The value of the mini-cuff technique in fenestrated/branched endovascular aortic repair: Efficacy validation based on the composite end point of target vessel instability.

Abstract

To evaluate whether adjunctive mini-cuff use is associated with a reduced risk of postoperative target vessel instability (TVI) after physician-modified endograft (PMEG)-based fenestrated/branched endovascular aortic repair (FB-EVAR). This single-center retrospective cohort study included 216 patients with complex aortic diseases treated with PMEG-based FB-EVAR between January 2018 and June 2024. Patients were divided into two groups based on the use of the mini-cuff technique: the FB-EVAR with mini-cuff group (FM group; n = 79) and the FB-EVAR without mini-cuff group (FB group; n = 137). A total of 666 target vessels were analyzed at the branch level, including 193 reconstructed with adjunctive mini-cuff and 473 without mini-cuff. The primary end point was TVI, a composite of target vessel occlusion, >70% stenosis, reintervention, or type Ic/target vessel-related type III endoleak. Time-to-event data were analyzed using Cox proportional hazards regression with robust standard errors to account for within-patient clustering of vessels. Key covariates were prespecified and forced into the multivariable model, including pathology (degenerative vs postdissection), prior aortic endovascular surgery, aneurysm neck-to-sac β-angle of >60°, adverse target vessel condition, and age. The FM group had a higher prevalence of prior aortic endovascular surgery (48.1% vs 16.1%) and postdissection pathology (65.8% vs 27.7%); at the branch level, adverse anatomical conditions were also more frequent in the FM group (26.4% vs 19.2%). In the unadjusted branch-level analysis, TVI occurred less often with mini-cuffs (10.9% vs 16.3%), although this difference did not attain statistical significance (P = .074). Because mini-cuffs were selectively used in higher-risk anatomies, multivariable adjusted analyses were performed. In the multivariable Cox model with robust standard errors, mini-cuff use was independently associated with a lower hazard of TVI (adjusted hazard ratio, 0.882; 95% confidence interval, 0.802-0.969; P = .009). At 24 months, the Kaplan-Meier-estimated branch-level TVI risk was approximately 20% with mini-cuffs vs 25% without, corresponding with an absolute risk reduction of approximately 5% and an estimated number needed to treat of approximately 21. Perioperative outcomes were similar between the groups. In this retrospective PMEG-based FB-EVAR cohort, adjunctive mini-cuff use was independently associated with improved midterm target vessel stability without increased perioperative risk. However, given the nonrandomized design and selective use in higher-risk anatomies, residual confounding and selection bias cannot be excluded.