Outcomes from the Real-World Multicenter Laser In-Situ Fenestrated Endovascular Repair (LIFE) Registry for Complex Thoracoabdominal and Pararenovisceral Aortic Pathology.

OBJECTIVE: Laser in-situ fenestrated endovascular (LIFE) repair allows fenestrated endovascular aortic repair in complex and challenging cases, including urgent and emergency presentations and patients with prior aortic repairs. The real-world multicenter LIFE Registry reports the results of this unique approach for thoracoabdominal and pararenovisceral (TAAA/PAA) pathologies. METHODS: All patients (2017-2022) undergoing LIFE for TAAA/PAA were identified at nine high-volume institutions and collected in a retrospective multicenter registry database. Descriptive statistics and Kaplan-Meier analysis were used. The primary outcomes were technical success and target vessel instability. Secondary outcomes included mortality, stroke, paraplegia, and reinterventions. RESULTS: 210 patients undergoing LIFE were included (mean age 72.3, 27% female, 83% white). Notable demographics included previous stroke in 14%, COPD in 26%, renal insufficiency in 27% (dialysis 3%) and previous aortic repair in 55% of patients. Indications for repair included fusiform aneurysm in 69%, Type Ia endoleak in 21%, saccular aneurysm in 10% and aortic dissection in 7%. Repair was performed for symptomatic/ruptured pathologies in 39%. Thirty-day deaths were seen in 17 patients overall (8%) with 15 deaths in symptomatic/ruptured patients and 2 deaths in asymptomatic patients (p<.0001). Proximal seal was achieved in Zone 2 (1%), Zone 3 (5%), Zone 4 (10%), Zone 5 (34%), Zone 6 (14%), Zone 7 (16%) and Zone 8 (17%). A total of 529 target vessels were incorporated (one vessel 18%, two vessel 26%, three vessel 29%, four vessel 24%, NR 3%) with a mean of 2.5 target vessels per patient. Technical success for LIFE repair was 95%. Fifteen of those deaths occurred in 77 symptomatic/ruptured patients (19%). There were six strokes (2.9%) and permanent paraplegia in four patients (2%). At mean follow-up of 9 months (range 1-35), there were twelve additional deaths (5.7%), four of which were aneurysm-related (2%). Kaplan-Meier survival for the overall cohort at 36 months was 70% with 80% freedom from bridging stent reintervention at 24 months (both SE < 10%) (Figure 1). By group, asymptomatic patients experienced higher overall survival (82% vs. 63%, p=.0007) at 20 months and freedom from bridging stent reintervention (88% vs. 77%; p=.0005) at 21 months than symptomatic/ruptured patients (SE < 10%). Overall reinterventions were performed in 45 patients (21%) with additional aortic stent graft in 21 patients (10%), bridging stent reintervention to 24 target vessels (4.5%), coil embolization in four patients for Type II endoleak and to the false lumen of a dissection (2%) and other surgical procedures in three patients (1.4%). CONCLUSIONS: The LIFE registry represents the largest multicenter experience with the laser in-situ fenestrated endovascular (LIFE) technique to date. Perioperative and mid-term outcomes are reasonable in a cohort with a significant proportion of symptomatic and ruptured patients. There was a higher-than-expected need for aortic stent graft reinterventions, which may be related to the learning curve with the technique and is higher than described for physician-modified endografts or fenestrated/branched EVAR. These data suggest that LIFE repair is a viable treatment option when no commercially-available solution exists, particularly among patients presenting with symptomatic or ruptured thoracoabdominal and pararenovisceral aortic pathologies. The need for longer-term evaluation of durability and reintervention rate is of paramount importance to fully assess the applicability of this technique.