Long Term Target Vessel Outcomes in Patients Treated with Fenestrated Endovascular Aortic Repair

OBJECTIVE: Fenestrated endovascular aortic repair (FEVAR) has been proposed as an alternative to open surgical repair (OSR) in complex aortic cases. Target vessel outcomes have shown good results, with re-interventions constituting an important FEVAR pitfall. This single centre, retrospective, observational cohort study presented the target vessel outcomes in patients treated with FEVAR in a high volume aortic centre. METHODS: Consecutive patients managed with custom made FEVAR from 2010 to 2024 were included. Vessels targeted through scallops or intentionally unstented fenestrations were excluded from the main analysis. Primary outcomes were target vessel technical success and primary patency, along with freedom from target vessel instability (TVI), endoleak, and re-intervention during follow up, all assessed using Kaplan-Meier estimates. Regression analyses were performed. RESULTS: The study included 340 patients and 1 181 target vessels. Technical success was 99.2%. The mean follow up was 41.5 ± 32 months. Freedom from TVI was 87.7% (standard error [SE] 1.6%) at 60 months. Previous endovascular aortic repair (hazard ratio [HR] 2.14, 95% confidence interval [CI] 1.18 - 3.87; p = .012) and thoraco-abdominal aortic aneurysm (TAAA) (HR 3.3, 95% CI 2.07 - 5.25; p < .001) were independently related to instability. Primary patency was 97.2% (SE 0.7%) at 60 months and was negatively associated with Lifestream use (HR 3.61, 95% CI 1.26 - 8.67; p = .019), while the presence of aortic dissection (HR 0.14, 95% CI 0.001 - 0.98; p = .047) was a positive prognostic factor. Freedom from target vessel endoleak was 90.4% (SE 1.5%) at 60 months. Endoleaks were associated with previous OSR (HR 2.59, 95% CI 1.20 - 5.59; p = .016), number of fenestrations per device (HR 1.69, 95% CI 1.06 - 2.71; p = .029), and TAAA (HR 3.66, 95% CI 2.10 - 6.38; p < .001). Freedom from re-intervention at 60 months was 88.5% (SE 1.6%); only TAAA presence was associated with re-interventions (HR 3.43, 95% CI 2.12 - 5.54; p < .001). CONCLUSION: Target vessel performance in FEVAR demonstrated high long term freedom from adverse events, highlighting the effectiveness of the technique. TAAA was found to negatively affect outcomes, as well as previous open or endovascular abdominal aortic procedures.