This study states that Endovascular aneurysm repair (EVAR) is associated with worse outcomes in patients not meeting device instructions for use (IFU). However, whether open surgical repair (OSR) and fenestrated EVAR (FEVAR) represent better options for these patients is unknown. We identified all patients without prior aortic surgery undergoing elective repair of juxtarenal and infrarenal aortic aneurysms at a single institution with EVAR, OSR, and FEVAR. We applied device-specific aneurysm neck-related IFU to EVAR patients and generic IFU to FEVAR and OSR patients. We calculated propensity scores and used inverse probability weighting, clustering by surgeon, to compare outcomes among EVAR patients by adherence to IFU and by treatment modality in patients not meeting IFU. When only patients deemed fit for OSR were considered, survival was similar for EVAR and OSR, but mortality and reinterventions were significantly higher for FEVAR (mortality: HR, 3.0 [1.3-7.0; P = .01]; reinterventions: HR, 3.4 [1.7-7.1; P =.001]). Treatment outside device-specific IFU is associated with adverse long-term outcomes. OSR is associated with higher long-term survival in patients who fall outside of the EVAR IFU and should be favored over EVAR in this cohort.

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