Citations

Objective: The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms (TAAAs) and complex abdominal aortic aneurysms (CAAAs) in patients actively smoking at the time of repair compared with previous smokers and non-smokers. Methods: Single-center retrospective review of elective FB-EVARs for TAAA and CAAAs between 2007 and 2023 was conducted. Demographics, comorbidities, aneurysm extent/ morphology, technical details, and peri-operative outcomes were collected. Patients were grouped into 1 of 3 groups: active smokers, prior smokers, and never smokers. Patients who stopped smoking within 6 weeks to surgery were considered active smokers. Rupture and symptomatic aneurysms were excluded. Endpoints included early (<30 days) mortality and major adverse events (MAEs). Results: There were 676 patients (73% male, mean age 74 ± 7.8). There were 141 (21%) active smokers, 455 (67%) prior smokers, and 80 (12%) never smokers. Active smokers were significantly younger than prior or never smokers (71 ± 6.7, 75 ± 6.9, and 76 ± 12, respectively; P < .001). Cardiovascular risk factors were similar, except active smokers were significantly more likely to have chronic obstructive pulmonary disease (60% vs 42% vs 6.2%, P < .001) and peripheral arterial disease (31% vs 24% vs 10%, P = .002) when compared to prior and never smokers, respectively. Patients who never smoked had significantly more extent II aneurysms (34%) than prior (18%) and active (15%) smokers, P = .001. Univariable and multivariable logistic regression analyses showed no statistically significant associations between smoking status and any specific peri-operative adverse events following surgery. Conclusion: Active smoking status does not appear to affect peri-operative outcomes after FB-EVAR for complex aortic aneurysms. Although smoking cessation must be strongly encouraged, repair should not be delayed due to active smoking status. Clinical Impact These data suggest that active smoking, in isolation, should not be considered a contraindication to elective FB-EVAR when anatomy is suitable and patients are otherswise optimized. This is particularly relevant for high-risk patients who may have limited alternative treatment options. Proceeding with FB-EVAR in active smokers does not appear to compromise early safety or procedural efficacy.

Background: Aortic endograft infection (AEGI) is a rare complication of abdominal endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Surgical explantation with reconstruction is recommended, but data on medical management remain limited. We present our institutional experience with AEGI. Objective: To describe the clinical presentation, microbiology, management strategies, and outcomes of patients with AEGI, with the aim of addressing current gaps in the literature and informing future research to improve patient outcomes. Design: Retrospective descriptive study. Methods: Adult patients admitted with AEGI at our institution between January 2017 and August 2024 were identified using ICD-10 codes and confirmed using the Management of Aortic Graft Infection Collaboration (MAGIC) diagnostic criteria. Clinical, microbiological, radiographic, treatment, and outcome data were collected and analyzed. Results: We screened 517 patients, and 46 met AEGI criteria (EVAR 54%, TEVAR 46%). Most (63%) presented with late-onset infections (⩾3 months). Fever (54%) and sepsis (48%) were common presenting symptoms. Computed tomography (CT) (85%) was the primary imaging modality. Blood cultures were positive in 54% of the cases, with Staphylococcus aureus being the most common monomicrobial pathogen (24%), and 24% of cases were polymicrobial. The majority (67%) received combined medical and surgical therapy. Chronic antibiotic suppressive therapy was used in 34 (74%), most often tetracyclines (33%). Overall, treatment success rates were similar between surgical and medical groups (58% vs 60%, p = 0.250) with comparable mortality. However, relapses were more frequent in the medical-only group (33% vs 16%, p = 0.185). Conclusion: Most patients presented with late-onset AEGI. Fever was absent in nearly half of cases, and blood cultures were positive in only 54%. Overall, surgical and medical therapy had similar success, though relapses were more frequent in those treated medically alone.

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.

