Staged total endovascular aortic repair (TEAR) utilising arch branched and thoracoabdominal fenestrated and branched endografts is effective, but identified predictors of morbidity and mortality—including stroke—highlight the importance of individualised risk assessment to optimise outcomes. These are some of the key findings of a study presented at the 2025 Vascular Annual Meeting (VAM; 4–7 June, New Orleans, USA).
Submitting and presenting author Enrico Gallitto (University of Bologna, Bologna, Italy) was speaking on behalf of the transatlantic TEAR study group, which includes four sites in the USA and 12 in Europe.
The study aimed to identify outcomes of TEAR extending from the ascending to the infrarenal aorta or iliac arteries with arch-branched en-dovascular aneurysm repair (ARCH-BEVAR) in combination with thoracoabdominal-fenestrated/ branched EVAR (TAAA-F/BEVAR). “There are very few patients who are reported in the literature up to now,” Gallitto commented.
The investigators retrospectively analysed 95 patients who underwent TEAR from 2014–2024. These patients had a mean follow-up of 32±29 months, the presenter noted, adding that 45 (47%) and six (6%) had undergone previous ascending and TAAA surgery, respectively.
“I’d like to stress the concept that these patients were historically treated by aortic arch replacement followed by open thoracoabdominal aneurysm repair, with high postoperative morbidity and mortality, and for these reasons up to 40% of patients did not complete the second procedure; thanks to this less invasive approach, the rate of not completed procedure was 3%,” Gallitto told Vascular News following his presentation.
Gallitto reported that a staged approach, with the first stage involving ARCH-BEVAR followed by TAAA-F/BEVAR, was consistently used, with a mean time between two stages of 11±5 months.
One (1%) rupture occurred between the staged procedures, the presenter reported, detailing that this was successfully managed with off-the-shelf TAAA-BEVAR.
Gallitto specified that custom-made and off-the-shelf TAAA- F/BEVAR devices were used in 79 (83%) and 16 (17%) cases, respectively. Among 351 abdominal target arteries, he continued, 208 (59%) utilised fenestrations, and 143 (41%) branches. Iliac branch devices and prophylactic cerebrospinal- fluid drainage were used in 33 (35%) and 11 (12%) cases, respectively.
Gallitto reported that there were 12 (13%) transient ischaemic attacks (TIAs)/strokes (10 associated with ARCH-BEVAR and two with TAAAs-F/BEVAR), with five (5%) having a modified Rankin Scale score (mRS) >3. He detailed that independent determinants of stroke included degenerative TAAAs and previous TAAA surgery.
Furthermore, it was noted that 16 (17%) patients experienced SCI (two associated with ARCH-BEVAR and 14 with TAAAs-F/BEVAR) with three (3%) cases of paraplegia. Independent determinants of SCI included major adverse events and iliac branch device use.
Regarding mortality, Gallitto noted that four (4%) patients died within 30 days, with independent determinants of 30- day mortality including stroke with mRS >3, and that aortic- related mortality was 2%.
Out of 67 (71%) patients with available one-year follow-up, Gallitto shared that there were six (9%) target artery instabilities and five (7%) cardiovascular events, respectively.
The estimated three-year survival and freedom from reintervention rates were 79% and 66%, respectively, with Gallitto noting that independent predicted of survival included previous abdominal aortic surgery, postoperative acute kidney injury, and cardiovascular events within one year.
Concluding, Gallitto informed the VAM 2025 audience that staged TEAR utilizing ARCH-BEVAR in combination with TAAAs-F/BEVAR is effective, “demonstrating satisfactory early and midterm outcomes, with low aortic-related mortality and acceptable freedom from reintervention and target artery instability rates.”
Additionally, Gallitto warned that the risk of stroke and SCI remain “significant” and “must be carefully weighed during patient selection and treatment planning.” In addition, the presenter noted that cardiac dysfunction at one year is not rare—citing a rate of 7%—and affects mortality. With this in mind, he suggested that specific cardiac evaluation is needed to investigate the potential role of aortic stiffness.
Gallitto also outlined some limitations of the study, underscoring its retrospective nature and the fact that the timeframe of 10 years introduces the variables of technological innovations and operators’ learning curves. He added that the small sample size, limited follow-up, and the inclusion of only a single brand—Cook Medical—within the study are further limitations.
In the discussion following Gallitto’s presentation, session co-moderator Thomas Forbes (University of Toronto, Toronto, Canada) brought up the time between stages. “I notice that the time interval between stage one and stage two was a mean of 11 months, with some variability. That seems a little long to me,” he commented, going on to ask for an explanation. “This is a great point, because 11 months is probably too high in our routine clinical practice,” Gallitto responded, noting that one of the main determinants would have been the factor of recovery time from the first stage of the procedure.
