For Doctors in a Hurry
- Clinicians lack long-term data regarding the safety and durability of fenestrated and branched endovascular aortic repair for complex aneurysms.
- The researchers conducted a retrospective study of 916 consecutive patients treated with these specialized endovascular devices between 2010 and 2024.
- Technical success reached 93.6%, while 30-day mortality was 7.4% and permanent spinal cord ischemia occurred in 2.9% of patients.
- The authors concluded that urgent presentation negatively impacts early outcomes, though elective cases demonstrate acceptable safety and long-term survival rates.
- Physicians should note that 40.0% of patients remained free from aortic reintervention at 60 months, highlighting the need for surveillance.
Longitudinal Durability of Complex Endovascular Aortic Repair
Endovascular management of complex aortic aneurysms is increasingly utilized for patients at high surgical risk, with meta-analytical data demonstrating technical success rates of 98.5% for renal fenestrated repair and 97% for more complex configurations [1, 2]. While these endovascular techniques significantly reduce perioperative morbidity compared to open surgery, they carry a persistent risk of spinal cord ischemia (a condition where compromised blood supply to the spinal cord can lead to varying degrees of paralysis), with pooled rates reaching 12.3% in non-elective cases [2, 3, 4]. Long-term durability remains a critical consideration for the practicing clinician, as open surgery maintains a lower risk of reintervention at 24 months compared to fenestrated endovascular aortic repair (odds ratio 2.48; 95% confidence interval, 1.08 to 5.73) [4]. Furthermore, the risk of permanent renal failure requiring dialysis is 1.61% for complex endovascular repairs (95% confidence interval, 0.65% to 2.57%), particularly when suprarenal manipulation is required [5]. A new analysis from a high-volume center now provides essential longitudinal evidence to help clinicians weigh these procedural risks against long-term outcomes.
Procedural Success in Complex Anatomical Profiles
The researchers conducted a retrospective single-center analysis of 916 consecutive patients managed with fenestrated or branched endovascular aortic repair (f/bEVAR) between 2010 and 2024. This substantial cohort was primarily male at 73.6%, with a mean age of 71.7 ± 0.6 years, and the underlying etiology for the majority of patients was degenerative in 81.7% of cases. Anatomical challenges were significant: 53.7% of patients were treated for thoracoabdominal aortic aneurysms (TAAA), which involve the aorta both above and below the diaphragm, and 33.4% presented with juxtarenal aneurysms, located in immediate proximity to the renal arteries. To mitigate the physiological stress of these extensive repairs, the clinical team utilized staging (the strategy of performing the repair in multiple separate procedures to reduce the immediate surgical burden and allow for physiological adaptation) in 26.0% of the cases.
Device selection was tailored to individual anatomy, with custom-made devices (CMD) used in 74.4% of patients. These patient-specific grafts consisted of 37.1% fenestrated and 28.9% branched configurations. Despite the complexity of the cohort, which included 20.8% urgent cases, the study reported an overall technical success rate of 93.6%. Technical success was defined as the successful delivery and deployment of the endograft with all target vessels remaining patent. Multivariate logistic regression (a statistical method used to determine the independent effect of multiple variables on a single outcome) identified that technical success was independently associated with the urgent setting (P < 0.001) and the presence of Type II thoracoabdominal aortic aneurysms (P = 0.03). These findings suggest that while high success rates are achievable, the clinical context and the extent of the aortic disease remain the primary determinants of procedural outcomes.
Perioperative Mortality and Neurological Complications
The researchers observed an overall 30-day mortality rate of 7.4% across the entire cohort of 916 patients, though this figure was notably lower in stable patients. When isolating those who underwent planned procedures, the elective 30-day mortality rate was 4.4%. Multivariate logistic regression analysis demonstrated that early mortality was not uniform across clinical presentations; instead, 30-day mortality was independently related to aortic rupture (P = 0.03). This finding underscores the significant survival disadvantage faced by patients requiring emergency intervention compared to those managed in an elective setting, reinforcing the importance of timely diagnosis and planned repair.
Neurological morbidity remains a primary concern in complex aortic repair, particularly spinal cord ischemia (SCI), which occurred in 16% of all patients and 12.7% of those in the elective group. While many instances of ischemia are transient, the study tracked non-recovery Grade 3 SCI (defined as permanent severe neurological deficit or paralysis), which was recorded in 2.9% of the total population and 2.3% of elective patients. The incidence of spinal cord ischemia was not random; the condition was significantly related to aortic rupture (P = 0.009) and the use of off-the-shelf devices (P < 0.001). These correlations suggest that both the acuity of the patient's presentation and the choice of endovascular hardware, such as standardized versus custom-tailored grafts, are critical determinants of postoperative neurological integrity.
Long-Term Survival and the Reintervention Burden
Long-term outcomes for patients undergoing complex endovascular aortic repair demonstrate high rates of survival despite the inherent risks of the procedure. The researchers reported that the overall survival at 60 months was 82.6% (Standard Error [SE] 1.9%). When focusing specifically on deaths directly caused by aortic complications, the freedom from aorta-related mortality at 48 months was 89.2% (SE 1.3%). These figures suggest that while the patient population often presents with significant comorbidities, the endovascular approach effectively manages the primary vascular threat over a multiyear period.
To identify which clinical factors most heavily influenced these outcomes, the authors utilized a Cox-regression analysis (a statistical method used to determine the effect of several variables on the time it takes for a specific event, such as death, to occur). This analysis identified three primary factors independently related to worse survival: advanced age (P = 0.002), an American Society of Anesthesiologists (ASA) physical status score of 4 or higher (P = 0.02), and the occurrence of spinal cord ischemia (P < 0.001). These findings emphasize that the patient's baseline physiological reserve and the avoidance of neurological complications are the strongest predictors of long-term longevity following repair.
Despite the high survival rates, the study highlights a substantial need for ongoing surveillance and secondary procedures. The freedom from any aortic reintervention at 60 months was 40.0% (SE 2.5%), indicating that 60% of patients required at least one follow-up procedure within five years. The researchers found that the quality of the initial procedure was a critical determinant of this burden, as technical success was significantly related to freedom from reintervention (P < 0.001). For the practicing clinician, these data underscore that while complex endovascular repair is durable in terms of survival, it necessitates a lifelong commitment to monitoring and a high likelihood of secondary intervention to maintain the integrity of the repair.
References
1. Yazar O, Tiwana BS, Daemen JHT, et al. Impact of Stent-Graft Complexity on Outcomes of Complex Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis.. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists. 2025. doi:10.1177/15266028251397841
2. Spath P, Campana F, Tsilimparis N, et al. SYSTEMATIC REVIEW AND META-ANALYSIS ON ENDOVASCULAR REPAIR OF NON-ELECTIVE THORACO-ABDOMINAL AORTIC ANEURYSMS AND ANEURYSMS INVOLVING VISCERAL ARTERIES.. Journal of Vascular Surgery. 2025. doi:10.1016/j.jvs.2025.08.030
3. Blakeslee-Carter J, Novak Z, Jansen JO, et al. Prospective randomized pilot trial comparing prophylactic vs therapeutic cerebrospinal fluid drainage during complex endovascular thoracoabdominal aortic aneurysm repair.. Journal of Vascular Surgery. 2024. doi:10.1016/j.jvs.2024.02.041
4. 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
5. 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
