Comparison of EndoSuture vs fenestrated aortic aneurysm repair in treatment of abdominal aortic aneurysms with unfavorable neck anatomy

Background: Hostile aortic neck anatomy is associated with loss of proximal seal and increased late reinterventions. Although both EndoSuture aneurysm repair (ESAR) and fenestrated endovascular aortic repair (FEVAR) are commercially available options for treatment of short neck aneurysms, branch vessel patency is a potential tradeoff for improved seal with FEVAR owing to the incorporation of renovisceral vessels. This study compares the performance of ESAR vs FEVAR in hostile aortic necks. Methods: Patients who underwent elective ESAR or FEVAR for hostile neck AAAs at a single center from 2012 to 2024 were reviewed retrospectively. Exclusion criteria included pararenal or thoracoabdominal aortic aneurysm, off-label modifications, and nonstandard FEVAR configurations. Propensity matching weights were generated based on age, year of operation, preoperative estimated glomerular filtration rate, neck length, neck diameter, and infrarenal angulation. Rates of survival, reintervention, dialysis, chronic kidney disease stage progression, type IA endoleak (EL), and sac regression (>5 mm) were assessed at latest follow-up. Results: Of 391 patients, 60 with ESAR and 207 with FEVAR were included. FEVAR patients were younger (74.4 years vs 79.8 years; P < .001) with larger neck diameters (25.0 mm vs 23.6 mm; P = .016), shorter neck length (5.0 mm vs 9.8 mm; P < .001), and decreased infrarenal angulation (20 degrees vs 40 degrees; P < .001). After propensity score-adjusted regression (58 ESAR, 169 FEVAR), FEVAR, compared with ESAR, was associated with decreased IA EL (hazard ratio, 0.341; 95% confidence interval [CI], 0.061-0.72; P = .031) and increased sac regression (hazard ratio, 3.92; 95% CI, 1.25-5.14; P = .02). Notably, FEVAR was associated with increased 1-year aneurysm-related reintervention (odds ratio, 4.33; 95% CI, 1.12-10.54; P = .046). On Kaplan-Meier analysis, FEVAR was associated with reduced freedom from reinterventions at 3 years (71.8% [95% CI, 0.630.78] vs 93.5% [95% CI, 0.80-0.97]; log-rank P = .019) but a trend toward improved survival at 3 years (79.15% [95% CI, 0.700.85] vs 61.5% [95% CI, 0.44-0.74]; log-rank P = .095). There was no significant difference in new-onset chronic dialysis between ESAR and FEVAR at 3 years (94.2% [95% CI, 0.82-0.98] vs 97.4% [95% CI, 0.93-0.99]; log-rank P = .124). Conclusions: In the treatment of abdominal aortic aneurysms with hostile neck anatomy in this propensity-matched cohort, FEVAR was associated with fewer type IA ELs and greater sac regression compared with ESAR, with no detrimental impact on long-term renal function. There were more reinterventions, mostly branch related, in the FEVAR group. We await the results of the current randomized prospective trial comparing these strategies to further determine the impact of these clinical differences on aneurysm-related mortality. (J Vasc Surg 2025;81:856-65.)