for Thoracoabdominal Aneurysms
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1 Durability of F/BEVAR for Thoracoabdominal Aneurysms Athanasios Katsargyris, MD, Eric Verhoeven MD, PhD Department of Vascular and Endovascular Surgery Paracelsus Medical University, Nuremberg, Germany
2 None Disclosures
3 Important Topic! Lay-Out - Data from Nuremberg - Data from Cleveland Clinic - Multi-Center Data from S. Haulon & T. Mastracci
4 Nuremberg Experience FEVAR/BEVAR 1st Line Treatment for suitable TAAA
5 Article: Combined Experience Gro/Nue Updated Nuremberg Experience (N=300 Pts) Suprarenal Aneurysms excluded Early Outcomes Technical Success: 95% 30d Mortality: 7% Initial learning curve...
6 Durability? Follow-up Data Mean follow-up: 36.2 ± 19 months
7 Late Mortality All cause late mortality: N=47 2 Related deaths (aortoesophageal fistula, graft infection) Late mortality in ASA IV vs ASA III pts Estimated Survival 83 ± 3% at 1 year 70 ± 5.6% at 5 years
8 Estimated Target Vessel Patency 98.1 ± 0.5% at 1 year 94.2 ± 1.5% at 5 years
9 Freedom from Reintervention 89.9 ± 2.6% at 1 year 79.8 ± 4.6% at 3 years
10 Late (>30d) Reinterventions N=42 Reintervention N Branch relining/extension 20 Distal stent-graft extension 4 Proximal stent-graft extension 4 Coil embolization for endoleak 5 Thoracic bridging stent-graft for disconnection 2 Reintervention for iliac occlusion 1 Target vessel thrombolysis 1 Fem-fem crossover bypass 1 Groin drainage due to seroma infection 1 Laparotomy-lavage due to stent-graft infection 1 Ilio-renal bypass 1 Iliac Thormbectomy 1 90% ENDO 10% OPEN
11 Late (>30d) Reinterventions N=42 Reintervention N Branch relining/extension 20 Distal stent-graft extension 4 Proximal stent-graft extension 4 Coil embolization for endoleak 5 Thoracic bridging stent-graft for disconnection 2 Reintervention for iliac occlusion 1 Target vessel thrombolysis 1 Fem-fem crossover bypass 1 Groin drainage due to seroma infection 1 Laparotomy-lavage due to stent-graft infection 1 Ilio-renal bypass Iliac Thormbectomy 1 1
12 Branches Potential Problems Mastracci et al. JVS 2013
13 Cleveland Clinic Experience , 650 pts with FEVAR/BEVAR Suprarenal included! Mean F/U: 3 ± 2.3 years (range: 1-9 years) Reintervention for 0.6% CA, 4% SMA, 5.5% RAs
14 Branch-related Mortality 3 pts (0.46%) all due to Mesenteric ischemia Branches of FEVAR/BEVAR are durable and rarely the cause of patient death
15 Cleveland Clinic Experience (2) , 610 pts with FEVAR Mean F/U: 8 years! FEVAR safe & effective in the long-term Aortic related mortality of 2% at 8 years
16 Do we need longer F/U? After 8 years survival is only 20%... Cause of death Aneurysm Unrelated Cancer, COPD, Heart failure etc.
17 Fenestrations or Branches for Renal Arteries in TAAAB grafting? 449 pts (235 BEVAR, 214 FEVAR)
18 Fenestrations or Branches for Renal Arteries in TAAAB grafting? Fenestrations significantly better patency rates! Branches significantly higher instability (occlusion/reintervention)
19 Balloon- or Self-Expandable Stent? No difference between BE & SE Stents Renal branches fail more often than visceral branches Smaller vessel diameter? Material fatigue due to respiratory movements? Kidney: High-resistance end organ?
20 Confounding Factors Not comparable cohorts Patients Anatomy, number of target vessels Center Experience High vs Low volume centers Set-up in different centers/countries Patient selection bias Learning Curve!
21 Follow-up after Open Surgery? The long-term function of branch grafts to the visceral and renal arteries during open thoracoabdominal aneurysm repair is unknown
22 This represents the largest series of patients with branch grafts for open thoracoabdominal aortic aneurysm repair with extended angiographic follow-up Thirty-four patients receiving 74 grafts were followed for more than 5 years Largest series with branch grafts follow-up after open TAAA repair with only 34 pts
23 Conclusions FEVAR/BEVAR for TAAA Robust Treatment Aortic related death during follow-up Durability of branches Fenestrations better than branches for RAs Need for reintervention mostly endovascular
24 Conclusions Room for Improvement Dedicated bridging stent-grafts etc. More long-term studies...
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