Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults

OBJECTIVEIn this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD).METHODSThe medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups.RESULTSThe bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27–0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43–2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06–0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively).CONCLUSIONSDuring the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.

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361 Bypass Surgery Versus Medical Treatment for Symptomatic Moyamoya Disease in Adults

Neurosurgery ◽

10.1093/neuros/nyx417.361 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 283-284

Author(s):

Kwan-Sung Lee ◽

Dong-Kyu Jang ◽

Hyoung Kyun Rha ◽

Pil-Woo Huh ◽

Ji-Ho Yang ◽

...

Keyword(s):

Medical Treatment ◽

Bypass Surgery ◽

Cox Regression ◽

Recurrent Stroke ◽

Perioperative Complications ◽

Adult Patients ◽

Stroke Recurrence ◽

Cox Regression Analysis ◽

Long Term Treatment ◽

Significant Difference

Abstract INTRODUCTION The current study investigated the long-term treatment effect of bypass surgery for stroke prevention and mortality reduction in adult patients with symptomatic MMD in a real-world setting. METHODS The medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups. RESULTS >The bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27 0.86, P = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43 2.66, P = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06 0.49, P = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; P = 0.524, P = 0.828, and P = 0.616, respectively) CONCLUSION During the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.

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Analisis Survival Kecepatan Kekambuhan Stroke

Jurnal Biometrika dan Kependudukan ◽

10.20473/jbk.v6i1.2017.62-69 ◽

2018 ◽

Vol 6 (1) ◽

pp. 62

Author(s):

Karina Pramudita ◽

Hari Basuki Notobroto

Keyword(s):

Diabetes Mellitus ◽

Recurrence Rate ◽

Cox Regression ◽

Recurrent Stroke ◽

Secondary Data ◽

Stroke Recurrence ◽

Stroke Patients ◽

Cox Regression Analysis ◽

History Of ◽

Heart Abnormalities

The objective of this study was to apply cox regression to factor analysis of stroke recurrence rate. This type of research was applied research on secondary data. The samples were 178 first stroke patients who are enrolled in inpatient period January to December 2011 and then made observations on the incidence of recurrent strokes up in February 2017 in medical record. Analysis techniques using Cox regression analysis on risk factors of stroke recurrence rate in RSAU dr. Esnawan Antariksa Halim Perdana Kusumah Jakarta. The analysis exhibited that the rate of recurrence of stroke has the same risk between categories of obesity. Stroke patients with a history of hypertension had a risk of a stroke recurrence rate of 5.594 times more likely than stroke patients with no history of hypertension, stroke patients with a history of diabetes mellitus had a risk of stroke recurrence rate of 1.912 times more likely than stroke patients with no history of diabetes mellitus, stroke patients with a history of dyslipidemia The risk of a recurrence rate of stroke was 2.153 times more likely than stroke patients without a history of dyslipidemia, and stroke patients with a history of heart abnormalities had a risk of recurrent stroke rates of 2.321 times more likely than stroke patients without a history of heart abnormalities. For stroke patients with a history of hypertension, diabetes mellitus, dyslipidemia and a history of cardiac abnormalities, need to do regular check-ups and controls every month to avoid recurrence of stroke.

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Abstract TMP37: Adult Moyamoya Disease : Clinical Presentation, Treatment Outcome and Prognostic Factor

Stroke ◽

10.1161/str.44.suppl_1.atmp37 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Dong-Kyu Jang ◽

Kwan-Sung Lee ◽

Hyung-Keun Rha ◽

Pil-Woo Huh ◽

Jiho Yang ◽

...

Keyword(s):

