Highlights
1. Study of 916 patients undergoing fenestrated/branched EVAR (f/bEVAR) for complex aortic aneurysms demonstrated 93.6% technical success.
2. Thirty-day mortality was 7.4% overall (4.4% elective), with spinal cord ischemia occurring in 16% (12.7% elective).
3. Five-year survival reached 82.6%, though freedom from reintervention was only 40% at 60 months.
4. Urgent procedures and thoracoabdominal aneurysms showed worse outcomes, while elective cases had acceptable complication rates.
Background
Complex aortic aneurysms involving visceral branches present significant treatment challenges. While fenestrated and branched endovascular aortic repair (f/bEVAR) has evolved technically, long-term outcomes remain poorly characterized, particularly in high-volume centers. This study from a leading aortic center provides crucial real-world data on both custom-made and off-the-shelf devices across a 14-year period.
Study Design
The retrospective single-center analysis included 916 consecutive patients treated with f/bEVAR between 2010-2024, following STROBE guidelines. The cohort comprised both elective (79.2%) and urgent (20.8%) cases, with 53.7% thoracoabdominal (TAAA) and 33.4% juxtarenal aneurysms. Custom-made devices dominated (74.4%), with staging employed in 26%. Primary endpoints included technical success, 30-day mortality/SCI, and long-term survival/reintervention rates.
Key Findings
Technical Outcomes
The 93.6% technical success rate was significantly lower in urgent cases (P<0.001) and TAAA type II (P=0.03). Off-the-shelf devices showed reduced success compared to custom solutions.
Early Complications
Thirty-day mortality reached 7.4% overall (4.4% elective), strongly associated with aortic rupture (P=0.03). Spinal cord ischemia occurred in 16% (12.7% elective), with 2.9% experiencing permanent paraplegia. SCI risk increased with aortic rupture (P=0.009) and off-the-shelf devices (P<0.001).
Long-term Results
Survival rates were 82.6% (SE 1.9%) at 60 months. Cox regression identified age (P=0.002), ASA≥4 (P=0.02), and SCI (P<0.001) as mortality predictors. Freedom from aortic-related death was 89.2% at 48 months. Reinterventions were frequent, with only 40% free at 60 months (P<0.001 for technical success association).
Expert Commentary
These findings affirm f/bEVAR as a viable solution for complex aneurysms, particularly in elective settings. The acceptable permanent paraplegia rate (2.3% elective) compares favorably with open surgery. However, the high reintervention rate underscores the need for improved device durability and follow-up protocols. The study’s single-center design may limit generalizability, though the large sample size and long follow-up provide valuable insights.
Conclusion
This real-world analysis demonstrates that f/bEVAR can achieve good long-term survival in complex aortic aneurysms, particularly in elective cases. While technical success rates are high, the frequent need for reinterventions suggests room for device improvement. These findings support centralized care in high-volume centers and highlight the importance of careful patient selection, especially for urgent cases.
Funding and Registration
The study was conducted at a high-volume aortic center without specified external funding. As a retrospective analysis, it was not registered on clinicaltrials.gov.