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Home > Vascular Annual Meeting > RR11. Surgeon-Modified Fenestrated and Branched...

RR11. Surgeon-Modified Fenestrated and Branched Stent Grafts for High Risk Patients with Juxtarenal, Paravisceral, and Thoracoabdominal Aortic Aneurysms: Comparison with Open Abdominal Debranching in a Single Center

Gustavo S. Oderich, Joseph J. Ricotta, II, Janet Hofer, Rafael Malgor, Audra A. Duncan, Thomas C. Bower, Manju Kalra, Peter Gloviczki
Mayo Clinic, Rochester, MN

OBJECTIVES: To compare the outcomes of surgeon-modified fenestrated-branched stent grafts (mFBSG) and abdominal debranching (AD) in patients unfit for conventional open repair of complex abdominal (AAA) and thoracoabdominal aortic aneurysms (TAAA).

METHODS: We reviewed the outcomes of 35 high-risk patients (30 male, 5 female; median age 75 years) treated for large (7.2±1 cm) complex AAA and TAAA between 2006 and 2008. Fifteen patients had AD of 43 vessels (26 mesenteric, 17 renal) with aortic stent grafting. Twenty patients had 1 to 4-vessel mFBSG with branch artery stenting of 52 vessels (32 renal, 18 mesenteric, 2 hypogastric). End-points were mortality, morbidity, patency, endoleak and re-intervention rates.

RESULTS: mFBSG patients had higher comorbidity scores (16±5 vs. 12±3; p<.03) and more (P<.05) stress-induced cardiac ischemia (60% vs. 27%), renal insufficiency (65% vs. 20%) and trans-renal aneurysm extension (100% vs. 67%). The number of target vessels per patient (2.8±1) was similar in both groups, but AD patients had more thoracic extension (80% vs. 32%; p<.05). Technical success for branch artery stenting was 98% (51/52). mFBSG required more (p<.05) fluoroscopy time (+135±20 min) and contrast dose (+105±89 ml), but less operative time (-151±49 min), blood loss (-1±0.8 L) and fluid requirement (-7±2 L). There was 1 (5%) operative death after mFBSG and 3 (20%) after AD (p=0.19). Patients treated with mFBSG had less complications (40% vs. 73%; p<.05), similar paraplegia rate (5% vs 13%; P=.39) and decreased hospital stay (-10±7 days; p<.05). Type I endoleak was noted in 3 mFBSG (2 resolved) and in 4 AD patients (1 resolved). There was no difference in 1-year freedom from endoleak (83±9% vs. 74±9%), re-intervention (83±9% vs. 58±9%), target vessel patency (95±9% vs. 98±2%) and survival (72±8% vs. 71±9%) in mFBSG vs AD patients. Sac shrinkage (>5mm) was noted in 7 of 9 (78%) mFBSG patients with >6 months follow up, and in none of the AD patients (p<.02). There were no migrations, component separations, fractures, or aneurysm ruptures after mFBSG.

CONCLUSIONS: Surgeon-modified fenestrated and branched stent grafts can be performed with high procedural success in high-risk patients with complex AAA and TAAA. This study supports the use of mFBSG as an alternative to AD in patients who are suitable candidates for both techniques.

AUTHOR DISCLOSURES: G.S. Oderich, Cook Medical and WL Gore; J.J. Ricotta, None; J. Hofer, None; R. Malgor, None; A.A. Duncan, None; T.C. Bower, None; M. Kalra, None; P. Gloviczki, None.