Midterm single-center results with the use of custom-made endografts with inner branches, a call for attention

Abstract

Objective: The aim of this study was to evaluate the patency of bridging covered stents (BCS) bridged to inner branches in custom-made thoracoabdominal endografts.

Methods: This was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f/b EVAR) in whom the reno-visceral target vessels (TVs) were bridged with a BCS to an inner branch of a custom-made (CMD) endograft. Technical success and perioperative complications were noted. Follow-up BCS patencies were evaluated, and in patients with follow-up, two groups based on BCS were created, a group with BCS occlusion and a group with BCS patent. Univariable and multivariable analyses were performed to analyze factors related to visceral and renal bridging stent occlusion.

Results: From 2019 through 2022, 69 patients undergoing complex aortic repair had at least one TV bridged to an inner branch built into a CMD endograft. Eighty-six percent of the grafts had only inner branches, whereas 14% had a mix of fenestrations for the visceral TVs and inner branches for the renal arteries. Twenty-five percent of patients presented as urgent and received an endograft originally designed for another patient and available on our shelf at the time. A total of 245 TVs were connected to inner branches: celiac trunk (CT), 54; superior mesenteric artery (SMA), 59; and renal artery (RA), 132. Technical success was 99%. There was a 23% complication and 9% perioperative mortality rate. At follow-up, we identified 6% of visceral and 14% of renal BCS occlusions. The primary patency for RA BCS was 83% at 12 months and 58% at 24 months. For the CT-SMA BCS, Kaplan-Maier showed a patency of 99% and 96% at 12 and 24 months. In the univariate analysis, a misaligned TV ostium (P = .001), the postoperative BCS diameter on postoperative computed tomography angiography (P = .02), and the preoperative infrarenal aortic angle >60° (P = .007) were correlated with RA BCS occlusion. In the multivariate analysis, only the misaligned TV ostium (P = .002) and infrarenal angle >60° (P = .01) were significantly correlated.

Conclusions: In our series of complex aortic repair, the incorporation of inner branches to bridge TVs is associated with a high renal BCS occlusion rate. Improper alignment of the branches with the TV ostium and acute aortic angles might play a significant role. Further research on this technology is needed.

Keywords: Aortic aneurysm; EVAR; Endovascular aneurysm repair; Inner branches; Renal artery.