Skill Mastery and Learning Curve Analysis in Fenestrated Endovascular Aortic Repair with Physician-Modified Endograft

Objectives: This study aims to delineate the unique learning curve for fenestrated endovascular aortic repair (FEVAR) at our institution. Materials and Methods: We measured the FEVAR-specific procedure time (FSPT) as the duration from device deployment to bridging stent completion. To maintain consistency in technical complexity, the study focused on 38 cases with four-fenestration FEVAR for juxtarenal abdominal aortic aneurysms, selected from 103 of all FEVAR procedures between June 2011 and February 2024. In these cases, superior mesenteric and bilateral renal arteries were preserved with fenestration with bridging stents insertion, while celiac arteries fenestrations without fenestrations. Learning curve and cumulative sum (CUSUM) analyses assessed FSPT reduction against increased FEVAR experiences. Results: A significant learning curve was observed, with the procedure time (y) and experience (X) correlation given by y = -39.95 log(X) + 283.6 (R² = 0.5758). CUSUM indicated that 30 to 50 cases were required for skill stabilization and maturation. Conclusion: Our endovascular team required 30-50 cases to establish reliable FEVAR proficiency. Beyond cumulative experiences, pivotal elements in the learning trajectory seemed to include technological advancements and team augmentation.