Fenestrated endovascular aortic repair for complex abdominal aortic aneurysms using in situ laser fenestrations

In situ fenestration (ISF) is a technique for fenestrated endovascular aortic repair (FEVAR) that can be used for urgent repairs of abdominal aortic aneurysms (AAAs) when there is an inadequate infrarenal landing zone for use of a conventional aortic endograft. It involves deliberate endograft coverage of indispensable branch vessels with ISF of the endograft fabric followed by a bridging covered stent. The aim of this series was to review the indications, early clinical outcomes, and technical feasibility of ISF technique for FEVAR of complex AAAs.

This single-center retrospective case series included all patients with complex aortic aneurysms involving visceral branch vessels requiring urgent repair who were selected for FEVAR using the ISF technique. Briefly, the minimum length of proximal landing zone was determined for each patient. The branch vessels in this segment were prestented as radiographic markers. A polyester-based endograft was fully deployed. Using a steerable sheath, fenestrations were created using a CVX-300 excimer laser and covered, balloon-expandable stents were used to restore perfusion to the target vessels.

From February 2023 to December 2024, 12 patients underwent ISF-FEVAR with 33 intended target vessels. Technical success per Society for Vascular Surgery reporting standards was 91% (30/33). Perioperative complications included 30-day mortality (n = 2), failure to create a fenestration (n = 1), target vessel dissection (n = 2), transient acute kidney injury (n = 1), spinal cord ischemia (n = 1), and femoral artery pseudoaneurysm (n = 1). There were one type II (n = 1) and one type IIIb endoleak at 1 month, and three secondary interventions performed during the follow-up period. There was no aneurysm growth and one patient experienced sac shrinkage.

ISF of aortic stent grafts is a feasible and useful technique for urgent FEVAR of complex AAAs.