(IP063) Physician modified endografts compared to custom-made commercial devices for juxtarenal abdominal aortic aneurysms in the Vascular Quality Initiative

Objectives: Endovascular repair of juxtarenal AAA using fenestrated/branched endografts (F/BEVAR) has become increasingly popular given the expansion of commercially available repair options. As such, few studies have compared the use of physician modified endografts (PMEG) to custom-made commercial devices (CCMD).

Methods: We included patients who underwent elective primary F/BEVAR in the VQI from 2013-2024 for proximal aneurysm extent in zone 9. We compared rates of perioperative mortality, complications, and long-term mortality stratified by repair type (PMEG vs CCMD) using univariate analyses as well as inverse probability of treatment weighting (IPTW) to adjust for demographics, comorbidities, and aneurysm characteristics.

Results: We identified 994 patients undergoing F/BEVAR (N=248[25%] PMEG), increasing from 18% in 2015 to 55% in 2024. Compared to patients receiving CCMD, patients receiving PMEGs were more likely older (76, IQR:[71-81] vs 74 IQR:[68-79]years), non-white (15% vs 10%), have COPD (45% vs 38%), and eGFR < 45ml/1.72m2 (25% vs 17%)(all p≤0.05). Furthermore, PMEGs were associated with larger aneurysm diameters (62[56-70] vs 58[54-64]mm), higher seal zones (5[5-6] vs 7[7-7]) and more branch involvement (celiac, SMA, right renal arteries)(all p≤0.05). PMEGs were associated with higher contrast use (110[75-145] vs 103[75-138]ml) and arm/neck access rates (18% vs 4%), as well as longer procedure (225[173-284] vs 177[75-138]min) and fluoroscopy time (59[42-77] vs 48[34-66]min)(all p< 0.05). Following IPTW, there were no differences in rates of perioperative death or any complication (Table I). PMEG was associated with higher rates of perioperative stroke (1.6% vs 0.1%) and post-operative temporary dialysis (3.3% vs 0.6) (all p< 0.05). Five-year mortality between PMEG (16%) and CCMD (12%) was similar, a finding that remained after adjustment (Fig 1).

When excluding patients with arm/neck access, dialysis rates(1.1% vs 0.6%) were similar (p>0.05) and the association of PMEGs with higher rates of stroke weakened (1.1% vs 0.1%, p=0.04)(Table I).

Conclusions: Compared to CCMD, F/BEVAR with PMEGs are associated with more complex, longer repairs in more comorbid patients. Although PMEGs and CCMDs have similar perioperative and 5-year mortality, PMEGs were associated with higher rates of stroke and dialysis. However, these seem to be driven by higher rates of arm/neck access in PMEGs, suggesting arm/neck access should be avoided when possible. These data illustrate the importance in pre-operative risk stratification and patient selection in patients undergoing F/BEVAR. Future studies should examine long-term outcomes of temporary dialysis patients, patency of bridging stents, and future need for more proximal reintervention.