Propensity Score Matched Comparison of EndoSuture versus Fenestrated Aortic Aneurysm Repair in Treatment of Abdominal Aortic Aneurysms with Unfavorable Neck Anatomy.

Introduction: Hostile aortic neck anatomy is associated with loss of proximal seal and increased late reinterventions. While both EndoSuture aneurysm repair (ESAR) and fenestrated endovascular aortic repair (FEVAR) are commercially available options for treatment of short-neck aneurysms, branch vessel patency is a potential tradeoff for improved seal with FEVAR due to incorporation of renovisceral vessels. This study compares the performance of ESAR versus FEVAR in hostile aortic necks.

Methods: Patients who underwent elective ESAR or FEVAR for hostile neck AAAs at a single center from 2012-2024 were retrospectively reviewed. Exclusion criteria included pararenal or thoracoabdominal aortic aneurysm, off-label modifications, and non-standard FEVAR configurations. Propensity matching weights were generated based on age, year of operation, pre-operative eGFR, neck length, neck diameter and infrarenal angulation. Rates of survival, reintervention, dialysis, CKD stage progression, type IA endoleak (EL), and sac regression (>5mm) were assessed at latest follow-up.

Results: Of 391 patients, 60 with ESAR and 207 with FEVAR were included. FEVAR patients were younger (74.4 vs 79.8; P<.001) with larger neck diameters (25 vs 23.6 mm; P=.016), shorter neck length (5 vs 9.8 mm, P<.001), and decreased infrarenal angulation (20 vs 40 deg; P<.001). After propensity-score adjusted regression (58 ESAR, 169 FEVAR), FEVAR, compared to ESAR, was associated with decreased 1A EL ( HR:0.341, 95% CI:0.061-0.72; P=0.031) and increased sac regression (HR:3.92, 95% CI: 1.25-5.14; P= 0.02). Notably, FEVAR was associated with increased 1-year aneurysm-related reintervention (OR: 4.33, 95% CI: 1.12-10.54; P=0.046). On Kaplan-Meier analysis, FEVAR was associated with reduced freedom from reinterventions at 3 years (71.8% [CI: 0.63-0.78] vs 93.5% [CI: 0.80-0.97]; log-rank P=0.019) but a trend towards improved survival at 3 years (79.15% [CI: 0.70-0.85] vs 61.5% [CI: 0.44-0.74]; log-rank P=0.095). There was no significant difference in new-onset chronic dialysis between ESAR and FEVAR at 3-years (94.2% [CI: 0.82-0.98] vs 97.4% [CI: 0.93-0.99]; log-rank P=0.124).

Conclusion: In the treatment of AAA with hostile neck anatomy in this propensity-matched cohort, FEVAR was associated with reduced type 1A EL and greater sac regression compared to ESAR with no detrimental impact on long-term renal function. There were more reinterventions, mostly branch-related, in the FEVAR group. We await results of the current randomized prospective trial comparing these strategies to further determine the impact of these clinical differences on aneurysm-related mortality.