Use of Fenestrated/Branched Devices for Rescue of Proximal Endograft Failure After Endovascular Aneurysm Repair: A Systematic Review of the Literature and an Updated Meta-Analysis

Abstract

Objective:

To present the current outcomes of fenestrated and branched endovascular aneurysm repair (F/BEVAR) for rescue of proximal endograft failure after endovascular aneurysm repair (EVAR). A systematic review of the currently published literature on F/BEVAR for failed EVAR is undertaken, and the eligible studies are combined into a meta-analysis with the intention of evaluating the safety, efficacy, and the durability of this treatment option.

Materials and Methods:

A systematic review of the literature up to September 2024 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (CRD42024590847). Studies were included in the meta-analysis if they reported ≥10 patients and at least one of the major outcomes was stated. Primary endpoint was technical success (efficacy). Secondary endpoints included 30-day/in-hospital mortality and morbidity (safety) and survival and reinterventions rate (durability). Methodological quality and robustness of the results of the eligible articles were assessed according to Joanna Briggs Institute (JBI’s) critical appraisal tool.

Results:

A total of 16 studies with overall 1079 patients were included. The pooled estimate for technical success was 94.4% (95% CI 92.5–95.8), whereas for the 30-day/in-hospital mortality 3.9% (95% CI 2.9–5.4). Permanent paraplegia was developed in a pooled rate of 1.6% (95% CI 0.8–3.0), whereas a cerebrovascular event in a pooled rate of 1.5% (95% CI 0.9–2.8). An acute renal function impairment requiring new onset dialysis occurred with a pooled rate of 4.4% (95% CI 3.2–6.1). Postoperative respiratory failure was observed with a pooled estimate of 7.2% (95% CI 5.5–9.4). The pooled estimate for 12-month overall survival was 88% (95% CI 83.4–91.4), and the pooled estimate for 24- and 36-month survival were 79.8% (95% CI 75.6–83.4) and 72.2% (95% CI 66.7–77.2), respectively. Freedom from reintervention was estimated at 83.7% (95% CI 79.9–86.9) for 12 months, 75.8% (95% CI 61.0–86.2) for 24 months and 59.3% (95% CI 36.5–78.7) for 36 months.

Conclusion:

This study showed that F/BEVAR is a feasible, safe, and reliable strategy for achieving proper proximal endograft sealing when previous EVAR has failed. The midterm survival of these patients is acceptable, whereas reinterventions are not negligible.

Clinical Impact

This work summarizes the current experience with fenestrated and branched endovascular aneurysm repair for the rescue of failed endovascular aneurysm repair in the most contemporary meta-analysis including 16 studies with a total of 1079 analyzed patients. Feasibility of the method is proven with a technical success of 94.4%, whereas a 30-day/in-hospital mortality of 3.9% was recorded. The compromised survival and freedom from reinterventions rates (72.2% and 59.3% for 36 months, respectively) pose, however, concerns regarding durability of the method.