Fenestrated and Branched Endograft after Previous Aortic Repair

Para-anastomotic aneurysms (P-AAA) and proximal aortic aneurysmal degeneration after previous aortic open repair (OR) or endovascular repair (EVAR) are challenging clinical scenarios. OR is technically demanding, and standard EVAR could be impossible due to the absence of proximal landing zone. The aim of the study is to report midterm results of fenestrated and branched endografts (FB-EVAR) to treat proximal aortic lesions after previous aortic repair.

Since 2010, patients that underwent FB-EVAR after previous aortic repair were prospectively enrolled. Clinical or morphologic or intraoperative or postoperative data were collected and retrospectively analyzed. Primary end points were technical success and clinical success. Secondary end points were procedure-related events (endoleaks, target visceral vessels occlusion, mortality), midterm survival and freedom from FB-EVAR-related reinterventions.

Twenty patients (Male: 98%, age: 75 ± 6 years, American Society of Anesthesiologists [ASA] ≥ III: 100%) were enrolled. Fifteen patients (75%) underwent previous aortic OR and 5 (25%) standard EVAR. The mean time since the previous treatment was 12 ± 10 years. Present aortic lesions included thoracoabdominal aneurysms 12 (60%) and juxtarenal and pararenal aneurysms 8 (40%). The mean aortic aneurysm diameter was 67 ± 15 mm. All patients were at high risk for OR and had anatomies precluding standard EVAR. Seventy-two visceral vessels (renal arteries: 34, superior mesenteric artery: 20, celiac trunk: 18) were targeted: 49 fenestrations, 19 branches, and 4 scallops. An FB-EVAR tube and trimodular endograft was planned in 17 and 3 cases, respectively. Technical success was 95%; operative target vessel perfusion was 98.5%. Thirty-day mortality was 0%. Clinical success was 80% because there was a transient renal function worsening in 4 patients (>30% of baseline). One distal type I endoleak was detected and treated at 1-month. The mean follow-up was 15 ± 11 months. There were not proximal type I endoleaks, target visceral vessel occlusions, or aneurismal-related mortality. Survival at 1 year was 85 ± 5%. One late FEVAR-related reintervention occurred.

According to the reported data, FB-EVAR for treating P-AAA or proximal aneurysmal degeneration after previous aortic OR/EVAR in high-risk patients is a safe and/or effective solution.