Survival Rate ◽

Moyamoya Disease ◽

Adult Patients ◽

Neurologic Outcome ◽

Stroke Recurrence ◽

Observation Group ◽

Female Ratio ◽

Free Survival ◽

Kaplan Meier ◽

Significant Difference

Background and Purpose: This study was aimed to investigate treatment results and outcome predictors in adult patients with moyamoya disease. Methods: During the period from 2000 to 2011, a clinical database of adult patients with definite moyamoya disease were collected retrospectively from 8 participating centers in Korea during the period from 2000 to 2011. Among total 399 elligible patients, 355 cases were evaluated about clinical and radiological outcomes through medical records. Stroke-free survival rate and prognostic factors for stroke recurrence were measured by Kaplan-Meier and Cox regression methods. Neurologic outcome was assessed according to surgical revascularization and conservative observation. Results: The mean age of symptom onset was 39.4 ( ± 13.8) years. Male to female ratio was 1 to 2.16. Presenting symptoms were ischemia in 197 (55.5%), hemorrhage in 118 (33.2%), and asymptomatic in 40 (11.3%) patients. The median follow-up was 34.3 months (range 0.4 to 284.8). One hundred thirty seven (38.6%) of the 355 patients received observational conservative management. The remaining 218 (61.4%) patients underwent one of direct, indirect or combined revascularization. In the total adult moyamoya patients, 5 year stroke-free survival rate of surgery and observation group was 82.8% vs 73.4%, respectively. In the ischemic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 80.9% vs 76.2%, respectively. In the hemorrhagic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 83.7% vs 70.1%, respectively. In the asymptomatic cases, 5 year stroke-free survival rate of surgery and observation group was 95.3% vs 83.1%. There was no significant difference between surgical and observation group in Kaplan Meier Survival analysis. Angiographic stage was only a significant factor for stroke recurrence (HR 3.275, 95% CI; 1.251-8.575, P=0.016). Neurologic outcome tended to be better in the surgical group than the observation group (88.5% vs 81.8%, P=0.074) Conclusions: In adult moyamoya patients, the long-term prognosis of surgical treatment may be better than that of conservative observation under real-world setting. Angiographic stage is a predictor of future stroke

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Encephaloduroarteriosynangiosis for hemorrhagic moyamoya disease: long-term outcome of a consecutive series of 95 adult patients from a single center

Journal of Neurosurgery ◽

10.3171/2017.12.jns172246 ◽

2019 ◽

Vol 130 (6) ◽

pp. 1898-1905 ◽

Cited By ~ 5

Author(s):

Qian-Nan Wang ◽

Xiang-Yang Bao ◽

Yong Zhang ◽

Qian Zhang ◽

De-Sheng Li ◽

...

Keyword(s):

Moyamoya Disease ◽

Symptom Onset ◽

Cox Regression ◽

Adult Patients ◽

Consecutive Series ◽

Long Term Outcome ◽

Cox Regression Analysis ◽

Posterior Group

OBJECTIVEThe objective of this study was to investigate long-term outcomes after encephaloduroarteriosynangiosis (EDAS) for the treatment of hemorrhagic moyamoya disease (MMD) and identify the risk factors for recurrent hemorrhages.METHODSThe authors retrospectively reviewed 95 patients with hemorrhagic MMD who were treated with EDAS at 307th Hospital PLA. Clinical features, angiographic findings, and clinical outcomes were investigated. Rebleeding incidences were compared between anterior or posterior hemorrhagic sites. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to estimate rebleeding risks after EDAS.RESULTSThe average age at symptom onset was 37.1 years (range 20–54 years) for adult patients. The ratio of female to male patients was 1.16:1. In 61 of 95 hemorrhagic hemispheres (64.2%), the anterior choroidal artery (AChA) or posterior communicating artery (PCoA) was extremely dilated, with extensive branches beyond the choroidal fissure, which only occurred in 28 of 86 nonhemorrhagic hemispheres (32.6%). Fifty-seven incidences were classified as anterior hemorrhages and 38 as posterior. Sixteen of 95 patients (16.8%) suffered cerebral rebleeding after a median follow-up duration of 8.5 years. The annual rebleeding rate was 2.2% per person per year. The incidence rate was higher for the posterior group than for the anterior group, but this difference was not statistically significant (p > 0.05). Cox regression analysis revealed that the age of symptom onset (OR 1.075, 95% CI 1.008–1.147, p = 0.028) was a predictor of rebleeding strokes.CONCLUSIONSThrough long-term follow up, EDAS proved beneficial for patients with hemorrhagic MMD. Dilation of the AChA-PCoA is associated with the initial hemorrhage of MMD, and rebleeding is age-related. Patients with hemorrhagic MMD should undergo follow-up over the course of their lives, even when neurological status is excellent.

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Impact of cortical hemodynamic failure on both subsequent hemorrhagic stroke and effect of bypass surgery in hemorrhagic moyamoya disease: a supplementary analysis of the Japan Adult Moyamoya Trial

Journal of Neurosurgery ◽

10.3171/2020.1.jns192392 ◽

2020 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Jun C. Takahashi ◽

Takeshi Funaki ◽

Kiyohiro Houkin ◽

Satoshi Kuroda ◽

Miki Fujimura ◽

...

