Introduction: Ongoing innovations in the minimally invasive management of complex abdominal aortic aneurysms (cAAA), including physician-modified endografts (PMEG) and, more recently, Fiber Optic RealShape (FORS) technology, have allowed vascular surgeons to expand surgical indications and complexity of care to this multifaceted patient population. Prior analyses have demonstrated intraoperative advantages of FORS in the management of cAAA for lower total procedural radiation and cannulation tasks, however, few analyses have evaluated the technology's effect on peri- and post-operative outcomes.
Methods: All PMEGs performed at our institution between 2020-2024 were retrospectively reviewed. Primary intra- and perioperative outcomes included fluoroscopy time and dose, target vessel cannulation failure, target vessel dissection or perforation, and perioperative complications. Primary post-operative (6-month) outcomes included target vessel related (Type Ic or IIIc) endoleak and target vessel instability (TVI) - defined as any branch-related complication leading to aneurysm rupture, death, occlusion, component separation, or reintervention. Inverse Probability of Treatment Weighting (IPTW) was used to account for factors of clinical significance. Chi-squared, logistic regression, and Cox regression were used to evaluate perioperative outcomes in the weighted cohort.
Results: Between 2020 and 2024, 118 patients underwent a PMEG: 49 with FORS and 69 using standard fluoroscopy. Baseline characteristics were similar between groups. After weighting, usage of FORS exhibited lower fluoroscopy time (38 minutes vs. 56 minutes, p<.01) and Air Kerma (429mGy vs. 655mGy, p=.01). Between FORS and standard fluoroscopy, there were no differences noted in target vessel cannulation failure (4.7% vs. 1.0%) nor in intra- or perioperative target vessel perforation (1.9% vs. 1.0%) or dissection (6.7% vs. 2.1%) (all p>.05). Perioperative complications were similar between groups (22% vs. 21%), including spinal cord ischemia (temporary: 8.4% vs. 6.1%, permanent: 2.0% vs. 3.9%) and bowel ischemia (0% vs. 2.6%). FORS usage did demonstrate lower rates of target vessel instability (1.2% vs. 10%, p=.02) at 6 months, however this difference did not persist on multivariable analysis.
Conclusion: Since the implementation of FORS at our institution, when compared to standard fluoroscopy, there is a significantly lower intraoperative fluoroscopy time and total radiation dose with no difference in target vessel cannulation failure, dissection, perforation, perioperative complications, or TVI at 6 months following a PMEG. Although these data may represent our institution's gradual improvement in expertise of this new technology, our results underscore the importance of additional analyses on this evolving technology as it becomes more integrated into standard practice of the management of complex aortic pathologies.
Keywords: Complex aortic aneurysm; FORS; Outcome research; PMEG; Radiation; Target Vessel Instability.
Copyright © 2024. Published by Elsevier Inc.