Technical and Clinical Outcomes of 13 years of Endovascular Repair of Infrarenal, Atherosclerotic, Penetrating Aortic Ulcers.

BACKGROUND

To report the technical and clinical outcomes of endovascular repair of all infrarenal, penetrating aortic ulcers (PAUs) that were treated at a single institution over a 13-year period.

METHODS

This is a single-center, retrospective observational study. All patients consecutively treated for atherosclerotic, infrarenal PAU were included between 2010 and 2023. Outcomes were technical success, overall survival, PAU-related death, freedom from secondary rupture, freedom from secondary interventions, freedom from aortic expansion >5 mm, freedom from type 1 and type 3 endoleak (EL), and freedom from stent graft migration, each at 30 days, 1 year, 2 years, and 5 years of follow-up. The study was registered at the German Clinical Trials Register (DRKS00028794).

RESULTS

Forty-seven patients were included (8 female patients, 17.0%) with a median age of 75.7 years (interquartile range (IQR): 70.2-81.0). The median maximum aortic diameter was 39.7 mm (IQR: 33.6-45.2). Overall, primary and secondary technical success was achieved in 42 of 47 (89.4%) and 46 of 47 patients (97.9%). Standard aortobiiliac endovascular aneurysm repair (EVAR) was the most frequent procedure in 25 patients (53.2%). An aortomonoiliac stent graft system was used in 5 patients (10.6%). The remaining 17 patients (36.2%) were treated using an aorto-aortic tube stent graft configuration. The median clinical follow-up was 5.1 years (IQR: 1.9-8.1) with a median imaging follow-up of 1.5 years (IQR: 0.4-5.0). Overall survival at 30 days, 1, 2, and 5 years of follow up was estimated at 100% (confidence interval (CI), 100%-100%), 95.4% (CI, 89.4%-100%), 87.9% (CI, 78.4%-98.4%), and 82.0% (70.7%-95.2%), respectively. There was 1 PAU-related death (2.1%). Freedom from secondary intervention at 30 days, 1, 2, and 5 years of follow-up was 93.6% (CI, 86.9-100%), 89.2% (CI, 80.6-98.6%), 81.5% (CI, 70.7-94.0%), and 75.2% (CI, 62.8-90.2%), respectively. No patient who underwent either preoperative (n = 1) or intraoperative embolization (N = 7) of lumbar arteries (LAs) and/or the inferior mesenteric artery (IMA) demonstrated type 2 EL during follow-up.

CONCLUSION

A variety of alternatives to standard aortobiiliac EVAR are required for endovascular PAU repair. To identify the optimal management strategy in these cases further studies are needed. Type 2 EL in abdominal PAU disease appears to be preventable by LA and/or IMA embolization.