Background Fenestrated and branched endovascular aneurysm repair can be complicated by branch vessel occlusion in the absence of structural stenosis. We hypothesized that computational flow simulation could identify adverse hemodynamic features associated with postfenestrated and branched endovascular aneurysm repair branch occlusion. Methods Patients undergoing 4‐vessel fenestrated and branched endovascular aneurysm repair for Extent II to IV thoracoabdominal aortic aneurysms were retrospectively reviewed. Branches that occluded without identifiable kinking or stenosis on computed tomography were included, along with an equal cohort of anatomy‐matched patent controls. Patient‐specific pulsatile rigid‐wall simulations were performed using SimVascular with individualized geometries and boundary conditions. Abnormal time‐averaged wall shear stress (TAWSS) was defined as <10 or >70 dynes/cm 2 . Results Nine patients (36 target vessels) experienced 10 branch occlusions. Postoperative pressure and flow did not differ significantly between occluded and patent renal or mesenteric branches. However, occluded renal and mesenteric branches demonstrated significantly larger postoperative areas of abnormal TAWSS compared with controls (renal: 14.5% versus 5.9%, P =0.003; mesenteric: 17.7% versus 9.9%, P =0.035). Logistic generalized estimating equation modeling showed abnormal TAWSS to be a significant predictor of renal branch occlusion ( P =0.0085). Model estimates suggested occlusion probabilities of 1.1%, 31%, and 94% at 0%, 10%, and 20% abnormal TAWSS surface area, respectively. A cluster‐bootstrapped receiver operating characteristic curve (area under the curve, 0.876) identified a >10.2% threshold that correctly classified 92% of renal occlusions. Abnormal TAWSS frequently localized to distal stent–artery interfaces. Conclusions Elevated abnormal TAWSS within stented renal branches is associated with subsequent branch occlusion after fenestrated and branched endovascular aneurysm repair. Computational flow simulation‐derived TAWSS thresholds may help identify high‐risk branches before failure, warranting prospective validation.

Purpose: Fenestrated stent-grafts with proximal bare-metal fixation stent (BMFS) may provide better rotational movement to facilitate vessel catheterization, but novel designs with covered fixation stents (CFSs) have been increasingly utilized with lower profile fabric. This study aimed to evaluate procedural metrics and outcomes of fenestrated endovascular repair (FEVAR) using BMFS and CFS devices. Methods: Clinical data of 502 consecutive patients enrolled in a prospective, non-randomized investigational device exemption (IDE) study were reviewed. Patients with 4-vessel fenestrated stent-grafts with BMFS or CFS for treatment of complex abdominal aortic aneurysms (CAAAs) and Extent IV thoracoabdominal aortic aneurysms (TAAAs) were included. Patients with Extent I-III TAAAs and stent-grafts designed with <4 fenestrations or scallops were excluded. Endpoints were technical success, radiation exposure, major adverse events (MAEs), patient survival, freedom from secondary interventions, and target artery instability (TAI). Results: There were 147 patients (29%; 85% male, median 75 years old) treated by FEVAR using 4-vessel fenestrated stent-grafts with BMFS in 79 patients or CFS in 68 patients. Patients treated with BMFS designs had significantly (p<0.05) higher prevalence of cigarette smoking and peripheral artery disease and less often had Extent IV TAAAs. Use of BMFS designs decreased from 88% (64/73) to 20% (15/74) after 2018 (p<0.001). Technical success was similar in patients treated with or without BMFS designs (99% vs 100%, p=0.47), but total operating time and cumulative air karma were significantly lower (p<0.05) in patients with CFS designs. Overall 30-day mortality was 1%, with no difference in mortality and MAEs among patients treated with or without BMFS (1% vs 1%, p=1.0 and 15% vs 12%, p=0.59), respectively. Patient survival at 1 and 3 years was 95%±2%, and 85%±4% for all patients with no difference between groups (p=0.51). Freedom from secondary interventions was 88%±3.6% for patients with BMFS and 86%±4.6% for those with CFS at 1 year (p=0.71), with also no difference at 3 years (p=0.55). Conclusion: FEVAR for CAAAs and Extent IV TAAAs was performed with high technical success, low mortality, and MAEs, independent of the use of BMFS. There is no difference in patient survival and freedom from secondary interventions in patients treated with or without BMFS. Clinical Impact One hundred forty-seven patients were treated with bare-metal fixation-stent (79) or covered fixation stents (68). Technical success was similar (p=.47). Overall 30-day mortality was 1%, with no difference in major adverse events (MAEs; p=.59). At 1- and 3-year, there was no difference in patient survival (p=.51), freedom from secondary intervention (p=.71). In conclusion, FEVAR for CAAAs and Extent IV TAAAs was performed with high technical success, low mortality and MAEs, independent of the use of bare-metal fixation stent.

