Long-term Outcomes Among Patients Treated With Physician Modified Endograft for Juxtarenal Aortic Aneurysms

The use of physician-modified endografts (PMEGs) to treat juxtarenal aortic aneurysms has increased since the first investigational device exemption (IDE) was granted in 2011. However, there is a paucity of long-term data beyond 5 years. This study aims to describe the long-term outcomes of patients who underwent PMEG for juxtarenal aneurysm and compare aortic behavior among those who survived beyond 5 years compared to those who did not. Patients who underwent PMEG under a single IDE from 2011-2018 were evaluated. Demographics, comorbidities, and anatomic and operative details were assessed. Long-term survival and reintervention were documented, and cause of death was identified. Late aortic behavior including stent patency, sac behavior, and endoleak were noted, as were rare late events including rupture and graft infection. Patients who survived beyond 5-year follow-up were compared to those who did not. Ninety-eight patients underwent PMEG from 2011-2018 for juxtarenal aneurysms. Survival was 87% at 1 year, 66% at 5 years, and 11% at 10 years (Fig I). Comorbidities were the leading causes of death (cardiac: 17%, cancer: 12%, pulmonary 12%) with no differences seen between those who survived beyond 5 years and those who did not. Aortic-related mortality was 10%. Patients who survived beyond 5 years more frequently died in hospice (56% vs 15%; P < .01). There were no differences in late outcomes between those who survived beyond 5 years and those who did not (Table I). Among patients who survived beyond 5 years, total visceral patency was 94%. Fifty-seven percent of patients had sac regression, 19% had sac stability, and 24% had sac growth beyond 5-year follow-up. Thirty-seven percent of these patients experienced an endoleak, the majority of which were type II (25%) followed by type III (9.2%), and type I (7.7%). Aortic rupture and graft infection were rare and occurred in 3% and 1% of all patients, respectively. Reintervention was 11%, 26%, and 30% at 1-, 5-, and 10-year follow-up. Patients who survived beyond 5 years were more likely to decline an indicated reintervention (11% vs 3%; P = .02) and be lost or decline ongoing follow-up (52% vs 15%; P < .01). PMEGs are a safe and durable long-term treatment for juxtarenal aneurysms. Though survival beyond 10 years is low, PMEGs are successful in preventing aortic-related mortality with 90% of patients dying from alternative causes. Given high rates of reintervention which do not decline over time, long-term follow-up remains critical to the success of this treatment modality. TableLate outcomes by survival to 5 years after PMEGLate outcomesAll patients (N = 98)Survived to 5 yearsP valueYes (n = 65)No (n = 33)Rupture3 (3.1)2 (3.1)1 (3.0).531Graft infection1 (1.0)0 (0)1 (3.0).499Reintervention any point29 (30)19 (29)10 (30).456 Reintervention post 5 years5 (5.1)5 (7.7)--Declined indicated reintervention8 (8.2)7 (11)1 (3.0).021 Died before surgery3 (3.1)3 (4.6)0 (0) Patient declined2 (2.0)2 (3.1)0 (0) Physician declined due to frailty3 (3.1)2 (3.1)1 (3.0)Sac behavior.113 Decrease49 (50)37 (57)12 (36) Increase16 (16)9 (14)7 (21) Stable24 (24)12 (19)12 (36)Visceral stenosis.059 Any visceral stenosis9 (9)8 (12)1 (3.0).077 Single renal1 (1.0)1 (1.5)0 (0) Bilateral renal1 (1.0)0 (0)1 (3.0) SMA7 (7.1)7 (11)0 (0)Total visceral patency91 (93)61 (94)30 (91).537Type of endoleak.722 Any endoleak40 (41)24 (37)16 (48).271 Type I7 (7.1)5 (7.7)2 (6.1)Type Ia1 (1.0)1 (1.5)0 (0)Type Ib6 (6.1)4 (6.2)2 (6.1) Type II30 (31)16 (25)14 (42) Type III8 (8.2)6 (9.2)2 (6.1) Multiple8 (8.2)4 (6.2)2 (6.1) Unknown type1 (1.0)0 (0)1 (3.0)Lost to follow-up39 (40)34 (52)5 (15)< .001Data are presented as number (%). Open table in a new tab