Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology Salvatore T. Scali, MD, Dan Neal, MS, Vida Sollanek, BS,

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Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology Salvatore T. Scali, MD, Dan Neal, MS, Vida Sollanek, BS, Tomas Martin, MD, Julie Sablik, MBA, Thomas S. Huber, MD, PhD, Adam W. Beck, MD Journal of Vascular Surgery Volume 62, Issue 5, Pages 1148-1159.e2 (November 2015) DOI: 10.1016/j.jvs.2015.06.133 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Example of a patient transferred from an outside hospital with a hemodynamically stable contained rupture of a thoracoabdominal aneurysm after a previous endovascular aneurysm repair (EVAR). A-C, Preoperative imaging of a ruptured Crawford extent III thoracoabdominal aortic aneurysm (TAAA) above a previous Medtronic Talent EVAR (A; red arrow). This patient had a chronically occluded celiac and left renal artery, necessitating a two-vessel fenestrated repair with inclusion of the superior mesenteric artery (SMA) and right renal artery (RRA). The contained rupture was adjacent to the left renal artery (B/C; yellow arrow), and the RRA was nearly occluded and appeared dissected at the origin (C; white arrow). D-F, The repair and postoperative three-dimensional reconstruction. D, The nearly occluded RRA, with successful revascularization through the graft fenestration (E). F, A 6-month postoperative computed tomography (CT) that demonstrated no endoleaks and continued perfusion of the RRA and SMA. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Description of inpatient aortic referral volumes and annual elective, urgent, and emergent operative volumes for complex aortic disease at the University of Florida. A, The total number of inpatient aortic referrals that encompasses all potential patients with acute visceral aortic disease is depicted in this figure. Approximately 40% of cases were found to be nonurgent/emergent and subsequently managed in the outpatient setting. The remaining patients underwent open and/or endovascular operations involving the thoracic, thoracoabdominal, and abdominal aorta. B, The elective and ruptured pararenal and thoracoabdominal open and endovascular surgical volumes are highlighted in the graph. Notably, despite adoption of fenestrated/branched endovascular aortic repair (F/B-EVAR) for elective and acute visceral aortic disease in selected patients, no decrease in open operative volumes is noted, supporting the assertion that judicious application of the technology occurred during this time period. AAA, Abdominal aortic aneurysm. FEVAR, fenestrated endovascular aneurysm repair; OR, operating room; TAAA, thoracoabdominal aortic aneurysm. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 This Kaplan-Meier curve demonstrates the estimated midterm survival after urgent/emergent fenestrated/branched endovascular repair (F/B-EVAR). All reported intervals are less than 10% standard error of the mean. FEVAR, Fenestrated endovascular aneurysm repair. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 The freedom from reintervention after nonelective fenestrated/branched endovascular aortic repair (F/B-EVAR) is highlighted in the figure. Notably, six patients underwent remediation, and all were managed with endovascular techniques. All reported intervals are less than 10% standard error of the mean. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 There were 10 patients (27%) who survived initial hospitalization with an outpatient contrasted postoperative computed tomography (CT) scan during follow-up with evidence of endoleak. If patients were noted to have an intraoperative endoleak with graft implantation, this did not lead to higher likelihood of endoleak after hospitalization. Seventy percent of the posthospital discharge endoleaks were type II. The remaining endoleaks (type III; n = 3) all underwent successful endovascular remediation. All reported intervals are less than 10% standard error of the mean. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 6 The primary patency of all fenestrated/branched endografts in the series is displayed. Excellent 12-month patency is reported; however, one celiac fenestration was documented to have occluded at 12 months postoperatively. All reported intervals are less than 10% standard error of the mean. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 7 The overall trajectory of aortic diameter remodeling is demonstrated in this figure. Because repeated measures over time in the same patient are not independent, simple linear modeling is not appropriate. Mixed statistical models were applied to better understand the behavior of the aorta after nonelective fenestrated/branched endovascular aortic repair (F/B-EVAR). Notably, aortic diameter stabilization and/or regression were observed in the majority of patients with available postoperative imaging. CI, Confidence interval; FEVAR, fenestrated endovascular aneurysm repair. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 8 The posthospital discharged renal outcomes are significantly different for patients with pre-existing renal insufficiency. Specifically, patients with a preoperative estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 who survived initial hospitalization after urgent/emergent fenestrated/branched endovascular aortic repair (F/B-EVAR) had significantly worse renal function in short-term follow-up. These findings have significant implications on long-term survival, as well as surveillance and reintervention protocols. FEVAR, Fenestrated endovascular aneurysm repair; preop, preoperative. Journal of Vascular Surgery 2015 62, 1148-1159.e2DOI: (10.1016/j.jvs.2015.06.133) Copyright © 2015 Society for Vascular Surgery Terms and Conditions