Quadruple Fenestrated Stentgrafts for Complex Aortic Aneurysms: Outcomes of Non-Stented Celiac Artery Fenestrations

Background: Fenestrated stentgrafting has become a first-line treatment for juxtarenal aneurysms, and the incorporation of all renovisceral vessels with fenestrations has become common to increase the proximal sealing zone. This increases the complexity of the repair compared to using fewer fenestrations, and stenting of the celiac artery (CA), in particular, can be technically challenging. Objective: This study evaluates the mid-term outcomes of leaving the celiac artery unstented during quadruple fenestrated stentgrafting for complex aortic aneurysms. Additionally, it explores the clinical and anatomical factors that influence the decision to not stent the celiac artery. Methods: A retrospective review was conducted of patients with complex aortic aneurysms who underwent elective fenestrated endovascular aneurysm repair (FEVAR) between 2018 and 2023. Custom Cook Zenith grafts were used, and all patients underwent preoperative computed tomography angiography (CTA) as well as follow-up CTA to assess the celiac artery. This study evaluated celiac artery anatomic factors, such as proximal and distal diameter; presence of stenosis (<50% or >50%) and patency; length of any CA stenosis; CA takeoff angulation, CA tortuosity, early CA division; calcification; and presence of CA aneurysm or ectasia anatomical abnormalities. Recorded outcomes of CA instability included any stent stenosis, target vessel occlusion, reintervention, or endoleak (types 1C and 3). Results: A total of 101 patients underwent FEVAR, with 72 receiving a stent in the celiac artery and 29 not receiving it. Rates of technical success (96.5% vs. 100%), intervention times (256 min vs. 237 min), and lengths of hospital stay (5.1 vs. 4.7 days) were similar between unstented vs. stented groups. At one year, no significant difference in celiac artery instability was noted (17.2 vs. 5.5%; p = 0.06). Risk factors for CA occlusion on univariate analysis included a steep takeoff angle (≥140°), length of stenosis >6.5 mm, proximal diameter ≤6.5 mm, preoperative stenosis ≥50%, and celiac artery tortuosity. Conclusions: Anatomical features of the CA impact the ability to achieve routine CA stenting during FEVAR. Selectively not stenting the celiac artery during FEVAR might simplify the procedure without compromising patient safety and mid-term outcomes.