Implementation of a Comprehensive Endovascular Aortic Programme and Maintenance of Clinical Excellence during Fenestrated Branched Endovascular Aortic Repair in Two Centres

Objective: Comprehensive endovascular aortic programmes need optimal infrastructure and multidisciplinary teams to manage complex aortic aneurysms. This study assessed the implementation of such a programme in two centres and its impact on fenestrated or branched endovascular aortic repair (FB-EVAR) outcomes.

Methods: A retrospective review of patients treated for complex abdominal and thoraco-abdominal aortic aneurysms (TAAAs) by FB-EVAR between 2013 and 2023 was undertaken. All FB-EVAR patients were analysed, including investigational trials and high risk patients with physician modified endografts. Centre 1 (2013 - 2020) and Centre 2 (2020 - 2023) were compared. Primary endpoints were 30 day and or in hospital mortality and major adverse event (MAE) rates. Secondary endpoints were procedural metrics, spinal cord injuries, freedom from all cause death, failure to rescue, and one year mortality and re-intervention rates.

Results: A total of 629 patients were included (475, 75.5% at Centre 1 and 154, 24.5% at Centre 2). The median age was 74 years (interquartile range 68, 79) and 441 (70.1%) were male. Centre 2 had a higher proportion of American Society of Anesthesiology class ≥ 3, genetically triggered aortic diseases (p = .002), chronic post-dissection aneurysms, prior aortic repairs, TAAAs (each p < .001), and symptomatic, larger aneurysms (p < .021). Technical success rates were similar between centres (97.9% vs. 98.1%; p = .91). The early mortality rate was 1.1% (7/629) with no statistically significant difference. No statistically significant differences (p > .050) in new onset permanent dialysis (0.6% vs. 2.0%), major stroke (0.6% vs. 0.6%), and permanent paraplegia (0.8% vs. 2.0%) were observed. Failure to rescue rates were 5.3% in Centre 2 and 3.5% in Centre 1 (p = .74). The one year mortality rate (91% vs. 89%; p = .71) and re-intervention rate (sub-distribution hazard ratio 1.30; p = .21) were similar between centres.

Conclusion: FB-EVAR was performed with low mortality and risk of disabling complication rates. No differences in mortality and MAE rates were observed after establishing a comprehensive endovascular programme, despite higher risk and more extensive cases at the new institution.