OBJECTIVE:To report peri-operative and midterm outcomes following open surgical, endovascular, and hybrid revascularisation for acute lower limb ischaemia (ALLI) using contemporary techniques and to provide adjusted comparative analyses accounting for key baseline differences. METHODS:This was a multicentre, retrospective study including patients treated for ALLI (January 2016 - November 2024) across 20 international vascular centres. Patients underwent open surgery (55.8%), endovascular treatment (20.2%), or hybrid procedures (24%). Primary outcome was major amputation and or death at the latest follow up. Secondary outcomes included peri-operative death, amputation, acute kidney injury, and re-intervention. Multivariable Cox regression analyses adjusted for age, sex, Rutherford stage, and chronic kidney disease were performed. A Fine-Gray competing risk model accounted for death as a competing event for major amputation. RESULTS:From 19 European centres and one centre in New Zealand, 1 259 patients (55.4% men; mean age 72 ± 14 years; no popliteal aneurysms) were included. At 30 days, the peri-operative mortality rate was 11.2% (open 12.3%, endovascular 3.1%, hybrid 7.4%; p = .042), and major amputation occurred in 9% (open 10.1%, endovascular 8.3%, hybrid 7.2%; p = .41). Median follow up was 36 months (range 8 - 49 months). At three years, the estimated mortality rate was 22.9% (standard error [SE] 1.5%) after open, 11.5% (SE 1.9%) after endovascular, and 19.6% (SE 2.2%) after hybrid procedures. Adjusted analyses demonstrated that endovascular treatment was associated with a lower risk of the composite outcome of major amputation and or death compared with open surgery (hazard ratio 0.69, 95% confidence interval [CI] 0.53 - 0.89; p = .005). For major amputation, the Fine-Gray competing risk analysis showed a reduced subdistribution hazard with endovascular treatment (subdistribution hazard ratio 0.71, 95% CI 0.33 - 0.99; p = .006). CONCLUSION:Endovascular ALLI intervention was associated with lower long term amputation risk compared with open surgery, with comparable survival. These findings support endovascular treatment as a safe alternative in patients with ALLI.

Although endovascular repair is preferred over open techniques for chronic dissection-related thoracoabdominal aneurysms, specific adjunctive maneuvers are frequently required to optimize the distal landing zone of the thoracic endovascular aortic repair (TEVAR) or to enlarge the narrowed true lumen to deploy a branched endograft. Recently, transcatheter endovascular septotomy (TES) has gained attention as an evolving minimally invasive technique to optimize complex TEVAR procedures creating a better apposition of the endograft to the native aortic wall with the primary aim to block the retrograde perfusion of the false lumen. Initial results have been described satisfactory, but not negligible rates of intraprocedural complications in the form of lamella prolapse/migration leading to branch vessels occlusion have been described too. Herein we describe a complication that occurred after TEVAR with TES, causing static malperfusion of the reno-visceral vessels.

INTRODUCTION:Intravascular ultrasound (IVUS) provides cross-sectional information on the intraluminal features of blood vessels, aiding procedural planning and postprocedural assessment of results. Although the use of IVUS in aortic procedures is increasing worldwide, consensus on best practices in aortoiliac interventions is still lacking. This study aims to obtain experts' consensus and define recommendations regarding applications of intravascular ultrasound in aortoiliac endovascular interventionsMethods:Delphi consensus methodology was performed over 3 rounds, using a panel of 27 experts. Each member was asked to grade (grade A-grade D) 26 statements regarding various applications of IVUS in aortoiliac surgery. Statements that passed the first round were proposed at the second round unmodified. Statements that failed the first round underwent stylistic modifications without altering their meaning and were proposed in the second and third rounds. Agreement and consistency were used to develop recommendations on the applications of IVUS in aortoiliac endovascular interventions. RESULTS:After 3 rounds, 17 recommendations were made (16 grade B, 1 grade A), whereas 8 statements were rejected, and the core team eliminated 1. Ten recommendations (58.8%) obtained grade IV (poor), 1 (5.9%) grade III (fair), 2 (11.8%) grade II (high), and 4 (23.5%) were classified as grade I (very high). CONCLUSIONS:Intravascular ultrasound is an important adjunct imaging technology in hybrid rooms. Most of the recommendations concerned the use of IVUS in aortic dissection. Other important recommendations for preoperative planning and evaluation of postoperative results were made in radioprotection, aortic aneurysms, and blunt thoracic aortic injury. Intravascular ultrasound assistance in aortoiliac occlusive disease is not routinely recommended at the present time.Clinical ImpactThis international expert-based Delphi consensus provides a comprehensive perspective on the current applications of intravascular ultrasound across various aspects of aortoiliac endovascular therapy. Clinical practice guidelines are currently lacking recommendations on the use of intravascular ultrasound (IVUS) as an adjunctive tool in aortoiliac endovascular surgery; therefore, this study aims to fill the current gap in the literature by assessing the role of IVUS across high-volume aortic centers and offering recommendations on possible IVUS applications in aortoiliac endovascular interventions. Areas of ongoing debate regarding IVUS are also highlighted in this article, to provide inputs for further research.

