Impact of Stent-Graft Complexity on Outcomes of Complex Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

Abstract

Objectives:

This study aims to systematically review and meta-analyze the available literature to compare the early and mid-term clinical outcomes (including technical success, mortality, complications, and reinterventions) of renal fenestrated endovascular aortic repair (FEVAR) versus complex FEVAR in the treatment of pararenal aortic aneurysms (PAAs) and type IV thoracoabdominal aortic aneurysms (TAAAs).

Methods:

A systematic review and meta-analysis of studies focusing on results of patients treated with renal FEVAR and comparing with complex FEVAR in endovascular treatment of PAA and type IV TAAA was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. PubMed, EMBASE, the Cochrane Library, and Web of Science were searched for studies till mid-February 2025. Observational and randomized studies were included. Reasons for exclusion were series less than 10 patients and ruptured aneurysms. Primary outcomes were technical success, perioperative reinterventions, 30-day or in-hospital mortality, and reintervention for endoleak type I or type III during follow-up. Secondary outcomes were target vessel patency, myocardial infarction, bowel ischemia, limb ischemia, acute renal failure, stroke or transient ischemic attack, spinal cord ischemia, length of hospitalization, overall survival, and aneurysm-related reintervention.

Results:

The search yielded a total of 9366 studies. After screening, 9 studies with 1103 patients (517 renal FEVAR and 586 complex FEVAR) were included for analysis. The cumulative technical success rates for the renal group and the complex group were 98.5% and 97%, respectively. Combining perioperative and follow-up reinterventions no significant difference (p=0.44) was observed between the 2 groups. The all-cause mortality rate during hospital stay or within 30 days was one-and-a-half times higher for the complex group (3.0% [n=17/558]) than for the renal group (1.9% [n=9/464]), however, without statistical difference (p=0.65). Reinterventions for type I and III endoleaks were not significantly different between the 2 groups, p=0.07. No significant difference was revealed between the 2 groups regarding secondary outcomes.

Conclusions:

This systematic review revealed no significant difference in mortality, complications, or reintervention between renal FEVAR and complex FEVAR. Renal FEVAR in juxtarenal aneurysms remains a safe and effective treatment option with no higher risk on type Ia endoleak or reinterventions during follow-up compared with complex FEVAR. The current data do not provide a clear understanding of the long-term benefits associated with complex FEVAR compared with renal FEVAR.

Clinical Impact

This systematic review found no significant differences in mortality, complications, or reinterventions between renal and complex FEVAR. The results indicate that renal FEVAR remains an effective option for appropriately selected patients, and that the added complexity of incorporating mesenteric vessels does not necessarily translate into improved outcomes. Current evidence does not clarify whether complex FEVAR provides long-term advantages over renal FEVAR. These findings underscore the importance of anatomy-driven, individualized decision-making in complex aortic aneurysm repair.

Keywords

systematic review meta-analysis pararenal (complex) aortic aneurysm type IV thoracoabdominal aortic aneurysms

Get full access to this article

View all access options for this article.

References

Mastracci

Eagleton

Kuramochi

, et al. Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms. J Vasc Surg. 2015;61(2):355–364.

Sveinsson

Sobocinski

Resch

, et al. Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm. J Vasc Surg. 2015;61(4):895–901.

Crawford

Safi

, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg. 1986;3(3):389–404.

Patel

Constantinou

Simring

, et al. Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification. J Vasc Surg. 2015;62(2):319–325.

Banga

Oderich

Farber

, et al. Impact of number of vessels targeted on outcomes of fenestrated-branched endovascular repair for complex abdominal aortic aneurysms. Ann Vasc Surg. 2021;72:98–105.

Motta

Crowner

Kalbaugh

, et al. Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair. J Vasc Surg. 2019;70(3):691–701.

Jain

Oderich

Tenorio

, et al. VESS10. Natural history of target vessel endoleaks after fenestrated-branched endovascular aortic repair. Journal of Vascular Surgery. 2018;67(6):e53–e54.

Budtz-Lilly

Wanhainen

Eriksson

, et al. Adapting to a total endovascular approach for complex aortic aneurysm repair: outcomes after fenestrated and branched endovascular aortic repair. J Vasc Surg. 2017;66(5):1349–1356.

Jammeh

Sanchez

Ohman

JW.

Anatomic characteristics associated with superior mesenteric artery stent graft placement during fenestrated para/suprarenal aneurysm repair. J Vasc Surg. 2022;75(6):1837–1845.

10.

Manning

Agu

Richards

, et al. Early outcome following endovascular repair of pararenal aortic aneurysms: triple- versus double- or single-fenestrated stent-grafts. J Endovasc Ther. 2011;18(1):98–105.

11.

Metcalfe

Holt

Hinchliffe

, et al. Fenestrated endovascular aneurysm repair: graft complexity does not predict outcome. J Endovasc Ther. 2012;19(4):528–535.

12.

Oikonomou

Kasprzak

Schierling

, et al. Graft complexity-related outcomes of fenestrated endografting for abdominal aortic aneurysms. J Endovasc Ther. 2017;24(2):230–236.

13.

Roy

Millen

Jones

, et al. Long-term follow-up of fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg. 2017;104(8):1020–1027.

14.

Lala

Knowles

Timaran

, et al. Superior mesenteric artery outcomes after fenestrated endovascular aortic aneurysm repair. J Vasc Surg. 2016;64(3):692–697.

15.

Sorondo

Dossabhoy

Tran

, et al. Large fenestrations versus scallops for the superior mesenteric artery during fenestrated endovascular aneurysm repair: does it matter. Ann Vasc Surg. 2022;87:71–77.

16.

Motta

Vallabhaneni

Kalbaugh

, et al. The role of selective stenting for superior mesenteric artery scallops during fenestrated endovascular aneurysm repair. J Vasc Surg. 2019;69(1):47–52.

17.

Katsargyris

Oikonomou

Kouvelos

, et al. 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. J Vasc Surg. 2017;66(1):29–36.

18.

Goudeketting

Heinen

SGH

Ünlü

, et al. Pros and cons of 3D image fusion in endovascular aortic repair: a systematic review and meta-analysis. J Endovasc Ther. 2017;24(4):595–603.

19.

McNally

Scali

Feezor

, et al. Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair. J Vasc Surg. 2015;61(2):309–316.

20.

Rastogi

de Bruin

Varkevisser

RRB

, et al. Proximal seal dilatation following fenestrated endovascular repair for complex abdominal aortic aneurysms. J Vasc Surg. 2022;75(5):1521–1529.

21.

O’Callaghan

Greenberg

Eagleton

, et al. Type Ia endoleaks after fenestrated and branched endografts may lead to component instability and increased aortic mortality. J Vasc Surg. 2015;61(4):908–914.

22.

Yazar

Pilz

Cunha

de Haan

, et al. Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms. J Cardiovasc Surg (Torino). 2023;64(3):268–278.

23.

Mastracci

Greenberg

Eagleton

, et al. Durability of branches in branched and fenestrated endografts. J Vasc Surg. 2013;57(4):926–933; discussion 933.

24.

Martin-Gonzalez

Mastracci

Carrell

, et al. Mid-term outcomes of renal branches versus renal fenestrations for thoraco-abdominal aneurysm repair. Eur J Vasc Endovasc Surg. 2016;52(2):141–148.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB