Physician-Modified Fenestrated Endovascular Aortic Aneurysm Repair After Failed EVAR with Type I Endoleak Offers Favorable Results Compared to Open Conversion.

OBJECTIVE: EVAR failure due to type Ia endoleak is prevalent. Conversion to open repair (EVAR-c) is associated with technical and physiologic challenges. Endovascular salvage by obtaining a more proximal seal zone with a physician-modified fenestrated/branched endovascular repair (F/BEVAR) is an alternative treatment option. There is limited data directly comparing outcomes of EVAR-c and PM-F/BEVAR. The purpose of this study was to compare outcomes of EVAR-c and PM-F/BEVAR in patients with prior EVAR with type Ia endoleak and to assess changes in our clinical management of these patients over time. METHODS: A prospective database of patients treated at a single-center with EVAR failure due to type Ia endoleak between January 2015 and November 2025 was retrospectively reviewed. The cohort was stratified by treatment strategy, either EVAR-c or PM-F/BEVAR. Demographics, operative details, postoperative complications were compared between the groups using univariate analysis. Four-year overall survival was compared using Kaplan-Meier method. RESULTS: Of the 101 patients treated for failed EVAR with type Ia endoleak, 41 underwent EVAR-c and 60 underwent PM-F/BEVAR. While both groups had similar preoperative characteristics, PM-F/BEVAR had significantly decreased 30-day mortality (n=6[15%] vs n=0[0%]; p=.004) and postoperative complications (n=14[23%] vs n=30[75%]; p<.001. There was no difference in 4-year overall survival (EVAR-c=64% vs PM-F/BEVAR=49%; p=0.71). The improved perioperative outcomes with PM-F/BEVAR was persistent when excluding urgent/emergent cases from analysis. CONCLUSIONS: Endovascular salvage of failed prior EVAR due to type Ia endoleak with PM-F/BEVAR is safe and effective with significantly better 30-day outcomes compared to EVAR-c but this survival advantage is lost over time.