INTRODUCTION:Current diagnostic reference levels (DRLs) for endovascular aortic repair (EVAR), based on iodinated contrast media (ICM) protocols, range from 100 to 200 Gy·cm2. As CO2 is a negative contrast agent requiring digital subtraction angiography (DSA) for visualization, it may be associated with increased radiation exposure. This multicenter study presents the largest prospective data set to date evaluating radiation dose during EVAR using CO2 angiography alone with an automated injector. METHODS:A prospective, multicenter, nationwide, nonrandomized, investigator-initiated observational study of dosimetry recorded during EVAR procedures with CO2 as exclusive contrast medium was conducted. Primary endpoints included dose-area product (DAP) and reference air kerma (Kar) measurements across all participating centers. Secondary objectives focused on evaluating optimization strategies to reduce radiation exposure for both patients and operators at a single investigational site. RESULTS:A total of 293 patients were enrolled across 10 centers, between January 2023 and January 2024, median DAP and Kar were 189 Gy·cm2 (interquartile range [IQR] 107-285) and 626.5 mGy (IQR 145.5-1373.5), respectively, with significant inter-center variability (all p<0.001). Newer angiographic systems demonstrated markedly lower DAP (median: 90 Gy·cm2, IQR 71-153) vs older systems (191 Gy·cm2, IQR 111-409; p<0.001). Through sequential optimization, we achieved progressive dose reductions: 38.5% via low-dose protocols, 52.3% with modern equipment, culminating in a 56% overall reduction (p<0.001) with synchronized CO2-DSA-yielding a final median DAP of 28.5 Gy·cm2. CONCLUSIONS:CO2-guided EVAR exhibits substantial radiation dose variability, driven by angiographic system generation, software, and synchronization protocols. Modern systems with optimized low-dose protocols and CO2-DSA synchronization reduce radiation exposure to levels comparable to ICM-based EVAR.Clinical ImpactThis large multicenter prospective study establishes a reliable radiation dose benchmarks for CO2-guided endovascular aortic repair (EVAR), showing that modern angiographic systems with optimized low-dose protocols and synchronized CO2-digital subtraction angiography achieve median dose-area product values comparable with conventional iodinated contrast media EVAR, thereby dispelling concerns about excessive radiation exposure with CO2-guided EVAR.

BACKGROUND:Refractory hypertension (RH) is a critical complication of type B aortic dissection (TBAD) in acute and chronic phases. Adequate long-term pressure control reduces aortic-related adverse events, yet approximately 40% of patients do not achieve optimal therapeutic goals. Renal denervation (RDN) is an established technique used for chronic RH, but no experiences are reported in acute TBAD. FIRST-IN-HUMAN:The current series presents the first-in-human experience of RDN in acute TBAD: 2 patients were treated with thoracic endovascular aortic repair because of RH. RDN was performed as an adjunctive procedure to optimize long-term pressure control. Both procedures were successful. At the 3-month follow-up, the patients experienced satisfactory blood pressure control with a reduced antihypertensive regimen. TAKE-HOME MESSAGES:RDN is a feasible adjunctive tool for achieving sustained blood pressure control in acute TBAD. Larger prospective studies are needed to confirm its safety and efficacy and its impact on long-term aortic outcomes.

