SS12 - Cause-specific Long-Term Mortality After Physician-Modified Branched/Fenestrated Endovascular Aortic Repair

Objectives: Physician-modified endografts(PMEG) are being increasingly utilized for treatment of complex aortic diseases. Several series describe short and mid-term outcomes, but limited long-term data is available. Here we sought to evaluate the long-term causes of death after PMEG, and the association with type and complexity of repair.

Methods: A single, high-volume, academic aortic referral center retrospectively reviewed all consecutive branched/fenestrated PMEG procedures from 2010-2016 which allowed all subjects the opportunity for ≥ 5-years of survival time. All subjects were deemed either high anatomic and/or physiologic risk for open repair. Commercial custom and chimney EVAR procedures were excluded. Death certificates, obituary websites, and electronic medical records were reviewed to assign cause-specific mortality. The primary end-point was all-cause mortality. Secondary end-points included cause-specific-death categorized as: major adverse cardiovascular event(MACE: MI, malignant arrythmia, CHF, sudden death), malignancy, pulmonary(COPD/respiratory failure), infection, aorta-related, and other(including metabolic/stroke/trauma, etc.). Kaplan-Meier methodology was used to estimate survival.

Results: A total of 232 consecutive PMEG procedures were analyzed(male, 72%; mean age 73±8 years). Indications included thoracoabdominal aneurysm(TAAA, extent I-V: 58%), pararenal AAA(33%), post-surgical pseudoaneurysm/failed EVAR(6%), chronic dissection(2%), and penetrating paravisceral ulceration(1%). A majority were performed electively(75%, n=174) while the remaining were completed for symptomatic/intact(20%, n=47) and emergent/ruptured(5%, n=11) presentations. 762 target vessels were included(Celiac, n=179, SMA, n=204, renal n=379) and most procedures had 4-vessel revascularization(61%, n=142). 30-day mortality was: elective, 3%(n=5/174), non-elective, 14% (n=8/58). Secondary intervention occurred in 18%(n=42).

Mean survival was 4.9± 3.2 years(median, 5.4[IQR 1.9-7.5], 95%CI 4.9-6.1) and 57%(n=132/232) died during follow-up. Among 132 documented deaths, 10%(n=13/132) occurred before hospital discharge and/or ≤ 30-days, while 90%(n=119/132) occurred >30-days and/or after hospital discharge. Cause-specific mortality was attributed to: MACE(21%), other(18%), aorta-related(13%), unknown(13%), pulmonary(12.5%), infection(12.5%) and malignancy(10%). Causes of late aorta-related death(n=16/232, 6.9% overall; 12.1% of all deaths recorded) were: rupture(n=5) and mesenteric ischemia(n=2), respectively.

Freedom from long-term all-cause and aorta-related mortality was: 5-years, 56±3% and 90±2%; 8-years, 43±4% and 87±3%, respectively(Figure 1). Non-elective presentation had higher long-term risk of all-cause and aorta-related mortality(all-cause: HR 1.6, 95%CI 1.1-2.4; aorta-related, HR 3.2, 95%CI 1.2-8.5)(Figure 2). 4-vessel repairs were associated with improved survival(vs. < 4-vessels, HR 0.6, 95%CI 0.4-0.9).

Conclusions: PMEG in high-risk patients was durable and provided excellent long-term outcomes in patients deemed high-risk for open repair. Cardiovascular morbidity is the most significant factor leading to late mortality after PMEG. Aorta-related mortality is low; however, elective repairs with more proximal coverage appear to be protective from poor long-term outcomes.