Vessel-level comparative analysis of 5-year renal branch performance following fenestrated-branched endovascular aortic repair using thoracoabdominal multibranched endoprostheses and physician-modified endografts.

Abstract

Endovascular repair options for pararenal aortic aneurysms (PRAs) and thoracoabdominal aortic aneurysms (TAAAs) include physician-modified endografts (PMEGs), and thoracoabdominal multibranch endoprosthesis (TAMBE). However, long-term renal artery performance of TAMBE is unknown. Thus, we aimed to compare renal artery outcomes between TAMBE and PMEG. Patients who received TAMBE and PMEG at two aortic centers from 2015 to 2025 were reviewed. Aneurysm extent, branch stent size, antiplatelet regimen, laterality, and relining stents were compared by vessel level analysis. Primary outcome was freedom from target vessel instability (TVI). The secondary outcomes included primary patency, freedom from branch reintervention and branch endoleak. Cox proportional hazard regression was performed comparing PMEG and TAMBE RAs for TVI. We included 716 patients and 1339 RAs (633 patients/1180 RAs for PMEG and 83 patients/159 RAs for TAMBE groups). RAs in PMEG had higher 5-year freedom from TVI compared with TAMBE (89.5% vs 82.7%; P = .005), driven by higher freedom from branch reintervention (90.8% vs 82.5%; P = .002) and primary patency (93.7% vs 83.3%; P < .001), albeit with similar freedom from branch endoleak (93.9% vs 98.2%; P = .3). This finding was likely due to the higher freedom from TVI in the right renal artery (91.3% vs 77.9%; P = .002), but not left renal artery (87.6% vs 87.9%; P = .375). Subgroup analysis showed similar freedom from TVI in the TAAA patients (P = .691), whereas the PRA subgroup showed significantly lower freedom from TVI in the TAMBE compared PMEG group (P < .001). Cox regression, adjusting for aneurysm extent, branch stent size, relining, and dual antiplatelets, showed that the right RAs in TAMBE were more likely to develop TVI (hazard ratio, 4.2; P < .001) than PMEG. The right renal artery may be the principal site of failure for TAMBE, contributing to lower 5-year freedom from TVI compared with PMEG. TAAA appears to confer protection against renal TVI in TAMBE, compared with PRA. These findings warrant revisiting anatomical criteria and further optimization of renal bridging stent design for TAMBE.