Bijan Modarai

Objective: To define contemporary medium and long term survival and durability outcomes after elective fenestrated and branched endovascular aortic repair (F/BEVAR) for complex abdominal and thoracoabdominal aneurysms and to assess the certainty of the available evidence. Data Sources: MEDLINE, Embase and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Review Methods: Published Kaplan Meier time-to-event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the GRADE framework. Results: Twenty-four studies comprising 8,886 patients were included. Pooled overall survival was 91.3% (95% CI: 90.7, 91.9) at 1 year, 73.0% (95%CI: 71.9, 74.0) at 3 years and 55.4% (95% CI: 53.9, 56.8) at 5 years. Estimated median overall survival was 6.36 years. At 5 years, freedom from aneurysm-related mortality was 96.4% (95%CI: 95.3, 97.2), freedom from reintervention was 66.5% (95%CI: 64.6, 68.2), and target vessel patency (TVP) was 94.8% (95%CI: 93.3, 96.0). Certainty of evidence was low for overall survival, aneurysm related mortality and reintervention, and very low for TVP. Conclusion: Elective F/BEVAR provides durable aneurysm exclusion with low aneurysm related mortality; however, long term survival declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair. What this paper adds: This study provides a time-to-event synthesis of medium and long term outcomes after elective F/BEVAR for complex abdominal and thoracoabdominal aortic aneurysms, analysing reconstructed survival data from 8,886 patients across 24 studies published between 2000 and 2025. This analysis provides empirical survival data to inform recent European Society for Vascular Surgery guidance, demonstrating a median survival of 6.36 years and showing that most late deaths are not aneurysm related. These findings quantify the divergence between procedural durability and long term survival, supporting an individualised treatment strategy grounded in assessment of life expectancy, competing risk and shared decision making.

Aims: To develop an in-silico model of the aorta and its spinal cord-supplying branches, and to characterise haemodynamic changes following aortic aneurysm (AA) repair with such a model. The work is motivated by the risk of spinal cord ischaemia (SCI) and paraplegia, serious complications that can arise from disruption of spinal cord perfusion during AA surgery. Methods: SimVascular was used to retrospectively create models of a 76 year old female patient's aorta pre- and post- uncomplicated endovascular AA repair. The full extent of the aorta and its branches, including vessels supplying the spinal cord, was segmented. Pulsatile flow simulations were conducted under the assumption of rigid vessel walls, with patient-specific inlet and three-element Windkessel models for the outlet boundary conditions on the SimVascular Gateway Cluster. Results: Postoperatively, segmental artery flow to the spinal cord decreased by 51.86% due to exclusion of lumbar and posterior intercostal arteries by the stent graft. Spinal cord-supplying arteries showed increased TAWSS (+5.2%) and reduced RRT and ECAP, with minimal change in OSI. Consistent with redistribution away from the spinal territory, modest postoperative flow increases were observed in non-spinal vascular beds, including the legs (+6.09%), reno-visceral vessels (+5.89%), and supra-aortic branches (+5.97%). Across vascular territories, visceral arteries had the highest TAWSS and lowest RRT and ECAP, while leg arteries had the lowest TAWSS and highest RRT and ECAP; supra-aortic vessels exhibited the highest OSI. Conclusion: This study lays a foundation for computational prediction of SCI risk. It leverages in-silico modelling, using an open-source software pipeline and routine medical imaging, to assess spinal cord blood flow alterations after aortic surgery. This may forge a path towards a clinical decision-making tool.