Complex endovascular arch repair using fenestrated and branched devices: a single-centre experience

OBJECTIVES: Endovascular arch repair is a reasonable alternative for patients at high risk for open surgery. Despite a reduction in procedural invasiveness, complications remain, particularly in elderly and urgent cases. This study aimed to evaluate our institutional experience at a high-volume aortic center. METHODS: Retrospective, single-center study of endovascular arch repair, along with subgroup analyses for urgent settings, octogenarian patients and graft design. Primary outcomes were technical success, 30-day mortality and morbidity. During follow-up, survival estimation, cumulative incidence of reintervention, endoleak and target vessels instability were evaluated. RESULTS: The study included 74 patients (mean age 72 ± 9 years) treated, between September 2018 and April 2024, with custom-made fenestrated/branched endograft. Technical success was achieved in 93.2% of the patients. Thirty-day mortality in elective setting was 5.4%, and 44.4% in urgent repairs. Major stroke occurred in 6.8% of patients. Urgent repairs showed higher rates of technical failure (22.2 vs 1.8% P < 0.01), 30-day mortality (44.4 vs 5.4%; P < 0.001) and major strokes compared to elective repairs (22.2 vs 1.8%; P < 0.01). Octogenarians had significantly higher 30-day mortality but no difference in major adverse events compared to younger patients (P < 0.01). Branched endografts had higher rates of type Ia endoleaks and reinterventions than fenestrated endografts. At 24 months, the estimated rates were as follows: survival 79% (standard error-SE 0.09), cumulative incidence of reintervention 24% (SE 0.074), endoleak 9% (SE 0.037) and target vessel instability 9% (SE 0.04). CONCLUSIONS: Endovascular arch repair is feasible and yields satisfactory outcomes in high-risk populations, particularly in elective settings. Urgent and elderly patients remain challenging, underscoring the importance of careful patient selection.