The aim of the study is to review the literature available about in-situ fenestration (ISF) techniques and their applicability to "zone 2" TEVAR for the revascularization of left subclavian artery (LSA), and retrospectively analyze a cohort of patients submitted to this type of endovascular approach in a single center. It is a single-center, retrospective, physician-initiated cohort study of patients treated in our institution from November 2023 to May 2024. Inclusion criteria were isolated left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was the technical feasibility and the technical success of the procedure. Secondary outcomes were perioperative complications and follow-up. During the study period, 7 patients (all men; mean age of 73 + 9 [62-83] years) received ISNF for LSA revascularization, urgently in 4 patients (57%). In all cases (100%), it was possible to obtain the technical success with correct ISNF and exclusion of the aortic pathology. In the first two cases (28%), the procedure highlighted focal dissection of the axillary artery, necessitating PTA and stenting to properly restore the flow. No perioperative major adverse event occurred within 30 days. No patient underwent reoperation for aortic pathology; all patients are still alive today. Overall, postoperative CTA showed regular follow-up of the aortic pathology. Our initial case series analysis, in agreement with the current literature, suggests that ISNF for LSA revascularization in TEVAR provides encouraging midterm results and seems to be feasible and effective. ISF using the Ankura™ device showed promising outcomes.

BACKGROUND:Endovascular strategies represent minimally invasive and valid alternatives to surgical debranching for left subclavian artery (LSA) revascularization in Zone 2 thoracic endovascular aneurysm repair (TEVAR). This study aims to review the literature on the use of Cook Medical Custom-Made Devices (CMDs) incorporating an inner retrograde LSA branch and report a single-center experience with this approach. METHODS:A retrospective analysis was conducted on patients treated in a single high-volume aortic referral center between November 2023 and August 2025. Patients included underwent Zone 2 TEVAR using a CMD stent graft with a single retrograde inner LSA branch (Cook Medical, Bjaeverskov, Denmark). Literature on CMDs for LSA preservation was also reviewed to contextualize findings. RESULTS:Sixty patients underwent LSA revascularization in Zone 2 TEVAR, including 28 carotid-subclavian bypasses, eight in-situ fenestrations, 16 off-the-shelf branched devices, and eight Cook Medical CMDs, of which seven single LSA inner branches and one was incorporated with a fenestration. All LSA branch CMD cases were elective, with a 100% technical success rate. Two early reinterventions were performed: one for a persistent Type Ia endoleak managed with proximal coil embolization, and another for a Type IIIc endoleak treated by relining the LSA stent graft. One postoperative death occurred due to cerebral embolization. There were no instances of branch occlusion, device migration, or target vessel stenosis during a short-term follow-up. CONCLUSIONS:CMD LSA branch endografts represent a valid solution for complex Zone 2 aortic pathology, offering full endovascular repair with individualized anatomical adaptation over off-the-shelf solutions. Our outcomes demonstrate early feasibility with high technical success; however, further studies with larger cohorts and long-term follow-ups are warranted.

Background Covered stents commercially available are frequently used off-label in conjunction with fenestrated and branched aortic stent grafts, but there is a lack of dedicated devices. Objective This study aims to assess the safety and mid-term clinical performance of a new dedicated covered stent, the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (VBX stent graft), when used as a bridging stent with branched and fenestrated aortic endografts in treating complex abdominal aortic and thoraco-abdominal aneurysms. Methods A retrospective, multicenter, single-arm study in the European Union (ClinicalTrials.gov NCT05143138) enrolled patients treated with the VBX stent graft as a bridging stent in branched endovascular repair (BEVAR) and fenestrated endovascular repair (FEVAR) to allow endovascular aneurysm repair between January 2017 and December 2021. Up to 15 sites in Europe were required to enroll a minimum of 220 patients. Patients’ medical records were reviewed by the investigator, and specific data were collected ambispectively for up to 5 years of follow-up from the index procedure. The primary end point is target vessel patency (patient level) through 12 months. The registry was designed to statistically test target vessel patency at 12 months in both FEVAR and BEVAR populations. The hypothesis will be tested separately in the 2 cohorts (fenestrated or branched endovascular repair), using patients with core laboratory imaging results available annually through 5 years. The binomial exact test will be used with a 1-sided 2.5% level of significance to test the null hypothesis. Results In total, 259 patients were retrospectively enrolled for a prospective follow-up of 5 years: 136 patients (n=99, 72.8% male; mean age 73, SD 8.9 y) in the BEVAR cohort, 92 patients (n=80, 87.0% male, mean age 72.7, SD 8.1 y) in the FEVAR cohort, and 31 patients (n=17, 54.8% male, mean age 70.9, SD 9.4 y) in the mixed fenestrated or branched endovascular repair cohort. Overall, 662 target vessels were stented with the investigational covered stents: 163 (24.6%) celiac trunk, 192 (29.0%) superior mesenteric artery, and 307 (46.4%) renal arteries. The VBX stent grafts were paired with branches in 451 (68.1%) cases or fenestrations in 211 (31.9%) cases among all Cook Medical stent graft cases. The 1-year results will be published in the fourth quarter of 2025, and the 5-year follow-up results will be analyzed by mid-year 2028. Conclusions This study will investigate the VBX stent graft performance in combination with fenestrated and branched aortic grafts to corroborate its use in complex aortic endovascular procedures and support the modification of current device instructions for use. Trial Registration ClinicalTrials.gov NCT05143138; https://clinicaltrials.gov/study/NCT05143138 International Registered Report Identifier (IRRID) DERR1-10.2196/78970

