• Joel L Ramirez, Nicholas Govsyeyev, Rebecca Sorber, James C Iannuzzi, Andres S Schanzer, Caitlin W Hicks, Mahmoud B Malas, and Devin S Zarkowsky.
• From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky).
• J. Am. Coll. Surg. 2023 Oct 1; 237 (4): 633643633-643.

BackgroundEndovascular aneurysm repair (EVAR) is often attempted in patients with marginal anatomy. These patients' midterm outcomes are available in the Vascular Quality Initiative for analysis.Study DesignRetrospective analysis of prospectively collected data in the Vascular Quality Initiative from patients who underwent elective infrarenal EVAR between 2011 and 2018. Each EVAR was identified as either on- or off-instructions for use (IFU) based on aortic neck criteria. Multivariable logistic regression models were used to assess associations between aneurysm sac enlargement, reintervention, and type Ia endoleak with IFU status. Kaplan-Meier time-to-event models estimated reintervention, aneurysm sac enlargement, and overall survival.ResultsWe identified 5,488 patients with at least 1 follow-up recorded. Those treated off-IFU included 1,236 patients ([23%] mean follow-up 401 days) compared with 4,252 (77%) treated on-IFU (mean follow-up 406 days). There was no evidence of significant differences in crude 30-day survival (96% vs 97%; p = 0.28) or estimated 2-year survival (97% vs 97%; log-rank p = 0.28). Crude type Ia endoleak frequency was greater in patients treated off IFU (2% vs 1%; p = 0.03). Off-IFU EVAR was associated with type Ia endoleak on multivariable regression model (odds ratio 1.84 [95% CI 1.23 to 2.76]; p = 0.003). Patients treated off IFU vs on IFU experienced had increased risk of reintervention within 2 years (7% vs 5%; log-rank p = 0.02), a finding consistent with results from the Cox modeling (hazard ratio 1.38 [95% CI 1.06 to 1.81]; p = 0.02).ConclusionsPatients treated off IFU were at greater risk for type Ia endoleak and reintervention, although they had similar 2-year survival compared with those treated on IFU. Patients with anatomy outside IFU should be considered for open surgery or complex endovascular repair to reduce the probability for revision.Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

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