Iliac Tortuosity Increases Reinterventions, but not Adverse Outcomes Following Repair of Juxtarenal Aneurysms using Physician Modified Endografts.

INTRODUCTION: Increased angulation of the proximal aortic neck has been associated with complications following endovascular repair of infrarenal aortic aneurysms, including increased incidence of endoleaks, stent migration, secondary interventions, and conversions. However, knowledge on the impact of aortoiliac tortuosity on outcomes following fenestrated repair remains limited. This study aims to quantify the effect of aortoiliac tortuosity on outcomes following fenestrated repair.

METHODS: A single center, retrospective review of all patients who underwent a physician-modified endovascular repair (PMEG) for the treatment of juxtarenal aortic aneurysms under a single physician sponsored investigation device exemption study from 2011-2021 was performed. Center luminal lines and geometric distances were obtained using TeraRecon software (San Mateo, CA). A tortuosity index (TI) was calculated (TI= centerline distance/geometric line distance) for each iliac vessel as well as for the infrarenal aorta according to SVS reporting standards. Aortic and iliac tortuosity were assessed independently and stratified as low and high. Demographics, comorbidities, anatomic and operative details, and outcomes were compared using univariable and multivariable analysis.

RESULTS: A total of 135 patients were identified. Thirty-eight (28%) patients had high aortic tortuosity, and 55 (42%) patients had high iliac tortuosity. Patients with high tortuosity were older (Aortic: 78 vs 76 years, p=0.04; Iliac: 78 vs 75 years, p=0.01) and differed by sex.22% of men and 50% of women had high aortic tortuosity (p=0.01). 47% of men and 20% of women had high iliac tortuosity (p=0.01). There were no differences in comorbidities based on aortic tortuosity but coronary artery disease (high: 58% vs low: 36% p =0.01) and hypertension (high: 69% vs low: 86%, p=0.02) differed based on iliac tortuosity. Aneurysm diameter was larger for patients with high iliac tortuosity (72mm vs 64mm, p<0.01) and fluoroscopy time was longer for patients with high aortic tortuosity (41 vs 31 minutes, p=0.02). When outcomes were assessed, high iliac tortuosity was associated with increased rate of reinterventions (HR 2.6, 95% CI 1.2-6.0) and type 1 or 3 endoleak (HR 5.2, 95% CI 1.7-16); however, all other outcomes were similar.

CONCLUSION: Among patients treated with PMEG for juxtarenal aneurysms, iliac tortuosity but not aortic tortuosity, is associated with increased reinterventions and type 1 or type 3 endoleaks. Long term follow-up is critical for patients with high iliac tortuosity to ensure that high risk endoleaks are identified and treated early to avoid the risk of rupture.