Cross, JE; (2015) Fenestrated Endovascular Aneurysm Repair – Validation of Current UK Practise. Doctoral thesis , UCL (University College London).

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Abstract

EVAR has revolutionised aneurysm management; level one evidence shows advantages of endovascular repair over open repair. However, analysis of the EUROSTAR database of >11,000 aneurysms shows that use of EVAR outside manufacturer’s instructions for use is associated with a significant risk of aneurysm related mortality and type 1 endoleak. Recent advances have seen the evolution of fenestrated endografts (FEVAR) to enable endovascular repair of aneurysms with a compromised proximal neck. However, these complex endografts are often technically difficult to insert and long term durability is unknown. In this thesis I hypothesise that all abdominal aortic aneurysms should be treated endovascularly and aim to determine the indications for fenestrated endografts. A meta-analysis found current evidence for FEVAR to be limited. A weakness in current evidence base is lack of concurrence between definition of juxta/para and supra-renal aneurysms leading to difficulty in comparison between series. A new classification system of aneurysm necks based on the endograft seal zone is proposed. Further adjuncts to complex endograft insertion are discussed including use of CO2 angiography to reduce incidence of contrast induced nephropathy and use of temporary axillo-bifemoral grafts to reduce reperfusion injury. Indications for FEVAR based on current evidence are unclear and a consensus statement to determine the indications was undertaken. An initial survey outlined current UK practise of aneurysm management. The consensus statement using RAND methodology determined the indications for FEVAR in approximately two thirds of all scenarios but outlined a grey area of equipoise in almost one third of scenarios. In conclusion, whilst most aneurysms are technically suitable for endovascular repair, it is not possible to conclude that FEVAR is superior to open repair in the long term. A grey area of equipoise was highlighted for the indications of EVAR; further evidence is required to determine guidelines for patient suitability.

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