A Multicentre Observational Cohort Study to Compare Short Term and Midterm Outcomes after Fenestrated Endovascular Aortic Repair and Open Surgical Repair in Juxtarenal and Pararenal Aortic Aneurysm: The FEORA Study

Objective: This multicentre, retrospective cohort study aimed compare fenestrated endovascular (FEVAR) with open surgical repair (OSR) for treatment of juxtarenal and pararenal aortic aneurysms (J/PAAA). Methods: Consecutive patients undergoing elective repair of J/PAAA between 2017 - 2022 in ten high volume centres across five countries were examined. Primary endpoints were midterm mortality and re-intervention. Secondary endpoints included 30 day mortality and re-intervention. Propensity score matching (PSM; 1:1) was performed to adjust for baseline differences. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were followed. Results: A total of 714 patients were included: 399 (55.9%) FEVAR and 315 (44.1%) OSR. Thirty day mortality (1.5% vs. 1.0%; p = .74) and re-interventions (9.0% vs. 6.3%; p = .21) were similar after FEVAR and OSR. Mean follow up was 26.2 months, without loss to follow up in either group. The 1, 3, and 5 year survival rates were 94.7%, 86.1%, and 71.7% after FEVAR vs. 95.6%, 90.3%, and 86.5% after OSR (p = .042). Re-intervention free survival at 1, 3, and 5 years was lower after FEVAR (89.2%, 81.4%, and 73.3% vs. 98.9%, 97.7%, and 96.3%; p < .001). Similarly, major re-intervention free survival was lower after FEVAR (96.6%, 92.3%, and 91.3% vs. 98.9%, 97.7%, and 96.3% after OSR; p = .045). FEVAR was identified as a predictor of all re-interventions (hazard ratio [HR] 4.40, 95% confidence interval [CI] 1.65 - 11.74; p = .003) but not major re-interventions (HR 2.44, 95% CI 0.98 - 6.04; p = .054) or survival (HR 1.8, 95% CI 0.92 - 3.60; p = .085) on Cox regression analysis. Cox regression analysis of the PSM cohorts confirmed similar results. Conclusion: Both FEVAR and OSR achieved excellent early outcomes for elective J/PAAAs. Although FEVAR was associated with increased overall re-interventions, it was not a predictor of major re-intervention or mortality. In adequately matched patients, overall survival, and freedom from major re-intervention appear comparable between approaches.