title: Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology.
abstract: OBJECTIVE
  Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease.
  
  
  METHODS
  A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change.
  
  
  RESULTS
  Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5-31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ± 1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2-60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1-0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m(2).
  
  
  CONCLUSIONS
  F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients surviving the initial hospitalization for F/B-EVAR of acute aortic disease can anticipate good long-term survival.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla. Electronic address: salvatore.scali@surgery.ufl.edu.
authors.forename: Salvatore T
authors.initials: ST
authors.lastname: Scali
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Dan
authors.initials: D
authors.lastname: Neal
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Vida
authors.initials: V
authors.lastname: Sollanek
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Tomas
authors.initials: T
authors.lastname: Martin
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Julie
authors.initials: J
authors.lastname: Sablik
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Huber
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Adam W
authors.initials: AW
authors.lastname: Beck
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D005431:Florida; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency