From the Guidelines
Complex branched endovascular techniques for abdominal aortic aneurysms (AAAs) involve using custom-made stent grafts with branches or fenestrations to treat aneurysms that extend into major branch vessels, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. These techniques are used for AAAs that involve the renal arteries, superior mesenteric artery, or celiac artery, which cannot be treated with standard endovascular repair. The procedure typically includes:
- Pre-operative imaging and planning to design a custom stent graft
- Insertion of the main body stent graft via femoral artery access
- Catheterization of branch vessels through fenestrations or branches in the main graft
- Deployment of additional stents into the branch vessels The procedure requires advanced endovascular skills and specialized equipment. Patients typically receive heparin during the procedure and are maintained on dual antiplatelet therapy post-operatively. Follow-up imaging with CT angiography is usually performed at regular intervals to monitor for endoleaks or graft-related complications, as suggested by the ACR appropriateness criteria for abdominal aortic aneurysm: interventional planning and follow-up 1. The use of fenestrated or branch stent endografts is recommended for complex endovascular treatment of AAAs, particularly in cases of juxta- or para-renal AAA, where both open and endovascular treatment can be proposed in high-volume centers, with similar short- and long-term results 1. These techniques allow for minimally invasive treatment of complex AAAs in patients who may not be candidates for open surgical repair, potentially reducing perioperative morbidity and mortality. However, they require careful patient selection and long-term surveillance due to the risk of late complications. Current devices offer features like active fixation, repositioning ability, low-profile design, and polymer-filled rings for improved sealing, and new devices demonstrate similar long-term outcomes with reduced re-intervention risk, expanding treatment possibilities to 60%–70% of infrarenal AAA cases 1.
From the Research
Complex Branched Endovascular Techniques
The complex branched endovascular techniques for treating abdominal aortic aneurysms (AAA) include:
- Fenestrated endovascular aneurysm repair (FEVAR) 2, 3, 4, 5
- Branched endovascular aneurysm repair (BEVAR) 2, 3, 4, 6, 5
- Physician-modified stent grafts containing fenestrations and side-arm branches for visceral and renal artery incorporation 2
- Inner branch configurations for complex anatomy, where application of fenestrations or side-arm branches can be challenging 2, 6
- Custom-made stent grafts consisting of one or more inner branches 6
- Chimney techniques 3
Indications and Outcomes
These techniques are used to treat complex abdominal and thoracoabdominal aortic aneurysms, including:
- Juxtarenal abdominal aortic aneurysms 6
- Pararenal abdominal aortic aneurysms 4
- Thoracoabdominal aortic aneurysms (TAAAs) 2, 4, 6
- Type 1A endoleaks 6
- Paraanastamotic aneurysms 6 The outcomes of these techniques include:
- High technical success rates 2, 6
- Low perioperative mortality rates 2, 4, 6
- Low major adverse event rates 2, 4
- High primary branch patency rates 2, 6
- Low reintervention rates 2, 6
Comparison with Open Surgical Repair
Fenestrated and branched endovascular aneurysm repair have been compared with open surgical repair (OSR) in several studies: