Long-term outcomes of open versus endovascular complex aortic aneurysm repairs at centers without access to custom made devices in the fenestrated/branched stent graft era.

Abstract

To evaluate and compare long-term outcomes of complex aortic aneurysms (cAAs) treated with open surgical repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B-EVAR) between 2010 and 2023 at two institutions. This retrospective analysis compares the outcomes of cAAs treated by OR vs F/B-EVAR at two centers with no access to custom-made fenestrated/branched devices. cAAs were defined as those requiring a suprarenal or higher clamp (OR) or unsuitable for commercially available infrarenal endografts. Primary end points were technical success and major adverse events (MAEs); secondary end points included target vessel patency, reintervention rate, and long-term survival. MAEs encompassed in-hospital death, stroke, myocardial infarction, paraplegia, renal insufficiency, dialysis, return to the operating room, target vessel loss, and conversion to open surgical repair (OR). We included 507 patients (OR, 157; F/B-EVAR, 350) underwent cAA repair. The majority were male (76%) with a median age of 74 years (interquartile range, 68-80 years). F/B-EVAR patients were older and had more comorbidities (P > .001). For OR, the clamp site was suprarenal/supramesenteric in 143 (91.1%) and intrathoracic in 14 (8.9%) patients with thoracoabdominal aneurysms. Complications were higher in patients requiring supraceliac clamp. In the F/B-EVAR group, 99.4% of 1239 target vessels were successfully incorporated. The overall technical success rate was 97% (OR, 100%; F/B-EVAR, 96%). The 30-day mortality rates was similar between groups (F/B-EVAR, 3.4%; OR, 1.9%; P = .4), as were MAEs (F/B-EVAR, 20%; OR, 15%; P = .12). However, operating room time, estimated blood loss, and ICU/hospital length of stay were higher in the OR group (P < .001). Paraplegia occurred only in the F/B-EVAR group (1.7%), and pneumonia and wound complications were more common in the OR group (P < .001). At a median follow-up of 60 months, actuarial 5-year survival was significantly higher in the OR group (89% vs 85%; P = .041). Long-term reintervention rates were similar (OR, 7.4%; F/B-EVAR, 5.1%; P = .3). Both approaches are safe and effective for cAA repair. F/B-EVAR offers perioperative advantages-faster recovery and shorter intensive care unit and hospital stays-although OR provides excellent long-term outcomes in selected patients. Comprehensive aortic centers should maintain expertise in both techniques to optimize individualized treatment.