Objective: Target vessel stenosis or occlusion is a common indication for secondary intervention after fenestrated-branched endovascular aortic repair requiring long-term imaging surveillance including duplex ultrasound (DUS). This study aimed to describe and compare longitudinal changes in peak systolic velocity (PSV) measurements for renal and mesenteric arteries targeted by directional branches (DBs) or reinforced fenestrations (RFs). Methods: Patients enrolled in a prospective, nonrandomized study (2013-2020) had DUS of celiac axis, superior mesenteric artery, and renal arteries (RAs) obtained preoperatively, at 6 to 8 weeks, 6 months, and annually. Vessels with preprocedural stenosis were excluded. Outcomes were variations in PSV over time for target vessels incorporated by DBs or RFs, differences in balloon-expandable stent-grafts (BESGs) and self-expandable stent-grafts (SESGs), PSV measurements prior to secondary interventions related to vessel stenosis, and a predictive value of PSV for stenosis requiring secondary intervention. Results: A total of 419 patients (292 male, mean age 74 ± 8 years old) were enrolled, with 1,311 target vessels analyzed preoperatively, including 607 mesenteric and 704 RAs. Over a median follow-up of 23 months (interquartile range [IQR], 7-36), PSV measurements decreased in the first 6 to 8 weeks after DB incorporation, remained stable, followed by a nonsignificant increase at 5 years. PSV increased in the first 6 months using RFs with postoperative velocities significantly higher ( P < .05) for RFs compared to DBs. Branched mesenteric vessels stented with BESGs had higher velocities than SESGs ( P < .05). Of the 23 target vessels treated by secondary intervention for stenosis, 19 (83%) had velocities above the thresholds for native, nonstented vessels. Furthermore, in RAs (n = 20) PSV effectively predicted clinically relevant stenosis, AUC was 0.98, with a 231 cm/s threshold offering 84% sensitivity with 100% specificity. Conclusion: Longitudinal follow-up shows that velocity changes vary depending on the type of incorporation, vessel, and bridging stent. For DBs, PSV decreased initially, stabilized, and showed a nonsignificant increase at 5 years. In contrast, PSV increased with RFs and remained higher than DBs. Despite these variations, velocities remained below established thresholds for clinically significant stenosis in nonstented vessels. Criteria for in-stent stenosis may differ, and PSV alone should not be the sole indicator for reintervention. Clinical Impact This study provides new insight into duplex ultrasound (DUS) surveillance after fenestrated and branched endovascular aneurysm repair (FB-EVAR). Peak systolic velocity (PSV) trends differed between fenestrations and branches, and stent type influenced flow dynamics. Importantly, most vessels with secondary interventions had elevated PSVs, but many others exceeded native stenosis thresholds without clinical consequence. Despite these variations, velocities remained below established thresholds for clinically significant stenosis in non-stented vessels. Criteria for in-stent stenosis may differ, and PSV alone should not be the sole indicator for reintervention.The reported PSV measurements served as a benchmark for DUS surveillance following FB-EVAR.

Objective: To evaluate treatment trends and compare outcomes following fenestrated-branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAA). Background: FB-EVAR has been increasingly utilized as a less invasive alternative to OSR for treatment of TAAAs. Methods: We studied patients who underwent elective FB-EVAR or OSR of TAAAs (2008-2020), since the initiation of an Advanced Endovascular Aortic Program. Primary endpoints were early major adverse events (MAE) and early and late all-cause mortality. Propensity score overlap weighting analysis was performed to adjust for measured confounders between groups. Results: There were 357 (70.8%) patients treated by FB-EVAR and 147 (29.2%) with OSR. The use of FB-EVAR increased from 16.7% in 2008 to >80% since 2017 ( P <0.001). Incidences of early MAEs were 25.8% and 49.0%, respectively; early mortality rates for FB-EVAR and OSR were 2.5% and 6.8%, respectively. In the weighted cohort, FB-EVAR patients had decreased early MAEs (weight-adjusted odds ratio [aOR], 0.28; 95% confidence interval [CI], 0.18-0.41; P <0.001) and mortality (aOR, 0.35; 95% CI, 0.17-0.73; P =0.005) versus OSR patients. Five-year survival estimates were 52.2% (95% CI, 45.2-60.4%) and 78.0% (95% CI, 70.6-86.2%), respectively. In the weighted cohort, there was no significant difference in late survival between groups (weight-adjusted hazard ratio, 1.33; 95% CI, 0.74-2.39; P =0.34). Conclusions: This study confirmed the change in practice from OSR to FB-EVAR for treatment of TAAAs over the past decade. Incidences of early MAEs and mortality were lower with FB-EVAR, with no significant difference in late survival in the weighted cohort.

