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Online ISSN 1827-1847
Tulsyan N., R. K. Greenberg R. K.
Department of Vascular Surgery Cleveland Clinic Foundation, Cleveland, OH, USA
Dramatic improvements in endoluminal techniques, stent-graft design, and diagnostic imaging have increased the frequency with which infrarenal aortic aneurysms are being repaired by an endovascular route. However, healthy, non-aneurysmal infrarenal aortic neck of adequate length is needed for durable results. Diseased infrarenal aortic necks (aneurysmal, short, and/or thrombus-laden) temper the ability to achieve sealing or fixation with current commercialized stent-grafts. In the setting of a compromised aortic neck or when aneurysmal disease extends to or involves the visceral aortic segment, patients may benefit from open aortic reconstruction as opposed to endovascular aneurysm repair. In these situations, though, it is likely that an aortic clamp will be placed in the suprarenal or supra-visceral position. While the open repair of infrarenal aortic aneurysms can be performed with low perioperative morbidity and mortality, complication rates are greater with conventional repair of pararenal and thoracoabdominal aneurysms. Patients with diseased necks, deemed to be at a high operative risk with a relatively high risk of aneurysm rupture, may be considered for fenestrated or fenestrated-branched aortic endografting. Custom configured fenestrated stent grafts and fenestrated-branched stent grafts were designed to incorporate the renal arteries and visceral arteries into the repair, thereby extending the proximal sealing zone into a more stable segment of aorta. Fenestrated stent-grafting requires detailed preoperative imaging for accurate sizing of the device, high quality intraoperative imaging, and expertise in advanced endoluminal techniques. Due to the high-risk nature of patients’ currently treated by fenestrated endografting, meticulous postoperative care is necessary to minimize the risk of complications. The investigational nature of such reconstructions requires aggressive postoperative surveillance for device-related failures, visceral vessel patency, aneurysm sac size changes, and endoleaks to be performed. Of patients who have undergone fenestrated stent-grafting of juxtarenal and thoracoabdominal aortic aneurysms at the Cleveland Clinic Foundation, no patients have experienced acute or chronic aneurysm rupture, or late aneurysm-related deaths. Furthermore, no patients have required open conversion of their endoluminal reconstruction.