title: Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms.
abstract: OBJECTIVE
  The practice of using fenestrated endografts to treat juxtarenal and group IV thoracoabdominal aortic aneurysms (TAAAs) has become more accepted, but long-term outcomes are still unknown. We report long-term survival, complications, and branch-related outcomes from a single-center experience.
  
  
  METHODS
  The study included consecutive patients enrolled prospectively into a physician-sponsored investigational device exemption classified as undergoing group IV TAAA or juxtarenal aneurysm repair by the treating surgeon using fenestrated endografts. Device morphology was used to subclassify this group of patients. Long-term survival and a composite outcome of secondary intervention, branch occlusion, stent migration, endoleak, aneurysm growth, or spinal cord injury were calculated. Descriptive analysis of branch-related outcomes and need for any reintervention was performed. Univariate and multivariate analysis of mortality and the composite outcome was performed to determine associative risks.
  
  
  RESULTS
  Long-term survival for patients with juxtarenal and group IV TAAA aneurysms treated with fenestrated stent grafts was 20% at 8 years. Multivariate analysis showed long-term survival for this patient population was negatively associated with increasing age, congestive heart failure, cancer, and previous aneurysm repair. The risk of spinal cord ischemia (SCI) in this group was 1.2% and of aortic-related mortality was 2%. The risk of a spinal event increased with coverage above the celiac artery (52 mm of coverage above the celiac artery in patients with SCI vs 33 mm without SCI; P = .099). More complex device configurations were more likely to require an increased rate of reinterventions, and patients with celiac fenestrations were more likely to experience celiac occlusion over time (3.5% vs 0.5%; P = .019). However, less complex designs were complicated by an increased risk of type I endoleak over time (10.4% for renal fenestrations only vs 1.9% for others; P < .01). As experience evolved, there was a trend to increase the number of fenestrations in devices treating the same anatomy.
  
  
  CONCLUSIONS
  The use of fenestrated devices to treat juxtarenal and group IV TAAA is safe and effective in long-term follow-up. Mortality in this patient population is largely not aortic-related. Devices designed for fenestrated repair of juxtarenal and group IV thoracoabdominal aneurysms within a physician sponsored investigational device exemption have changed over time. Further research is needed to determine the best configuration to treat aneurysms requiring coverage proximal to the celiac artery.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Electronic address: mastrat@ccf.org.
authors.forename: Tara M
authors.initials: TM
authors.lastname: Mastracci
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Eagleton
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Yuki
authors.initials: Y
authors.lastname: Kuramochi
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Shona
authors.initials: S
authors.lastname: Bathurst
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Katherine
authors.initials: K
authors.lastname: Wolski
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016009:Chi-Square Distribution; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009820:Ohio; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011474:Prosthesis Design; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome