Peri-operative and Midterm Results of Supracoeliac versus Infracoeliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

Objective: The aim of this study was to investigate peri-operative and midterm outcomes, including sac dynamics, of fenestrated endovascular aortic repair (F-EVAR) for juxtarenal abdominal aortic aneurysms (JAAAs), comparing supracoeliac with infracoeliac sealing. Supracoeliac sealing may offer an advantage due to a longer proximal sealing zone, but is associated with a more complex procedure and increased risk of complications. Furthermore, it is unknown whether supracoeliac sealing actually leads to increased durability. Methods: Patients undergoing elective F-EVAR for JAAAs from 2008 – 2021 at two hospitals in the Netherlands were included. The definition of supracoeliac sealing was sealing in zone 5 or 6, with incorporation of the coeliac axis. Infracoeliac sealing was defined below zone 6. The primary endpoints included peri-operative outcomes. Secondary endpoints included one year aneurysm sac dynamics, freedom from secondary intervention, five year mortality rate, and sac dynamics over time. Results: Among 167 patients, 78 (46.7%) had a proximal sealing at an infracoeliac level and 89 (53.3%) at a supracoeliac level. The median proximal sealing length was 37 (interquartile range [IQR] 28, 52) mm for the supracoeliac group and 26 (IQR 19, 34) mm for the infracoeliac group. Patients with supracoeliac sealing had more often had prior endovascular aortic aneurysm repair (31% vs. 12%; p = .004). Type IIIc endoleaks only occurred in patients with supracoeliac sealing (7% vs. 0%; p = .032). Other peri-operative complications and mortality rates were similar between the groups. Furthermore, no significant differences were found in one year aneurysm sac dynamics, freedom from secondary interventions, five year mortality rate, and sac dynamics over time. Conclusion: Proximal supracoeliac and infracoeliac sealing showed similar midterm outcomes, including sac dynamics, despite the higher procedural complexity of supracoeliac sealing. Supracoeliac sealing had a higher rate of 30 day type IIIc endoleak, but no difference in five year secondary intervention rate. Theoretically, supracoeliac sealing may be advantageous as sealing zones dilate over time, although future studies with longer than five year follow up are needed to determine its impact on long term aneurysm sac exclusion.