Plain cone beam computed tomography during fenestrated endovascular aortic repair minimizes secondary interventions...

Structural defects during fenestrated endovascular aortic repair (FEVAR) can be difficult to identify only on two-dimensional imaging. This study aims to assess the potential additional value of routine intraoperative completion plain cone-beam computed tomography (CBCT) in identifying such defects during FEVAR.

We conducted a retrospective review of all consecutive FEVARs performed at a tertiary aortic center between January 2013 and December 2022. Patients with intraoperative plain CBCT and at least one postoperative computed tomography angiography were selected. Baseline characteristics, operative data and follow-up data were collected. All imaging was re-reviewed for the purpose of the study. End points included clinically significant structural defects on CBCT and postoperative computed tomography angiography and postoperative reinterventions. Data are presented as median and interquartile range or number (%).

Of the 271 patients treated with FEVAR during the study period, 234 were included in the analysis (197 male, 72 years old (range, 68-77 years), 219 [94%] elective repairs). A median of four fenestrations (range, 3-4 fenestrations) were incorporated into the main body. Intraoperatively, 40 patients (17%) had a total of 45 clinically significant structural defects identified on CBCT, mostly related to target vessel bridging stents (n = 38). Postoperatively, 18 patients (8%) had 21 clinically significant structural defects, again mostly involving target vessels (n = 8). Three of these were symptomatic, including one renal artery occlusion and two cases of lower limb claudication. Among the 18 patients with intraoperatively undiagnosed defects, retrospective re-review of the CBCT revealed that the findings had been visible in 11 cases (61%). In five cases, image quality was insufficient, and in two cases the defect was outside the CBCT field of view.

The routine use of intraoperative plain CBCT enabled the identification and immediate correction of more than two-thirds of all structural defects during FEVAR; however, it remains challenging to completely eliminate secondary interventions owing to structural defects. Further improvements can be expected with more detailed CBCT analysis and improvements in imaging quality and increasing the field of view.