Cause-specific long-term mortality after physician-modified branched/fenestrated endovascular aortic repair

Physician-modified endografts (PMEGs) are being increasingly utilized for treatment of complex aortic diseases. Several series describe short and mid-term outcomes, but limited long-term data is available-nor has there been extensive evaluation into cause-specific mortality. Here, we sought to evaluate the long-term causes of death after PMEG, and the association with type and complexity of repair.

This study was a retrospective review in a single, high-volume, academic aortic referral center of all consecutive fenestrated PMEG procedures from 2010 to 2016. Study timeline was selected to allow all subjects the opportunity for ≥5 years of survival time. All subjects were deemed either high anatomic and/or physiologic risk for open repair by the primary surgeon. Commercial custom and chimney endovascular aortic repair procedures were excluded. Death certificates, obituary websites, and electronic medical records were reviewed to assign cause-specific mortality. The primary endpoint was all-cause mortality. Secondary endpoints included cause-specific death categorized as: major adverse cardiovascular event (myocardial infarction, malignant arrythmia, congestive heart failure, sudden death), malignancy, pulmonary (chronic obstructive pulmonary disease/respiratory failure), infection, aortic, and other (including metabolic/stroke/trauma, etc). Kaplan-Meier methodology was used to estimate survival.

A total of 232 consecutive PMEG procedures were analyzed (male, 72%; mean age, 73 ± 8 years). Indications included thoracoabdominal aneurysm (extent I-V, 58%), juxtarenal aneurysm (9%), pararenal aneurysm (25%), post-surgical pseudoaneurysm/failed endovascular abdominal aortic aneurysm repair (6%), chronic dissection (2%), and penetrating aortic ulceration (1%). A majority were performed electively (75%; n = 174), whereas the remaining were completed for symptomatic/intact (20%; n = 47) and emergent/ruptured (5%; n = 11) presentations. A total of 762 target vessels were included (celiac, n = 179; superior mesenteric artery, n = 204; renal, n = 379), and most procedures had four-vessel revascularization (61%; n = 142). Secondary intervention occurred in 18% of cases (n = 42). The mean survival was 4.9 ± 3.2 years (median, 5.4 years; interquartile range, 1.9-7.5 years; 95% confidence interval [CI], 4.9-6.1 years) and 57% (n = 132/232) died during follow-up. Among 132 documented deaths, 12 occurred before hospital discharge and/or ≤30 days, whereas 90% occurred >30 days and/or after hospital discharge. The majority of 30-day deaths occurred in emergent cases. Cause-specific late mortality was attributed to major adverse cardiac events (24%), unknown (18%), other (18%), aortic (14%), pulmonary (12,5%), infectious (12.5%), and malignancy (10%). Causes of 30-day aortic-related death (n = 7/232; 3%) were rupture (n = 5) and mesenteric ischemia (n = 2). Freedom from long-term all-cause and aorta-related mortality at 5 years was 56% ± 3% and 90% ± 2%, respectively. Freedom from long-term all-cause and aorta-related mortality at 10 years was 43% ± 4% and 87% ± 3%, respectively. Nonelective presentation had higher long-term risk of all-cause and aorta-related mortality (all-cause: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; aorta-related: HR, 3.2; 95% CI, 1.2-8.5). Four-vessel repairs were associated with improved survival (vs <4 vessels: HR, 0.6; 95% CI, 0.4-0.9).

PMEG in high-risk patients was durable and provided excellent long-term outcomes in patients deemed high-risk for open repair. Cardiovascular morbidity is the most significant factor leading to late mortality after PMEG. Aorta-related mortality is low; and elective repairs with more proximal coverage appear to be protective from poor long-term outcomes.