Peri-operative and Midterm Results of Supracoeliac vs. Infracoeliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

Titia A L Sulzer; Jorg L de Bruin; Vinamr Rastogi; Gert Jan Boer; Klaas H J Ultee; Bram Fioole; Gustavo S Oderich; Marc L Schermerhorn; Hence J M Verhagen

doi:10.1016/j.ejvs.2024.11.019

Peri-operative and Midterm Results of Supracoeliac vs. Infracoeliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

Eur J Vasc Endovasc Surg. 2024 Nov 19:S1078-5884(24)00975-4. doi: 10.1016/j.ejvs.2024.11.019. Online ahead of print.

Authors

Titia A L Sulzer¹, Jorg L de Bruin², Vinamr Rastogi², Gert Jan Boer³, Klaas H J Ultee⁴, Bram Fioole³, Gustavo S Oderich⁵, Marc L Schermerhorn⁶, Hence J M Verhagen²

Affiliations

¹ Erasmus University Medical Center, Rotterdam, the Netherlands. Electronic address: titiasulzer@gmail.com.
² Erasmus University Medical Center, Rotterdam, the Netherlands.
³ Maasstad Hospital, Rotterdam, the Netherlands.
⁴ Erasmus University Medical Center, Rotterdam, the Netherlands; Maasstad Hospital, Rotterdam, the Netherlands.
⁵ Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
⁶ Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

PMID: 39571884
DOI: 10.1016/j.ejvs.2024.11.019

Abstract

This retrospective observational study using clinical data from two large hospitals in the Netherlands evaluated midterm outcomes of fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysms (JAAAs), comparing supracoeliac with infracoeliac sealing. Supracoeliac sealing is considered advantageous due to a longer proximal sealing, but morbidity is usually higher. Supracoeliac proximal sealing was found to be safe and effective for treating JAAAs, with peri-operative and midterm outcomes comparable with infracoeliac proximal sealing. Future studies and extended long term follow up are required to determine whether supracoeliac sealing results in a more durable exclusion of the aneurysm sac.

Objective: The aim of this study was to investigate peri-operative and midterm outcomes, including sac dynamics, of fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms (JAAAs), comparing supracoeliac with infracoeliac sealing. Supracoeliac sealing may offer an advantage due to a longer proximal sealing zone, but it is associated with a more complex procedure and increased risk of complications. Furthermore, it is unknown whether supracoeliac sealing actually leads to increased durability.

Methods: Patients undergoing elective FEVAR for JAAAs from 2008 - 2021 at two hospitals in the Netherlands were included. The definition of supracoeliac sealing was sealing in zone 5 or 6, with incorporation of the coeliac axis. Infracoeliac sealing was defined below zone 6. The primary endpoints included peri-operative outcomes. Secondary endpoints included one year aneurysm sac dynamics, freedom from secondary intervention, five year mortality, and sac dynamics over time.

Results: Among 167 patients, 78 (46.7%) had a proximal sealing at an infracoeliac level and 89 (53.3%) at a supracoeliac level. Median proximal sealing length was 37 (interquartile range [IQR] 28, 52) mm for the supracoeliac group and 26 (IQR 19, 34) mm for the infracoeliac group. Patients with supracoeliac sealing more often had prior endovascular aortic aneurysm repair (31% vs. 12%; p = .004). Type IIIc endoleaks only occurred in patients with supracoeliac sealing (6% vs. 0%; p = .03). Other peri-operative complications and mortality were similar between the groups. Furthermore, no significant differences were found in one year aneurysm sac dynamics, freedom from secondary interventions, five year mortality, and sac dynamics over time.

Conclusion: Proximal supracoeliac and infracoeliac sealing showed similar midterm outcomes, including sac dynamics, despite the higher procedural complexity of supracoeliac sealing. Supracoeliac sealing had a higher rate of 30 day type IIIc endoleak, but no difference in five year secondary intervention rate. Theoretically, supracoeliac sealing may be advantageous as sealing zones dilate over time, although future studies with longer than five year follow up are needed to determine its impact on long term aneurysm sac exclusion.

Keywords: Fenestrated endovascular aneurysm repair; Infracoeliac; Juxtarenal AAA; Proximal landing zone; Supracoeliac.