Commentary: Physician-Modified Fenestrated/Branched EVAR and Hybrid Techniques for Acute Thoracoabdominal Aortic Pathologies: Inequality When Comparing Alternative Options With Different Philosophies Does Not Equal Lower Quality

In the October 2020 issue of the JEVT, Yang et al1 have reported valuable research comparing fenestrated/branched physician-modified endovascular grafts (f/bPMEGs) to hybrid open debranching of the visceral aorta with bypass graft revascularization plus endovascular aneurysm exclusion (EVAR) for the treatment of complex thoracoabdominal aortic aneurysms (TAAAs), mainly symptomatic and in high-risk patients. Based on the current absence of published large clinical trials providing the necessary supporting evidence for both techniques, such comparative studies, although retrospective, are meaningful until reliable and more applicable “off-the-shelf” stent-grafts are universally available in the marketplace. Whereas significant differences favoring f/bPMEGs over hybrid reconstructions were seen relative to operative technique and efficiency (duration of operation, blood loss, shock, acute renal failure requiring dialysis, renal and pulmonary complications, and lengths of intensive care and hospital stays), these did not translate into differences in early or late mortality rates.1 Notably, low 30-day mortality was reported for the f/bPMEG and hybrid repair groups (3.3% and 3.6%, respectively) despite the high rate of symptomatic or contained rupture cases (42%). Similar excellent 30-day mortality outcomes for f/bPMEGs have also been obtained from dedicated teams in high-volume centers (5.1%,2 5.5%,3 3.7% in the most recent period,4 and 4.9%5) having gained initial experience much earlier (2007, 2007, 2009, and 2010, respectively) than the present authors (2016),1 highlighting the substantial learning curve effect and also the ability of the Chinese authors to replicate the usual methods of device construction and delivery system preparation. Like Yang et al,1 innovative physicians who are capable of performing complicated procedures (f/bPMEGs or hybrid techniques) for aortic disease can give the patient a better chance of surviving this morbid and potentially lethal disease in the acute setting (urgent repair of a large aneurysm, rapid sac expansion, impending or contained rupture), without always taking into consideration alternative techniques (eg, offthe-shelf stent-grafts that fit many different anatomies). Contradictory to these data, Tsilimparis et al6 reported that hybrid procedures are independently associated with >6 times early mortality when compared with customdesigned fenestrated/branched stent-grafts. Notably, acute renal failure and mesenteric ischemia presented more commonly in the hybrid group (2.6% vs 18% and 3% vs 23%, respectively).6 This was also true in the study by Yang et al1 (renal deterioration 25%, dialysis on discharge 21%) but surprisingly not related to increased mortality even though 934469 JETXXX10.1177/1526602820934469Journal of Endovascular TherapyGeorgiadis et al article-commentary2020