Nationwide outcomes of fenestrated endovascular aneurysm repair

Background: Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in patients who are not eligible for standard endovascular aneurysm repair (EVAR) devices due to anatomical constraints, principally of the proximal aortic neck. The long-term outcomes of FEVAR are not well described and therefore the aim of this study was to perform an analysis of a national registry in the UK.

Methods: The UK GLOBALSTAR registry (2003–2022) was analysed to report the long-term outcomes of FEVAR. Patients were included if they underwent FEVAR with custom-made devices for infradiaphragmatic aortic aneurysmal disease. Patients with extent I-III thoracoabdominal aneurysms or those who underwent other complex EVAR techniques were excluded. Time-to-event analyses were conducted for survival, aneurysm-related mortality, reintervention, endoleak, and target vessel patency. Subgroup analyses were conducted for octogenarians and patient sex. 

Results: Some 1651 patients across 15 centres were included. The median age was 75 (interquartile range 69–79) years and 87.9% were male. Estimated survival at 3, 5, and 10 years was 79.5% (95% c.i. 77.6% to 81.5%), 64.1% (95% c.i. 61.7% to 66.6%), and 30.5% (95% c.i. 27.7% to 33.5%) respectively; median survival was 6.9 (95% c.i. 6.6 to 7.2) years. Aneurysm-related mortality was 6.4% (95% c.i. 5.1% to 7.7%) at 10 years. There were 36 secondary sac ruptures over follow-up. The cumulative incidence of reintervention at 3, 5, and 7 years was 21.5% (95% c.i. 19.5% to 23.6%), 25.6% (95% c.i. 23.4% to 27.8%), and 27.6% (95% c.i. 25.3% to 30.0%) respectively. Graft-related complications accounted for 74.5% of reinterventions. Women had significantly worse 2-year survival (81.1% (95% c.i. 75.8% to 86.8%)) than men (86.1% (95% c.i. 84.3% to 87.9%)) (P = 0.041), driven by increased perioperative mortality. Beyond 2 years, the differences in survival were not statistically significant. Octogenarians had equivalent survival (89.4% (95% c.i. 86.4% to 92.4%)) to non-octogenarians (92.1% (95% c.i. 90.7% to 93.6%)) up to 1 year (P = 0.074). Octogenarians’ median survival was 5.4 (95% c.i. 5.0 to 6.1) years. 

Conclusions: Long-term outcomes of FEVAR appear acceptable, with low rates of secondary sac rupture. FEVAR is associated with a significant risk of reintervention, with graft-related complications being a key driver, suggesting effective planning and graft surveillance are key to long-term durability.