Global Multi-Center Outcomes of Fenestrated and Branched Endovascular Aortic Repair

Objectives: Complex aortic aneurysms involving visceral vessels pose prohibitive surgical risk, driving rapid adoption of fenestrated and branched endovascular aortic repair (F/BEVAR) as a less invasive alternative. Outcomes remain highly variable across single-center experiences, and robust pooled benchmarks are lacking. We performed a systematic review and meta-analysis to establish pooled estimates of technical success, perioperative mortality, complications, endoleaks, and target vessel outcomes after F/BEVAR. Methods: A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science identified 44 studies (2014-2024) reporting F/BEVAR outcomes. Patient demographics, comorbidities, procedural characteristics, and clinical outcomes were extracted. Pooled event rates were calculated using random-effects methodology with 95% confidence intervals (CI) by Wilson score method. Statistical heterogeneity was assessed and funnel plot analysis performed to evaluate publication bias. Results: A total of 6,137 patients (mean age 72.4 ± 1.9 years; 74.4% male) underwent F/BEVAR. Mean aneurysm diameter was 63.3 ± 3.9 mm. Comorbidity burden was substantial: hypertension (87.8%), smoking history (72.7%), coronary artery disease (44.9%), chronic obstructive pulmonary disease (36.4%), chronic kidney disease (32.5%), and diabetes mellitus (14.2%). Technical success was achieved in 96.6% (95% CI: 95.6-97.6%). Thirty-day mortality was 3.40% (95% CI: 2.94-3.93%). Overall endoleak rate was 15.1% (95% CI: 14.2-16.2%), comprising Type I (4.3%; 95% CI: 3.7-4.9%), Type II (11.0%; 95% CI: 9.9-12.2%), and Type III (4.3%; 95% CI: 3.7-5.0%). Target vessel stenosis occurred in 6.0% (95% CI: 5.2-6.8%) and occlusion in 5.6% (95% CI: 4.8-6.5%), with patency maintained in >94% of cases. Stent instability was observed in 17.5% (95% CI: 16.3-18.7%) and reintervention required in 17.6% (95% CI: 16.4-18.8%). Major early complications included renal dysfunction or dialysis (7.1%; 95% CI: 6.4-7.7%), ischemic events (6.4%; 95% CI: 5.9-7.1%), cardiac complications (3.7%; 95% CI: 3.3-4.2%), respiratory complications (3.5%; 95% CI: 3.0-4.0%), spinal cord ischemia (2.2%; 95% CI: 1.9-2.6%), and stroke (0.7%; 95% CI: 0.5-0.9%). Mean length of stay was 7.6 ± 3.3 days. Conclusion: This largest meta-analysis of F/BEVAR to date demonstrates excellent technical success and acceptable perioperative mortality in a high-risk, comorbidity-laden population. Cardiac and renal complications remain clinically significant given the high prevalence of coronary artery disease and chronic kidney disease in this cohort. While endoleak and reintervention rates warrant surveillance, target vessel patency exceeding 94% is reassuring. This pooled data provides the most comprehensive benchmark available for patient counseling, quality assessment, and future comparison with open surgical repair.