Proximal Instructions for Use Violations in Elective Endovascular Aneurysm Repair in the Vascular Quality Initiative: Retrospective Analysis

Mid-term results of "off-label" use of the Endurant stentgraft in patients with infrarenal abdominal aortic aneurysms

ObjectivesEVAR is the preferred treatment modality for patients with an infrarenal abdominal aortic aneurysm with suitable anatomy. Each manufacturer of aortic stentgrafts has specific anatomic requirements. In some patients, it is not possible to adhere to the instructions for use, but alternative treatment is also not possible. In these patients, EVAR can be performed outside instructions for use.MethodsIn this study, all consecutive patients in whom an Endurant II or IIS stentgraft was used between 1 January and 31 December were reviewed. We compared the two patient groups in whom this stentgrafts was used outside and inside instructions for use. Patients with planned adjuvant therapy, for example, chimney procedure or iliac side branches, were excluded.ResultsIn 74 of 178 (41.6%) patients, the instructions for use were not adhered. The main reason was pathology of the aortic neck. There were more patients with type IA endoleak, this difference was borderline significant (p = .06). There were more patients with limb occlusion in the early postoperative period, but at the end of the follow-up period, the incidence was comparable. Aneurysm-related mortality and all-cause mortality were comparable in both groups.ConclusionIn this study, real-life experience with the Endurant II and IIS stentgraft is described. Non-adherence with instructions for use was associated with a higher risk of endoleak type IA (p = .06). In the early postoperative period, there were more patients with limb occlusion; this finding was not observed anymore at the end of the follow-up period.

Fenestrated and Branched Endovascular Aortic Repair and Mortality at Hospitals Without Investigational Device Trials

Importance

Fenestrated and branched endovascular aortic repairs (F/BEVAR) have been adopted by many centers. However, national trends of F/BEVAR use remain unclear, particularly at sites who perform them without an US Food and Drug Adminstration (FDA)-approved investigational device exemption (IDE).

Objective

To quantify the use of F/BEVAR in the US and to determine if mortality was different at IDE vs non-IDE sites.

Design, Setting, and Participants

This retrospective cohort study examined 100% fee-for-service Medicare claims data from 2016 to 2023. Participants were patients who underwent endovascular treatment of the visceral aorta incorporating 2 or more visceral artery endoprostheses. Hospitals with vs without an IDE were identified using hospitals' Employer Identification Number as a time varying exposure.

Exposure

F/BEVAR.

Main Outcomes and Measures

Trends in the center-level F/BEVAR case volume stratified by IDE status were assessed using cumulative incidence curves. Mortality outcomes at 30 days and 3 years were compared using Kaplan-Meier methods and Cox proportional hazards models with adjustment for baseline patient characteristics.

Results

From 2016 to 2023, 8017 patients were treated with F/BEVAR at 549 hospitals. The median (IQR) age was 75.8 (71.3-80.8) years; 5795 patients (72.3%) were male and 2222 (27.7%) female. A total of 2226 F/BEVAR (27.8%) were performed at 22 hospitals with an IDE. The number of patients treated with F/BEVAR increased from 771 in 2016 to 1251 in 2023. The median (IQR) annual case volume per hospital was significantly higher at IDE sites (22.3 [11.0-30.4] vs 1.2 [1.0-2.0] cases/y; P < .001); 18 IDE sites (90.0%) and 20 non-IDE sites (3.7%) completed 9 or more cases per year. The 30-day mortality (3.0% vs 4.9%) but not 3-year mortality (26.0% vs 27.1%) was lower for patients treated at hospitals with vs without an IDE. After risk adjustment, both 30-day (odds ratio, 0.47; 95% CI, 0.32-0.69) and midterm mortality (hazard ratio, 0.81; 95% CI, 0.69-0.95) were lower for patients treated at IDE sites.

Conclusions and Relevance

The use of F/BEVAR is increasing across the United States, with the majority of cases being performed outside of IDE studies and at low-volume centers. F/BEVAR performed at non-IDE centers are associated with higher adjusted 30-day and midterm mortality. Transparent outcome reporting and identification of process measures from IDE sites may help achieve more equity in patient outcomes.

Impact of Sex-Related Differences in Infrarenal Aortic Neck Morphology on Outcomes of Endovascular Aneurysm Repair for Similar-Sized Aortic Aneurysm

Objectives: This study aimed to evaluate whether gender-related anatomical differences in proximal aortic neck morphology affect the feasibility and outcomes of endovascular aortic aneurysm repair (EVAR) in women with abdominal aortic aneurysms (AAA). Methods: This study performed a retrospective analysis of patients electively treated by EVAR for infrarenal AAA between January 2019 and December 2023. Demographics, anatomical characteristics, and stent graft details were analyzed. The primary endpoint was technical success. Secondary endpoints included freedom from aortic and neck-related reinterventions, endoleak rate, and freedom from aneurysm-related mortality during follow-up. Technical aspects, including adherence to the instructions for use (IFUs), were retrospectively analyzed. Results: One-hundred-seventeen patients (fifty-six females; mean age 76.2 ± 5.3 years) underwent elective EVAR for AAA. Demographics and comorbidities were homogeneous across genders. Female patients (Group A) demonstrated a higher prevalence of hostile proximal aortic neck features, including neck length < 10 mm and angulation > 60° (p = 0.009, p = 0.029, respectively) and a higher frequency of off-label EVAR procedures (28.6% vs. 11.5%; p = 0.034). The overall technical success rate was 98.3%, with no significant differences between genders in terms of stent graft selection, use of suprarenal fixation, or incidence of type 1-3 endoleaks. The median follow-up period was 35.2 ± 12.7 months, showing comparable rates of neck-related reinterventions, open conversions, and aneurysm-related mortality between genders. Notably, off-label EVAR was identified as an independent risk factor for type 1A endoleaks, reinterventions, and aneurysm-related mortality (p < 0.00001, p < 0.0001, and p = 0.001, respectively). Conclusions: Female patients undergoing EVAR often present with hostile proximal aortic neck features and are treated at an older age than males. Despite these differences, technical success rates and mid- to long-term outcomes were comparable between genders, with no variation in stent graft selection or suprarenal fixation use. Effective procedural planning, device selection, and surgical expertise appear to mitigate historical gender-related anatomical challenges. Further large-scale studies are needed to confirm whether anatomical factors alone drive outcomes, irrespective of gender.