Comparison of outcomes for double fenestrated endovascular aneurysm repair versus triple or quadruple fenestrated endovascular aneurysm repair in the treatment of complex abdominal aortic aneurysms

Objective: This study compared outcomes of standard fenestrated endovascular aneurysm repair (St-FEVAR) with renal artery fenestrations only with more complex FEVAR (Co-FEVAR) with additional fenestrations for the superior mesenteric artery or the celiac trunk, or both. Methods: All consecutive patients treated with FEVAR for short-necked, juxtarenal, or suprarenal aortic aneurysms between January 2010 and July 2016 were included. Patients with stent grafts with a combination of fenestrations and branches were excluded. Data were collected prospectively. All stent grafts used were customized based on the Zenith system (William A. Cook Australia, Ltd, Brisbane, Queensland, Australia). Results: A total of 384 patients (345 men; meanage, 72.7 +/- 7.8 years) were treated. St-FEVAR was used in 199 patients (51.8%) and Co-FEVAR in 185 (48.2%), including 30 patients with a quadruple FEVAR. Overall technical success was 373 of 384 (97.1%), and the difference between the St-FEVAR group (195 of 199 [98%]) and the Co-FEVAR group (178 of 185 [96.2%]) was not statistically significant (P =.37). Mean operative time was 135 +/- 46 minutes for St-FEVAR and 176 +/- 53 minutes for Co-FEVAR (P <.001). Mean fluoroscopy time was 45 +/- 17 minutes for St-FEVAR and 57 +/- 21 minutes for Co-FEVAR (P <.001). Overall 30-day mortality was two of 384 (0.5%), and the difference between the two groups was not statistically significant (St-FEVAR: 1 of 199 [0.5%] vs Co-FEVAR: 1 of 185 [0.5%]; P = 1.0). Major perioperative complications between St-FEVAR group (22 of 199 [11.1%]) and Co-FEVAR group (24 of 185 [13%]) were similar (P =.64). Mean follow-up was 20 +/- 17.1 months. Estimated survival at 1 and 3 years was 95% +/- 1.7% and 83.4% +/- 3.6% for St-FEVAR vs 94% +/- 2.4% and 89.4% +/- 3.5%, respectively, for Co-FEVAR(P =.96). Estimated freedom from reintervention at 1 and 3 years was 97.9% +/- 1.2% and 90.5% +/- 3.1% for St-FEVAR vs 95.4% +/- 2.0% and 89.1% +/- 4.2%, respectively, for Co-FEVAR (P =.5). Estimated target vessel patency at 1 and 3 years was 99.2% +/- 0.4% and 98.6.0% +/- 0.6% for St-FEVAR vs 98.6% +/- 0.6% and 97.9% +/- 0.9%, respectively, for Co-FEVAR (P =.48). Conclusions: Co-FEVAR is not associated with an increase in perioperative mortality and morbidity compared with St-FEVAR. Co-FEVAR requires longer procedure and fluoroscopy duration, but technical success rates are as high as in St-FEVAR. A liberal use of Co-FEVAR is therefore justified whenever a longer and higher proximal sealing zone is needed.