Choosing Between Fenestrated Endografting and Standard EVAR with Adjuncts

by Debra L. Beck

Hollywood, FL (January 24, 2020) – At an International Symposium on Endovascular Therapy (ISET) talk on choosing between fenestrated endografting (FEVAR) and standard endovascular aneurysm repair (EVAR) with adjuncts, Benjamin Starnes, MD, Chief of Vascular Surgery at University of Washington (Seattle, WA) flipped things around right up front by disclosing that he hasn’t used adjuncts for standard EVAR in years.

“I abandoned them and I think a more suitable title for this talk would be ‘Fenestrated EVAR: A Cure for the Disease,’” said Dr. Starnes.

“I'm going to start with a premise [that] type 1A endoleaks lead to rupture and are primary failure of any mode of endovascular therapy to treat abdominal aortic aneurysms,” he said. “And this comes directly from the SVS reporting standards, of which I was an author.”

The length of the instructions for use (IFU) for most standard infrarenal grafts is 15 mm, or about the size of a coffee bean, said Dr. Starnes. Reinterventions are seen in nearly 50% of patients treated outside the IFU, two-thirds of secondary interventions being for endoleak.

“I get referred a lot of these patients who are treated with standard EVAR with adjuncts and they don't work. The patient comes in with a type 1A endoleak and I'm forced to extend higher,” said Dr. Starnes. “Now this is a difficult procedure because the length between my celiac and my native graft bifurcation is very short and there aren't many endovascular solutions for that.”

He reported doing more than 350 fenestrated EVARs in the past 13 years. In a review of just his last 10 procedures, he had a mean operative time of 78 minutes, mean fluoro time of 24.2 minutes, and mean estimated blood loss of 50 L, “all done percutaneously.”

“The reason to use FEVAR is to extend the seal zone,” emphasized Dr. Starnes. In findings soon to be published, his group saw a final seal zone of 40.8 mm with FEVAR compared to 21.1 mm in the CHIMPS PERICLES registry (Donas et al. Ann Surg. 2015;262:546-553.) They also had zero percent rates of type 1A endoleak and branch occlusion at latest follow-up, compared to 5.9% and 13%, respectively, for PERICLES.

To cap things off, Dr. Starnes also showed some compelling comparative data from his group in the Pacific Northwest compared to groups in the rest of the nation. “We have the lowest procedure times. We have the lowest estimated blood loss. We have the lowest risk of postoperative complications, excluding death. We have the lowest rate of cardiac complications across the nation, and we have the highest return of our patients to their pre-surgical setting with nearly 80% of the patients going home as opposed to a skilled nursing facility. These are efficient procedures for these elderly patients.”

Regarding the learning curve, he said 50 cases is needed and then “your results get much, much better.”

In conclusion, fenestrated EVAR is often a cure for the disease leaving AAA no longer a chronic condition with high rates of secondary intervention, and offering excellent branch vessel patency of around 98% at 5 years. “I hope that I've convinced you that this is the future,” concluded Dr. Starnes.