Physician-Modified Endograft Total Endovascular vs Open Repair of Degenerative Thoracoabdominal Aortic Aneurysms

Fenestrated-branched endovascular aortic repair (FB-EVAR) is emerging as the preferred option for repair of degenerative thoracoabdominal aortic aneurysms (TAAAs). This shift has occurred despite limited data comparing open and endovascular techniques, particularly for FB-EVAR with physician-modified endografts outside of physician-sponsored investigational device exemption trials.

Patients undergoing open repair or FB-EVAR of degenerative (non-hereditary) TAAA at a single institution (Duke University Medical Center, Durham, NC) between 2005 and 2024 were included. All FB-EVARs were performed using physician-modified endografts. To minimize confounding, a 1:1 propensity score-matched comparison was performed between the 43 patients undergoing FB-EVAR and 43 patients undergoing open repair. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included 30-day or in-hospital major morbidity, 2-year overall survival, and late freedom from a composite of aorta-specific mortality or reoperation on the treated segment.

A total of 178 patients (open repair, 135; FB-EVAR, 43) were included. Comorbidities and TAAA extents were similar after matching. FB-EVAR was associated with a significantly shorter length of stay (3.0 days vs 8.0 days; P < .001). There were no significant differences in 30-day or in-hospital mortality (5% vs 12%; P = .43), 2-year overall survival (75% vs 68%; P = .49), or freedom from the composite aortic outcome (86% vs 91%; P = .29) between FB-EVAR and open repair.

In this propensity-matched comparison of open repair vs FB-EVAR of degenerative TAAA, FB-EVAR using PMEGs outside of a physician-sponsored investigational device exemption trial was feasible and associated with comparable early and late outcomes, as well as shorter length of stay. These findings support the real-world applicability of FB-EVAR using PMEGs, although longer-term follow-up is needed.