Page 211 - Read Online

Rodrigues et al. Vessel Plus 2024;8:10 https://dx.doi.org/10.20517/2574-1209.2023.109 Page 11 of 15

paraplegia resulting from drain complications, such as spinal hematoma, which led to a change in practice
in our group to the utilization of SCD in selected cases. The mean days of hospitalization were 6.5 ± 6.1 days
and were significantly longer (P < 0.001) in patients treated for Extent I-III TAAAs (10 ± 11 days) in
[62]
comparison to those treated for Extent IV and PRAs (6 ± 5 and 5 ± 5 days), respectively .

Other researchers assessed patients who underwent F/B-EVAR between 2008 and 2019 in four Italian
university centers. A total of 596 patients were included in the study, and of those, 351 were TAAA. Early
outcomes were more ominous than those reported by Oderich and Motta, with 8% of mortality, and a high
rate of renal (17%), pulmonary (12%), and cardiac (9%) complications. SCI was identified in 11% of cases,
and permanent paraplegia was identified in 5%. Other contemporary reports consistently show in-hospital
mortalities for F/B-EVAR in the range of 2% to 5.6% for TAAAs, and more recently, US ARC from nine PS-
IDE studies demonstrated an overall mortality of 3% [Table 2] [63-65] .

SECONDARY INTERVENTIONS AND LATE OUTCOMES
While recent series have reported favorable outcomes regarding safety with F/B-EVAR, a notable concern
remains the high rate of secondary interventions. According to data published by Zettervall et al., after
analyzing 1,681 cases from the US ARC, 385 (23%) needed a secondary intervention. The follow-up period
had a mean duration of 23 months. Freedom from reintervention rates were reported as 82% and 59% at 1
and 5 years of follow-up, respectively. Endoleaks were the main indication for secondary intervention,
accounting for 57% of the secondary interventions . Stenosis and occlusion were also reported to represent
[65]
10% of the indications. As secondary interventions, renal stenting was the most frequent procedure (30%),
followed by open treatment of access site complications (24%). Conversion to open repair was necessary in
[65]
six patients and 16 patients had aneurysm rupture demanding repair . Technical success rate for secondary
interventions was 94%, and the mortality rate associated with these interventions was less than 1%. The
study found that, overall, secondary interventions were associated with improved survival, with a hazard
ratio of 0.6 and a 95% confidence interval ranging from 0.5 to 0.7 .
[65]
Similar findings were shared by Oderich et al., who reported 23% of secondary interventions in 430 cases ;
[62]
in that series, freedom from secondary intervention at 1, 3, and 5 years was 81%, 74%, and 64%, respectively.
Freedom from target artery instability was reported to be 89% and significantly lower for renal arteries
(85%) compared to superior mesenteric arteries (SMA) (91%) and celiac axis (97%), P < 0.001. As previously
mentioned, directional branches had lower freedom from target artery instability compared to reinforced
[62]
fenestrations, with rates of 87% and 91% (P = 0.03), respectively . Target vessel patency followed similar
trends, revealing that primary and secondary patency rates were significantly lower for renal arteries
compared to SMA and celiac axis. Specifically, the primary patency rate for renal arteries was 89%, while the
secondary patency rate was 95%. In contrast, the SMA exhibited a primary patency rate of 97% and a
secondary patency rate of 99% (P < 0.001). The celiac axis demonstrated even higher rates, with a primary
patency rate of 99% and a secondary patency rate of 99% (P = 0.02). At 5 years, the primary patency of all
target vessels was 94%, while the secondary patency was 97%. Reinforced fenestrations had a significantly
higher primary patency rate at 5 years compared to directional branches (95% vs. 91%, P = 0.036) . These
[62]
differences in stability and patency rates of target vessels suggest variations in the long-term effectiveness of
vessel repair in different anatomical locations and the influence of incorporation technique.

Outcomes on late mortality were recently published by Chait et al. after analyzing 156 patients treated with
PMEGs (89 complex AAAs, 33 type IV TAAAs, and 34 type I to III TAAAs) . After a mean follow-up of
[66]
49 ± 38 months, there were 12 aortic-related deaths (7.6%), including nine early deaths (5.7%) from
perioperative complications and three late deaths (1.9%) from rupture. At 5 years, patient survival was 41%.