Impact of Aortoiliac Tortuosity in Outcomes of Fenestrated Endovascular Aortic Repairs

Anatomy plays a key role in the suitability of and outcomes for endovascular aortic repair of abdominal aneurysms. Angulation of the proximal aneurysm neck has been associated with adverse events after endovascular repair, including endoleaks, stent migration, and secondary interventions. Still, information on the impact of aortoiliac tortuosity in fenestrated repairs of aortic aneurysms remains limited. We aimed to quantify effects of aortoiliac tortuosity on outcomes in complex endovascular aortic repairs. Patients who underwent a physician-modified endovascular repair for the treatment of juxtarenal aortic aneurysms at a single center, under a physician-sponsored investigation device exemption study, from 2011 to 2021 were reviewed. Center luminal lines and geometric distances were obtained using TeraRecon software. A tortuosity index was calculated. Aortic and iliac tortuosity were assessed independently and stratified into low (<1.15) and high (>1.15) using the Society for Vascular surgery aortic tortuosity reporting standards. Univariable and multivariable analyses were applied. We identified 108 patients, including 72 with low and 36 with high aortic tortuosity, and 65 with low and 42 with high iliac tortuosity. Patients with high aortic tortuosity were older (76 years vs 79 years; P = .03) and more commonly female (35 vs 78; P = .03). On univariable analysis, a high aortic tortuosity index was associated with increased fluoroscopy time (30 minutes vs 40 minutes; P = .02); however, no differences were noted in outcomes (Table). When iliac tortuosity was assessed, a high tortuosity index was associated with an increased risk of type I or III endoleak (30 vs 23; P = .0001), as well as reinterventions (20 vs 16; P = .04) (Table). In multivariable analysis, higher iliac tortuosity was again associated with secondary interventions (odds ratio, 2.8; 95% confidence interval, 1.1-7.2), including those for type I or type III endoleaks (odds ratio, 4.0; 95% confidence interval, 1.2-1.6). Among patients treated with physician-modified endovascular repair for juxtarenal aneurysms, iliac tortuosity but not aortic, is associated with increased reinterventions and type I or III endoleaks. Long-term follow-up is particularly critical for patients with high iliac tortuosity to ensure these high-risk endoleaks are identified and treated early to avoid the risk of rupture.TableOutcomesVariablesAortic tortuosityIliac tortuosityLow (n = 72)High (n = 36)P valueLow (n = 65)High (n = 42)P valueAdverse events (any)12 (17)12 (33).0918 (28)6 (14).15Death <30 days2 (3)3 (8).334 (6)1 (2).65Endoleak (any)39 (54)15 (42).3130 (85)23 (55).43Type I/type III endoleak3 (4)12 (33).383 (5)12 (29).001Type Ia3 (4)2 (6)1.003 (5)2 (5).99Type Ib2 (3)1 (3)1.001 (2)2 (5).99Type Ic0 (0)1 (3)1.001 (2)0 (0).99Technical success71 (99)34 (94).2663 (97)41 (98).99Reintervention (any)23 (32)12 (33)1.0020 (48)16 (25).04Reintervention for Endoleak10 (14)5 (14)1.005 (8)10 (24).02Pulmonary complications3 (4)0 (0).553 (5)0 (0).28Myocardial infarction3 (4)2 (6)1.005 (8)0 (0).15Acute renal failure1 (1)3 (8).113 (5)1 (2).99Mesenteric ischemia2 (3)0 (0).552 (3)0 (0).52Stroke0 (0)1 (3).331 (2)0 (0).99Spinal cord ischemia0 (0)2 (6).112 (3)0 (0).52Hospital length of stay, days3.9 ± 5.02.5 ± 2.0.683.7 ± 4.82.9 ± 3.0.58ICU length of stay, days1.5 ± 0.82.0 ± 2.7.061.3 ± 0.72.1 ± 2.6.06Values are number (%) or mean ± standard deviation. Boldface entries indicate statistical significance. Open table in a new tab