During fenestrated endovascular repair (FEVAR), mesenteric vessels may be incorporated
with a scallop or fenestration. The benefits/harms of techniques to incorporate the
coeliac axis (CA) have not been assessed for their impact on procedural complexity
vs. peri-operative and longer term outcomes; this assessment may instruct a balanced
operative strategy for the CA and complex FEVAR, minimising adverse intra- or peri-operative
events, and maximising durability.
This was a retrospective cohort study. Patients undergoing fenestrated or scalloped
CA incorporation during FEVAR for a juxtarenal/pararenal/suprarenal aortic aneurysm
(January 2015 – December 2019) were reviewed (n = 159) for demographics, intra-procedural/peri-operative outcomes, and re-interventions
to five years. Mean follow up for all groups was 3.28 years. The primary outcome of
CA instability (occlusion/stenosis/endoleak/re-intervention) was assessed. CA specific
re-intervention, re-intervention free survival, and all cause mortality were assessed
against incorporation strategy. Secondarily, the harm of CA stenting, comprising intra-operative
harms and peri-operative adverse outcomes was interrogated.
The CA was incorporated with a stented fenestration (n = 74), an unstented fenestration (n = 59), and a minority with scallop (n = 26). There were no between group differences in operative indication, or anatomical
aneurysm/CA features. Fenestrated stented and unstented patients had longer aortic
coverage but the same primary technical success. At follow up, three CA endoleaks
occurred in stented fenestrated patients, although scallop patients more often had
type 3 endoleaks at the SMA and renal fenestrations (23%). Elevated CA instability
in fenestrated unstented patients was driven by CA occlusion (16.9%), but not associated
with CA re-intervention, worse re-intervention free survival, or all cause mortality.
Regression analysis for visceral branch instability revealed predictors of CA non-stenting
and diminished aortic coverage.
In the present authors’ experience, the practice of not stenting a CA fenestration
does not pose peri-operative or long term clinical harm. At follow up, not stenting
the CA is associated with CA instability; however, both fenestration groups are preferable
to a shorter (scalloped) endograft as increasing aortic coverage reduces non-CA branch