Low-profile endografts are associated with increased risk of type I/III endoleaks at midterm follow-up of 1220 physician-modified fenestrated, branched endovascular repairs for complex abdominal and thoracoabdominal aortic aneurysms

Objective: Physician-modified endografts (PMEGs) are widely used for complex abdominal and thoracoabdominal aortic repairs, offering versatility in patient-specific stent graft configurations. Low-profile (LP) endografts improve deliverability and decrease access site complications compared with standard-profile (SP) devices. However, concerns have been raised about the long-term durability of certain LP devices. Although LP devices have been incorporated into PMEGs at many centers, data on their impact on outcomes are limited. Therefore, this study compared outcomes of LP and SP endografts used with PMEGs using an international multicenter database. Methods: A retrospective analysis of data on patients who received PMEGs at 19 international centers from 2009 to 2022 was conducted. Patients were grouped by LP or SP aortic endografts used for modification. Baseline patient characteristics, aortic pathologies, modification techniques, and outcomes were compared. Primary outcomes included technical success, 30-day mortality, and type I and III endoleaks. The secondary outcomes were major adverse events, access site complications, all-cause and aneurysm-related mortality, and target vessel instability during follow-up. Results: Among 1220 patients included (393 LP, 827 SP), the LP group was older and had higher rates of congestive heart failure, any history of smoking, and an American Society of Anesthesiologists risk score of ≥3. LP devices were more commonly used in elective cases; with short neck aneurysms, postdissection aneurysms, and prior endovascular repairs; and during the latter one-half of the study period. Reinforced fenestration was the most common modification in both groups, with directional branches and preloaded components more common in the LP groups. The LP group required fewer access conduits and a lower radiation dose. There was no difference in technical success (92.5 LP vs 94.5% SP; P = .19), mortality (4.1 LP vs 6.8% LP; P = .06), major adverse events (23.1 LP vs 25.7% SP; P = .38), and access-site complications (8.1 LP vs 11.7% SP; P = .06) at 30 days as well as all-cause and aneurysm-related mortality and target vessel instability during follow-up. However, at a median follow-up of 20 months, significantly more type I or III endoleaks (23% LP vs 13% SP; P < .001) were seen in the LP group. Furthermore, the estimated 2-year branch-related endoleaks (type Ic, IIIc) were higher (hazard ratio, 1.65; P = .014) in the LP group. Conclusions: The use of LP devices facilitated safe PMEG repair with a lesser need for access conduit. However, the higher rates of type I, type III, and branch-related endoleaks with LP devices raise concerns about their long-term durability; however, more study is required. Based on these data, the use of LP devices for PMEGs should be approached with caution.