Three-dimensional simulations for planning fenestrated/branched endografts in endovascular aneurysm repair for complex abdominal aortic aneurysm: a retrospective cohort study
Aug 2026· Therapeutic Advances in Cardiovascular Disease· Vol 20· 0 citations· 34 references
Medicine
TL;DR
F/B-EVAR guided by 3D simulation may allow for accurate planning of fenestration and branch positioning, potentially improving procedural success rate and suggesting a potential to enhance the quality of outcomes.
Abstract
Background: Endovascular aneurysm repair (EVAR) is used to treat patients with abdominal aortic aneurysm (AAA) who have suitable anatomy, while complex AAAs often require fenestrated and branched stent grafts, necessitating further refinement of the technique. Objective: To evaluate the safety and efficacy of fenestrated/branched EVAR (F/B-EVAR) assisted by three-dimensional (3D) printing for treating complex AAA. Design: Retrospective cohort study. Methods: This multicenter retrospective cohort study collected baseline data and clinical outcomes from patients treated with F/B-EVAR between January 2012 and June 2025. The population was divided into the 3D simulation group and the conventional measurement group. The 3D simulation group underwent a simulation to assess fenestration and branch positioning strategies. Study endpoints included procedural success rate, incidence of periprocedural complications and major adverse events, as well as procedural duration and radiation dose. Results: The mean age of patients was 70.2 ± 8.8 years, with 68.9% being male. Compared to the conventional measurement group, the 3D simulation group had a significantly higher procedural success rate (98.8% vs 91.6%, p < 0.001), shorter procedural duration ((115.2 ± 35.0) min vs (138.7 ± 43.7) min, p < 0.001), and lower radiation dose ((107.2 ± 43.9) mGy vs (144.5 ± 56.3) mGy, p < 0.001). Furthermore, although no significant differences were observed in the incidence of all-cause mortality and major cardiovascular adverse events during the 30-day follow-up between the two groups, the incidence of life-threatening major bleeding, major vascular complications, and acute kidney injury stage ⩾3 was significantly lower in the 3D simulation group. Conclusion: F/B-EVAR guided by 3D simulation may allow for accurate planning of fenestration and branch positioning, potentially improving procedural success rate and suggesting a potential to enhance the quality of outcomes.
Background The accuracy and clinical utility of patient-specific computational simulations for thoracic endovascular aortic repair (TEVAR) planning in Stanford type B aortic dissection (TBAD) patients remain insufficiently validated. Objectives This study aimed to develop and validate the safety and efficacy of a patient-specific computational simulation framework tailored for TEVAR in patients with TBAD. Methods This prospective, observational, multicenter study enrolled 153 consecutive patients with TBAD undergoing TEVAR. Patients were stratified into two groups: the simulation group (n=72) and non-simulation group (n=81). For the simulation cohort, personalized three-dimensional models of the stent frame and covered graft were constructed based on preprocedural computed tomography angiography, followed by computational simulation. The predictive performance of the simulation was evaluated by comparing simulated hemodynamic parameters with postprocedural measurements. The primary endpoint was the procedural success rate. Results The overall cohort had an average age of 67.1 ± 9.1 years, with 66.0% being male. The simulation group showed a higher procedural success rate (100.0% vs. 95.1%, P = 0.042), lower rates of endoleak (0% vs. 9.9%, P = 0.007) and stent-related rupture (0% vs. 4.9%, P = 0.002), and a lower complete false lumen thrombosis rate (61.1% vs. 79.0%, P = 0.015) compared to the non-simulation group. Notably, postprocedural hemodynamic metrics (including maximum pressure gradient, peak velocity, and wall shear stress) were significantly improved in the simulation group (all P < 0.001). Conclusions Patient-specific computational simulation of TEVAR was associated with postprocedural hemodynamic profiles that closely matched simulated predictions, and showed favorable periprocedural trends and potential utility in optimizing pre-TEVAR planning. These findings are preliminary and require validation in randomized controlled settings.
Xin-Bo Liu, Haibo Yang, Lei Yang et al.· Frontiers in Cardiovascular...· 0 citations
OBJECTIVE
This study evaluated the association between sac regression at one year and long-term outcomes after fenestrated and branched endovascular aortic repair (f/bEVAR) for thoracoabdominal aortic aneurysm (TAAA).
METHODS
A retrospective single-center cohort study was conducted of patients who underwent f/bEVAR for TAAA between April 2006 and March 2025 and had computed tomography angiography at one year. Sac diameter change was categorized as regression (≥5 mm decrease), stable (+/- 5 mm change), or growth (≥5 mm increase). Stable and growth were combined as failure to regress. The primary outcome was all-cause mortality. Secondary outcomes included late type I/III endoleaks and late reintervention. Kaplan-Meier analysis and Cox models were used.
