Outcomes from the real-world multicenter laser in situ fenestrated endovascular repair (LIFE) registry for complex...

Laser in situ fenestrated endovascular (LIFE) repair enables fenestrated endovascular aortic repair in complex and challenging cases, including urgent and emergency presentations and patients with prior aortic repairs. From the real-world multicenter LIFE registry, the results are reported for this unique approach for thoracoabdominal and pararenovisceral aortic aneurysm (TAAA/PAA) pathologies.

All patients (2017-2022) undergoing LIFE for thoracoabdominal and pararenovisceral aortic aneurysms were identified at nine high-volume institutions and were included in a retrospective multicenter registry database. Descriptive statistics and Kaplan-Meier analysis were used. The primary outcomes were technical success and target vessel instability. The secondary outcomes included mortality, stroke, paraplegia, and reintervention.

This study included 210 patients undergoing LIFE (mean age, 72.3, 27% female, 83% White). The notable demographics included previous stroke in 14%, chronic obstructive pulmonary disease in 26%, renal insufficiency in 27% (dialysis in 3%), and previous aortic repair in 55% of patients. Indications for repair included fusiform aneurysm in 69%, type Ia endoleak in 21%, saccular aneurysm in 10%, and aortic dissection in 7%. Repair was performed for symptomatic/ruptured pathologies in 39% of patients. Overall, 30-day deaths occurred in 17 patients (8%), with 15 deaths in patients with symptomatic/ruptured pathologies and 2 deaths in asymptomatic patients (P < .0001). Proximal seals were achieved in Zone 2 (1%), Zone 3 (5%), Zone 4 (10%), Zone 5 (34%), Zone 6 (14%), Zone 7 (16%), and Zone 8 (17%). A total of 529 target vessels were incorporated (one vessel in 18%, two vessel in 26%, three vessel in 29%, four vessel in 24%, and NR in 3% of patients), with a mean of 2.5 target vessels per patient. The technical success rate for LIFE repair was 95%. Fifteen of those deaths occurred in 77 patients (19%) with symptomatic/ruptured pathologies. The results revealed stroke in six (2.9%) and permanent paraplegia in four patients (2%). At the mean follow-up of 9 months (range, 1-35), 12 additional deaths (5.7%) occurred, four of which were aneurysm-related (2%). Kaplan-Meier survival for the overall cohort at 36 months was 70%, with 80% freedom from bridging stent reintervention at 24 months (both standard error <10%). By group, asymptomatic patients had higher overall survival (82% vs 63%; P = .0007) at 20 months and freedom from bridging stent reintervention (88% vs 77%; P = .0005) at 21 months than patients with symptomatic/ruptured pathologies (standard error <10%). Overall reinterventions were performed in 45 patients (21%), with additional aortic stent graft in 21 patients (10%), bridging stent reintervention to 24 target vessels (4.5%), coil embolization in 4 patients for type II endoleak and to the false lumen of a dissection (2%), and other surgical procedures in 3 patients (1.4%).

The LIFE registry represents the largest multicenter experience with the LIFE technique to date. The perioperative and mid-term outcomes are reasonable in a cohort with a significant proportion of patients with symptomatic/ruptured pathologies. There was a higher-than-expected need for aortic stent graft reinterventions, which may be related to the learning curve for the technique and is higher than described for physician-modified endografts or fenestrated/branched endovascular aneurysm repair. These data suggest that LIFE repair is a viable treatment option when no commercially available solution exists, particularly among patients presenting with symptomatic or ruptured thoracoabdominal and pararenovisceral aortic pathologies. The need for longer-term evaluation of the durability and reintervention rate is of paramount importance to fully assess the applicability of this technique.