Fenestrated Endovascular Repair with Large Device Diameters (34- to 36-Mm) is Associated with Increased Rates of Type 1 and 3 Endoleak and Reintervention

Patient-specific changes in aortic hemodynamics is associated with thrombotic risk after fenestrated endovascular aneurysm repair with large diameter endografts

Background

The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. In the present study, we used patient-specific computational fluid dynamic (CFD) simulation to investigate the effect of the endograft diameter on hemodynamics after fEVAR and explore the hypothesis that diameter-dependent alterations in aortic hemodynamics can predict for thrombotic events.

Methods

A single-institutional retrospective study was performed of patients who had undergone fEVAR for juxtarenal aortic aneurysms. The patients were stratified into large diameter (34-36 mm) and small diameter (24-26 mm) endograft groups. Patient-specific CFD simulations were performed using three-dimensional paravisceral aortic models created from computed tomographic images with allometrically scaled boundary conditions. Aortic time-averaged wall shear stress (TAWSS) and residence time (RT) were computed and correlated with future thrombotic complications (eg, renal stent occlusion, development of significant intraluminal graft thrombus).

Results

A total of 36 patients (14 with a small endograft and 22 with a large endograft) were included in the present study. The patients treated with large endografts had experienced a higher incidence of thrombotic complications compared with small endografts (45.5% vs 7.1%; P = .016). Large endografts were associated with a lower postoperative aortic TAWSS (1.45 ± 0.76 dynes/cm² vs 3.16 ± 1.24 dynes/cm²; P < .001) and longer aortic RT (0.78 ± 0.30 second vs 0.34 ± 0.08 second; P < .001). In the large endograft group, a reduction >0.39 dynes/cm² in aortic TAWSS demonstrated discriminatory power for thrombotic complications (area under the receiver operating characteristic curve, 0.77). An increased aortic RT of ≥0.05 second had similar accuracy for predicting thrombotic complications (area under the receiver operating characteristic curve, 0.78). The odds of thrombotic complications were significantly higher if patients had met the hemodynamic threshold changes in aortic TAWSS (odds ratio, 7.0; 95% confidence interval, 1.1-45.9) and RT (odds ratio, 8.0; 95% confidence interval, 1.13-56.8).

Conclusions

Patient-specific CFD simulation of fEVAR in juxtarenal aortic aneurysms demonstrated significant endograft diameter-dependent differences in aortic hemodynamics. A postoperative reduction in TAWSS and an increased RT correlated with future thrombotic events after large-diameter endograft implantation. Patient-specific simulation of hemodynamics provides a novel method for thrombotic risk stratification after fEVAR.

The durability of fenestrated endovascular aneurysm repair (fEVAR) has been threatened by thrombotic complications. Using patient-specific computational flow simulation, the present retrospective study of 36 patients with juxtarenal aortic aneurysms treated with fEVAR identified several endograft diameter-dependent changes in aortic hemodynamics associated with thrombotic complications. A postoperative reduction in aortic wall shear stress and increased particle residence time correlated with the development of intraluminal graft thrombus and renal stent occlusion in patients treated with large diameter (>34 mm) endografts. These computationally estimated hemodynamic parameters could provide a novel method for patient-specific risk stratification for adverse events after fEVAR.