Midterm outcomes of off-the-shelf multibranched versus physician-modified endografts for endovascular repair of complex and thoracoabdominal aortic aneurysms: A systematic review and meta-analysis.

Abstract

Custom-manufactured fenestrated-branched endovascular aortic repair devices have demonstrated excellent outcomes for elective repair of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). However, for symptomatic or ruptured aneurysms, the manufacturing and shipping time render this option impractical for urgent or emergent repair. To address this clinical need, alternative technologies have been developed, including physician-modified endografts (PMEGs) and off-the-shelf multibranched devices (OTSDs). In this systematic review and meta-analysis, we compare midterm outcomes between OTSDs and PMEGs. A systematic search was conducted using the MEDLINE, Embase, Scopus, and ClinicalTrials.gov databases through January 1, 2025. Studies with 10 or more patients reporting 1- or 2-year mortality or reintervention after PMEG or OTSD repair of CAAAs or TAAAs were included. Primary outcomes included midterm reintervention and mortality. Secondary outcomes included 30-day mortality, spinal cord ischemia (SCI), and technical success. Subgroup analyses by presentation and aneurysm extent were also performed. Eighteen studies (11 PMEG, 7 OTSD), including 994 patients (538 PMEGs, 456 OTSDs), were included in the review. One-year reintervention was 11% for PMEG and 12% for OTSD (P = .966), and 2-year reintervention was 15% for PMEG and 13% for OTSD (P = .820). One-year mortality was 9% for PMEG and 8% for OTSD (P = .714), and 2-year mortality was 11% for PMEG and 12% for OTSD (P = .758). Technical success was slightly higher with OTSD (98% vs 96%, P = .03), and SCI occurred more frequently with OTSD (6% vs 0%, P < .0001). Thirty-day mortality was 1% for PMEG and 2% for OTSD (P = .836). Subgroup analyses by presentation and aneurysm extent revealed no differences in primary outcomes. PMEGs and OTSDs demonstrate acceptable midterm outcomes. However, interpretation of comparative results is limited by substantial differences in aneurysm extent, symptomatic or ruptured presentation, and follow-up duration between the cohorts. Both remain viable strategies, with device selection guided by individual anatomy, urgency, and institutional expertise.