Planning and sizing of fenestrated/branched stent grafts

Precise preoperative planning for fenestrated and branched endovascular repair of aortic aneurysms is essential for safe and successful surgery. Planning should begin with a high-quality computed tomography angiography of the chest abdomen and pelvis, which is input into post-processing software to create centerline formatting of the aorta, iliac, and target vessels. The aorta and its branches should then be assessed for aberrant anatomy, dissection, and extent of disease. In any patient with evidence of dissection, a plan should be established for intravascular ultrasound assessment of wire location to confirm the appropriately selected lumen. The proximal and distal seal zones should be selected in areas of a healthy, nonangulated, and parallel vessel free from degeneration calcification and atheroma. The proximal and distal devices can then be selected with 10% to 20% oversizing. Target vessels are evaluated for incorporation and assessed for vessel size, stenosis, dissection, and distance to branching vessels, all of which guide suitability for fenestrated and branched endovascular repair of aortic aneurysms and sizing for bridging stents. The celiac and superior mesenteric arteries should be incorporated for repair, even if evidence of proximal stenosis is identified, as should accessory renal arteries >4 mm. Although total femoral access is now widely used, all access options should be carefully evaluated for size, calcification, and dissection, including bilateral femoral, iliac, subclavian, and brachial vessels. Finally, optimal C-Arm gantry angles should be planned to clearly identify the orifice and first branch of target vessels, as well as proximal and distal sealing zones.