VESS04 - Outcomes of Paravisceral Aortic Endarterectomy in the Endovascular Era: A 27-Year Single-Center Experience

Objectives: Endovascular therapies are increasingly performed to treat symptomatic atherosclerotic occlusive disease of the abdominal aorta and its branches. However, there are limits to these therapies in the paravisceral aorta. The aim of our study was to review perioperative outcomes and long-term durability following paravisceral aortic endarterectomy (PAE).

Methods: We conducted a retrospective analysis of patients undergoing elective PAE for atherosclerotic occlusive disease between 1997 and 2024 at a single tertiary care center. The inclusion criterion was endarterectomy of the abdominal aorta involving at least one paravisceral branch (celiac, superior mesenteric, or renal artery). Patients undergoing aortic thrombectomy only, concomitant aortic aneurysm repair, or isolated inferior mesenteric artery disease were excluded. Primary endpoints included 30-day mortality and 5-year primary and primary-assisted patency, analyzed using Kaplan-Meier methods. Changes in ankle-brachial index (ABI) from preoperative to postoperative measurements were evaluated. Secondary endpoints included freedom from reintervention, new-onset dialysis, progression to chronic kidney disease (CKD), recurrent stenosis and occlusion, and five-year overall survival.

Results: Eighty-three patients (38 male; 65±9.4 years old) underwent PAE with a median follow-up of 8 (IQR 3.5-15) years. Indications included chronic mesenteric ischemia (7.2%), renovascular hypertension (97.6%), and claudication (31.3%). Concomitant aortoiliac or infrainguinal bypass was performed in 41% of patients. Supra-celiac aortic clamping was performed in 15.7% of patients, and 65 % of patients required a supra-mesenteric clamp. 30-day mortality was 6%, five-year primary and primary assisted patency were 97.2% (95% CI, 93.5%-100%) and 93.2% (95% CI, 87.5%-99.1%) respectively (figure I), with overall freedom from reintervention of 92.8%. Among patients with preoperative claudication, ABI increased in both limbs (right: median 0.53 preoperatively to 0.96 postoperatively; median paired difference 0.24, 95% CI 0.05-0.4; p=0.02; left: median 0.71 preoperatively to 0.94 postoperatively; median paired difference 0.26, 95% CI 0.11-0.42; p=0.0008). New-onset permanent dialysis occurred in one patient with preexisting CKD. Progression to newly diagnosed CKD occurred in 8.4% of patients at a median of 7.8 years postoperatively. Recurrent stenosis was found on imaging in 21.7% of patients and recurrent occlusion in 2.4%, with 7.2% requiring secondary intervention. Five-year overall survival was 68.7%.

Conclusions: In carefully selected patients with complex paravisceral aortic occlusive disease, aortic endarterectomy can be performed with acceptable perioperative mortality. Long-term data supports robust performance and durable results, highlighting the importance of exposure to this operation for young trainees.