Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

Abstract

The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).

One Year Outcomes of 101 BeGraft Stent Grafts used as Bridging Stents in Fenestrated Endovascular Repairs

“…Renal impairment is a concern after FEVAR as it is the most frequent complication. 23 In the present study, only one permanent dialysis (2.6%) and one transient dialysis (2.6%) were required. These results are comparable with those of a recent study on F/BEVAR with a 5% rate of post-operative dialysis.…”

Percutaneous endovascular abdominal aneurysm repair: State‐of‐the art

“…The sandwich graft technique positions covered stents between two aortic main body components to maintain side branch patency in the midgraft position and has been described as an alternative to internal iliac or thoracoabdominal‐branched grafts . These techniques have increased in popularity because of the lack of availability of fenestrated devices …”

“…When deploying the proximal body of endograft, the snorkeled stent is withdrawn until it extends above the proximal endograft sealing zone . To avoid a Type Ia endoleak, positioning the proximal sealing‐zone into 10 or 20 mm of thrombus‐free aorta as the snorkel traverses the proximal sealing zone is recommended . In addition to oversizing the aortic endograft (15–20%), the proximal edge of the visceral vessel stent is extended above the anticipated proximal sealing‐zone of the endograft by at least 5 mm .…”

“…23 These techniques have increased in popularity because of the lack of availability of fenestrated devices. 31,32 When attempting to move the proximal sealing zone cranially due to a short infrarenal neck, taking advantage of every millimeter of aorta is necessary. 22 To place the snorkel, the renal artery is cannulated from above with a brachial or axillary approach.…”

“…22 To avoid a Type Ia endoleak, positioning the proximal sealing-zone into 10 or 20 mm of thrombus-free aorta as the snorkel traverses the proximal sealing zone is recommended. 22,23,32 In addition to oversizing the aortic endograft (15-20%), 21 the proximal edge of the visceral vessel stent is extended above the anticipated proximal sealing-zone of the endograft by at least 5 mm. 22 Gutter-related endoleaks can be successfully treated with postintervention kissingballoon dilations or neck lengthening with the creation of a longer seal zone and placement of additional snorkels.…”