French Study Evaluates Risk Factors for Early and Late Mortality After Fenestrated and Branched EVAR of Complex Aneurysms

 

May 1, 2019—The Society for Vascular Surgery (SVS) announced that results from a large, single-center data review in Lille, France, provide critical information regarding patient selection and expected outcomes in difficult endovascular aortic aneurysm repairs (EVARs). Katrien Van Calster, MD, et al published the findings in Journal of Vascular Surgery (2019;69:1342–1355).

As noted by SVS, paravisceral and thoracoabdominal aneurysms are the most challenging cases for vascular surgeons. The combination of patient comorbidity and complex paravisceral aortic anatomy mandates utmost surgical judgment, technical skill, and a multidisciplinary approach to achieve acceptable outcomes. Advances in endovascular techniques offer hope to those considered too high risk for surgery, the standard of care.

Although other research suggests advanced age, history of congestive heart failure, aneurysm diameter, and chronic renal insufficiency are the most important risk factors determining the outcomes for infrarenal EVAR, there are limited data for more complex proximal repairs with fenestrated and branched EVAR (F-B EVAR).

In the study, the investigators reviewed their prospectively collected single-center data involving 468 high-risk patients with pararenal or thoracoabdominal aneurysms treated with F-B EVAR between 2004 and 2016. The clinical and anatomic characteristics of the cohort included: age, 72 (65–77) years; sex, 94% male; 95% American Society of Anesthesiologists class 3 or 4; diameter, 58 (54–64) mm; 47% type I to III thoracoabdominal aortic aneurysm (TAAA); and 53% type IV and V TAAA. The technical success of target vessel stenting was 99%.

Their early results included 5% 30-day mortality, 4% spinal cord ischemia, and 4% postoperative dialysis (0.8% long term). With a median follow-up of 29 months, the 5-year rate of survival was 60%, freedom from vessel occlusions was 90%, and freedom from secondary procedures was 70%.

The investigators found that early mortality was associated with procedure time, aneurysm diameter, and chronic renal insufficiency. Mortality during the first 24 months was also associated with more extensive type I to III TAAAs.

In the SVS announcement, Professor Stéphan Haulon, MD, commented, “Our findings suggest that F-B EVAR can be performed in high-risk patients with excellent technical success, low 30-day mortality rate, and low rates of spinal cord ischemia and permanent dialysis. Additionally, our 5-year survival rate of 58% is similar to other series, with the majority of deaths attributed to nondevice- and nonaorta-related causes.” Prof. Haulon is with the Aortic Center, Hôpital Marie Lannelongue, Université Paris Sud in Le Plessis Robinson, France, and is a coauthor of the study.

Prof. Haulon continued, “The strength of this study lies in the large cohort of prospectively collected patient data, extensive follow-up, and systematic approach to preoperative planning, execution, and surveillance. Because the study covers a 12-year experience, there has been a transformation in practice and techniques over time. We believe these procedures can be offered safely, even in high-risk patients; however, this mandates that high-volume centers be prepared to invest in the incrementally complex learning curve that this technology and these patients demand.”

 

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