Frequency and type of interval adverse events during the waiting period to complex aortic endovascular repair

Abstract

Objective: The aim of the present study was to evaluate the frequency and type of adverse events that can occur during the waiting period to complex aortic endovascular repair.

Methods: We performed a retrospective study of all elective patients with complex aortic aneurysms (including pararenal, suprarenal, thoracoabdominal, and aortic arch aneurysms) that had required a custom-made device (CMD) from Cook Medical (Bloomington, Ind) at a tertiary referral vascular center (November 2010 to May 2020). The waiting period was defined as the interval between the date of the stent graft order and the date of the procedure or cancellation. Interval adverse events were defined as any event that had occurred during the waiting period and led to either mortality, aneurysm rupture, or cancellation of the planned procedure.

Results: A total of 235 patients (mean age, 72 years; 25% female) had had a CMD graft ordered (201 planned as a single-stage procedure). The median waiting time until surgery was 106 days (interquartile range [IQR], 77-146 days) in the whole cohort and 101 days (IQR, 77-140 days) for the single-stage cohort. The planned procedure was performed electively in 219 patients (93%), with an overall 30-day elective mortality of 2% (n = 5). A total of 16 interval adverse events occurred during the waiting period. Of these 16 events, 10 were aneurysm ruptures and 6 were cancellations of the procedure owing to non-aneurysm-related deaths (3% of the entire cohort). A total of 10 interval deaths were registered (4.2%), 4 of which were aneurysm related. The risk of rupture during the waiting period (Kaplan-Meier) was 6.1% ± 2.3% at 180 days. The median interval from the stent graft order to aneurysm rupture was 101 days (IQR, 54-200 days). Of the 10 aneurysm ruptures that had occurred, 6 had undergone emergent repair, with 0% mortality at 30 days (one open repair, one t-Branch, one physician-modified endograft, two cases for which the CMD was already available, one case for which a different CMD was available).

Conclusions: The median waiting time from the stent graft order to implantation was ∼15 weeks. During this waiting period, a substantial proportion of patients could experience adverse events, either related to aneurysm rupture or underlying comorbidities. The risk of rupture during the waiting period exceeded the risk of perioperative mortality. Thus, efforts to decrease this risk could significantly improve the outcomes. A combination of different techniques might play a vital role in reducing the mortality after cases of interval rupture.

Keywords: Complex aortic aneurysm; Custom-made stent graft; Fenestrated-branched endovascular aortic repair; Outcomes.