Dartmouth-Hitchcock Medical Center, Lebanon, NH.
OBJECTIVES: To report outcomes for branched-fenestrated (BEVAR) and chimney-type endovascular repair (CEVAR) of juxtarenal (JAAA) and thoracoabdominal aortic aneurysms (TAAA) as part of review for a multicenter IDE study and CMS LCD coverage.
METHODS: From 11/05 to 11/11, patients with JAAA and TAAA who were a prohibitive risk for open repair but at high risk of rupture were treated with complex endovascular interventions at a single institution. Review included CEVAR and surgeon-modified BEVAR cases with at least 1 month follow-up. Hybrid aortic debranching cases were excluded from this IRB-approved review.
RESULTS: Out of 107 repairs (85 BEVAR, 22 CEVAR), repair extent was 64 TAAA (15 Type II, 24 Type III, 25 Type IV) and 43 JAAA. TAAA were treated with BEVAR (63/64), while JAAA were treated with both (21 CEVAR, 22 BEVAR). Repair was urgent in 15, with 3 ruptured. Mortality (30-day plus Hospital) was 4.7% (TAAA 4/64, 6% and JAAA 1/43, 2%). Paraplegia/paresis not resolving with therapy occurred in 2 (Type II and III extent TAAAs). Aortic endografts were successfully implanted in all cases. Of the 273 target branches for stent-graft implantation (245 BEVAR, 28 CEVAR), 269 were successful, with 2 performed in delayed fashion. All 269 were patent at discharge. No patients required dialysis. One patient had sigmoid colon ischemia after coverage of a patent IMA.
Beyond 30 days, all branches remained patent. A single Type I endoleak (1 CEVAR) and 3 Type III endoleaks (3 BEVAR) were resolved with percutaneous intervention. Other secondary interventions were performed for branch stenosis (2), compartment syndrome (1) and adjacent aortic degeneration (1). There were no other Type I/III endoleaks, migration, aneurysm expansion, or rupture.
CONCLUSIONS: With appropriate anatomy, early results of BEVAR and CEVAR for JAAA and TAAA can be good, even in patients at a prohibitive risk for open repair. At this time, a VQI-based multicenter IDE is in process and our CMS carrier has approved regional LCD coverage.
AUTHOR DISCLOSURES: M. Fillinger, Nothing to disclose.
Posted April 2012