title: Type Ia endoleaks after fenestrated and branched endografts may lead to component instability and increased aortic mortality.
abstract: OBJECTIVE
  Fenestrated and branched endografts allow for proximal sealing zone extension into or above the visceral aorta to optimize landing in healthy aorta. We describe the incidence, causes, and implications of proximal endoleak development in patients undergoing complex endovascular aortic aneurysm repair.
  
  
  METHODS
  All patients undergoing a fenestrated/branched repair were entered onto a prospective database, and this analysis included all those with at least one postoperative contrast computed tomography scan. Preoperative and postoperative three-dimensional imaging was reanalyzed to characterize morphology and identify endoleak. A blinded assessor used the preoperative imaging to resize the repairs in the endoleak group and a matched cohort of patients without endoleak. The outcome measures were proximal endoleak development, mortality, and component stability, and a comparison was made with all patients undergoing complex aortic repair.
  
  
  RESULTS
  From 2001 to July 2013, 969 patients underwent repair in a physician-sponsored investigational device exemption trial. Excluded were 24 emergency patients and 21 patients without requisite imaging, leaving 924 available for analysis. A proximal type Ia endoleak developed in 26 patients (2.8%). Poor choice of landing zone was implicated in most cases, with an area of sealing in the visceral aorta, compared with the thoracic aorta, being significantly associated with endoleak development (P < .01). Aortic-related mortality was significantly higher in the endoleak group (26.9%) than in the group without endoleak (6.2%; P = .001). These patients also experienced a higher incidence of component instability of 30.8% compared with 9.6% in patients without type Ia endoleak (P < .01).
  
  
  CONCLUSIONS
  Fenestrated/branched endovascular repair has a low incidence of sealing zone failure despite the increased complexity. However, development of a proximal endoleak destabilizes the repair and leads to increased mortality. Increasing complexity of design seems to improve the long-term outcome for patients requiring complex aortic repair.
authors.affiliation: Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Adrian
authors.initials: A
authors.lastname: O'Callaghan
authors.affiliation: Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
authors.affiliation: Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Eagleton
authors.affiliation: Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: James
authors.initials: J
authors.lastname: Bena
authors.affiliation: Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Electronic address: tmastracci@gmail.com.
authors.forename: Tara Marie
authors.initials: TM
authors.lastname: Mastracci
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation* / Q000401:mortality; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D009820:Ohio; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011857:Radiographic Image Interpretation, Computer-Assisted; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome