(PC008) Textbook outcomes correlate with risk-adjusted one-year mortality for branch/fenestrated aortic repair in the United States Aortic Research Consortium

Objectives: Textbook outcomes (TO) represent the ideal surgical outcome. We sought to evaluate the association of TO with one-year mortality and assess risk for failure to achieve TO in patients treated with branch/fenestrated endovascular aortic repair (BFEVAR) in the United States Aortic Research Consortium (US-ARC).

Methods: Elective BFEVAR (investigational devices manufactured by Cook Medical) patients treated for juxta-/suprarenal (pAAA) and thoracoabdominal aortic aneurysms (TAAA) at US-ARC centers from January 2011-November 2024 were included. Exclusions included patients enrolled under compassionate use, non-elective cases, and zone 0-1 proximal landing zone. A TO was defined as freedom from major complication, prolonged length of stay (LOS), in-hospital mortality, 30-day mortality or reintervention, and non-home discharge. Ideal LOS was calculated by the 75th percentile LOS for the cohort stratified by Crawford Extent (CE) and adjusted for planned adjunctive procedures. Multivariable logistic regression analysis was performed to define risk factors for failure to achieve a TO. Survival analysis was conducted using Cox regression and Kaplan-Meier methods.

Results: Among 2,897 patients, 1,374 (47.4%) achieved a TO (37.8% of CE1-3, 51.2% of CE4-5, and 54.4% of pAAA patients). One-year survival was higher for TO vs. non-TO patients (pAAA TO 94.8±2.2% vs pAAA non-TO 84.6±3.7%; CE1-3 TO 90.6±3.1% vs CE1-3 non-TO 82.7±2.9%; CE4-5 TO 94.7±2.5% vs CE4-5 non-TO 85.0±3.7%; all log-rank p< 0.001). Failure to achieve a TO demonstrated the strongest association with one-year mortality when adjusting for other covariates (HR 2.95, 95%CI 2.13-4.10, p< 0.001). Variables associated with failure to achieve a TO included: CE1-3(OR 1.50, 95%CI 1.19-1.89, p< 0.001), blood loss>350cc(OR 2.15, 95%CI 1.71-2.70, p< 0.001), preoperative spinal drain(OR1.49, 95%CI 1.19-1.86, p< 0.001), anemia(OR 1.39, 95%CI 1.13-1.70, p=0.002), chronic obstructive pulmonary disease(OR 1.35, 95%CI 1.13-1.62, p< 0.001), congestive heart failure(OR 1.30, 95%CI 1.01-1.67), and prior coronary bypass graft(OR 1.33, 95%CI 1.06-1.68, p=0.02). A risk prediction model derived from b-coefficients showed that in non-TO patients, 30-day mortality was 6.5% and 2.5% for high- and low-risk patients, respectively. Corresponding one-year mortality was 19.1% vs. 10.0%, respectively. One-year survival of risk-adjusted cohorts demonstrated significantly better survival for patients achieving a TO vs non-TO regardless of high-(Figure 1) or low-risk(Figure 2) designation.

Conclusions: Failure to achieve a TO is significantly associated with one-year risk-adjusted mortality. Since most deaths occur outside the perioperative period, non-TO patients merit closer monitoring after discharge. TOs may serve as a benchmark for optimal care delivery given association with longer-term outcomes and provide guidance for patient expectations postoperatively.