Changes in quality of life and the impact of frailty after fenestrated-branched endovascular repair of pararenal and thoracoabdominal aortic aneurysms.

Abstract

Objective: Quality-of-life (QOL) metrics following infrarenal endovascular aortic aneurysm repair (EVAR) have been extensively studied and suggest that endovascular aortic aneurysm repair is more favorable than open repair. With the development of complex endovascular aortic repair, understanding postoperative health status is critically important for care delivery. As such, QOL outcomes are poorly understood for patients undergoing fenestrated-branched endovascular aortic aneurysm repair (F/BEVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms (TAAA). This study aimed to determine changes in QOL measures over time and delineate which variables influence this outcome measure in patients undergoing F/BEVAR.

Methods: Consecutive patients enrolled in a prospective, nonrandomized, single-center clinical trial using physician-modified F/BEVAR were included (June 2023-July 2024). QOL was evaluated using the EuroQol 5-dimension (EQ-5D) instrument, which measures five dimensions (such as mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) using five severity scores and rates overall health. Patient responses were collected at baseline preoperatively and 1-, 6-, and 12-months postoperatively. Preoperative characteristics including the 5-factor modified frailty index (mFI-5), operative variables, and postoperative outcomes were analyzed. The primary outcome measure was changes in EQ-5D scores over time. Generalized linear modeling was used to identify factors that influenced overall QOL over time.

Results: Sixty-four patients were treated during the study period, 56 of whom had EQ-5D measurements at all time points. Patients were predominantly elderly (74 ± 6.1 years), Caucasian (n = 57, 89%) men (n = 45, 70%) who suffered from hypertension (n = 58, 91%), coronary artery disease (n = 28, 44%), chronic obstructive pulmonary disease (n = 24, 38%), and chronic renal insufficiency (n = 12, 19%). The mean mFI-5 score was 0.34 ± 0.16. Mean aneurysm size was 65 ± 15.5 mm with 27 (42%) patients classified as pararenal aortic aneurysms, 24 (38%) extent IV TAAA, and 13 (20%) extent I, II, or V TAAA. Mean number of target arteries incorporated per patient was 3.9 ± 0.5. Overall technical success was 100%; procedure time was 193 ± 81 minutes; contrast volume was 98 ± 25 mL; and cumulative air kerma was 2877 ± 1528 mGy. Postoperative complications developed in 13 (20%) patients and four (6%) patients died within 30-days. The 2-year overall survival was 88%. All 5 EQ-5D dimensions declined 1 month after surgery, with some returning to baseline 6 months postoperatively. The EQ-5D overall health score also declined after surgery, rebounded with time, and surpassed baseline levels. On generalized linear modeling, higher mFI-5 score (P = .009) negatively impacted EQ-5D overall health score across all time points. On estimated marginal means analysis, those patients with postoperative complications had worse QOL scores compared with those patients without at the 1-month time point (P = .007), but this effect was no longer present at the 6- and 12-month time points.

Conclusions: F/BEVAR is considered a minimally invasive surgical approach for complex abdominal aortic aneurysms. Although this technique provides technical success, it is associated with a negative impact on perceived QOL within the 6-month postoperative period, particularly in frail patients and those who undergo postoperative complications. Transparent discussions preoperatively should address the anticipated changes in QOL for all patients undergoing these surgeries. Furthermore, in nonfrail patients, there may be significant benefit to F/BEVAR in terms of QOL perception.