Comparing Outcomes of Open Explant and Fenestrated Endovascular Repair for Infrarenal Endovascular Aortic Repair Failure

Background Failure after endovascular aneurysm repair (EVAR) requires secondary intervention. Two broad strategies are used: open explantation (OE) and fenestrated EVAR (FEVAR). We compared outcomes using real-world data from a high-volume academic center, incorporating detailed anatomic characterization. Methods Patients treated between 2007 and 2024 for failed EVAR with either OE or FEVAR were reviewed. Demographics, procedural characteristics, imaging variables, and outcomes were compared using appropriate statistical tests. Cox regression evaluated associations and outcomes between repair strategies at 1 year. Results Among 137 patients with failed EVAR, 90 underwent open explant, and 47 underwent FEVAR. Patients with FEVAR were older (median age, 78.0 vs 74.0 years; P = .005) and more frequently had chronic kidney disease (44.7% vs 18.9%; P = .001), whereas other baseline comorbidities were similar. OE was more often performed for urgent interventions (26.7% vs 4.3%; P = .001). Failed EVAR management was frequently performed open when the indication was for infection (14.4% vs 0%) and rupture (8.9% vs 2.1%). Anatomic imaging demonstrated that FEVAR treated more proximal aortic disease than OE (proximal median zone: 8 vs 9, P = .011; distal median zone: 10 vs 9, P < .001). Differences in maximal aneurysm diameter, renal-to-bifurcation length, total number of zones involved, and neck angulation were not statistically significant. Perioperative outcomes favored FEVAR with a shorter intensive care unit stay (median, 2 vs 5 days; P < .001) and hospital stay (median, 4 vs 12.5 days; P < .001), along with fewer complications (12.8% vs 45.7%; P < .001). Thirty-day outcomes favored FEVAR with lower mortality (0% vs 11.1%; P = .018) and reintervention rates (2.1% vs 13.3%; P = .034). At 1 year, there was no significant difference in mortality (14.6% overall; 15.6% OE vs 12.8% FEVAR; P = .661) or reintervention (16.8% overall; 16.7% OE vs 17.0% FEVAR; P = .958). Repair strategy was not significantly associated with mortality at 1 year [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.29-1.95; P = .55] or freedom from reintervention at 1 year (HR, 1.07; 95% CI, 0.71-1.63; P = .75). Furthermore, endoleak type IA was not associated with a significantly higher risk of mortality at 1 year compared with Type IB-V endoleak (HR, 0.45; 95% CI, 0.15-1.37; P = .16). Conclusions FEVAR was associated with more favorable perioperative outcomes and lower 30-day mortality and reintervention despite similar anatomic characteristics. Long-term survival was comparable, and therefore, patient-specific factors and indication should guide therapy.