Baghbani, Aidin

Purpose: Familial history of aortic disease has been associated with increased risk of aneurysm-related complications after standard endovascular aortic repair. The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for complex aortic aneurysms in patients with or without familial aortic aneurysms (FAAs). Materials and Methods: We reviewed the clinical data of consecutive patients enrolled in a prospective non-randomized study to investigate outcomes after FB-EVAR for treatment of complex aortic aneurysms between 2013 and 2022. Familial aortic aneurysm was defined as occurrence of an aortic aneurysm or dissections in a first- or second-degree relative and compared with patients with sporadic aortic aneurysms (SAAs). Endpoints included procedural metrics, 30-day mortality and major adverse events (MAEs), mid-term patient survival, freedom from reintervention and endoleak, and aneurysm sac shrinkage. Results: There were 499 patients treated with FB-EVAR (70% males, mean age was 74±7.7 years) including 66 (13%) patients with FAAs and 434 (87%) with SAAs. Both groups had similar demographics, clinical characteristics, aneurysm extent, and prior history of aortic dissection or aortic repair. Patients with FAAs had longer fluoroscopy time (82 vs 71 minutes) and radiation exposure (1856 vs 1213 mGy; each p<0.05), with no difference in technical success (FAA, 94% vs SAA, 97%; p=0.51). There was no difference in 30-day mortality (1.5% vs 0.9%; p=1.00) and MAEs (23% vs 18%; p=0.44) among patients with FAA and SAA, respectively. Median follow-up was 28 months. At 3 years, patient survival, freedom from secondary interventions, and cumulative incidence of sac shrinkage were 76±2.5%, 74±2.5%, and 32±2.6% for all patients, respectively, with no difference between FAA and SAA groups. Conclusion: Fenestrated-branched endovascular aortic repair was performed with high technical success, low mortality, and low incidence of MAEs regardless of the presence of FAA. There was no difference in mid-term patient survival, secondary interventions, and sac changes among patients with or without family history of aortic disease. Clinical Impact This study demonstrates that fenestrated-branched endovascular aortic repair (FB-EVAR) can be performed with high technical success and comparable early and mid-term outcomes in patients with or without a familial history of aortic aneurysm, after exclusion of genetically triggered aortic diseases. These findings challenge the assumption that family history alone should preclude complex endovascular repair. Clinically, this supports broader use of FB-EVAR in carefully selected patients with familial aortic disease, emphasizing anatomical suitability rather than pedigree alone. The innovation lies in validating FB-EVAR as a safe alternative to open repair for this understudied population, informing patient selection, counseling, and surveillance strategies.

Objective: To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). Background: FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. Methods: Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006–2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. Results: A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P<0.001) and rates of MAEs (34% vs 20%, P<0.001). Median follow-up was 15 months (interquartile range, 7–37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P<0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50–2.44; P<0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63–3.62; P<0.001). Conclusions: Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.

Purpose: The Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) uses a bare-metal stent to scaffold the true lumen in patients with acute or subacute aortic dissections. While it is designed to facilitate remodeling, some patients with chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) require repair. This study describes the technical pitfalls of fenestrated-branched endovascular aortic repair (FB-EVAR) in patients who underwent prior PETTICOAT repair. Technique: We report 3 patients with extent II TAAAs who had prior bare-metal dissection stents treated by FB-EVAR. Two patients required maneuvers to reroute the aortic guidewire, which was initially placed in-between stent struts. This was recognized before the deployment of the fenestrated-branched device. A third patient had difficult advancement of the celiac bridging stent due to a conflict of the tip of the stent delivery system into one of the stent struts, requiring to redo catheterization and pre-stenting with a balloon-expandable stent. There were no mortalities and target-related events after a follow-up of 12 to 27 months. Conclusion: FB-EVAR following the PETTICOAT is infrequent, but technical difficulties should be recognized to prevent complications from the inadvertent deployment of the fenestrated-branched stent-graft component in-between stent struts. Clinical Impact The present study highlights a few maneuvers to prevent or overcome possible complications during endovascular repair of chronic post-dissection thoracoabdominal aortic aneurysm following PETTICOAT. The main problem to be recognized is the placement of the aortic wire beyond one of the struts of the existing bare-metal stent. Moreover, encroachment of catheters or the bridging stent delivery system into the stent struts may potentially cause difficulties.