A 15-Year Single-Center Experience Treating Complex Aortic Aneurysms: Transitioning From Open to Complex Endovascular...

This is a descriptive study analyzing all surgically treated complex aneurysm patients in a tertiary referral center, during a 15-year time period in which complex endovascular aortic repair (complex EVAR) was introduced alongside open surgical repair (OSR). The goal was to present the real-world clinical profiles and surgical outcomes of complex (thoraco-)abdominal aneurysm patients, based on the current decision-making process.

Patients undergoing OSR and complex EVAR between January 2008 and August 2023 were retrospectively included. The reasoning behind each treatment decision was analyzed. Both groups were described in terms of baseline characteristics and outcomes. A subanalysis was made for the frailest complex EVAR patients, considered unfit for OSR.

As of 2008, 112 patients underwent OSR, whereas 119 patients underwent complex EVAR since 2013. When both modalities were considered opportune, the patient's preference toward complex EVAR was often decisive in shared decision-making. Based on the current selection process, 47 patients were considered too frail for OSR. Complex EVAR patients had a higher Charlson Comorbidity Index (3.0 [IQR: 2.0,4.0] vs 4.0 [3.0, 5.0], p=0.002). More complications occurred after OSR (31.3% vs 18.5%, p=0.027), while reinterventions were more common after complex EVAR (20.2% vs 8.0%, p=0.008). The 47 frailest complex EVAR patients had a lower median survival time and high 1-year mortality of 23.8%.

Although less invasive compared to OSR regarding complications, complex EVAR still comes with considerable risks. For some frailest patients, complex EVAR might be a bridge too far. Specific insights in patient selection are warranted.Clinical ImpactWith the introduction of complex EVAR, more complex aneurysms were treated, in an overall frailer patient cohort. The frailest complex EVAR patients had a high 1-year mortality and a significantly lower mean survival compared to fit complex EVAR patients and patients undergoing OSR. The current selection process seems effective in recognizing the frailest patients and assigning them to complex EVAR, as guidelines propose. However, it might not yet be able to select patients that would benefit more from conservative non-surgical management. Specific insights in patient selection are warranted.