Fenestrated Endografts Provide Superior Outcomes Compared to Branched Devices in Juxtarenal Aortic Repair

Introduction Urgent endovascular juxtarenal aortic repair with custom-made fenestrated devices is not feasible due to its long elaboration time. Off-the-shelf branched devices can be used, however, durability of the target vessels, especially renal artery branches, is of concern. Our objective is to compare mid and long-term patency of target vessels (TV), especially renal arteries (RA) in juxtarenal fenestrated or branched aortic endovascular repair. Methods Single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular repair (f/bEVAR) for juxtarenal aortic aneurysms (JAA) between 2011-2022. A FEVAR group with use of fenestrations to incorporate target vessels (TV) and a BEVAR group, with use of branches were created. Clinical and anatomical characteristics as well as perioperative technical success and complications were compared. The primary endpoint was the assessment of RA primary patency, freedom from endoleaks and instability (endpoint including occlusion, endoleak or need for reintervention) at follow-up. Secondary endpoints were the assessment of CT-SMA patency rates, freedom from endoleak and instability at follow-up and the evaluation of the anatomical and clinical factors associated with renal artery bridging covered stent (BCS) occlusion. Results From 2011-2022, FEVAR was performed in 212 patients and BEVAR in 57. There were no statistical differences in demographics. The BEVAR group presented more frequently as urgencies (61% vs 11% for FEVAR p <,001). 955 TV were incorporated, including 536 RA. Technical success was 99%. BEVAR patients experienced higher perioperative death rates (14% vs 3% in FEVAR; p 0,005) and major complications (53% vs 17% in FEVAR; p <,001). Primary patency of RA in FEVAR was 99% at 3 years vs 74% for BEVAR (p < ,001). Freedom from RA BCS endoleaks were 97% at 3 years for the FEVAR group vs 87% in the BEVAR group (p <,001). Freedom from RA instability at 3 years was 95% in the FEVAR group vs 63% for the BEVAR group (p <,001). For CT-SMA only freedom from instability showed significant better outcomes at 3 years in the FEVAR group (96% vs 88% for BEVAR ; p ,006). In the multivariate analysis, the use of branches was the only factor associated with loss of patency in the RA. Conclusions In complex aortic repair for JAA, fenestrated devices achieved high patency rates while branched devices, mostly done for urgencies, are associated with significantly worse RA outcomes.