Midterm Results of Antegrade Laser Fenestrations Using Image Fusion Guidance in Complex Aortic Aneurysm Repair

This retrospective, observational, single centre study aimed to describe midterm results of physician modified stent grafts using antegrade laser fenestrations and image fusion guidance (lEVAR) for the treatment of complex abdominal aortic aneurysms, thoraco-abdominal aortic aneurysms, and type I endoleaks.

All lEVAR procedures between 1 September 2016 and 1 January 2022 were reviewed. Endpoints included intra-operative adverse events (IOAEs), in hospital death, re-interventions, and target vessel patency. Midterm outcomes were estimated using the Kaplan-Meier time to event method with 95% confidence intervals (95% CI).

Sixty patients underwent lEVAR procedures during the study period. All patients were deemed unfit for open repair. The lEVAR cases included 12 symptomatic aneurysms, 33 enlarging aneurysms > 65 mm, 14 anatomical constraints and or presence of previous renal stents, and one rupture. The median aneurysm diameter was 65.5 mm (IQR 13). One hundred and seventy antegrade laser fenestrations were performed (mean 2.8/patient). IOAEs were recorded in 21 cases (35%). Technical success was recorded in 98% of cases. The in hospital mortality rate was 5% (n = 3). The median follow up was 35.7 months. The estimates of overall survival and freedom from re-intervention at three years were 81% (95% CI 68.3 - 89) and 60.2% (95% CI 43.4 - 73.4), respectively. Six target vessels occluded during follow up, giving a three year target vessel patency rate of 90.1% (95% CI 77.5 - 95.8). Two lEVAR explantations were recorded during follow up, either for infection or persistent endoleak. The three year freedom from aortic death estimate was 92% (95% CI 86.9 - 99.7).

In high risk patients deemed unfit for open repair, lEVAR may provide satisfactory midterm overall survival and target vessel patency rates, although re-intervention rates were high in this study, requiring close and extensive follow up.