Outcomes and evolution of fenestrated-branched EVAR: a 10-year single-centre learning curve analysis

INTRODUCTION: Fenestrated and branched endovascular aneurysm repair (f/bEVAR) represents an advanced technique for treating aortic aneurysms that extend to or involve visceral and renal vessels. This technically demanding procedure requires specialised skills and has a steep learning curve. This study aimed to analyse a single-centre 10-year experience with F/BEVAR, focusing on the learning curve effect. METHODS: A retrospective analysis was conducted on all f/bEVAR cases performed between 2016 and the present day. Patients without follow-up were excluded. Cases were stratified by study period quartile to account for unequal case distribution over the years. Primary outcomes included technical success (defined as successful incorporation of target vessels), 30-day mortality, major adverse events (MAE), and one-year reintervention rates. Procedural characteristics and outcomes were compared across quartiles. RESULTS: A total of 53 cases were included, with a median age of 71 years, and 49 (92.5%) of the patients were male. Six (11.3%) were symptomatic aneurysms, and one patient presented with a ruptured aneurysm. Twenty-one (39.6%) cases had thoracoabdominal aneurysms, followed by juxta-renal (19 cases, 35.8%). Five patients (9.4%) had a history of aortic dissection. Six patients (11.3%) underwent arch procedures. Most cases (44 cases, 83%) had 4 target vessels incorporated. Thirty-day mortality was 11.3%, and 30-day MAE was 13.2%. When analysing by temporal quartile, the 4th study quartile demonstrated higher proportions of arch procedures, higher numbers of vessels incorporated, increased use of femoral-only access, higher implementation of fusion imaging, and lower 30-day mortality and MAE rates. A proctor was present in 34% of cases, primarily in the first 2 study quartiles. CONCLUSION: This 10-year experience with f/bEVAR demonstrates a significant learning curve effect. These findings highlight the importance of specialised training, proctorship in early experience, and the value of cumulative institutional expertise in managing complex aortic pathologies with f/bEVAR.