Endovascular treatment of complex abdominal and thoracoabdominal type IV aortic aneurysms with fenestrated technology

Abstract

The establishment use of fenestrated and branched devices to treat complex aortic aneurysms as a first-line management option has been previously reported. This article reviews the current literature of the use of fenestrated devices to treat complex abdominal and thoracoabdominal type IV aortic aneurysms as a first-line management option. A literature search was performed. This review particularly focuses on all the aspects of the use and results of fenestrated stent-grafts (SGs) in patients with complex abdominal and type IV thoracoabdominal aortic aneurysms and summarizes the available evidence. The use of fenestrated SGs for complex aortic aneurysm disease has grown enormously the last years. SGs with fenestrations, scallops and occasionally branches have to be customized to each patient's anatomy and precisely deployed in vivo. Bridging covered stents between the main graft and the target vessels eventually exclude the aneurysm preserving blood flow to vital organs. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. High technical success rates and satisfactory perioperative outcomes are described as well as mid- and long-term success and durability including target vessel and branch stent perfusion, data emerging mainly from high volume specialized centers. Percentage of target vessel successfully perfused was reported between 90.5 and 100%. 30-day mortality is reported between 0% and 4.1% while the lowest type 1 or type 3 endoleak rates were 2.5% and 1.3% respectively. Migration rates are kept below 3%. Renal failure was the most frequent complication reported. Advances in SG technology have reduced but not eliminated secondary interventions. Outcomes depend mostly on proximal extension of the disease which increases also the complexity of the repair. High level of expertise and organizational facilities are required for better mid- and long-term outcomes. Fenestrated EVAR (fEVAR) has been shown to be safe and effective in the short and mid-term follow-up. Remaining issues including secondary interventions and the need for follow-up are still within the range of those reported for EVAR. These, continue to plague fEVAR for complex abdominal or type IV thoracoabdominal aortic aneurysms.