IP039 - Clinical Outcomes of Physician Modified Endograft for Thoracoabdominal Aneurysm: A Multi-Center Experience

Objectives: Physician-modified endografts (PMEG) comprise an endovascular technique for treatment of thoracoabdominal aortic aneurysms (TAAA) and abdominal aortic aneurysms (AAA) involving the renal and mesenteric arteries. Compared with commercially available fenestrated endografts, limited reports document PMEG results. This study characterizes the clinical outcomes of a PMEG series to demonstrate the versatility, efficacy, and safety of PMEG in the treatment of complex aneurysmal disease.

Methods: Charts of all patients who underwent PMEG using Gore Excluder and/or TAG grafts at Essentia Health/St. Mary’s Medical Center and Thomas Jefferson University Hospital between 2013 and 2021 were retrospectively reviewed. Primary outcomes included 30-day morbidity and mortality and target vessel patency. Secondary outcomes included incidence of endoleaks and change in aneurysm diameter.

Results: 66 patients were treated with PMEG for juxtarenal AAA (43, 65%), paravisceral AAA (4, 6%), suprarenal AAA (4, 6%), and TAAA (14, 21%). 61 procedures were performed electively (92%); 4 for symptomatic (6%) and 1 for ruptured (1.5%) aneurysms. Branch fenestrations were based upon individual patient anatomy and included modular bifurcated stent grafts to 6 renal arteries and one combined hepatic/SMA. Fenestrated treatment of 178/183 (97%) renal/mesenteric arteries was successful. 23 patients experienced 31 < 30-day complications. Systemic complications included cardiac (6, 9%), renal (6, 9%), pulmonary (4, 6%), stroke (3, 5%), and spinal cord ischemia (2, 3%). Local complications included access (5, 8%), target vessel perforation (1, 1.5%), and compartment syndrome (1, 1.5%). 30-day mortality occurred in 4 (6%) patients secondary to stroke (1), hemorrhage (1), aspiration pneumonia (1), and unknown (1). At latest follow-up, aneurysm size decreased or remained unchanged in 59 patients (mean decrease: 1.83cm, SD: 1.99) and increased in 7 patients (mean increase: 1.25cm, SD: 1.49). At mean follow-up of 37.25±30 months, primary patency was noted in 166/178 (93%) vessels. Secondary interventions were performed on 10 vessels, providing combined primary and assisted primary patency in 176/178 (99%) vessels at 37.5±23 months. 10 patients (15.2%) were noted to have endoleaks: 5 type II endoleaks did not require treatment; 2 Type Ia, 1 Type Ib, and one patient with multiple Type IIID endoleaks were successfully managed with secondary procedures. No aneurysm-related late mortalities occurred.

Conclusions: Our multi-center experience demonstrates PMEG to be safe, effective, and associated with satisfactory early and mid-term outcomes for complex aneurysmal disease. Excellent patency of branch fenestrations was demonstrated. Operative morbidity and mortality are not unexpected in these high-risk patients and will likely improve as experience increases.