Fenestrated endografting of juxtarenal aneurysms after open aortic surgery

Abstract

Introduction: Juxtarenal aneurysms after previous surgical aortic reconstruction constitute a complex clinical scenario. Open redo surgery is technically demanding and usually requires suprarenal or supraceliac clamping. Standard endovascular repair is prohibited due to the lack of a proximal landing zone. We present our experience with fenestrated endovascular aneurysm repair (F-EVAR) in the treatment of juxtarenal aneurysms after previous open surgery.

Methods: A prospectively maintained database including all patients with juxtarenal abdominal aortic aneurysm after previous surgical reconstruction that underwent F-EVAR within the period from November 2003 to February 2013 under the instruction of the senior author. Evaluated outcomes included initial technical success and operative mortality and morbidity as well as late survival, target vessel patency, aneurysm diameter regression, renal function, and reintervention.

Results: A total of 35 patients (33 male; mean age, 71.5 ± 6.2 years) were treated. Median interval from the primary surgical reconstruction was 126 months (range, 48-223 months). All patients had proximal anatomies precluding standard endovascular techniques and were considered high risk for open repair due to their comorbidities and redo nature of the operation. In total, 111 vessels were targeted: 77 with small fenestrations, 33 with scallops, and 1 vessel with a downward branch. The operation was completed by totally endovascular means in 34 patients (97.1%). In one patient, a retroperitoneal approach was needed to gain retrograde access to a renal artery. Operative target vessel perfusion success rate was 100%. Operative mortality was 0% and median hospital stay 6 days (range, 2-40 days). Mean follow-up (FU) was 37.5 ± 25 months. Mean aneurysm maximal diameter decreased from 60 ± 4 mm to 47 ± 8 mm (P < .05). No type I endoleak was diagnosed, and no reintervention was required during FU. There were eight late deaths, all unrelated to the aneurysm. Estimated survival rates at 1, 2, and 4 years were 92.0% ± 5.5%, 82.8% ± 7.9% and 76.9% ± 9.3%, respectively. Three target vessel occlusions occurred during FU. One patient suffered a bilateral renal artery occlusion resulting in dialysis. In a second patient, one renal artery occluded without clinical symptoms. No other cases of renal function deterioration were observed.

Conclusions: F-EVAR is a valid treatment option for juxtarenal aneurysms after previous surgical reconstruction. F-EVAR represents a less morbid alternative to redo open surgery, has a high technical success rate, and shows durability in mid-term FU.