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OBJECTIVES: The current study compares changes in AAA sac size(maximal aneurysm diameter) after fenestrated repair and standard endovascular repair.METHODS: Data were reviewed from two separate prospective, non-randomized clinical trials for the endovascular treatment of AAAs: the Cook Zenith standard AAA Endovascular Graft(Zstan) trial for infrarenal AAAs and the Cook Zenith Fenestrated (Zfen) trial for juxtarenal AAAs. The core lab results of the two trials were compared with respect to post-procedural AAA sac size changes.RESULTS: Sixty-seven Zfen patients(42 pivotal, 25 continued access) were compared with 739 Zstan patients(352 pivotal, 387 continued access). While both groups had similar demographics and medical history, the Zfen patients were more likely to be female(19.4% vs 8.1%, p=.006) and to have a history of hypertension(89.6% vs 68.3%, p<.001) and diabetes(23.9% vs 14.4%, p=.049). Besides a shorter infrarenal neck(10.2±5.5mm vs 33.3±15.1mm, p<.001) as per study criteria, Zfen patients had a larger preoperative AAA diameter(59.3±9.7mm vs 56.8±8.7mm, p=.03) and greater angulation between the suprarenal and infrarenal neck(15.6±9.4° vs 8.2±9.4°, p<.001) as well as between the proximal neck and the longitudinal AAA axis(32.1±14.1° vs 21.4±16.4°, p<.001). Zfen patients were also more likely to have an irregular, funnel, or inverted funnel shaped neck(32.8% vs 13.7%, p<.001). At 2 years, the majority of patients in Zfen and Zstan groups experienced a sac size decrease>5mm(75.9% vs 70.5%) and very few experienced a sac size increase>5mm at 2 years(0% vs 3.8%); there was no significant difference between groups in the proportion of patients with sac size change at any time point(Table 1). Proximal type I endoleak was rare in both groups at any point(0% in Zfen and ≤0.7% in Zstan, p>.99 at any time point). Average sac size significantly decreased from post-procedure to 2 years within each group(p<0.001), with a greater decrease in average sac size(11.5 mm vs 9.3 mm, p=0.02) in the Zfen group.CONCLUSIONS: Despite a shorter, more adverse infrarenal neck anatomy, the Zfen group showed postoperative AAA sac shrinkage, and therefore successful treatment, at least comparable to that of the Zstan group. This supports a wider use of fenestrated endografts in patients with unfavorable infrarenal necks.