Post-dissection thoracoabdominal aortic aneurysm (PD-TAAA) is a late sequela of chronic aortic dissection. Complex endovascular aneurysm repair (EVAR), including fenestrated and branched techniques (F/B-EVAR), enables aneurysm exclusion while preserving visceral perfusion; however, bridging stents are not specifically designed for PD-TAAA and are frequently used off-label. Evidence on bridging stent performance is largely derived from degenerative aneurysm cohorts, and PD-TAAA-specific data remain limited. This study evaluated outcomes of the VBX Stent Graft when used as a bridging stent during F/B-EVAR for PD-TAAA. This retrospective analysis included patients with PD-TAAA from the EMBRACE registry (ClinicalTrials.gov: NCT05143138), a multicenter, single-arm registry with retrospective and prospective components, with all outcomes core-laboratory-adjudicated. Procedural, early (thirty-day), and midterm outcomes at one and three years were assessed. The primary endpoints were all-cause mortality and freedom from target vessel instability, defined as loss of durable target vessel reconstruction. Twenty-one patients (mean age 61.5 years; range, 28-77 years) underwent F/B-EVAR with at least one VBX Stent Graft. In total, 82 visceral arteries were treated, of which 51 were bridged with a VBX Stent Graft. Technical success was 100%. Two serious adverse events occurred perioperatively, one requiring reintervention, with no thirty-day mortality or major adverse events. Freedom from all-cause mortality was 95.2% at one year and 90.5% at three years, with two deaths during follow-up. Freedom from target vessel instability at the patient level was 85.7% at both one and three years (95% CI, 62.0-95.2%). VBX Stent Grafts used as bridging stents during F/B-EVAR for PD-TAAA demonstrated high technical success, low early morbidity and mortality, and acceptable mid-term survival and target vessel stability, supporting their use in this challenging anatomical setting within the limitations of a small PD-TAAA cohort.

Background and Clinical Significance: Treatment options for chronic type B aortic dissections (TBADs) remain a topic of ongoing debate. Patients with post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) are typically younger than those with degenerative TAAAs, and their aortas undergo continuous remodeling over their lifetime. Fenestrated/branched endovascular aortic repair (F/B-EVAR) has shown promising results, but it can be challenged by the presence of a narrow true lumen, which hinders navigation and deployment of bridging components. Moreover, the presence of patent segmental arteries originating from the false lumen may prevent aneurysm shrinkage due to persistent flow, which may also result in insufficient spinal cord protection strategies and an increased risk of spinal cord ischemia. Consequently, multiple endovascular interventions are often necessary to address the persistent anatomical changes in these patients. Case Presentation: We present the case of a patient affected by a post-dissecting TAAA who underwent multiple open and endovascular treatment attempts. The presence of prior multiple laparotomies discouraged a new open surgical repair, while the hypertrophic segmental arteries and the presence of a narrow true lumen made standard F/B-EVAR unfeasible. The patient was successfully treated using a combination of different adjunctive advanced endovascular techniques, including minimally invasive segmental artery coil embolization (MiSACE) as a spinal cord preconditioning strategy and prevention of type II endoleak. Moreover, transcatheter electrosurgical septotomy (TES) was used to create a single aortic channel in the presence of a narrow true lumen, which allowed the deployment of a multifeatured, custom-made branched endograft. Conclusions: Endovascular repair of post-dissection TAAAs requires a thorough understanding of advanced endovascular adjuncts, which are often combined to overcome the complex anatomical challenges inherent to this disease. Although encouraging results have been reported, both segmental artery embolization for the indications described here and TES warrant further evaluation in prospective multicenter studies to confirm their safety and efficacy.