RESULTS
Sixty-eight patients met inclusion criteria. Sac regression one year after f/bEVAR occurred in 24 patients (35.3%), whereas 44 (64.7%) demonstrated failure to regress (35 stable, 51.5%; nine growths, 13.2%). Median age was 67.5 years (IQR 65.0 - 74.8) and 74.0 years (IQR 68.0 - 76.8), and 12 (50.0%) and 32 (72.7%) patients were male, for the aneurysm regression and failure to regress groups, respectively. During a median follow-up of 56.5 months, overall mortality was 55.9% (38 patients). In a univariable model, failure to regress was significantly associated with higher all-cause mortality (HR 2.78, 95% CI 1.33-5.81; p=.007). This association was confirmed in multivariable analysis (HR 2.55, 95% CI 1.14-5.71; p=.023). Although there was no association between failure to regress and late type I or III endoleak (HR 1.50, 95% CI 0.48-4.64: p=.48), the need for late reintervention was higher for patients with failure to regress (HR 3.03, 95% CI 1.09-8.37; p=.033). Notably, all late reinterventions were percutaneous (5 main body relinings/extensions; 14 bridging-stent related; 2 coiling procedures) and did not increase mortality risk (HR 0.95, 95% CI 0.48-1.90; p=.89).
CONCLUSIONS
Aneurysm sac failure to regress at one year after f/bEVAR for TAAA is associated with worse long-term survival and increased reintervention rate. The predictive value of aneurysm sac dynamics at 1 year CTA, for adverse outcomes highlights its potential for risk stratification and guiding patient specific treatment regimen.
E. W. Huistra, I. Tielliu, B. Gareb et al.· Annals of Vascular Surgery· 0 citations
This study aimed to perform hemodynamic simulations using patient-specific models of abdominal aortic aneurysms (AAA) following endovascular aneurysm repair (EVAR) to investigate the association between energy loss (EL) and Type I endoleak.
Pre- and post-EVAR models were reconstructed from computed tomography angiography (CTA) for four patients with Type I endoleak and four without. Component quantification of EL, along with wall shear stress (WSS)-related hemodynamic parameters, were employed to evaluate the potential of endoleak.
Endoleaks following EVAR tended to occur at the junction of stent grafts, where high time-averaged wall shear stress (TAWSS), high turbulence EL, and high mean flow EL were observed. The turbulence EL values for the main stents, left iliac branch stents, and right iliac branch stents in the endoleak group were 516 ± 183*10
−6
W, 828 ± 195*10
−6
W, and 609 ± 193*10
−6
W, respectively, and the mean flow EL for those regions were 363 ± 125*10
−6
W, 631 ± 138*10
−6
W, and 352 ± 162*10
−6
W, respectively. Compared with the no endoleak group, the endoleak group exhibited significantly higher turbulence EL and mean flow EL at the iliac branch and main stent, whereas no significant difference in TAWSS was found.
Component quantification of EL demonstrated preliminary feasibility for evaluating Type I endoleak in patients with EVAR for AAA, demonstrating greater advantages over WSS-related hemodynamic parameters. This method may provide valuable support for clinicians in assessing surgical prognosis.
Ran Tao, Qiming Liu, Weihao Guo et al.· Frontiers in Cardiovascular...· 0 citations
OBJECTIVE
EVAR failure due to type Ia endoleak is prevalent. Conversion to open repair (EVAR-c) is associated with technical and physiologic challenges. Endovascular salvage by obtaining a more proximal seal zone with a physician-modified fenestrated/branched endovascular repair (F/BEVAR) is an alternative treatment option. There is limited data directly comparing outcomes of EVAR-c and PM-F/BEVAR. The purpose of this study was to compare outcomes of EVAR-c and PM-F/BEVAR in patients with prior EVAR with type Ia endoleak and to assess changes in our clinical management of these patients over time.
METHODS
A prospective database of patients treated at a single-center with EVAR failure due to type Ia endoleak between January 2015 and November 2025 was retrospectively reviewed. The cohort was stratified by treatment strategy, either EVAR-c or PM-F/BEVAR. Demographics, operative details, postoperative complications were compared between the groups using univariate analysis. Four-year overall survival was compared using Kaplan-Meier method.
RESULTS
Of the 101 patients treated for failed EVAR with type Ia endoleak, 41 underwent EVAR-c and 60 underwent PM-F/BEVAR. While both groups had similar preoperative characteristics, PM-F/BEVAR had significantly decreased 30-day mortality (n=6[15%] vs n=0[0%]; p=.004) and postoperative complications (n=14[23%] vs n=30[75%]; p<.001. There was no difference in 4-year overall survival (EVAR-c=64% vs PM-F/BEVAR=49%; p=0.71). The improved perioperative outcomes with PM-F/BEVAR was persistent when excluding urgent/emergent cases from analysis.
CONCLUSIONS
Endovascular salvage of failed prior EVAR due to type Ia endoleak with PM-F/BEVAR is safe and effective with significantly better 30-day outcomes compared to EVAR-c but this survival advantage is lost over time.
