Outcomes Following Fenestrated Endovascular Aortic Repair for Failed Infrarenal Endovascular Aortic Repair Compared With Primary Fenestrated Endovascular Aortic Repair

Fenestrated endovascular aortic repair (FEVAR) is a potential treatment option in patients with failed EVAR due to proximal disease progression. However, studies evaluating the outcomes after FEVAR in patients with prior EVAR are limited to data from single-center and high-volume institutions. Therefore, we compared the outcomes after FEVAR in patients with prior EVAR vs without any prior aortic surgery (primary FEVAR). We identified patients undergoing elective FEVAR for complex abdominal aortic aneurysm in the Vascular Quality Initiative between 2014 and 2022 and included those who underwent no prior aortic surgery (n = 2362) or prior EVAR (n = 117). Perioperative outcomes and 5-year mortality were analyzed using logistic regression and Cox regression models. Sac changes were assessed based on differences in aneurysm sac diameter between the 1-year computed tomography scan and preoperative imaging and were categorized as regression (>5 mm decrease), stability (<5 mm change in size), and expansion (>5 mm increase) for analysis. We included 2362 primary FEVAR patients and 117 patients who underwent FEVAR after EVAR. The FEVAR after EVAR patients were older (76 [72-82] years vs 74 [68-79] years; P < .001), less frequently female (12% vs 23%; P = .004), had larger aneurysm diameters (68 [60-80] mm vs 58 [55-63] mm; P < .001), and more preoperative comorbidities. After EVAR patients, FEVAR patients were more likely to undergo repairs at high-volume centers performed by high-volume surgeons (P < .001). Furthermore, FEVAR after EVAR involved more proximal aortic zones with a higher number of branches and longer procedural time and radiation (all P < .05). Despite these differences, FEVAR after EVAR showed comparable perioperative outcomes relative to primary FEVAR (Table I). However, in the FEVAR, after EVAR group, 1-year sac regression rates were lower (24% vs 51%; P = .005), whereas sac expansion was more likely (39% vs 7.3%; P < .001) compared with the primary FEVAR group (Table II). At 2-year follow-up, FEVAR after EVAR was associated with similar mortality (26% vs 19%; hazard ratio: 1.4, 95% confidence interval: 0.84-2.2; P = .20) and reinterventions (14% vs 13%; hazard ratio: 1.04, 95% confidence interval: 0.36-3.0; P = .91) compared with primary FEVAR. FEVAR after EVAR has a similar risk of perioperative and 2-year mortality compared with primary FEVAR. However, the higher rate of sac expansion at 1 year in these patients raises significant concerns about the durability of these repairs. Therefore, patients undergoing FEVAR after EVAR may benefit from closer surveillance or even consideration for open conversion. Future studies should evaluate open conversion as an alternative to endovascular treatment for proximal failure of EVAR.Table IPerioperative outcomes after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 2373)FEVAR after EVAR (n = 130)P valueFEAVR after EVAR vs primary FEVARP valueUnadjusted rates, %Adjusteda OR [95% CI]Perioperative death2.82.3.800.62 [0.13-2.2].50Any complication9.611.770.65 [0.29-1.4].30 Stroke0.60.66NANA AKI1214.700.75 [0.38-1.4].4 Postoperative dialysis1.72.3.740.73 [0.10-3.28].71 Bowel ischemia1.91.51.01.4 [0.18-6.2].71 Spinal cord ischemia1.53.1.270.85 [0.11-4.0].85 Leg ischemia1.92.3.740.68 [0.10-3.0].65 Pulmonary complications3.64.6.620.70 [0.21-2.0].52 Cardiac complications3.53.81.00.53 [0.14-1.6].30 Completion type 1A endoleak3.40.8.120.32 [0.02-1.73].29Reintervention during index hospitalization4.26.2.380.73 [0.48-1.1].12Unadjusted rates, %P valueAdjusteda HR [95% CI]P value2-year reintervention1314.201.04 [0.36-3.0].912-year mortality1926.701.4 [0.84-2.2].20AKI, Acute kidney injury; CI, confidence interval; EVAR, endovascular aortic repair; FEVAR, fenestrated EVAR; HR, hazard ratio; OR, odds ratio.aAdjusted for age, gender, diameter (>65 mm), hypertension, diabetes, prior myocardial infarction, prior chronic obstructive pulmonary disease, obesity, prior chronic kidney disease, anemia, proximal sealing zone, center volume, and physician volume. Open table in a new tab Table IISac dynamics at 1 year after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 853), %FEVAR after EVAR (n = 33), %P valueSac regression, >5 mm5124.005Stable sac, <5 mm4232.67Sac expansion, >5 mm7.339<.001EVAR, Endovascular aortic repair; FEVAR, fenestrated EVAR.Boldface P value represents significance P < .05. Open table in a new tab