Fenestrated endovascular aortic repair and clinical trial devices for complex abdominal aortic aneurysms

Endovascular aortic repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysm (AAA), with consistently low reported perioperative morbidity and mortality. Universal applicability of EVAR to treat AAA is hindered by several specific anatomic constraints, however, and many patients cannot be treated with commercially available stent-grafts within the device specific instructions for use. Treatment of these complex pararenal aneurysms is increasingly accomplished by extension of EVAR into the visceral segment of the abdominal aorta with branches or fenestrations that allow perfusion of the visceral and renal arteries. Fenestrated endovascular aneurysm repair (FEVAR) was initially developed to treat high-risk patients unfit for open surgery and anatomically ineligible for standard infrarenal EVAR, but this technique has evolved over the past decade into a mature treatment option for complex AAA. High-volume, single-center reports, multicenter series and clinical reviews have demonstrated that FEVAR is a safe and effective technique with favorable results at proficient centers. Generalizability of these outcomes to less advanced centers remains unproven, and reintervention rates following FEVAR in the mid- and long-term, even among the most experienced centers, remain a concern. Several off-the-shelf devices that are undergoing clinical trial seek to broaden the anatomic applicability and overall availability of FEVAR. A significant number of patients are not candidates for off-the-shelf or customized stent-grafts, however, stressing the need for continued refinement of existing devices, development of novel devices with broader indications for use, and maintenance of open surgical skills.