Fenestrated and branched endovascular techniques for thoraco-abdominal aneurysm repair

Since 1991, endovascular aortic aneurysm repair (EVAR) has been established as an alternative for open surgical repair of aortic aneurysms. One of the main limitations for EVAR is the need for a sufficient sealing zone below or above vital aortic side branches. Recently, efforts have been made to overcome these limitations by incorporating fenestrations or branches in customized stent-grafts. This paper reviews the technical and clinical possibilities, as well as the results with fenestrated and branched stent-grafts. All these techniques can be classified into 6 groups, including abdominal fenestrated, abdominal branched, thoraco-abdominal fenestrated, thoraco-abdominal branched, thoracic fenestrated, and thoracic branched stent-grafting. The only well-elaborated technique at this moment is abdominal fenestrated stent-grafting. Currently, branched stent-grafting must be regarded as experimental, but advancements are taking place rapidly. It is anticipated that wider adoption will take place in the near future. New developments include the further use of reinforced fenestrations, indwelling catheters and flexor sheaths, as well as the use of new type branches.