Textbook outcomes as a composite quality metric following fenestrated-branched endovascular aortic repair

Fenestrated-branched endovascular aortic repair (FB-EVAR) has been increasingly utilized to treat complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Textbook Outcome (TO) is a composite quality metric designed to reflect the ideal postoperative course. This study aimed to evaluate the incidence of TO following FB-EVAR and to identify the predictors of TO failure.

This study reviewed the data of consecutive patients enrolled in a prospective nonrandomized sponsor-initiated investigational device exemption study to assess FB-EVAR for CAAAs and TAAAs between 2013 and 2025. TO was defined as the absence of major complications, early reintervention, prolonged hospital length of stay (LOS; based on the 75th percentile of the cohort), non-home discharge, and early mortality (death within 30 days or during the index hospitalization). The primary end point was the incidence of TO. The secondary end points included the identification of the predictors of TO achievement, individual TO component contributions, early morbidity and mortality, and overall survival.

A total of 609 patients (422 [69%] males, median age, 74 years [interquartile range, 68-79]) were analyzed. The aneurysm extent included CAAA in 164 (27%) and TAAA in 445 patients (73%). The early mortality rate was 1.3% (n = 8), and the 30-day major adverse event rate was 10.2% (n = 62). TO was achieved in 64.2% of patients (n = 391). The most common components of TO failure were prolonged LOS (23.6%) and major complications (17.9%), and failure occurred due to a single component in 48.2% of non-TO patients. According to multivariable analysis, the independent predictors of failure to achieve TO were female sex (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.35-0.77; P = .001), increased age (OR, 0.97; 95% CI, 0.95-0.99; P = .013), chronic obstructive pulmonary disease (OR, 0.58; 95% CI, 0.39-0.85; P = .006), chronic kidney disease stage 3-5 (OR, 0.63; 95% CI, 0.44-0.92; P = .015), chronic post-dissection aneurysms (OR, 0.53; 95% CI, 0.29-0.97; P = .041), larger aneurysm diameter (OR, 0.97; 95% CI, 0.96-0.99; P = .001), and extent I-III TAAA (OR, 0.51; 95% CI, 0.29-0.89; P = .019). TO achievement was independently associated with improved overall survival (adjusted hazard ratio, 0.58; 95% CI, 0.43-0.78; P < .001), with an unadjusted 1-year survival rate of 96% in TO vs 83% in non-TO patients.

FB-EVAR was performed with low early mortality, and TO was achieved in nearly two-thirds of patients. The primary components of TO failure were major complications and prolonged LOS. Several independent predictors of TO failure were identified, and TO achievement was associated with improved overall survival. These findings establish TO after FB-EVAR as a benchmark and a practical framework to guide risk stratification, patient counseling, and targeted quality-improvement efforts.