When open repair is selected for thoracic or thoracoabdominal aortic aneurysms, despite the significant physiological burden for both patients and surgeons, there is often a sense that a more definitive solution has been achieved. In contrast, TEVAR or EVAR mandates lifelong surveillance, as adverse events such as endoleaks—although fortunately uncommon—remain possible.

Nevertheless, late anastomotic pseudoaneurysms of the descending thoracic and thoracoabdominal aorta do occur and represent one of the most feared complications after open aortic surgery. Although exceedingly rare, their potential for rupture and the technical complexity of their repair make them a first-order surgical challenge. In this context, Nowrouzi et al. report the three-decade experience of a high-volume referral center, describing the transition from open surgery to endovascular repair and comparing early and long-term outcomes.

This study is a retrospective analysis of a prospectively maintained single-center database and includes 108 repairs of distal anastomotic pseudoaneurysms in 102 patients previously treated for descending thoracic aortic disease. The cohort reflects an especially complex population, characterized by a high prevalence of heritable thoracic aortic disease, multiple prior reinterventions, and a substantial proportion of infection-associated cases.

One of the most relevant findings is the clear temporal shift in therapeutic strategy. Before 2005, open repair was essentially the only available option; following regulatory approval of thoracic endografts for this indication, the use of TEVAR increased progressively, accounting for nearly half of the cases in the contemporary era. This evolution reflects not chance but a conceptual change in the management of these reinterventions, historically associated with considerable morbidity and mortality.

Early outcomes reveal a striking difference between treatment strategies. No operative mortality or major adverse events were observed in the endovascular group, whereas the open repair cohort experienced an operative mortality of 9% and an adverse event rate of 15%. However, this apparent superiority of TEVAR must be interpreted with caution. As acknowledged by the authors—and supported by the data—there is a significant selection bias: patients undergoing open repair more frequently presented with active infection, visceral patch pseudoaneurysms, and anatomy clearly unsuitable for an endovascular approach.

The analysis of late outcomes is equally informative. Despite a relatively low rate of repair failure—9% at 5 years and 14% at 10 years—overall survival remains limited, with only 29% of patients alive at 10 years. This finding highlights that anastomotic pseudoaneurysm is not an isolated event but rather a marker of advanced aortic disease in patients with a very high comorbidity burden, whether driven by underlying connective tissue disorders or extensive atherosclerotic disease. Of note, no significant differences were observed in the cumulative incidence of repair failure between open surgery and TEVAR at mid-term follow-up, reinforcing the notion that durability remains a concern for both strategies.

From a technical perspective, the study provides valuable insights into approach selection. Endovascular repair appears particularly appealing for pseudoaneurysms arising from intercostal patches or graft-to-graft anastomoses, even in patients with heritable thoracic aortic disease, provided that adequate prosthetic landing zones are available. In contrast, infection continues to represent the Achilles’ heel of endovascular therapy, maintaining open surgery as the preferred option in this setting.

The authors conclude that late anastomotic pseudoaneurysms are severe but treatable complications, amenable to both open and endovascular repair with acceptable outcomes. TEVAR offers excellent early results in carefully selected patients, whereas infection and specific anatomic considerations still mandate open surgery. The durability of both approaches remains a concern, justifying strict long-term imaging surveillance not only after endovascular repair but also following open reconstruction.

COMMENTARY:

This study confirms what many aortic surgeons perceive in daily practice: the management of anastomotic pseudoaneurysms is no longer an exclusively surgical domain but has evolved into a hybrid landscape in which patient selection is paramount. This series—one of the largest published to date—offers an honest and realistic perspective, avoiding simplistic comparisons between techniques.

Perhaps the most important message is not the apparent early superiority of TEVAR, but rather the recognition that these patients have long, complex aortic histories with multiple prior interventions. In this context, the goal is not always a “definitive solution,” but a safe repair that minimizes invasiveness while preserving future therapeutic options. The absence of early mortality in the endovascular group is undoubtedly attractive, yet it should not trivialize a condition whose natural history remains burdened by high late mortality. Indeed, the study does not fully address the unresolved question of endovascular treatment in infected cases deemed unsuitable for open repair, where a strategy combining TEVAR with lifelong suppressive antibiotic therapy might offer survival outcomes superior to highly aggressive open procedures carrying a substantial risk of intraoperative death.

Traditionally, complex endovascular problems were considered amenable to either endovascular or open solutions, whereas complex open scenarios were thought to mandate surgery alone. This work challenges that paradigm. Given that this field is undergoing genuine expansion, it may pave the way for more advanced endovascular strategies, such as the use of fenestrated or branched endografts for visceral patch pseudoaneurysms. This remains an evolving area that will require dedicated series and long-term follow-up before becoming established. Within the same philosophy, albeit in a different clinical scenario such as aortobifemoral bypass thrombosis in Leriche syndrome, our institution has explored endovascular alternatives—such as EVAR salvage with meticulous distal outflow optimization through profundoplasty—before resorting to traditionally disparaged options like axillobifemoral bypass.

REFERENCE:

Nowrouzi R, Green SY, Nguyen LH, et al. Three-decade evolution from open to endovascular aortic repair of late anastomotic pseudoaneurysm of the descending thoracic or thoracoabdominal aorta. J Thorac Cardiovasc Surg.2026;171:74–81.