IYSC15 - Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

Objectives: Complex chronic post-dissection aneurysms pose difficult challenges for endovascular management, and reports are limited to high volumes centers, posing questions about generalizability.

Methods: We studied all intact endovascular repairs of complex degenerative and chronic post-dissection aneurysms incorporating at least one branch vessel (zone 2 and below) in the VQI from 2014-2020. We compared perioperative and long-term outcomes between repairs of degenerative aneurysms and post-dissection aneurysms; staged repairs were compared separately by each stage. Perioperative outcomes were compared using mixed effects logistic regression, and long-term outcomes with cox regression.

Results: There were 3810 operations for degenerative aneurysms and 155 post-dissection, with 53% of post-dissection repairs and 9.5% of degenerative repairs performed in staged fashion (P <.001). The majority (78%) of post-dissection aneurysms were extent 1, 2 or 3, compared to 19% of degenerative aneurysms (P <.001). Physician modified endografts (PMEG) were the primary repair type for post-dissection aneurysms (77%, with 18% chimney/snorkel, and 5% commercially available fenestrated graft), while commercially available fenestrated grafts were the dominant repair for degenerative (49%, with 35% PMEG, 16% chimney/snorkel). The first stage of staged procedures in patients with post-dissection and degenerative aneurysms were associated with similar rates of perioperative death(post-dissection: 3.3% vs degenerative 7.4%, P=.26), stroke (0% vs 5.8%, P=.06), major adverse cardiac event (8.3% vs 13.2%, P=.31), acute kidney injury (20% vs 13.2%, P=.2), spinal cord ischemia (1.7% vs 7.4%, P=.1), and new dialysis (0% vs 1.1%, P=.42). During final stage procedures, procedural metrics including procedure time, estimated blood loss, fluoroscopy time and contrast used were similar between degenerative and post-dissection repairs. However, technical success was lower for post-dissection aneurysms (76% vs 83%, OR 0.6 [0.4-0.99], P=.04), driven by higher rates of type 1 or 3 endoleaks (18% vs 10%, OR 2.4 [1.4-4.0], P=.001). Adjusted perioperative outcomes were mostly similar between post-dissection and degenerative aneurysm repairs, but post-dissection patients had higher odds of stroke (OR 2.8 [1.3-6.2], P=.01) and early reintervention (OR 1.9[1.02-3.5], P=.043) (Table 1). Crude and adjusted 3-year survival was similar between post-dissection and degenerative aneurysm repairs, but 3-year reinterventions were significantly higher with post-dissection repairs (59% at 3 years vs 25%, P=.008) (Figure 1).

Conclusions: Complex endovascular repair of chronic post-dissection aneurysms is safe and feasible, but is associated with high rates of reinterventions. More data are needed to evaluate the long-term durability of these procedures.