Midterm outcomes of side branch embolization and endovascular abdominal aortic aneurysm repair
Takuro Shirasu, Atsushi Akai, Manabu Motoki, Masaaki Kato
Abstract
ObjectiveTo analyze the effects of total side branch embolization at endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) on the incidences of persistent type 2 endoleak (pT2EL), changes in sac diameter, and re-intervention.MethodsBetween 2013 and 2021, all patients who underwent primary EVAR with a few exceptions were included. Side branch embolization was considered during EVAR for inferior mesenteric artery (IMA) or IMA plus lumbar artery (LA) when feasible for contrast agent use. Outcomes measured were pT2EL, sac diameters, re-intervention, ruptures, and aneurysm related mortality. Radiation exposure and safety outcomes were also reported.ResultsAmong 732 patients undergoing EVAR, 616 patients (84.2%) were included, of whom 223 patients (36.2%) did not undergo side branch embolization (NO-E), while 228 patients (37.0%) underwent IMA only (IMA-E) and 165 patients (26.8%) IMA+LA including median sacral artery (IMA+LA-E). The technical success rate of IMA and LA embolization was 97.0% and 74.7%, respectively. Crude incidences of pT2EL was significantly different from 6 months through 3 years (NO-E, 27.8%; IMA-E, 31.7%; IMA+LA-E, 9.4% at 3 years; p = .007). In the multivariate analysis adjusted for background differences, the incidences of pT2EL was significantly higher in the NO-E (odds ratio [OR], 3.21; 95% confidence intervals [CIs], 1.08–9.57; p = .004) and IMA-E (OR, 4.86; 95% CIs 1.68–14.11; p = .004) compared to the IMA+LA-E group. Similarly, any re-intervention until 3 years was significantly frequent in the NO-E (OR, 5.26; 95% CIs 1.76–15.70; p = .003) and IMA-E group (OR 4.19; 95% CIs 1.38–12.67; p = .01). Surgical conversion and secondary rupture were seen only in 1 patient without any aneurysm related mortality. % sac shrinkage from the baseline was significantly promoted in the IMA+LA group (NO-E, 12.1% ± 16.6%; IMA-E, 11.4% ± 16.7%; IMA+LA-E, 18.0% ± 18.8%; p = .047). Fluoroscopy time was significantly longer in the IMA+LA-E group (NO-E, 60.2 ± 47.4 min; IMA-E, 59.3 ± 39.5 min; IMA+LA-E, 75.5 ± 42.8 min, p < .0001), and so do the dose-area product (NO-E, 424.6 ± 333.4 Gycm2; IMA-E, 477.7 ± 342.4 Gycm2; IMA+LA-E, 631.8 ± 449.1 Gycm2, p < .0001). No embolization-related complications or radiation-related adverse events were recorded.ConclusionsPreemptive embolization of IMA, LAs and median sacral artery at the time of EVAR reduced the incidences of pT2EL and any re-intervention and promoted sac shrinkage during the follow-up period of 3 years.