Long-term outcomes of patients with failed abdominal aortic aneurysm repairs rescued using fenestrated/branched stent-grafts at centers without access to custom-made devices.

Abstract

Failed abdominal aortic aneurysm (AAA) repair due to disease progression, graft migration, or type IA endoleak presents a complex management challenge. Although open conversion remains the traditional treatment, fenestrated/branched endovascular aneurysm repair (F/B-EVAR) offers a less invasive alternative but is technically challenging due to added anatomic constraints and presence of previous graft material. We evaluate outcomes of F/B-EVAR for failed previous AAA repair at centers without access to custom-made devices (CMDs). We retrospectively reviewed prospectively maintained databases of patients with failed AAA repairs rescued with F/B-EVAR between 2013 and 2025 at two tertiary centers without access to CMDs, under senior author's investigational device exemption. Primary endpoints were technical success (completion of F/B-EVAR without open conversion, target-vessel loss, or type IA/B/III endoleak), device integrity, and vessel patency. Secondary endpoints were major adverse events, mortality, and reintervention. Among 486 patients who underwent F/B-EVAR, 75 (15.4%) had a failed previous AAA repair. Median age was 77 years (interquartile range, 72-82), and 91.8% were male. Previous failed repairs included infrarenal EVAR (80.0%), previous open repair (14.7%), and previous FEVAR (5.3%); 48.0% had ≥1 previous reintervention. The primary indication was proximal seal failure, most commonly type IA endoleak (78.7%). Technical success was 100%. Device modification was frequently required, including main graft shortening (26.7%), distal bifurcated graft use (61.3%), inverted distal limb configuration (34.8% of bifurcated repairs), and distal graft shortening (8.7%). A total of 277 target vessels were successfully incorporated. Perioperative morbidity occurred in eight patients (10.7%), including renal failure without need for dialysis in 5.3%, paraplegia in 1.3%, and compartment syndrome in 2.7%. Two patients (2.7%) died during the index hospitalization. At a mean follow-up of 42 ± 37 months, 21.0% required reintervention. Primary and primary-assisted branch patency were 97.5% and 99.6%, respectively. Sac regression >5 mm occurred in 51 patients (68.0%). Kaplan-Meier estimated freedom from reintervention was 85.8% at 1 year and 76.2% at 5 years; with overall survival of 95.7% and 84.0%, respectively. F/B-EVAR for failed AAA repair is feasible and effective, even at centers without CMD, with excellent technical success and durable mid- to long-term outcomes. These findings support F/B-EVAR as a viable alternative to open conversion across a broad risk spectrum.