Keyword(s):

Risk Factor ◽

Moyamoya Disease ◽

Independent Risk Factor ◽

Bypass Surgery ◽

Cox Regression ◽

Cox Regression Analysis ◽

Hemodynamic State ◽

Hemorrhagic Events ◽

Direct Bypass ◽

Hemodynamic Failure

OBJECTIVEHere, the authors aimed to determine whether the presence of cerebral hemodynamic failure predicts subsequent bleeding attacks and how it correlates with the effect of direct bypass surgery in hemorrhagic moyamoya disease.METHODSData from the Japanese Adult Moyamoya (JAM) Trial were used in this study: 158 hemispheres in 79 patients. A newly formed expert panel evaluated the SPECT results submitted at trial enrollment and classified the cortical hemodynamic state of the middle cerebral artery territory of each hemisphere into one of the following three groups: SPECT stage (SS) 0 as normal, SS1 as decreased cerebrovascular reserve (CVR), and SS2 as decreased CVR with decreased baseline blood flow. In the nonsurgical cohort of the JAM Trial, the subsequent hemorrhage rate during the 5-year follow-up was compared between the SS0 (hemodynamic failure negative) and SS1+2 (hemodynamic failure positive) groups. The effect of direct or combined direct/indirect bypass surgery on hemorrhage prevention was examined in each subgroup.RESULTSThe hemodynamic grade was SS0 in 59 (37.3%) hemispheres, SS1 in 87 (55.1%), and SS2 in 12 (7.6%). In the nonsurgical cohort, subsequent hemorrhage rates in the SS0 and SS1+2 groups were 12 cases per 1000 person-years and 67 cases per 1000 person-years, respectively. Kaplan-Meier analysis revealed that hemorrhagic events were significantly more common in the SS1+2 group (p = 0.019, log-rank test). Cox regression analysis showed that hemodynamic failure was an independent risk factor for subsequent hemorrhage (HR 5.37, 95% CI 1.07–27.02). In the SS1+2 subgroup, bypass surgery significantly suppressed hemorrhagic events during 5 years (p = 0.001, HR 0.16, 95% CI 0.04–0.57), with no significant effect in the SS0 group (p = 0.655, HR 1.56, 95% CI 0.22–11.10). Examination of effect modification revealed that the effect of surgery tended to differ nonsignificantly between these two subgroups (p = 0.056).CONCLUSIONSHemodynamic failure is an independent risk factor for subsequent hemorrhage in hemorrhagic moyamoya disease. Direct bypass surgery showed a significant preventive effect in the hemodynamically impaired hemispheres. Thus, hemodynamic failure, as well as previously proposed factors such as choroidal anastomosis, should be considered for the surgical indication in hemorrhagic moyamoya disease.Clinical trial registration no.: C000000166 (umin.ac.jp)

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P44 Direct and Combined Revascularization Versus Indirect Revascularization in the Treatment of Moyamoya Disease: A Systematic Review and Meta-Analysis

BJS Open ◽

10.1093/bjsopen/zrab032.043 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Keng Siang Lee ◽

John J Y Zhang ◽

Mario Teo ◽

Gary K Steinberg ◽

Keng Siang Lee

Keyword(s):

