Technical Feasibility and Outcomes of t-Branch Proximal Shortening in Urgent Complex Aortic Repair

INTRODUCTION: Branched endovascular repair has shown consistently good outcomes, being sometimes the only available endovascular solution for aortic emergencies. However, in cases of limited proximal extension of the disease, such as juxtarenal or pararenal aneurysms, branched endografts usually cover a greater extent of the aorta than needed to establish a seal zone, thus increasing the risk for spinal cord ischemia (SCI) by unnecessarily covering segmental arteries.Our objective is to analyze a series of patients who underwent proximal shortening of an off-the-shelf (OTS) branched endograft to limit aortic coverage and preserve segmental arteries. METHODS: Single-center retrospective study identifying all patients undergoing branched endovascular aortic repair (BEVAR) with a shortened t-Branch, through the removal of the first stent row, from April 2020 to March 2026.Perioperative technical success and complications were evaluated. Primary endpoints were technical success. Secondary endpoints were 30-day mortality, SCI, assessment of number of saved segmental arteries, and endograft migration at follow-up. RESULTS: Fifteen patients underwent BEVAR with a shortened t-Branch endograft. All were urgencies, 60% being ruptured abdominal aortic aneurysms (AAAs). Thirteen (86%) cases were juxta/pararenal aortic aneurysms, and 3 (20%) had a previous endovascular aortic repair. In all cases, the proximal sealing stent of the t-Branch was removed, whereas in 2 cases, an additional large posterior fenestration at the second sealing stent was created. Technical success was 93%, with 1 severely stenotic renal artery not able to be catheterized and left unbridged. No endograft deployment complication (migration or malrotation) were experienced. There was 1 postoperative mortality in a patient with a ruptured AAA. Major complication rate was 27%, including 2 patients having SCI (one grade 2, one grade 3). A median of 2 segmental arteries were saved through the endograft modification.At a median follow-up of 1 year no endograft migration was observed. CONCLUSIONS: In urgent complex aortic repair for circumscribed anatomies such as juxta/pararenal aneurysms, the use of a modified OTS branched endograft proved to be a reproducible and safe technique, allowing the preservation of segmental arteries and possibly affecting favorably the spinal cord ischemic rates.Clinical ImpactOn-table shortening of the t-Branch endograft, optionally creating a big fenestration at the second sealing stent, is a feasible and reproducible option for urgent juxta/pararenal aortic aneurysm repair when custom-made devices are not available. The modification allowed sparing a median of two segmental arteries otherwise covered with a standard t-Branch, which might help mitigating the risk of spinal cord ischemia.