Fenestrated and Branched Endovascular Repair for Mycotic Aortic Aneurysms

Management of mycotic complex aortic aneurysms (MAAs) involving the supra-aortic or reno-visceral vessels is highly challenging. Radical open repair carries substantial mortality and morbidity and may not always be technically feasible. Fenestrated or branched endovascular aortic repair (F/BEVAR) offers a less invasive alternative, although current experience remains limited. This study describes the outcomes of complex endovascular repair of MAAs.

This single-center retrospective cohort study included all consecutive patients with MAA who underwent F/BEVAR between November 2017 and August 2024. Mycotic aortic aneurysm diagnosis was established using a combination of clinical presentation, laboratory markers, and imaging findings according to current guidelines. All patients received broad-spectrum antibiotics at presentation before undergoing F/BEVAR, followed by targeted antibiotics as appropriate. Collected data included patient demographics, operative details, early and long-term complications, infection-related complications (IRC), all-cause mortality, and infection-related mortality.

A total of 21 patients (81% male, mean age 73.3 ± 5 years) were treated for MAAs affecting the aortic arch (n = 4), thoracoabdominal aorta (n = 9), or pararenal aorta (n = 8). Procedures involved in situ laser fenestration (n = 13), physician-modified endografts (n = 2), off-the-shelf branched devices (n = 2), and custom-made devices (n = 4). Technical success was 20/21 (95.2%; 1 type IIIC endoleak), and no target vessel loss. No deaths occurred within 30 days postoperatively. Three early reinterventions (14.3%) were required. During a mean follow-up of 37.4 ± 26.7 months, 2 asymptomatic renal branch occlusions were detected but did not require revascularization. Four patients (19%) developed IRCs at 1, 9, 9, and 13 months after the surgery, managed either conservatively with antibiotics alone (n = 2) or combined with computed tomography (CT)-guided drainage (n = 2), both of whom died 11 and 31 months after CT-guided drainage. The 3-year Kaplan-Meier estimated survival was 85% (95% CI = 58%-95%).

Complex endovascular repair of MAAs is feasible, with high technical success and favorable short- to mid-term outcomes. Late IRCs do occur in some cases, but may be managed semi-conservatively.Clinical ImpactPatients with mycotic aneurysms involving aortic side branches are at increased risk when treated with open aortic repair. These results demonstrate that fenestrated and branched endovascular techniques represent a viable therapeutic option in this challenging patient population, yielding excellent short-term and acceptable mid-term outcomes.