Open repair of Crawford extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial perioperative risk. In an effort to decrease this risk, endovascular technologies are increasingly used and include either a hybrid operation combining proximal thoracic endovascular aortic repair followed by staged open distal TAAA repair (hybrid) or a total endovascular approach using fenestrated/branched endografts (FEVAR). However, the benefits of these alternative approaches compared with open surgery remains unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. All patients undergoing extent II/III TAAA repair (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection related indications by the division of vascular surgery at a single institution were identified. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned reoperation and/or 90-day readmission, and survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted propensity analysis. Cox regression was used to estimate survival while cumulative incidence was employed to determine re-operation risk. There were 198 patients (FEVAR, 92; hybrid, 40; open, 66) underwent extent II/III TAAA repair. Seven hybrid patients (18%) were excluded in adjusted analysis because they never underwent the second stage operation (death, 5; lost follow-up, 2). In an unadjusted analysis, compared with hybrid/open repair patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or a dissection-related indication. The unadjusted 30-day mortality and complication risks were as follows: 30-day mortality—4% FEVAR, 13% hybrid, 12% open (P = .01); complications—36% FEVAR, 33% hybrid, 50% open (P = .11); and permanent SCI—3% FEVAR, 3% hybrid, 6% open (P = .64). In adjusted analysis, the 30-day mortality risk was significantly greater for open vs FEVAR (hazard ration, 3.6; 95% confidence interval, 1.4-9.2; P = .008) with no difference for hybrid versus open or hybrid versus FEVAR (Table). There was significantly lower risk of any SCI for FEVAR patients compared with open repair (open: FEVAR, 3.4; 95% confidence interval, 1.0-11.3; P = .04); however, there was no difference overall in the risk of permanent SCI. There was no difference in risk of major complications or unplanned reoperation, but hybrid repair patients had a greater risk of unplanned 90-day readmission compared with FEVAR/open repair patients (Table). There was a time-varying effect of procedure type on survival probability between 30 and 90 days with open repair having greater mortality risk. This difference led to a significant 1-year but not 5-year survival disadvantage compared with hybrid/FEVAR patients (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox model P = .03; Fig). Extent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when patients are matched based on preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.TableInverse probability weighted propensity analysis for inter-group comparison of outcomes after Crawford Extent II/III thoracoabdominal aneurysm (TAAA) repairaGroupHazard ratio95% Confidence intervalP value30-day Death Hybrid:FEVAR1.650.57-4.79.36 Open:FEVAR3.61.4-9.2.008 Hybrid:open0.460.18-1.15.10Permanent SCIb Hybrid:FEVAR0.830.07-10.2.89 Open:FEVAR0.720.14-3.65.68 Hybrid:open1.170.09-13.8.9030-Day death and/or SCIb Hybrid:FEVAR0.640.12-3.42.60 Open:FEVAR0.240.07-0.86.03 Hybrid:open2.680.48-14.84.28Any SCI Hybrid:FEVAR2.930.50-17.1.23 Open:FEVAR3.431.05-11.27.04 Hybrid:open0.850.13-5.46.87Any major complication Hybrid:FEVAR1.720.38-7.89.48 Open:FEVAR0.520.21-1.26.15 Hybrid:open3.330.67-16.47.1490-Day readmission Hybrid:FEVAR6.001.25-28.85.03 Open:FEVAR0.750.24-2.38.63 Hybrid:open7.961.59-39.79.01Any unplanned reoperationb Hybrid:FEVAR1.230.42-3.65.71 Open:FEVAR2.070.66-6.46.21 Hybrid:open0.640.23-1.76.38FEVAR, Fenestrated/branched endografts; SCI, spinal cord ischemia.aInverse probability weighted propensity analysis accounted for age, body mass index, gender, procedure urgency, pathologic indication, American Society of Anesthesia score, and all other cardiopulmonary risk factors.bDeath modeled as a competing risk. Open table in a new tab