Concomitant Fenestrated/Branched Endovascular Aortic Repair and Endovascular Hypogastric Preservation is a Safe Option for Complex Anatomy Aortic Aneurysms Compromising the Iliac Bifurcation

The aim of this study was to compare the outcomes of F/BEVAR patients treated with and without concomitant endovascular hypogastric preservation. This single-center retrospective cohort included patients with a diagnosis of Crawford types I-IV thoracoabdominal aneurysms (TAAAs), suprarenal or juxtarenal aortic aneurysms treated with either a patient-specific company-manufactured device (CMD) or an off-the-shelf device. Patients were divided into 2 groups:F/BEVAR (group-A) and F/BEVAR + iliac device (group-B). Patients in group-B had their iliac artery aneurysm treated either with an IBD (Zenith Branch Endovascular Graft ZBIS–Iliac Bifurcation–by Cook Medical), an IBE (iliac branch endograft,IBE,by Gore), or with an investigational patient-specific manufactured iliac fenestrated graft (by Cook Medical). Patients with implanted iliac devices prior to the F/BEVAR or with parallel stenting into the iliac system were excluded from the study. Primary outcomes were 30-day survival, freedom from secondary interventions (SIs), and long-term patency of the IB graft. Secondary outcomes included perioperative adverse events considering the first 30 days post-intervention and long-term survival. Four hundred ten patients treated between July/2012-February/2023 were included, 391 in group-A and 19 in group-B. Four cases in group-B had bilateral implantation of iliac grafts. The two groups were similar in terms of demographics and comorbidities. There was no difference between the groups in terms of aneurysm extent (P = .759). Mean follow-up for groups A and B were 33.6 ± 22.6 and 23.8 ± 20.1 months, respectively (P = .06). For patients in group-B, a larger volume of contrast was used (P = .007) and the duration of the procedure was longer (P = .003), as well as fluoroscopy time (P = .002) (Table I). As for the perioperative variables, there was no significant difference between the groups in terms of major cardiovascular events (P = .240), and the 30-day mortality was 2% in group-A and 0% in group-B (P > .99). There were 11 cases of spinal cord ischemia (2.8%) in group-A, but none in group-B. Considering long-term results, time-to-event analyses did not demonstrate a significant difference in freedom from SI (Log-rank P = .945) or long-term survival (Log- rank P = .545) (Fig 1) between the groups. Primary patency of the iliac grafts was 94.4% at 1 and 3 years. The incidence of Type Ib endoleak in group-A was 2.3% and 0% in group-B (P > .99). F/BEVAR for complex aortic aneurysms can be safely performed concomitantly with the endovascular treatment of common iliac artery aneurysms using iliac branched or fenestrated grafts. Despite the longer duration of the procedures, longer fluoroscopy times, and higher doses of contrast, these patients do not present significant differences in terms of short and long-term outcomes when compared to the ones that were submitted to a F/BEVAR alone.TableMain aortic device typeDevice typeF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P valueCMD356 (91.1)17 (89.4)>.99p-branch22 (5.6)1 (5.3)>.99t-branch13 (3.3)1 (5.3)>.99Intraoperative dataVariablesF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P valueEBL281.1 ± 599.3258.3 ± 279.3.755Procedure duration, minutes246.6 ± 93.8309.7 ± 77.2.003Fluoroscopy time, minutes79.4 ± 43.3114.1 ± 40.9.002Air kerma, mGy1808.52159.3.384Contrast volume, mL94.2 ± 42.6145.66 ±70.3.007Early outcomes (first 30-day period)VariablesF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P value30-day mortality8 (2)0 (0)>.99AKI (RIFLE criteria)17(4.3)1(5.2).542Spinal cord ischemia11 (2.8)0 (0)>.99MACE45 (11.5)0 (0).24030-day secondary interventions18 (4.6)0 (0)>.99Access complications50 (12.7)0 (0).146Bowel ischemia5(1.3)1 (5.3).249Postopertive hospital stay length, days5.08 ± 6.27.39 ± 15.527AKI, Acute kidney injury; CMD, custom-manufactured device; EBL, estimated blood loss; MACE, major adverse cardiovascular events.Data are presented as the total number (%) or mean ± standard deviation. Open table in a new tab