O-146 - ADDITIONAL AORTIC COVERAGE WITH OFF-THE -SHELF MULTIBRANCHED ENDOGRAFTS COMPARED TO CUSTOM-MADE DEVICES FOR ENDOVASCULAR REPAIR OF PARARENAL ABDOMINAL AORTIC ANEURYSM.

TOPIC:
Thoraco-abdominal Aortic Disease
AUTHORS:
Spath P. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Tsilimparis N. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Furlan F. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Hamwi T. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Fernandez-Prendes C. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Stavroulakis K. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Rantner B. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany) , Stana J. (Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany ~ Munich ~ Germany)
Introduction:
Pararenal AbdominalAortic Aneurysms (p-AAA) involve short-aortic-neck abdominal aneurysms, juxtarenal and supra renal aneurysms, in which complex endovascular aortic repair (EVAR) is required. Fenestrated and branched EVAR (F/B-EVAR) has revolutionized the treatment of p-AAA with favorable outcomes in terms of early mortality. However F/B-EVAR being custom-made devices (CMD) and are associated with production delays and no suitability for urgent cases. Off-the-shelf (OTS) multibranched devices, constructed with the goal of treating thoracoabdominal aortic aneurysms, can be considered as an option to treat complex AAA and even p-AAA without delay. However, OTS endografts require, due to their design, longer coverage of the descending thoracic aorta compared to CMD, but no specific data are available. The aim of this study is to determine the need for additional healthy aortic coverage by planning the use of the off-the-shelf multibranched endograft compared to CMD in the treatment of pararenal aneurysms.
Methods:
From January 2017 to December 2021, prospectively collected data on patients planned with CMD (Zenith Fenestrated CMD; Cook Medical, Bloomington, Ind, USA) were retrospectively analyzed in one single center. We included patients planned with CMD for p-AAA or failure of previous EVAR/open repair, requiring a proximal landing zone above the celiac artery (CA). Patients requiring proximal thoracic endovascular repair (TEVAR) were excluded. On the pre-operative computed tomography angiography (CTA), we planned all CMDs following the manufacturer instructions, and we planned the same patients for all the available OTS multibranched endograft: T-Branch (Cook Medical); E-Nside (Jotec GmbH, Hechingen, Germany); TAMBE (W.L. Gore & Associates, Flagstaff, Ariz). The composite primary endpoint was (1) the additional proximal aortic coverage needed for the OTS devices compared to the planned CMD; (2) the aortic coverage and the number of the segmental vessels covered from the CA to the top of the graft in the two groups. Secondary endpoints were the need for abdominal aortic bifurcated distal extension, and the aortic feasibility according to graft instructions for use (IFU). Analyses were performed using SPSS version 24.0 (IBM Corp, Armonk, NY). Continuous data are expressed as the mean value ± standard deviation. Categorical data are expressed as absolute values and percentages.
Results:
During the study period, 83 patients were planned with CMD for the treatment of c-AAA. Indications were: 40 (49%) juxtarenal-AAA, 17 (20%) short-neck-AAA, 14 (17%) suprarenal-AAA, 12 (14%) pararenal-AAA. All CMDs were FEVAR: 61 (74%) 4-fenestrations configuration and 22 (26%) 3-fenestrations+scallop. Overall, we planned 249 OTS endografts for study purposes. The additional proximal heathy aortic coverage needed for the OTS devices was in average 74 ± 19 mm. From the CA (Table 1), comparing the length of healthy covered aorta (CMD 33±19 mm vs OTS 108±6 mm; p<.001) and the number of segmental arteries sacrificed (CMD 1,3±0,8 vs OTS 3,8±0,9; p<.001), OTS devices showed more invasiveness. A distal bifurcated graft was requested in 73 (88%) CMD patients and in 66 (80%) OTS (p: n.s.). The mean aortic diameter at the level of the proximal sealing zone was 31±3 mm and the aortic diameter at the level of visceral arteries was 27±9 mm. The combined aortic feasibility (proximal sealing without extension + appropriate aortic diameter according to IFU) was present in 40(48%), 62 (75%) and 78 (94%) cases for the T-branch, E-nside and TAMBE endografts, respectively. Specifically, in 40 (48%) cases all grafts were suitable, in 5 cases (6%) no OTS endograft could be implanted, and in 94% of patients at least one of the available multibranched endograft could have been implanted inside IFUs.
Conclusion:
Despite being available for urgent cases and not requiring customization time, off-the-shelf endografts need an overall more extensive aortic coverage of 74 mm more than a custom made fenestrated endograft in the treatment of pararenal abdominal aortic aneurysm, with an average sacrifice of 2,5 segmental arteries. CMDs should be preferred over OTS devices for treatment of p-AAAs to limit the extent of unnecessary aortic coverage and the subsequent risk of spinal cord ischemia.
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