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Two strategies feasible after failed EVAR

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After failed endovascular aortic aneurysm repair, explant and fenestrated-branched endovascular aortic aneurysm repair are feasible and associated with similar outcomes, according to a presentation at the Society for Vascular Surgery Vascular Annual Meeting.

Researchers retrospectively analyzed 247 patients (mean age, 75 years; 87% men) who underwent explant (n = 162) or fenestrated-branched EVAR (n = 85) after failed EVAR between 1999 and 2016.

The researchers concluded that “both are excellent modalities for treating a complicated problem,” Matthew Eagleton, MD, vascular surgery director of the Aortic Center and vice chairman of research and education in the department of vascular surgery of the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, told Cardiology Today’s Intervention.

Matthew Eagleton

Agenor Dias, MD, aortic fellow at Cleveland Clinic, presented the findings, which included analyses of demographics, clinical presentation, failure etiology, perioperative management and rates of reintervention, morbidity and mortality.

“At Cleveland Clinic, we’ve had a growing number of patients that present with failed standard EVAR that we are required to repair, and historically, we have taken two different approaches to this,” Eagleton said in an interview. “Given that they’re two completely different modes of therapy, we wanted to compare [them] to see what are the differences between the two groups. Are there different types of patients that are getting treated one way vs. the other? Can we identify differences in outcomes with the loftier goal of trying to figure out if one way is ultimately better than the other in certain patient subsets?”

Mean time from primary EVAR was greater in the fenestrated-branched EVAR group compared with the explant group (P < .0001).

In the explant group, there were 24 patients (14.8%) who required urgent or emergent surgery, compared with three in the fenestrated-branched EVAR group (3.5%; P = .013), according to the researchers.

Among the 12 patients with aortic rupture, all were treated with explant. In addition, EVAR graft infection was observed in 17.3% of the explant group but in no patients in the fenestrated-branched EVAR group.

The most common reason for EVAR failure was endoleak (explant group, 74.1%; fenestrated-branched EVAR group, 63.5%; P = .24), according to the researchers. However, type 1 endoleak occurred more frequently in the fenestrated-branched EVAR group (63.5% vs. 39.5%; P = .0005) and type 2 endoleak occurred more frequently in the explant group (27.2% vs. 2.3%; P < .0001).

The fenestrated-branched EVAR group had higher rates of graft migration (25.9% vs. 11.7%; P = .0001) and neck degeneration or disease progression (58.8% vs. 12.9%; P < .0001), and the explant group had a higher rate of aneurysm enlargement (67.9% vs. 32.9%; P < .0001), the researchers found.

There was no significant difference between the groups in 30-day reintervention rates (explant group, 21%; fenestrated-branched EVAR group, 10.6%; P = .14) or 30-day mortality (explant group, 13%; fenestrated-branched EVAR group, 4.7%; P = .11), and the results did not change after excluding emergent/compassionate procedures, infections and ruptures, according to the researchers.

“Fenestrated-branched EVAR was never used in emergent situations such as ruptured aneurysms and infections,” Eagleton said. “Despite that, perioperative mortality and overall complication rates were lower in patients that underwent endovascular repair. The surprising finding we had, though, is that after 2 years, patients that survived open repair had improved survival over patients who underwent fenestrated endovascular repair. We don’t know why we have those results, which are the opposite of what we anticipated. It will take more investigation to figure out the long-term differences between the two patient populations.”

For now, clinicians can be reassured that “if they have a high-risk patient who is not going to tolerate conventional surgery, there will be no hesitation in moving forward to provide them with fenestrated endograft repair,” Eagleton told Cardiology Today’s Intervention. “Similarly, patients who are healthier can safely undergo open repair for this problem and can be expected to have a great long-term survival.”

He said the next steps are to determine which subsets of patients benefit most from endovascular repair and which benefit most from open repair, and to determine why the open-repair group had better long-term survival.

“That may just be due to the selection process,” he said. “They may have been selected for fenestrated repair simply because they were too sick to undergo an open repair.” – by Erik Swain

Reference:

Dias A, et al. S1: William J. von Liebig forum. Presented at: Society for Vascular Surgery Vascular Annual Meeting; May 31-June 3, 2017; San Diego.

Disclosure: Dias and Eagleton report no relevant financial disclosures.