Objective: To assess patient radiation exposure as reflected by cumulative air kerma (CAK) and dose area product (DAP) during fenestrated-branched endovascular aortic repair (FB-EVAR). Background: Patient radiation exposure during FB-EVAR has been reported inconsistently. Methods: Data from 2,111 patients enrolled in 10 physician-sponsored investigational device exemption studies (2012-2022) were analyzed from the United States Aortic Research Consortium database. Procedures were performed using seven fixed imaging systems (A to G). Patients were classified into three groups by imaging era: 2012-2015 (Group 1), 2016-2018 (Group 2), and 2019-2022 (Group 3). Primary endpoints were CAK and DAP risk factors, assessed using linear mixed-effect models. Secondary endpoints were diagnostic reference levels (DRL) for FB-EVAR. Results: Of the 2,111 patients (71% males; mean 74±9 years years-old) treated by FB-EVAR; 263 (12%) were in Group 1, 541 (26%) in Group 2, and 1,307 (62%) in Group 3. Use of ≥4 vessel stent-graft designs increased from 69% (Group 1) to 79% (Group 3) ( P <0.001). Median CAK decreased from 3,644 mGy (Group 1) to 1,753 mGy (Group 3), and DAP from 441 Gy.cm² to 208 Gy.cm² ( P <0.001). Higher BMI, iliac branch device (IBD) use, and longer fluoroscopy time (FT) were associated with increased CAK and DAP, while experienced operators and systems D, F, and G were protective ( P <0.05). DRLs for Group 3 were 2,800 mGy (CAK) and 340 Gy.cm² (DAP). Conclusions: Radiation exposure during FB-EVAR significantly decreased over time. Higher BMI, IBD use, and FT were linked to increased exposure, while experienced operator and System D, F or G were protective. Trial registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02043691 NCT00583817 NCT00483249 NCT01937949 NCT02050113 NCT02323581 NCT01874197 NCT01654133 NCT02266719.

Objective: To compare target artery (TA) outcomes after fenestrated or branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs). Background: Few studies have compared TA outcomes after endovascular incorporation and open reconstruction. Methods: Among consecutive patients who underwent elective OSR or FB-EVAR of TAAAs (2008–2020), we reviewed those who had postoperative imaging studies evaluating TA. Data of FB-EVAR patients were obtained from a prospectively maintained institutional database. TAs included celiac, superior mesenteric, right, and left renal arteries treated during TAAA repairs. The primary endpoint was TA patency (primary and secondary). Results: There were 131 patients (487 TAs) treated by OSR and 350 (1300 TAs) by FB-EVAR. In the OSR group, 440 TAs (90.3%) were reconstructed by bypasses, and 47 (9.7%) by reimplantation. In the FB-EVAR group, 841 TAs (64.7%) were incorporated by fenestrations and 459 (35.3%) by directional branches. Thirty-day TA primary patency rates were not significantly different between FB-EVAR and OSR (99.4%% vs 99.0%, P = 0.36), but the secondary patency rate was higher after FB-EVAR (99.8% vs 99.0%, P = 0.02). Three-year primary patency rates were 95.9% (95% CI: 94.7%–97.2%) and 94.7% (95% CI: 92.2%–97.2%), respectively; secondary patency rates were 98.5% (95% CI: 97.7%–99.2%) and 94.7% (95% CI: 95.7%–99.2%), respectively. There were no significant differences in late primary patency and secondary patency between groups (each P < 0.05). Conclusions: TA primary and secondary patency rates following elective OSR or FB-EVAR were high. Endovascular repair was not associated with loss of primary patency and late secondary patency.

Purpose: To report the use of modified ex vivo renal artery (RA) reconstruction in a patient with 2 small right RAs (RRAs) in anticipation of planned fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysm (TAAA). Case Report: A staged hybrid repair was utilized in a patient with Extent II TAAA involving celiac axis (CA), superior mesenteric artery (SMA), single left RA (LRA), and 2 small (<3 mm) RRAs. The first-stage operation consisted of hepato-renal bypass using modified ex vivo renal reconstruction with single end-to-end anastomosis to both RAs using a saphenous vein graft. A second stage FB-EVAR was performed using patient-specific manufactured stent-graft with 3 fenestrations for the CA, SMA, and LRA 6 weeks later. The patient recovered with no complications. At 4 years, the patient had widely patent hepato-renal bypass and target vessels with normal renal function. Conclusion: The use of adjunctive hybrid procedures may optimize or facilitate FB-EVAR. In this patient, salvage of 2 small RAs was not ideally suited for branch stenting but was possible using modified ex vivo RA reconstruction with preservation of kidney parenchyma and function. Clinical Impact This case report illustrates a hybrid approach to overcome one of the most frequent limitations to total endovascular incorporation of renal arteries, eg small diameter, early bifurcation and multiple vessels. The modified ex vivo technique allows meticulous renal artery reconstruction without the deleterious effect of warm ischemia and without the cumbersome reconstruction of ureter and vein that is needed with traditional on table ex vivo auto transplantation. The technique is used in a minority of cases and adds the morbidity of open approach. Case selection is of paramount importance.