O-064 - THE IMPACT OF ANEURYSM DIAMETER ON THE OUTCOME OF THORACOABDOMINAL ANEURYSM REPAIR BY FENESTRATED AND BRANCHED ENDOGRAFT

TOPIC:
Thoraco-abdominal Aortic Disease
AUTHORS:
Gallitto E. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy) , Tsilimparis N. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Faggioli G. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy) , Stana J. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Logiacco A. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy) , Fernandez Prendes C. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Pini R. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy) , Rantner B. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Mascoli C. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy) , Gargiulo M. (Vascular Surgery, University of Bologna, DIMES ~ Bologna ~ Italy)
Introduction:
Fenestrated and branched endografting (F/B-EVAR) is an established technique to treat thoracoabdominal aneurysm (TAAAs) with reliable early and mid-term results in patients at high surgical risk. Several clinical / morphological predictors of technical and clinical failure have been proposed, but data about the role of preoperative TAAAs diameter are currently lacking. Aim of the present study was to analyze the impact of the preoperative aneurysm diameter on the outcome of TAAAs repairs by F/B-EVAR.
Methods:
All consecutive patients underwent endovascular TAAAs repair by F/B-EVAR (Cook Zenith platform) in 2 European Aortic Centers between 2011 and 2021 were prospectively collected and retrospectively analyzed. Pre, intra and post-operative features / outcomes were defined and classified according with the current reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries 1. Technical success (TS), spinal cord ischemia (SCI) and 30-day / in-hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions (FFR) and target visceral vessels (TVVs) instability were assessed during follow-up. The aneurysm diameter (<70mm; >70mm; >80mm; >90mm) was analyzed as potential risk factor for the study's outcomes. Survival and FFR were reported by Kaplan-Meier analysis. Fisher's exact test, multi-variable and Cox-regression analysis were used to identify risk factors for the study's outcomes. T-student's test was adopted to compare the mean of quantitative data.
Results:
Overall, 247 TAAAs were managed by F/B-EVAR. Crawford's extent I-III and IV were 153 (62%) and 94 (38%), respectively. Eighty-five (34%) patients had a previous aortic repair and 39 (16%) cases were chronic post-dissection TAAAs. Forty-one (17%) procedures were performed in urgent clinical setting. Preoperative TAAAs diameter was < 70mm in 151 (61%) and > 70mm in 96 (39%) cases (> 80mm: 59 - 24%; > 90mm: 28 - 11%). Cases with preoperative TAAA diameter > 80mm had higher procedural time (450+186 vs 380+159 minutes; P:.04), DAP (988032+133683 vs 667482+102345 MGy/cm2; P:.02) and iodinated contrast media administration (283+180 vs 218+112 mL; P:.03) than cases with diameter < 80mm. Technical success was reported in 208 (84%) cases: [elective: 177/206 (86%); urgent: 31/41 (76%)]. Branched and off-the-shelf endografts were associated with technical failure by Fisher's exact test, with no confirmation at the multivariable analysis. Twenty-three (9%) patients had SCI [elective: 13/206 (6%); urgent: 10/41 (24%)]. Urgent repair (OR:3.2; 95%CI:1.2-8.6; P:.01) and reintervention within 30-days (OR:2.7; 95%CI:1.1-6.7; P:.03) were independent risk factors for SCI. Twenty-two (9%) patients died within 30-day or during the hospitalization [elective: 11/206 (5%); urgent: 11/41 (27%)]. Urgent repair (OR:8.4; 95%CI:2.3-31.6; P:.002), peripheral arterial occlusive disease (OR:8.2; 95%CI:1.8-36.5; P:.006), need of surgical iliac conduit (OR:5.2; 95%CI:1.1-26.1; P:.04), technical failure (OR:1.3; 95%CI:3.5-5.1; P:.001) and SCI (OR:7.3; 95%CI:1.7-31.2; P:.001) were independent risk factors for early mortality. The mean follow-up was 22+16 months. Survival and FFR were estimated at 3-year of 60% and 54% of cases, respectively. Peripheral arterial occlusive disease (HR:3.3; 95%CI:1.3-8.3; P:.01), preoperative TAAA diameter > 90mm (HR:3.4; 95%CI:1.3-8.4; P:.01), need of surgical iliac conduit (HR:4.7; 95%CI:1.6-13.5; P:.004) and postoperative respiratory morbidities (HR:5.8; 95%CI:1.7-19.9; P:.005) were independent risk factors for follow-up mortality. Crawford's extent I-III (HR:2.8; 95%CI:1.5-5.1; P:.001), preoperative TAAA diameter > 80mm (HR:1.9; 95%CI:1.1-3.6; P:.04) and TAAA diameter growth (>5mm) during follow-up (HR:3.6; 95%CI:1.6-8.4; P:.002) were independent risk factors for reinterventions. Overall, 45 (18%) patients had TVVs instability; post-dissection TAAAs (OR:3.3; 95%CI:1.2-3.2; P:.03), preoperative TAAA diameter > 80mm (HR:3.1; 95%CI:1.3-5.1; P:.04), technical failure (HR:2.7; 95%CI:1.1-3.1; P:.03) and TAAA diameter growth during follow-up (HR:3.2; 95%CI:1.2-7.7; P:.001) were independent risk factors for TVVs instability.
Conclusion:
Preoperative TAAA diameter does not impact on TS, SCI and 30-day/in-hospital mortality of F/B-EVAR for TAAAs. TAAAs > 80mm have longer procedural time and higher radiation exposure and iodinated contrast media administration than patients with TAAAs < 80mm. Preoperative TAAA diameter > 90mm is an independent risk factors for follow-up mortality and TAAA diameter > 80mm is an independent risk factors for reinterventions and TVVs instability. According with the present data, dedicated intra and postoperative care should be required to reduce early and follow-up complications in patients with preoperative TAAA diameter > 80mm.
References:
1. Oderich GS, Forbes TL, Chaer R, Davies MG, Lindsay TF, Mastracci T, Singh MJ, Timaran C, Woo EY; Writing Committee Group. Reporting standards for endovascular aortic repair of aneurysms involvingthe renal-mesenteric arteries. J Vasc Surg. 2021 Jan;73(1S):4S-52S.