Moyamoya Disease ◽

Pediatric Patients ◽

Perioperative Complications ◽

Meta Analysis ◽

Adult Patients ◽

Stroke Rate ◽

Perioperative Mortality ◽

Perioperative Stroke ◽

Significant Difference ◽

Indirect Revascularization

Abstract Introduction There is currently no definite consensus regarding the surgical treatment of moyamoya disease (MMD). This study aimed to compare direct and combined versus indirect bypasses with regard to perioperative complications in pediatric and adult patients with MMD. Methods Systematic searches of Medline, Embase and Cochrane Central were undertaken. Primary outcome measures analyzed included perioperative complications defined as any major adverse events within 30 days after bypass surgery. Results 2490 studies were identified. 20 reporting 2982 patients were eventually included in our meta-analysis. Pooled mean age was 37.5 years (95%CI:33.5–41.5) and 7.4 years (95%CI:4.1–10.7) in adult and pediatric patients respectively. For adult patients, perioperative stroke rate was comparable between direct/combined bypass and indirect bypass (OR = 1.26 [95%CI:0.81–1.96], p = 0.300 for indirect bypass). For pediatric patients, perioperative stroke rate was comparable between direct/combined bypass and indirect bypass (OR = 2.43[95%CI:0.74–7.94], p = 0.143 for indirect bypass). No difference was found in perioperative mortality between direct/combined bypass and indirect bypass for adult patients (OR = 1.16[95%CI:0.07–19.00], p = 0.915 for indirect bypass). There was no difference in perioperative mortality between direct/combined bypass and indirect bypass (OR = 1.39 [95%CI:0 –Inf], p = 1.00 for indirect bypass) in pediatric patients. There was no significant difference in perioperative neurological deficit rates between direct/combined bypass and indirect bypass (OR = 1.27[95%CI:0.68–2.39], p = 0.451 for indirect bypass). Discussions/Conclusions Our meta-analysis provides statistical evidence suggesting that both direct and indirect bypasses can be equally effective in preventing stroke, with similar rates of perioperative complications in pediatric and adult patients.

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Predictive Model for Live Birth at 12 Months After Starting In-Vitro Fertilization Treatment

MedPharmRes ◽

10.32895/ump.mpr.2.2.5 ◽

2018 ◽

Vol 2 (2) ◽

pp. 5-20

Author(s):

Vu Ho ◽

Toan Pham ◽

Tuong Ho ◽

Lan Vuong

Keyword(s):

In Vitro Fertilization ◽

Live Birth ◽

Cox Regression ◽

Financial Burden ◽

Oocyte Retrieval ◽

Operating Characteristics ◽

Vitro Fertilization ◽

Cox Regression Analysis ◽

Significant Difference

IVF carries a considerable physical, emotional and financial burden. Therefore, it would be useful to be able to predict the likelihood of success for each couple. The aim of this retrospective cohort study was to develop a prediction model to estimate the probability of a live birth at 12 months after one completed IVF cycle (all fresh and frozen embryo transfers from the same oocyte retrieval). We analyzed data collected from 2600 women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) at a single center in Vietnam between April 2014 and December 2015. All patients received gonadotropin-releasing hormone (GnRH) antagonist stimulation, followed by fresh and/or frozen embryo transfer (FET) on Day 3. Using Cox regression analysis, five predictive factors were identified: female age, total dose of recombinant follicle stimulating hormone used, type of trigger, fresh or FET during the first transfer, and number of subsequent FET after the first transfer. The area under the receiver operating characteristics curve for the final model was 0.63 (95% confidence interval [CI] 0.60‒0.65) and 0.60 (95% CI 0.57‒0.63) for the validation cohort. There was no significant difference between the predicted and observed probabilities of live birth (Hosmer-Lemeshow test, p > 0.05). The model developed had similar discrimination to existing models and could be implemented in clinical practice.

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The prognostic and diagnostic significance of the neutrophil-to-lymphocyte ratio in hepatocellular carcinoma: a prospective controlled study

British Journal of Cancer ◽

10.1038/s41416-021-01445-3 ◽

2021 ◽

Author(s):

Philip J. Johnson ◽

Sofi Dhanaraj ◽

Sarah Berhane ◽

Laura Bonnett ◽

Yuk Ting Ma

Keyword(s):

Hepatocellular Carcinoma ◽

Regression Analysis ◽

Prognostic Factor ◽

Cox Regression ◽

Prognostic Models ◽

Controlled Study ◽

Cox Regression Analysis ◽

Neutrophil Lymphocyte Ratio ◽

Lymphocyte Ratio ◽

Significant Difference

Abstract Background The neutrophil–lymphocyte ratio (NLR), a presumed measure of the balance between neutrophil-associated pro-tumour inflammation and lymphocyte-dependent antitumour immune function, has been suggested as a prognostic factor for several cancers, including hepatocellular carcinoma (HCC). Methods In this study, a prospectively accrued cohort of 781 patients (493 HCC and 288 chronic liver disease (CLD) without HCC) were followed-up for more than 6 years. NLR levels between HCC and CLD patients were compared, and the effect of baseline NLR on overall survival amongst HCC patients was assessed via multivariable Cox regression analysis. Results On entry into the study (‘baseline’), there was no clinically significant difference in the NLR values between CLD and HCC patients. Amongst HCC patients, NLR levels closest to last visit/death were significantly higher compared to baseline. Multivariable Cox regression analysis showed that NLR was an independent prognostic factor, even after adjustment for the HCC stage. Conclusion NLR is a significant independent factor influencing survival in HCC patients, hence offering an additional dimension in prognostic models.