BACKGROUND:The impact of a narrow true lumen (NTL) on the outcomes of fenestrated-branched endovascular repair in patients with postdissection thoracoabdominal aortic aneurysms (PD-TAAAs) is underreported. METHODS:Data from an international, multicenter registry were analyzed, to identify patients treated for PD-TAAAs (2015-2025) at 23 centers. All patients underwent fenestrated-branched endovascular repair using custom or off-the-shelf endografts. NTL was defined by a true lumen diameter <25 mm identified at any aortic level on preoperative computed tomography angiogram. Short-term endpoints compared between NTL and no-NTL patients included technical success, procedural metrics, 30-day mortality, and major adverse events (MAEs). Midterm endpoints included 5-year freedom from aortic adverse events (related mortality, rupture, reintervention, endograft instability) and freedom from target artery instability. RESULTS:Among 544 patients (1705 target vessels), 438 (80%) had an NTL. Device design did not differ between groups (52% branches, 30% fenestrated, and 18% fenestrated-branched combination; P = .053). Patients with an NTL more frequently received bridging stent reinforcement (P < .001), and renal inner branches (P = .038). Septotomy or false lumen occlusion were more often performed in NTLs (27% vs 11%; P = .006). Patients with NTLs had longer operating time (P = .031), fluoroscopy time (P = .007), and a higher dose area product (P = .046). Technical success was 95% in both groups (P = .750). Overall 30-day mortality was 4%, and MAEs occurred in 35%. NTLs did not have a significant impact on MAEs (adjusted odds ratio, 0.84; 95% confidence interval [CI], 0.28-2.76; P = .766). Freedom from any aortic adverse event at 5 years was lower in patents with NTL (73% vs 91%; P = .027), driven primarily by secondary procedures of false lumen embolization (P = .027). Freedom from target vessel instability was 86% ± 4% in the NTL group and 92% ± 4% in the no-NTL group (P = .072). Patients with NTLs had a similar primary patency (97% ± 2% vs 98% ± 2%; P = .380) but lower freedom from target vessel endoleak (89% ± 4% vs 97% ± 3%; P = .006). After adjustment, NTL diameter <10 mm (hazard ratio [HR], 2.45; 95% CI, 1.37-4.36; P = .002) was significantly associated with target artery instability. Use of inner branches (HR, 0.11; 95% CI, 0.02-0.87; P = .035) and bridging stent reinforcement (HR, 0.54; 95% CI, 0.31-0.96; P = .038) were protective. CONCLUSIONS:NTL is the most common anatomic presentation in PD-TAAAs and is associated with more complex procedures, but does not affect technical success, mortality, or MAEs. Patients with an NTL experience a higher rate or reinterventions, primarily false lumen embolization. NTL <10 mm is a risk factor for target vessel instability, and reinforcement of bridging stents may be beneficial in these cases.

OBJECTIVE:To report initial experience using endografts with exclusively retrograde inner branches for endovascular aortic arch repair. METHODS:A retrospective review of endovascular aortic arch repairs using custom made endografts exclusively integrating retrograde inner branches (Cook Medical, Brisbane, Australia) was conducted across seven tertiary centres (June 2022 and December 2024). Primary endpoints included technical success and peri-operative morbidity and mortality. All consecutive patients were included. Results are presented as numbers or median (interquartile range [IQR]). RESULTS:Twenty-one patients (nine women; median age, 72 years; IQR 66, 77 years; 13 with chronic dissection) were treated using 19 endografts with three branches and two endografts with two branches, totalling 61 retrograde inner branches. All target vessels were successfully bridged, mostly from femoral access (n = 18) but three required axillary (n = 2) or carotid (n = 1) accesses. Technical success was achieved in 18 patients; one patient experienced irreversible cardiac arrest, and two others had small residual type Ia endoleaks. Two patients required an iliac endoconduit for vessel rupture. These two patients were the only ones who developed a post-operative ischaemic stroke. One of them recovered fully in hospital, whereas the other patient died due to extensive renovisceral embolisation. No other peri-operative deaths were observed (two of 21 patients). Three patients presented with evidence of aortic graft stenosis in the arch that was corrected either during surgery or during early follow up. The latter, after new onset congestive heart failure, was reversed by correction of the aortic graft stenosis. During a median follow up of ten months (IQR 4, 13 months), one patient required false lumen embolisation due to type Ic endoleak, and two patients died due to distal aneurysm rupture and respiratory failure. CONCLUSION:Endovascular aortic arch repair with exclusively retrograde inner branches is feasible with acceptable technical success and no branch related re-intervention. Aortic graft stenosis in the arch is a concern with this design that requires further investigation. This design can potentially overcome the need for large bore upper extremity or carotid access, but larger series with longer follow up are needed to demonstrate safety, efficacy, and durability.

