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Physician-Modified Fenestrated Endovascular Aortic Aneurysm Repair after Failed EVAR with Type I Endoleak Offers
Jay P Natarajan1, Trung Nguyen1, Shivam Patel1
1Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL.
Background:
EVAR failure due to type Ia endoleak is prevalent. Conversion to open repair (EVAR-c) is associated with technical and physiologic challenges. Endovascular salvage by obtaining a more proximal seal zone with a physician-modified fenestrated/branched endovascular repair (F/BEVAR) is an alternative treatment option. There is limited data directly comparing outcomes of EVAR-c and PM-F/BEVAR. The purpose of this study was to compare outcomes of EVAR-c and PM-F/BEVAR in patients with prior EVAR with type Ia endoleak and to assess changes in our clinical management of these patients over time.
Methods:
A prospective database of patients treated at a single center with EVAR failure due to type Ia endoleak between January 2015 and November 2025 was retrospectively reviewed. The cohort was stratified by treatment strategy, either EVAR-c or PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. Four-year overall survival was compared using the Kaplan-Meier method.
Results:
Of the 101 patients treated for failed EVAR with type Ia endoleak, 41 underwent EVAR-c and 60 underwent PM-F/BEVAR. While both groups had similar preoperative characteristics, PM-F/BEVAR had significantly decreased 30-day mortality (n = 6 [15%] vs. n = 0 [0%]; P = 0.004) and postoperative complications (n = 14 [23%] vs. n = 30 [75%]; P < 0.001). There was no difference in 4-year overall survival (EVAR-c = 64% vs. PM-F/BEVAR = 49%; P = 0.71). The improved perioperative outcomes with PM-F/BEVAR was persistent when excluding urgent/emergent cases from analysis.
Conclusion:
Endovascular salvage of failed prior EVAR due to type Ia endoleak with PM-F/BEVAR is safe and effective with significantly better 30-day outcomes compared to EVAR-c, but this survival advantage is lost over time.
