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 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 endpoints were technical success and major adverse events (MAEs); secondary endpoints included target vessel patency, re-intervention rate, and long-term survival. MAEs encompassed in-hospital death, stroke, MI, paraplegia, renal insufficiency, dialysis, return to the operating room, target vessel loss, and conversion to open repair.

Results: 507 patients (OR: 157; F/B-EVAR: 350) underwent cAA repair. Majority were male (76%) with a median age of 74 (68, 80) years. F/B-EVAR patients were older and had higher comorbidities (p>0.001). For OR, 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 1,239 target vessels were successfully incorporated. The overall technical success rate was 97% (OR: 100%, F/B-EVAR: 96%). Thirty-day mortality was similar between groups (F/B-EVAR: 3.4%; OR: 1.9%, p=0.4), as were MAEs (F/B-EVAR: 20%; OR: 15%, p=0.12). However, operating room time, estimated blood loss, and ICU/hospital length of stay were higher in the OR group (p<0.001). Paraplegia occurred only in the F/B-EVAR group (1.7%), while pneumonia and wound complications were more common in the OR group (p<0.001). At a median follow-up of 60 months, actuarial 5-year survival was significantly higher in the OR group (89% vs. 85%, p=0.041). Long-term reintervention rates were similar (OR: 7.4%, F/B-EVAR: 5.1%, p=0.3).

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