Three Dimensional Printing Guidance is Associated with Improved Outcomes in Complex Aortic Repair: A Multicentre Comparative Study of Physician Modified Endografts.

Abstract

This multicentre, retrospective, comparative cohort study aimed to evaluate whether three dimensional (3D) printing guidance was associated with procedural efficiency and midterm outcomes of physician modified endovascular graft (PMEG) fenestrated and or branched endovascular aortic repair (FBEVAR) compared with traditional measurement guided planning. Consecutive patients undergoing PMEG FBEVAR at three centres (January 2018 - June 2024) were analysed: 318 with 3D printing guided (PG) and 195 with traditional measurement guided. The primary endpoint was target vessel instability (TVI), a composite of target vessel occlusion, > 70% stenosis, target vessel related re-intervention, or type Ic or III endoleak. Time to event outcomes were assessed using Kaplan-Meier analysis with log rank tests. TVI was evaluated using centre stratified Cox regression and centre adjusted logistic regression with pre-specified covariables including procedure year; a sensitivity analysis additionally adjusted for bridging strategy (balloon expandable covered bridging stent [CBE] only vs. non-CBE only). Technical success and thirty day outcomes were similar. PG was associated with shorter EVAR duration (109.8 ± 34.9 vs. 120.9 ± 45.4 minutes; p = .003), shorter fluoroscopy time (73.6 ± 24.9 vs. 85.7 ± 21.4 minutes; p = .001), lower contrast volume (116.0 ± 34.1 vs. 119.1 ± 38.1 mL; p = .029), and lower radiation dose (1 683.4 ± 536.4 vs. 1 900.8 ± 597.3 mGy; p = .001). At a median follow up of 26 months, TVI occurred less frequently in PG (27.0% vs. 35.4%; p = .046), with fewer target vessel related endoleaks (5.7% vs. 10.8%; p = .034) and target vessel related re-interventions (19.8% vs. 28.7%; p = .028). Freedom from TVI was higher in PG (log rank p = .028). In adjusted analyses, PG was associated with a lower TVI hazard (adjusted hazard ratio 0.75, 95% confidence interval [CI] 0.58 - 0.97; p = .030); the logistic model showed a directionally similar association (adjusted odds ratio 0.70, 95% CI 0.48 - 1.03; p = .069). Aortic angulation > 60°, severe abdominal aortic calcification, and dissection pathology were associated with higher TVI risk. In this retrospective, multicentre, cohort study, 3D printing guided planning in PMEG FBEVAR was associated with greater procedural efficiency and favourable midterm target vessel outcomes. The findings should be interpreted as associations, given the non-randomised design.