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Single modality radical radiotherapy is an acceptable alternative for the older patient with squamous cell carcinoma of the oesophagus

BMJ Open Gastroenterology ◽

10.1136/bmjgast-2020-000492 ◽

2021 ◽

Vol 8 (1) ◽

pp. e000492

Author(s):

Sarah Derby ◽

Matthew Forshaw ◽

Caroline Lowrie ◽

Derek Grose ◽

Husam Marashi ◽

...

Keyword(s):

Squamous Cell Carcinoma ◽

Cell Carcinoma ◽

Squamous Cell ◽

Cox Regression ◽

Multimodality Treatment ◽

Radical Radiotherapy ◽

Older Patient ◽

Older Population ◽

Cox Regression Analysis ◽

Significant Difference

BackgroundOesophageal cancer remains a common cause of cancer mortality worldwide. Increasingly, oncology centres are treating an older population and comorbidities may preclude multimodality treatment with chemoradiotherapy (CRT). We review outcomes of radical radiotherapy (RT) in an older population treating squamous cell carcinoma (SCC) oesophagus.MethodsPatients over 65 years receiving RT for SCC oesophagus between 2013 and 2016 in the West of Scotland were identified. Kaplan-Meier and Cox-regression analysis were used to compare overall survival (OS) between patients treated with radical RT and radical CRT.ResultsThere were 83 patients over 65 years treated with either RT (n=21) or CRT (n=62). There was no significant difference in median OS between CRT versus RT (26.8 months vs 28.5 months, p=0.92). All patients receiving RT completed their treatment whereas 11% of CRT patients did not complete treatment.ConclusionSurvival in this non-trial older patient group managed with CRT is comparable to that reported in previous trials. RT shows better than expected outcomes which may reflect developments in RT technique. This review supports RT as an alternative in older patients, unfit for concurrent treatment.

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Impact of Hybrid Operating Rooms on Long-Term Clinical Outcomes Following Fenestrated and Branched Endovascular Aortic Repair

Journal of Endovascular Therapy ◽

10.1177/1526602821996725 ◽

2021 ◽

pp. 152660282199672

Author(s):

Giovanni Tinelli ◽

Marie Bonnet ◽

Adrien Hertault ◽

Simona Sica ◽

Gian Luca Di Tanna ◽

...

Keyword(s):

Operating Room ◽

Clinical Outcomes ◽

Cox Regression ◽

Statistical Significance ◽

Aortic Aneurysms ◽

Study Patient ◽

Cox Regression Analysis ◽

Significant Difference ◽

The Impact

Purpose: Evaluate the impact of hybrid operating room (HOR) guidance on the long-term clinical outcomes following fenestrated and branched endovascular repair (F-BEVAR) for complex aortic aneurysms. Materials and Methods: Prospectively collected registry data were retrospectively analyzed to compare the procedural, short- and long-term outcomes of consecutive F-BEVAR performed from January 2010 to December 2014 under standard mobile C-arm versus hybrid room guidance in a high-volume aortic center. Results: A total of 262 consecutive patients, including 133 patients treated with a mobile C-arm equipped operating room and 129 with a HOR guidance, were enrolled in this study. Patient radiation exposure and contrast media volume were significantly reduced in the HOR group. Short-term clinical outcomes were improved despite higher case complexity in the HOR group, with no statistical significance. At a median follow-up of 63.3 months (Q1 33.4, Q3 75.9) in the C-arm group, and 44.9 months (Q1 25.1, Q3 53.5, p=0.53) in the HOR group, there was no statistically significant difference in terms of target vessel occlusion and limb occlusion. When the endograft involved 3 or more fenestrations and/or branches (complex F-BEVAR), graft instability (36% vs 25%, p=0.035), reintervention on target vessels (20% vs 11%, p=0.019) and total reintervention rates (24% vs 15%, p=0.032) were significantly reduced in the HOR group. The multivariable Cox regression analysis did not show statistically significant differences for long-term death and aortic-related death between the 2 groups. Conclusion: Our study suggests that better long-term clinical outcomes could be observed when performing complex F-BEVAR in the latest generation HOR.

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