Maxime Raux1, Virendra I Patel2, Frédéric Cochennec3, Shankha Mukhopadhyay4, Pascal Desgranges3, Richard P Cambria4, Jean-Pierre Becquemin3, Glenn M LaMuraglia4. 1. Department of Vascular and Endovascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 2. Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: vpate14@partners.org. 3. Department of Vascular and Endovascular Surgery, Henri Mondor Hospital, University of Paris XII, Créteil, France. 4. Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Abstract
OBJECTIVE: The benefit of fenestrated endovascular aortic aneurysm repair (FEVAR) compared with open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) is unknown. This study compares 30-day outcomes of these procedures from two high-volume centers where FEVAR was undertaken for high-risk patients. METHODS: Patients undergoing FEVAR with commercially available devices and OSR of CAAAs (total suprarenal/supravisceral clamp position) were propensity matched by demographic, clinical, and anatomic criteria to identify similar patient cohorts. Perioperative outcomes were evaluated using univariate and multivariate methods. RESULTS: From July 2001 to August 2012, 59 FEVAR and 324 OSR patients were identified. After 1:4 propensity matching for age, gender, hypertension, congestive heart failure, coronary disease, chronic obstructive pulmonary disease, stroke, diabetes, preoperative creatinine, and anticipated/actual aortic clamp site, the study cohort consisted of 42 FEVARs and 147 OSRs. The most frequent FEVAR construct was two renal fenestrations, with or without a single mesenteric scallop, in 50% of cases. An average of 2.9 vessels were treated per patient. Univariate analysis demonstrated FEVAR had higher rates of 30-day mortality (9.5% vs. 2%; P = .05), any complication (41% vs. 23%; P = .01), procedural complications (24% vs. 7%; P < .01), and graft complications (30% vs. 2%; P < .01). Multivariable analysis showed FEVAR was associated with an increased risk of 30-day mortality (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.1-24; P = .04), any complication (OR, 2.3; 95% CI, 1.1-4.9; P = .01), and graft complications (OR, 24; 95% CI, 4.8-66; P < .01). CONCLUSIONS: FEVAR, in this two-center study, was associated with a significantly higher risk of perioperative mortality and morbidity compared with OSR for management of CAAAs. These data suggest that extension of the paradigm shift comparing EVAR with OSR for routine AAAs to patients with CAAAs is not appropriate. Further study to establish proper patient selection for FEVAR instead of OSR is warranted before widespread use should be considered.
OBJECTIVE: The benefit of fenestrated endovascular aortic aneurysm repair (FEVAR) compared with open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) is unknown. This study compares 30-day outcomes of these procedures from two high-volume centers where FEVAR was undertaken for high-risk patients. METHODS:Patients undergoing FEVAR with commercially available devices and OSR of CAAAs (total suprarenal/supravisceral clamp position) were propensity matched by demographic, clinical, and anatomic criteria to identify similar patient cohorts. Perioperative outcomes were evaluated using univariate and multivariate methods. RESULTS: From July 2001 to August 2012, 59 FEVAR and 324 OSR patients were identified. After 1:4 propensity matching for age, gender, hypertension, congestive heart failure, coronary disease, chronic obstructive pulmonary disease, stroke, diabetes, preoperative creatinine, and anticipated/actual aortic clamp site, the study cohort consisted of 42 FEVARs and 147 OSRs. The most frequent FEVAR construct was two renal fenestrations, with or without a single mesenteric scallop, in 50% of cases. An average of 2.9 vessels were treated per patient. Univariate analysis demonstrated FEVAR had higher rates of 30-day mortality (9.5% vs. 2%; P = .05), any complication (41% vs. 23%; P = .01), procedural complications (24% vs. 7%; P < .01), and graft complications (30% vs. 2%; P < .01). Multivariable analysis showed FEVAR was associated with an increased risk of 30-day mortality (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.1-24; P = .04), any complication (OR, 2.3; 95% CI, 1.1-4.9; P = .01), and graft complications (OR, 24; 95% CI, 4.8-66; P < .01). CONCLUSIONS: FEVAR, in this two-center study, was associated with a significantly higher risk of perioperative mortality and morbidity compared with OSR for management of CAAAs. These data suggest that extension of the paradigm shift comparing EVAR with OSR for routine AAAs to patients with CAAAs is not appropriate. Further study to establish proper patient selection for FEVAR instead of OSR is warranted before widespread use should be considered.
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