Jay P. Natarajan, Trung Nguyen, Shivam Patel et al.· Annals of Vascular Surgery· 0 citations
To develop a patient-specific static and dynamic 3D-printing workflow for preoperative planning of endovascular repair in complex aortic disease with physician-modified stent grafts, to assess the respective roles of rigid anatomical and dynamic models, and to explore its association with intraoperative efficiency compared with conventional image-based planning. This retrospective study included 46 consecutive patients with complex aortic disease encompassing various segments between the aortic arch and the abdominal aorta, who underwent endovascular repair with physician-modified stent grafts. Patients were assigned to a 3D printing-guided group (n = 22) or a conventional image-guided group (n = 24) based on the preoperative planning strategy. In the 3D printing group, patient-specific 1:1 rigid anatomical models and compliant dynamic models were generated from computed tomography angiography data. Rigid models were used for anatomical visualization, device sizing, and fenestration planning. Dynamic models, fabricated using silicone material (Shore hardness 10A) and integrated into a pulsatile flow system, were used to simulate device passage, deployment, and device–vessel interaction under physiological flow conditions. Model accuracy was evaluated by surface deviation analysis, and dynamic model performance was evaluated by Doppler-based flow comparison with in vivo measurements. The two groups were compared regarding operative time, radiation dose, contrast volume, perioperative complications, and short-term outcomes. Rigid anatomical models demonstrated high geometric fidelity, with over 97% of surface deviations within 0.2 mm compared with CTA data. Dynamic models showed close agreement with in vivo hemodynamics, with comparable peak systolic velocities at the inlet (1.48 ± 0.20 m/s vs. 1.52 ± 0.18 m/s, p = 0.274), aneurysmal segment (1.20 ± 0.18 m/s vs. 1.25 ± 0.15 m/s, p = 0.312), and outlet (1.35 ± 0.17 m/s vs. 1.38 ± 0.16 m/s, p = 0.401). In the 3D printing-guided group, simulation findings were concordant with intraoperative findings in 21 of 22 cases. Compared with rigid static models, dynamic models provided additional planning information in anatomically challenging cases, including severe angulation of arch or neck, severe luminal stenosis or true lumen collapse, target vessels arise from the aneurysm sac, complex target vessel proximal segment and severe access tortuosity. In the exploratory clinical comparison, the 3D-printing-guided group had significantly shorter operative time (133.6 ± 43.3 min vs. 171.4 ± 72.1 min, p = 0.039) and lower contrast volume (181.7 ± 68.6 mL vs. 234.9 ± 101.0 mL, p = 0.044) than the conventional image-guided group. The need for intraoperative device adjustment did not differ significantly between groups. No major adverse events occurred within 30 days in either group. A patient-specific dual-model 3D printing workflow combining rigid anatomical models and dynamic models is feasible for planning endovascular repair of complex aortic disease with physician-modified stent grafts. The dynamic model provides complementary information beyond static anatomical assessment, particularly in anatomically complex cases requiring simulation of device–vessel interaction. The observed reductions in operative time and contrast use suggest potential intraoperative benefits.
Qincheng Gong, Yuan-ting Yang, Hongping Deng et al.· CVIR Endovascular· 0 citations
Intracranial aneurysms (IAs) are increasingly managed with endovascular techniques, with stent-assisted coiling offering superior outcomes for complex morphologies. The Neuroform Atlas (laser‑cut, open‑cell) and Leo Baby (braided, closed‑cell) are low‑profile stents deployable through small microcatheters, improving navigability in tortuous vasculature. However, direct comparative data on their relative efficacy and safety remains scarce. This retrospective study compares embolization outcomes and procedure‑related complications between the two devices. A total of 96 patients with IAs treated with stent-assisted coiling between January 2022 and December 2023 were enrolled: 46 received Atlas and 50 received Leo Baby. Baseline demographic and aneurysm characteristics were comparable between groups. Immediate post‑procedural angiography demonstrated similar complete occlusion rates (Atlas 89.1% vs. Leo Baby 88.0%; P = 0.3281), and no significant difference was found in Raymond grade distribution at 6‑month follow‑up (P = 0.5067). Favorable outcomes (modified Rankin Scale score 0-2) at 1 year were achieved in >90% of patients in both cohorts (P = 0.1528). Peri-procedural complications showed no statistically significant difference between the two groups (28.2% vs. 12.0%; P = 0.0857); however, post-hoc power analysis revealed that the current sample size provided only 42% power to detect this observed difference, indicating a high risk of Type II error. In conclusion, these findings suggested that both Atlas and Leo Baby stents afford similar angiographic and clinical efficacy for IA embolization; however, the numerically higher complication rate observed with the Atlas stent should be interpreted with caution due to insufficient statistical power, and our results should be considered hypothesis-generating rather than confirmatory. Further largescale, prospective multicenter studies are warranted to confirm these observations and refine device selection in clinical practice.
Hao Zhu, Jia-jia Xu, Yang Wang et al.· Journal of Visualized Experi...· 0 citations
We use cookies to run the site and, with your consent, for analytics and to show ads.
See our Cookie Policy.
