Combination of Fenestrated Endovascular Aortic Repair With Distal Unibody Anatomic Fixation

Standard fenestrated endovascular aortic repair (FEVAR) necessitates caudal extension using a distal bifurcated module, which can be difficult with severe aortoiliac occlusive disease or a small terminal aorta. We have described our experience with a distal-first sequence, beginning with an anatomically fixed bifurcated unibody. We performed a retrospective review of our experience with FEVAR for juxtarenal abdominal aortic aneurysms since 2014. Twenty-five procedures involving the use of the AFX2 device (Endologix, Irvine, Calif) were identified (AFX group: age, 74 ± 10 years, 15 men). A comparison cohort of 35 FEVAR procedures using a conventional distal body was also identified (age, 73 ± 8 years; 27 men). The demographics and baseline aneurysm diameter were comparable in both groups. The anatomic, procedural, and follow-up details are summarized in the Table. Severe underlying aortoiliac occlusive disease, including complete total occlusion and a small terminal aorta (<18 mm), were more common in the AFX group. A staged approach with common femoral artery reconstruction, iliac recanalization, and stenting with or without AFX deployment in the initial stage was used for four patients. The mean procedure duration was comparable, although a lower radiation dose was noted in the AFX group. Component instability had occurred more often in the AFX group (three vs one), albeit without a statistically significant difference. Unibody distal fixation (Fig) allowed for simplified planning and enabled a staged approach to address severe aortoiliac disease with an especially beneficial application in the setting of a prohibitive small terminal aorta (<18 mm in diameter). We found the reversed order deployment with the relatively rigid distal unibody to be helpful, especially in patients with severe aortoiliac tortuosity. The stiff unibody system can assist in straightening infrarenal aortic tortuosity and provides a stable platform for sheath tracking and fenestration alignment. The long-term benefits of the unibody could be important for patients with concomitant infrainguinal occlusive disease, facilitating future endovascular cross-over approaches. Although not significant, a higher incidence of component instability was noted in the AFX group. Our current practice has been to ensure maximum overlap between the fenestrated component and the AFX modules, down to the bifurcation, especially in the presence of highly angulated anatomy and in very large aneurysms.TableAnatomic, intraprocedural, and outcome comparison of conventional fenestrated endovascular aortic repair (FEVAR) vs distal unibody FEVARVariableConventional FEVARDistal unibody FEVARP valueaAnatomy, No. Infrarenal neck angle >40°1911.4 Terminal aorta diameter <20 mm28.03 Any AIOD1218.7 Severe AIOD/prior iliac stents27.02 Staged operation04.001Procedure Proximal fixation zone ≥72120 Proximal seal zone length, mm36 ± 739 ± 15.32 No. of incorporated branches3.0 ± 052.7 ± 1.0.17 Procedure duration, minutes309.7 ± 114.8284.2 ± 94.3.36 Fluoroscopy time, minutes84.9 ± 39.769.1 ± 39.3.21 Dose, mL6288 ± 38573911 ± 3760.05Follow-up Procedures before 2017, No. (%)14 (40)23 (92).001 CTA follow-up duration, weeks133 ± 8724 ± 29.001 Sac diameter change, mm−13.9 ± 12.4−9.4 ± 16.1.03 Component instability, No.13.1 Component instability with T3aEL, No.11.6 Reintervention for component instability, No.12.2 Reintervention for T3aEL, No.23.27 Reintervention for branch instability, No.63.44 Aneurysm-related mortality, No.21.4AIOD, Aortoiliac occlusive disease; CTA, computed tomography angiography; T3aEL, type IIIa endoleak.aDerived by χ2 test or Fisher exact test. Open table in a new tab