Predictors of failure to rescue after fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms

Objective: Failure to rescue (FTR), defined as mortality due to failure in responding to in-hospital complications, is an important quality indicator. This study aimed to assess incidence and predictors for FTR among centers performing fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms (TAAA). Methods: Consecutive patients treated by FB-EVAR for TAAAs between 2005 and 2022 in 27 centers of the International Multicenter Aortic Research Group were analyzed. Data were obtained from the United States Aortic Research Consortium which contains prospectively collected data of physician-sponsored investigational device exemption studies from 10 centers, and retrospective center data from Europe and New Zealand. FTR was defined as in-hospital mortality following ≥1 major adverse event (MAE). Primary endpoints were rates of postoperative major adverse events (MAE) including major cardiac (myocardial infarction, cardiovascular collapse, acute congestive heart failure) and respiratory events, major stroke, paraplegia, acute kidney injury (AKI) and bowel ischemia requiring surgical resection or escalation of care and FTR. Multivariate analysis was performed to identify predictors for MAEs and FTR. Results: There were 3,634 patients (68% males; mean age 71±9 years-old) treated by FB-EVAR for TAAAs. Technical success was achieved in 94% with 5% in-hospital mortality. Median incidences of MAEs and FTR were 27% (IQR, 18-33%) and 15% (IQR, 6-21%). There was a significantly (33% vs 20%, p<.001) higher rate of MAEs among centers with annual volume below the median (11 cases). Independent predictors for MAEs included age (OR 1.01, 95% CI 1.00-1.02, p=.02), chronic kidney disease (OR 1.88, 95% CI 1.54-2.29, p=<.001), ASA class ≥ 3 (OR 1.70, 95% CI 1.21 - 2.38, p=.002), previous aortic repair (OR 0.74, 95% CI 0.60-0.91, p=.004), symptomatic/ruptured (OR 1.76, 95% CI 1.36-2.28, p<.001), extent I-III TAAA (OR 2.28, 95% CI 1.75-2.97, p<.001) and lower annual volume (<11 cases/year, OR 1.83, 95% CI 1.40-2.38, p<.001). Symptomatic/ruptured TAAA was an independent predictor for FTR (OR 2.99, 95% CI 1.62-5.52, p<.001). Conclusions: FB-EVAR was performed with low in-hospital mortality. Lower volume centers had higher rates of MAEs, but center volume was not related to FTR. Symptomatic/ruptured TAAAs were independently predictive of FTR.