Secondary interventions after fenestrated/branched aneurysm repairs are common and nondetrimental to long-term survival

Objective: Secondary interventions are common after endovascular repair of aortic aneurysms. However, the frequency and procedural details of secondary interventions after fenestrated or branched endovascular abdominal aortic aneurysm repair (F/BEVAR) have been less well described, and the effects on long-term survival and aneurysm-related mortality are unknown. Methods: Consecutive patients enrolled as a part of a multicenter research consortium in nine independent physician-sponsored investigational device exemption studies from 2005 to 2020 were evaluated. All secondary interventions performed after the initial procedure were classified as open or percutaneous and as major or minor in accordance with the Society for Vascular Surgery reporting standards. Secondary interventions were further classified as high or low magnitude according to the physiologic effects of the intervention. The demographics, procedural details, and perioperative outcomes were compared between those who had and those who had not undergone secondary interventions. Kaplan-Meier and Cox proportional hazard ratio (HR) analysis were used to evaluate long-term survival. Results: Of 1681 patients who had undergone F/BEVAR, 385 (23%) had required a secondary intervention at any point during follow-up. Freedom from reintervention was 82% at 1 year and 59% at 5 years of follow-up. The mean follow-up period was 23 months. Most secondary interventions were percutaneous (84%), minor (70%), and of low magnitude (81%). Renal stenting (30%) and access-related procedures (24%) were the most frequent percutaneous and open procedures, respectively. High magnitude operations were required for 19% of the patients. Technical success was achieved for 94% of the secondary interventions, and mortality from the secondary interventions was <1%. Secondary interventions as a whole were associated with improved long-term survival (HR, 0.6; 95% confidence interval [CI], 0.5-0.7). In the subgroup analysis, major (HR, 0.6; 95% CI, 0.4-0.8), minor (HR, 0.6; 95% CI, 0.5-0.8), low magnitude (HR, 0.5; 95% CI, 0.4-0.7), and percutaneous (HR, 0.6; 95% CI, 0.5-0.7) secondary interventions were associated with improved survival. However, high magnitude (HR, 1.0; 95% CI, 0.7-1.5) and open (HR, 1.0; 95% CI, 0.7-1.5) secondary interventions were not. Similarly, when aneurysm-related survival was specifically assessed, low magnitude secondary interventions were found to improve survival (HR, 0.3; 95% CI, 0.1-0.7), and high magnitude secondary interventions (HR, 2.8; 95% CI, 1.4-5.8) and open secondary interventions (HR, 2.7; 95% CI, 1.3-5.5) were associated with increased mortality. Conclusions: Secondary interventions after F/BEVAR were frequent and were typically percutaneous, minor, and low magnitude procedures. Although uncommon, high magnitude and open secondary interventions were associated with decreased long-term survival and increased aneurysm-related mortality. These data highlight the importance of close, lifelong surveillance and suggest that a significant rate of secondary intervention should be anticipated but that these will not negatively affect survival.