OBJECTIVE:The aim of this study was to assess the results of an off the shelf inner branched thoraco-abdominal endograft for treating aortic pathologies, with a specific focus on comparing outcomes between antegrade and retrograde approaches for target vessel (TV) cannulation. METHODS:This was a national, physician initiated, multicentre, observational study. Data from a registry on patients treated with the E-nside endograft were gathered prospectively. Patients were divided into two groups based on the type of endovascular approach for TV cannulation. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS:From September 2020 to February 2024, 166 procedures were collected, of which 128 (77.1%) used an antegrade upper extremity approach to TV cannulation, while 38 (22.9%) employed a retrograde femoral approach. There were no statistically significant differences in terms of bridging stent choice (balloon expandable only, 69.4% vs. 73.7%; self expandable only, 12.9% vs. 7.9%; mixed configurations, 17.7% vs. 18.4%; p = .68). The mean operation time ± standard deviation was longer for the retrograde approach (282 ± 90 minutes vs. 313 ± 155 minutes; p = .006), but fluoroscopy time, dose area product, and the volume of contrast injected were similar. Six cases of post-operative stroke were reported in the antegrade group (4.7% vs. 0%; p = .17). The 30 day TV related technical success was 94.5% and 94.7%, respectively, for antegrade and retrograde approaches (p = .96). Mean follow up was 14.4 ± 11.3 months (median 12.5 months). Kaplan-Meier estimates (with 95% confidence interval [CI]) at twelve months revealed similar overall survival (87.7%, 95% CI 81 - 95% vs. 91.1%, 95% CI 82 - 100%; log rank = .009, p = .92). Competing risk analysis revealed similar one year estimates of TV instability and TV related re-intervention between groups both in patient centred and TV centred analyses. CONCLUSION:A total transfemoral retrograde approach for TV cannulation of inner branches proved to be effective and was not associated with any neurological events.

OBJECTIVE:To compare the early and midterm outcomes of left subclavian artery revascularization during thoracic endovascular aortic repair (TEVAR) following carotid subclavian bypass/transposition (CSB) vs. fenestrated repair when landing in zone 1/2. Propensity score matching (PSM) was applied to adjust for baseline differences. METHODS:DEbranching versus FENestrated Repair for Left SubClavian Artery REvascularisation (DEFENCE) was a retrospective, international multicentre observational study conducted between January 2019 and July 2023 on consecutive patients who underwent open debranching or fenestration of the left subclavian artery before TEVAR for various aortic arch and descending aortic pathologies. PSM (68 pairs) was performed using logistic regression. Primary endpoints included technical success and 30-day outcomes. Secondary endpoints included re-intervention, death, and aortic related complications at 12, 24, and 36 months. RESULTS:275 patients were included (198 CSB-TEVAR and 77 FTEVAR). Before PSM, statistically significant differences existed in patient demographics and the distribution of aortic pathology. In the matched cohort, CSB-TEVAR demonstrated higher overall re-intervention rates (15% vs. 3%, p = .031) and aortic related re-intervention rates (15% vs. 3%, p = .031) compared with FTEVAR. No statistically significant differences were observed in overall mortality rates (7% vs. 13%, p = .40) or aortic related mortality rate (3% vs. 3%, p = 1.0). Kaplan-Meier analysis indicated a statistically significant trend towards increased late re-intervention in the CSB-TEVAR group (log rank p = .019). Cox regression revealed that carotid subclavian bypass was associated with a fivefold increased independent risk of overall and aortic related re-interventions (hazard ratio 5.185, 95% confidence interval 1.13 - 23.86, p = .035). CONCLUSION:CSB-TEVAR and FTEVAR achieved high technical success, long term durability, and similar mortality rates. FTEVAR is a durable, low re-intervention alternative, while CSB-TEVAR remains a practical option in urgent cases despite its higher incidence of peri-operative and access related morbidity.