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Background: Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms, particularly useful after failed previous repairs. Previous EVAR with suprarenal fixation is considered a contraindication for FEVAR secondary to difficulty in accessing target vessels through the bare suprarenal stent and risk of technical failure with loss of renal and visceral arteries. The purpose of this study was to assess the feasibility of FEVAR in high-risk patients after failed EVAR with suprarenal fixation.
Methods: Over a 6-month period, 5 high-risk male patients underwent FEVAR using physician-modified Zenith endografts after failed EVAR with suprarenal fixation. Four patients presented with proximal type I endoleaks and aneurysm enlargement and one developed a suprarenal pseudoaneurysm with a suprarenal stent fracture. All renal and visceral vessels were sequentially catheterized through the fenestrations and suprarenal bare stent via brachial artery access in a cranial-to-caudal direction with progressive endograft deployment. Each fenestration was deployed, aligned, and catheterized separately while maintaining the endograft constrained distally. Technical success was defined as complete exclusion of the aneurysm sac with successful catheterization and preservation of target vessel patency.
Results: Median age was 70 years (range, 65-83). Two patients had undergone EVAR revision with the Zenith Renu device and one with a Talent cuff after prior failed EVAR secondary to migration of an AneuRx device. One patient had undergone EVAR with the Talent device with migration and loss of proximal fixation. One patient had undergone EVAR with the Excluder device and developed a proximal type I endoleak, unsuccessfully treated with a cuff and a transrenal Palmaz stent. To assess feasibility for repair, four patients underwent visceral and renal artery IVUS prior to FEVAR. Bilateral renal arteries were accommodated in all fenestrated grafts in addition to four superior mesenteric and three celiac arteries. Despite the difficulty associated with the presence of a suprarenal stent, technical success was 100% and no target vessels were lost. The median procedure time was 220 minutes (range, 150-440). No 30 day mortality occurred and renal function remained stable.
Conclusions: FEVAR for failed previous EVAR with suprarenal fixation is safe and effective despite the technical difficulty in accessing target vessels through the bare suprarenal stent.