Complex Endovascular Aortic Repair Shows 83% Five-Year Survival Despite High Reintervention

Long-term Durability and Complication Profiles in Complex Aortic Repair

Endovascular repair has become a primary strategy for managing complex aortic aneurysms, particularly for patients with significant comorbidities who are poor candidates for open surgical intervention [1]. While these techniques offer reduced perioperative morbidity, they are frequently associated with higher rates of secondary interventions to address endoleaks, which is persistent blood flow into the aneurysm sac, or to maintain branch vessel patency [2, 3]. Clinical outcomes are further influenced by patient-specific factors such as sarcopenia, the loss of skeletal muscle mass and strength, which has been linked to increased rates of spinal cord ischemia and mid-term mortality [4]. The risk profile also shifts dramatically in non-elective settings, where procedural mortality and neurological complications are significantly more prevalent than in elective cases [1, 5]. Understanding the long-term trajectory of these patients is essential for establishing effective postoperative surveillance protocols and managing patient expectations. A large-scale analysis from a high-volume center now provides longitudinal data on survival and reintervention over a 14-year period.

Cohort Characteristics and Procedural Success

The researchers conducted a retrospective single-center analysis of 916 consecutive patients managed with fenestrated/branched endovascular aortic repair (f/bEVAR) between 2010 and 2024. This 14-year study included a predominantly male cohort (73.6%) with a mean age of 71.7 plus or minus 0.6 years. The underlying etiology was degenerative in 81.7% of cases. While the majority of procedures were elective, 20.8% of the total cases were urgent, representing a significant subset of patients requiring immediate intervention for acute aortic pathology. The anatomical complexity of the cohort was high, with juxtarenal aneurysms, those involving the segment of the aorta adjacent to the renal arteries, accounting for 33.4% of cases. More than half of the patients, 53.7%, presented with thoracoabdominal aortic aneurysms (TAAA), which involve both the thoracic and abdominal segments of the aorta. To address these complex morphologies, clinicians utilized custom-made devices (CMD) in 74.4% of patients. These patient-specific grafts consisted of fenestrated designs (37.1%), which use small holes to maintain blood flow to visceral branches, and branched designs (28.9%), which utilize dedicated cuffs for vessel attachment. The remaining patients were treated with off-the-shelf devices, which are pre-manufactured for immediate use in urgent scenarios. The study reported an overall technical success rate of 93.6%, defined as the successful delivery and deployment of the endovascular components with target vessel patency and no type I or III endoleaks. However, certain clinical and anatomical factors were associated with lower procedural success. Specifically, the urgent setting (P < 0.001) and the presence of TAAA Type II (P = 0.03), which involves the most extensive segment of the thoracoabdominal aorta from the left subclavian artery to the iliac bifurcation, were independently associated with reduced technical success. These findings highlight the increased procedural difficulty encountered when treating extensive aortic disease or operating under emergency conditions.

Perioperative Mortality and Neurological Risks

The researchers reported an overall 30-day mortality rate of 7.4% across the entire cohort of 916 patients. When isolating elective cases, the 30-day mortality rate was 4.4%, reflecting the lower risk profile of planned interventions compared to emergency repairs. Multivariate analysis identified that aortic rupture was independently related to 30-day mortality (P = 0.03), highlighting the critical impact of hemodynamic instability and preoperative state on early survival outcomes. To mitigate the physiological stress of these complex repairs, clinicians utilized staging in 26.0% of patients. Staging involves performing the aortic repair in multiple separate procedures to allow the body, particularly the collateral circulation supplying the spinal cord, to adapt to changes in blood flow between interventions. Neurological complications remain a significant concern in complex endovascular repair, specifically spinal cord ischemia, which is a reduction in blood flow to the spinal cord that can lead to motor or sensory deficits. The overall rate of spinal cord ischemia was 16%, while the rate of spinal cord ischemia in elective cases was 12.7%. While many of these instances involved transient symptoms, non-recovery Grade 3 spinal cord ischemia, which refers to permanent paraplegia or severe neurological deficit, occurred in 2.9% of the total cohort. In the elective subgroup, the rate of non-recovery Grade 3 spinal cord ischemia was 2.3%. The analysis identified specific procedural and clinical factors that increased the likelihood of neurological injury. The development of spinal cord ischemia was significantly related to aortic rupture (P = 0.009) and the use of off-the-shelf devices (P < 0.001). Off-the-shelf devices are pre-manufactured grafts designed for immediate use in urgent scenarios where there is insufficient time to produce a patient-specific custom device. These findings suggest that the lack of anatomical customization and the emergency nature of the procedure contribute to a higher risk of ischemic spinal cord injury compared to elective, planned repairs using custom-made components.

Five-Year Survival and the Reintervention Burden

The long-term outlook for patients undergoing complex endovascular repair remains robust, with the study reporting an overall survival of 82.6% (SE 1.9%) at 60 months. When focusing specifically on deaths directly caused by aortic complications, the freedom from aorta-related mortality was 89.2% (SE 1.3%) at 48 months. To identify which patients were at the highest risk for poor outcomes, the researchers utilized Cox-regression, a statistical method used to determine the effect of several variables on the time it takes for a specific event to happen. This analysis identified that age (P = 0.002), an ASA score of 4 or higher (P = 0.02), and the occurrence of spinal cord ischemia (P < 0.001) were independent factors related to worse survival. The American Society of Anesthesiologists (ASA) physical status is a classification system used to grade a patient's preoperative health, where a score of 4 or higher indicates a patient with severe systemic disease that is a constant threat to life. Despite these high survival rates, the clinical management of these patients is characterized by a significant need for secondary procedures. The study found that freedom from any aortic reintervention was 40.0% (SE 2.5%) at 60 months, meaning that 60% of the cohort required at least one additional intervention within five years of the initial repair. This high reintervention burden underscores the necessity of lifelong surveillance for this population. Notably, the researchers found that technical success was significantly related to freedom from reintervention (P < 0.001). This suggests that achieving optimal anatomical results during the index procedure, such as successful branch cannulation and the absence of significant endoleaks, is a primary determinant of whether a patient will require future corrective surgeries, raising the prospect that future diagnostic tools could match patients to targeted interventions based on their neurobiological profile.

References

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2. Zhou Y, Wang J, He H, et al. Comparative Effectiveness of Treatment Modalities for Complex Aortic Aneurysms: A Network Meta-Analysis of Observational Studies.. Annals of Vascular Surgery. 2023. doi:10.1016/j.avsg.2023.02.023

3. Tsai J, Brown T, Charles E, Nicola M, Bicknell C, Pouncey A. Permanent Dialysis following Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-analysis.. European Journal of Vascular and Endovascular Surgery. 2025. doi:10.1016/j.ejvs.2025.10.031

4. Nana P, Spanos K, Brotis A, Fabre D, Mastracci T, Haulon S. Sarcopenia effect on mortality and spinal cord ischemia after complex aortic aneurysm repair A systematic review and meta-analysis.. European Journal of Vascular and Endovascular Surgery. 2023. doi:10.1016/j.ejvs.2023.01.008

5. Melo RGE, Prendes C, Caldeira D, et al. Systematic Review and Meta-analysis of Physician Modified Endografts for Treatment of Thoraco-Abdominal and Complex Abdominal Aortic Aneurysms.. European Journal of Vascular and Endovascular Surgery. 2022. doi:10.1016/j.ejvs.2022.04.015