Safety and Feasibility of Performing Fenestrated Endovascular Abdominal Aneurysm Repair Using a Portable C-arm Without Fusion Technology: A Single-Center Experience

Abstract

Objective Most centers performing fenestrated endovascular aneurysm repair (F-EVAR) use hybrid rooms with fusion technology for mapping. We present our experience of successfully performing F-EVAR using C-arm without fusion technology. Methods During the period of January 2016 to October 2018, data were collected from a prospectively maintained F-EVAR database at our tertiary care institute. The primary endpoint was technical success, and the secondary outcomes measured were short- and midterm clinical success (both defined by the Society for Vascular Surgery reporting standards), blood loss, radiation dose, operative time, postoperative endoleaks, aneurysm rupture, endograft patency, and complications. Results We performed 11 F-EVARs during the study period in five (45.5%) males and six (54.5%) females, with a mean age of 75+8 years. All procedures were performed under general anesthesia using OEC 9900 Elite Mobile C-arm (GE Healthcare, Chicago, IL, USA) without the use of fusion technology. Three patients had planned preoperative open procedures for access due to prior cutdown or bypass. Technical success was achieved in all 11 (100%) cases. The mean length of stay was 5+2 days, and the mean follow-up was 7.5+6.5 months. The mean procedure time was 301+167 minutes, and the mean blood loss was 361+233 mL. Mean fluoroscopy time was 72+31 minutes, and the mean radiation exposure time was 2,160+930 mGy. No patients required intraoperative transfusion. Thirty-day (short term) clinical success was achieved in 10 (90.0%), cases whereas six-month (midterm) clinical success was achieved in 7 (77.7%) patients. Branch vessel patency was 11 (100%) at 30 days and 9 (81.8%) at six months, and primary endograft patency was 100% (11) at six months. We had no perioperative mortality or major adverse cardiac event at 30 days. Thirty-day postoperative morbidity included readmission for pulmonary edema from cardiac failure in one patient. Two patients had clinically insignificant silent cardiac enzyme elevation. Three patients had re-interventions performed during the mean follow-up period. Two patients developed renal stent thrombosis resulting in renal insufficiency, which is defined as an increase in creatinine concentration ≥0.5 mg/dL, without the need for dialysis. One type II endoleak was identified postoperatively that required trans-lumbar embolization. No type I or III endoleaks were identified during the study period. Asymptomatic common femoral artery thrombosis was seen on follow-up imaging in one patient. Conclusions We conclude that F-EVAR can be safely performed using C-arm without the use of fusion technology. Its utility can be expanded to centers with appropriate skill set but no hybrid technology.

Keywords: aortic aneurysm; c-arm; endovascular; hybrid; radiation.