Anatomical factors influencing catheterization time in FEVAR procedures (KT-FEVAR study).

Abstract

Introduction: Catheterization of the target vessel (TV) during fenestrated endovascular aortic repair (FEVAR) can be challenging and contributes to significant radiation exposure and procedural time. The objective of this study was to investigate the link between the anatomical features of the TVs on CT-scan and procedural time.

Materiel and method: This prospective single-center study included patients who underwent FEVAR procedure between May 2020 and April 2022. Patients with branched, mixed (branched and fenestrated), off-the-shelf, or brachial access were excluded. Variables measured on CT-scan (EndoSize, Therenva Inc.) included, for each TV, its diameter, aortic diameter at the TV level, angulations with the aorta, and degree of ostial stenosis (>50%). The catheterization method was the same for all patients: femoral approach, short then long sheath, use of a catheter (no steerable sheath), and a soft then stiff guidewire. Catheterization time was defined as the fluoroscopy time from insertion of the soft guidewire in the short sheath until the placement of the non-expanded covered stent protected by the introducer. Each anatomical parameter was then correlated with this time interval using both uni- and multivariate analyses.

Results: 40 patients were included, and 132 TVs were catheterized. All procedures were guided by image fusion. The median catheterization time for renal arteries was 7±6.9 minutes, 4.5±3.1 minutes for the superior mesenteric artery, and 13±13.9 minutes for the celiac trunk (CT). There were 16% of TV with ostial stenosis . Of the 24 stented CTs, 5 had an arcuate ligament. The two variables significantly correlated with catheterization time in univariate analysis were the angulation of the TV (the more the artery is oriented downwards, the longer the time, p=0.01) and the presence of ostial stenosis in the TV (p<0.0001). In multivariate analysis, these two parameters remained significantly correlated (p=0.04 for angulation and p=0.0001 for the presence of ostial stenosis).

Conclusion: The presence of ostial stenosis and/or a very downward orientation of the TVs are independently correlated with catheterization time and should be considered when planning FEVAR procedures, either by proposing a brachial approach or using a steerable sheath.