Secondary Intervention Burden After Fenestrated Endovascular Aortic Repair: A Patient-Level and Procedure-Level Analysis of a 14-Year Single-Center Experience

Purpose: To quantify the patient-level and procedure-level burden, concentration, timing, and characteristics of secondary interventions after fenestrated endovascular aortic repair (FEVAR), and their association with subsequent mortality. Materials and Methods: This retrospective single-center study included 189 consecutive patients treated with FEVAR between 2007 and 2021. Secondary interventions were classified by clinical magnitude, approach, timing, and primary indication. The cumulative incidence of a first secondary intervention was estimated using the Aalen-Johansen method with death as a competing event. The association with subsequent mortality was assessed using a time-dependent Cox model. Results: Technical success was achieved in 185 of 189 patients (97.9%). Median observed follow-up was 40.9 months (interquartile range, 25.1-61.2), and median potential follow-up was 57.4 months. Forty-eight patients (25.4%) underwent 67 secondary procedures. Nine patients, representing 4.8% of the cohort, underwent repeated interventions and accounted for 28 procedures (41.8%). Of the 67 procedures, 25 (37.3%) were major, 42 (62.7%) were minor, and 52 (77.6%) were endovascular. Thirty-seven procedures (55.2%) occurred more than 1 year after FEVAR. The 48-month cumulative incidence of a first secondary intervention was 24.7%, compared with 27.0% using 1 minus Kaplan-Meier. At the last available imaging examination, 610 of 615 assessable fenestrated target vessels were patent (99.2%). Secondary intervention was not statistically associated with subsequent mortality (adjusted hazard ratio, 1.11; 95% confidence interval, 0.68-1.80; P = .687). Conclusion: Secondary interventions affected approximately one quarter of patients after FEVAR, but a small subgroup accounted for a disproportionate share of the procedural burden. Most procedures were minor and endovascular, and more than half occurred beyond 1 year. No statistically significant average association with subsequent mortality was identified. Reporting both patient- and procedure-level burden may better characterize FEVAR durability and follow-up requirements. Clinical Impact Secondary interventions after fenestrated endovascular aortic repair (FEVAR) are commonly reported as the proportion of patients undergoing at least 1 procedure, which does not capture cumulative procedural burden. In this cohort of 189 patients, 48 underwent 67 secondary interventions, whereas only 9 patients, representing 4.8% of the cohort, accounted for 41.8% of all procedures. Most interventions were minor and endovascular, but more than half occurred beyond 1 year. These findings indicate that first reintervention rates alone incompletely describe FEVAR durability. Reporting both patient- and procedure-level burden may better inform patient counseling, surveillance planning, and comparisons across devices and centers by highlighting the concentration of procedures in a small subgroup.