Textbook outcomes as a composite quality metric following fenestrated-branched endovascular aortic repair.

Abstract

Fenestrated-branched endovascular aortic repair (FB-EVAR) has been increasingly utilized to treat complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Textbook Outcome (TO) is a composite quality metric designed to reflect the ideal postoperative course. The aim of this study was to evaluate the incidence of TO following FB-EVAR and to identify predictors of TO failure. Consecutive patients enrolled in a prospective, non-randomized sponsor-initiated investigational device exemption study to assess FB-EVAR for CAAAs and TAAAs between 2013 and 2025 were reviewed. TO was defined as the absence of major complications, early reintervention, prolonged hospital length of stay (LOS; based on the 75th percentile of the cohort), non-home discharge, and early mortality (death within 30 days or during index hospitalization). The primary endpoint was incidence of TO. Secondary endpoints included identification of predictors of achieving TO, individual TO component contributions, early morbidity and mortality, and overall survival. A total of 609 patients (422 [69%] males, median age 74 years [IQR 68-79]) were analyzed. Aneurysm extent included CAAA in 164 (27%) and TAAA in 445 (73%). Early mortality was 1.3% (n=8) and 30-day MAE rate was 10.2% (n=62). TO was achieved in 64.2% of patients (n=391). The most common components of TO failure were prolonged LOS (23.6%) and major complications (17.9%), and 48.2% of non-TO patients failed due to a single component. Independent predictors of failure to achieve TO on multivariable analysis were female sex (OR, 0.52; 95% CI, 0.35-0.77; p=.001), increased age (OR, 0.97; 95% CI, 0.95-0.99; p=.013), COPD (OR, 0.58; 95% CI, 0.39-0.85; p=.006), CKD stage 3-5 (OR, 0.63; 95% CI, 0.44-0.92; p=.015), chronic postdissection aneurysms (OR, 0.53; 95% CI, 0.29-0.97; p=.041), larger aneurysm diameter (OR, 0.97; 95% CI, 0.96-0.99, p=.001) and Extent I-III TAAA (OR, 0.51; 95% CI, 0.29-0.89; p=.019). TO achievement was independently associated with improved overall survival (adjusted HR, 0.58; 95% CI, 0.43-0.78; P<.001), with unadjusted 1-year survival of 96% in TO versus 83% in non-TO patients. FB-EVAR was performed with low early mortality, and TO was achieved in nearly two-thirds of patients. The primary components of TO failure were major complications and prolonged LOS. Several independent predictors of TO failure were identified, and TO achievement was associated with improved overall survival. These findings establish a benchmark for TO after FB-EVAR, and a practical framework to guide risk stratification, patient counseling, and targeted quality-improvement efforts.