Long-term outcomes of open versus endovascular complex aortic aneurysm repairs at centers without access to custom made devices in the fenestrated/branched stent graft era.

OBJECTIVE

To evaluate and compare long-term outcomes of complex aortic aneurysms (cAAs) treated with open surgical repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B-EVAR) between 2010 and 2023 at two institutions.

METHODS

This retrospective analysis compares the outcomes of cAAs treated by OR vs F/B-EVAR at two centers with no access to custom-made fenestrated/branched devices. cAAs were defined as those requiring a suprarenal or higher clamp (OR) or unsuitable for commercially available infrarenal endografts. Primary end points were technical success and major adverse events (MAEs); secondary end points included target vessel patency, reintervention rate, and long-term survival. MAEs encompassed in-hospital death, stroke, myocardial infarction, paraplegia, renal insufficiency, dialysis, return to the operating room, target vessel loss, and conversion to open surgical repair (OR).

RESULTS

We included 507 patients (OR, 157; F/B-EVAR, 350) underwent cAA repair. The majority were male (76%) with a median age of 74 years (interquartile range, 68-80 years). F/B-EVAR patients were older and had more comorbidities (P > .001). For OR, the clamp site was suprarenal/supramesenteric in 143 (91.1%) and intrathoracic in 14 (8.9%) patients with thoracoabdominal aneurysms. Complications were higher in patients requiring supraceliac clamp. In the F/B-EVAR group, 99.4% of 1239 target vessels were successfully incorporated. The overall technical success rate was 97% (OR, 100%; F/B-EVAR, 96%). The 30-day mortality rates was similar between groups (F/B-EVAR, 3.4%; OR, 1.9%; P = .4), as were MAEs (F/B-EVAR, 20%; OR, 15%; P = .12). However, operating room time, estimated blood loss, and ICU/hospital length of stay were higher in the OR group (P < .001). Paraplegia occurred only in the F/B-EVAR group (1.7%), and pneumonia and wound complications were more common in the OR group (P < .001). At a median follow-up of 60 months, actuarial 5-year survival was significantly higher in the OR group (89% vs 85%; P = .041). Long-term reintervention rates were similar (OR, 7.4%; F/B-EVAR, 5.1%; P = .3).

CONCLUSIONS

Both approaches are safe and effective for cAA repair. F/B-EVAR offers perioperative advantages-faster recovery and shorter intensive care unit and hospital stays-although OR provides excellent long-term outcomes in selected patients. Comprehensive aortic centers should maintain expertise in both techniques to optimize individualized treatment.