ Germany) , Rantner B. (Ludwig Maximilian University Hospital ~ Munich ~ Germany) , Wanhainen A. (Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden. ~ Uppsala ~ Sweden) , S Oderich G. (Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, USA. ~ Houston ~ United States of America) , Tsilimparis N. (Ludwig Maximilian University Hospital ~ Munich ~ Germany)
Introduction:
Complex endovascular aortic repair with fenestrated and branched grafts has allowed to extend treatment for a wider variety of patients, including those who are less suitable or unfit for open surgery. Custom-made devices have been at the cornerstone of this improvement in outcomes. However, the limitation of this technique is the time needed for graft manufacturing, which can take up to 3 months, increasing the risk for aneurysm-related complications during this period. Patients with very large aneurysms, symptomatic or ruptured aneurysms cannot wait this time, which calls for alternative solutions. Physician modified endografts (PMEGs) have been proposed as an option for these situations and studies have reported acceptable results. However, data regarding this technique are dispersed and no multicenter studies have been performed. This means that a systematic review and meta-analysis of the literature analyzing the techniques and outcomes of this surgical option would aid in clinical decision making.
Methods:
We searched MEDLINE, CENTRAL, Web of Science Core Collection, Scielo and Open Grey databases from inception to July 2021 for studies reporting on outcomes of PMEGs for TAAA or C-AAA repair. A systematic review was conducted following the PRISMA guidelines (protocol CRD42021267856). Data were pooled using a random-effects model of proportions using Freeman-Tukey double arcsine transformation. The outcomes analyzed were major adverse events at 30-days [30-day mortality, myocardial infarction, respiratory failure requiring prolonged ventilation (>24h or re-intubation), renal failure requiring dialysis, bowel ischemia requiring surgery, major stroke or definitive paraplegia]; technical success; 30-day mortality; ruptures; spinal cord ischemia; endoleaks; re-interventions and target vessel patency. All outcomes were analyzed by urgency of repair, aneurysm location and technique of repair (fenestrated versus branched/fenestrated repair).
Results:
Twenty studies were included. Overall study quality assessment was found to be low seeing as most were single-center retrospective studies. Publication bias was found to be non-significant for small study effects. Overall, 909 PMEGs were reported and analyzed. Regarding aneurysm location, 222 patients had extent I-III TAAAs and 645 had C-AAA or extent IV TAAA. One study did not report specific TAAA subtype, reporting 23 C-AAA and 18 extent I-IV TAAAs. Regarding presentation, 14 studies reported if the patients were treated in an elective or urgent setting (n=782 patients). Overall, 500 (63.9%) patients were treated in an elective setting and 282 (36.1%) in an urgent setting. Major adverse events (at thirty-days) occurred in 15.5% of patients (95%CI: 10.8; 20.8; I2=63%, 135/832 cases), being 11.6% (95%CI: 8.1; 15.7; I2=0%, 23/280 cases) for elective patients and 24.6% for urgent (95%CI: 14.1; 36.6; I2= 65%, 50/192 cases). Overall technical success was 97.2% (95%CI: 95.4; 98.7; I2= 0%, 587/611 cases), being 98.0% (95%CI: 92.1; 100; I2= 0%, 106/113 cases) for extent I-III TAAAs and 99.4% (95%CI: 97.5; 100; I2= 0%, 317/324 cases) for C-AAA and extent IV TAAAs. Regarding technique, technical success was 96.1% for FEVAR (95%CI: 93.2; 98.4; I2= 0%, 313/329 cases) and 99.8% for F/B-EVAR (95%CI: 99.8; 100; I2= 0%, 17/18 cases).
Conclusion:
Physician modified fenestrated or branched grafts for endovascular aortic repair seems feasible and safe in the short-term follow-up. However, the quality of the available data is low and there is lack of homogenous reporting across studies and mid to long term follow-up data is scarce which highlights the need for better and more accurate data regarding this technique.