Outcomes of endovascular repair of chronic postdissection compared with degenerative thoracoabdominal aortic aneurysms using fenestrated-branched stent grafts

Objective: The objective of this study was to analyze outcomes of fenestrated-branched endovascular aneurysm repair (F/BEVAR) for treatment of postdissection and degenerative thoracoabdominal aortic aneurysms (TAAAs). Methods: We reviewed the clinical data of 240 patients with extent I to extent III TAAAs enrolled in seven prospective physician-sponsored investigational device exemption studies from 2014 to 2017. All patients had manufactured off-the-shelf or patient-specific fenestrated-branched stent grafts used to target 888 renal-mesenteric arteries with a mean of 3.7 vessels per patient. End points included mortality, major adverse events (any-cause mortality, stroke, paralysis, dialysis, myocardial infarction, respiratory failure, bowel ischemia, and estimated blood loss >1 L), technical success, target artery patency, target artery instability, occlusion or stenosis, endoleak, rupture or death, reintervention, and renal function deterioration. Results: There were 50 patients (21%) treated for postdissection TAAAs and 190 (79%) who had degenerative TAAAs. Postdissection TAAA patients were significantly younger (67 ± 9 years vs 74 ± 8 years; P <.001), were more often male (76% vs 52%; P =.002), and had more prior aortic repairs (84% vs 67%; P =.02) and larger renal (6.4 ± 1.2 mm vs 5.8 ± 0.9 mm; P <.001) and mesenteric (8.9 ± 1.7 mm vs 7.8 ± 1.4 mm; P <.001) target artery diameters. There was no difference in aneurysm diameter (66 ± 13 mm vs 67 ± 11 mm; P =.50), extent I or extent II TAAA classification (64% vs 56%; P =.33), and length of supraceliac coverage (22 ± 9.5 cm vs 20 ± 10 cm; P =.38) between postdissection and degenerative patients, respectively. Preloaded guidewire systems (66% vs 43%; P =.003) and fenestrations as opposed to directional branches (58% vs 24%; P <.001) were used more frequently to treat postdissection patients. Technical success was 100% for postdissection TAAAs and 99% for degenerative TAAAs (P =.14). At 30 days, there was no difference in mortality (2% postdissection, 3% degenerative), major adverse events (24% postdissection, 26% degenerative; P =.73), spinal cord injury (6% postdissection, 12% degenerative; P =.25), paraplegia (2% postdissection, 7% degenerative; P =.19), and dialysis (0% postdissection, 5% degenerative; P =.24). Mean follow-up was 14 ± 12 months. Endoleaks were significantly more frequent in patients with postdissection TAAAs (76%) compared with degenerative TAAAs (43%; P <.001). At 2 years, there was no difference in patient survival (84% ± 7% vs 72% ± 4%; P =.13), freedom from aorta-related death (98% ± 2% vs 94% ± 2%; P =.45), primary (95% ± 2% vs 97% ± 1%; P =.93) and secondary target artery patency (99% ± 1% vs 98% ± 1%; P =.48), target artery instability (89% ± 3% vs 91% ± 1%; P =.17), and freedom from reintervention (58% ± 10% vs 67% ± 5%; P =.23) for postdissection and degenerative TAAAs, respectively. Conclusions: Despite minor differences in demographics, anatomic factors, and stent graft design, F/BEVAR was safe and effective with nearly identical outcomes in patients with postdissection and degenerative TAAAs. Larger clinical experience and longer follow-up are needed to better evaluate differences in mortality, spinal cord injury, target artery instability, and reintervention.