Invited commentary

Abstract

The successful use of fenestrated endografts for the treatment of complex aortic aneurysms was first published nearly 2 decades ago, in 1999.1Faruqi R.M. Chuter T.A. Reilly L.M. Sawhney R. Wall S. Canto C. et al.Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft.J Endovasc Surg. 1999; 6: 354-358Crossref PubMed Scopus (102) Google Scholar, 2Browne T.F. Hartley D. Purchas S. Rosenberg M. Van Schie G. Lawrence-Brown M. A fenestrated covered suprarenal aortic stent.Eur J Vasc Endovasc Surg. 1999; 18: 445-449Abstract Full Text PDF PubMed Scopus (166) Google Scholar Now, we are in the midst of a rapid evolution of technical advances in endovascular catheter-based treatments for aortic aneurysms. Endografts designed with scallops, fenestrations, and branches allow for stent grafts to be placed across visceral arteries and great arteries of the arch, while preserving flow to the critical end organs supplied by these arteries. New fabrics and stent materials have allowed for these devices to be packaged and delivered through smaller and smaller sheaths. Preloaded wires and catheters, integrated into the actual endovascular graft delivery system, help streamline these complex procedures. Despite these advances, we remain far from achieving consensus on how best to treat patients with fenestrated and branched endografts. Access to this diverse array of devices remains highly restricted, and substantial resources are required to successfully execute these repairs and care for these complex patients. Very few centers have a large volume of experience with fenestrated and branched endografts. In many ways, we are still working on the basic questions: How do we identify areas of “normal aorta” for a proximal seal, and how much length is required? When is an “off the shelf” fenestrated device appropriate and when is a “patient-specific” custom fenestrated device required? What are the ideal characteristics for a bridging stent that will ensure durability of repairs? In the current state, we have more questions than answers. Timaran et al take an important step toward reducing the technical challenges inherent to endovascular repair of complex aortic aneurysms. They describe the Sequential Catheterization Amid Progressive Endograft Deployment (SCAPED) technique, which can facilitate target artery cannulation via a brachial or axillary approach. This technique is elegant and highlights how anatomic differences between patients necessitate a diverse array of approaches. Serial deployment, by keeping the endograft constrained, creates space outside of the endograft. Increased space between the endograft and the origin of the target artery is key to facilitate catheter/wire mobility and subsequent target artery cannulation. The use of preloaded wires to bring the sheath to, or out of, fenestrations also facilitates target artery cannulation. As the authors carefully acknowledge, this technique is not ideal for all patients (eg, upgoing target arteries) and many patients and physicians may prefer, when appropriate, transfemoral access only. Better understanding the exact anatomic characteristics where the SCAPED technique provides a significant reduction in procedure time, radiation dose, and morbidity is a key next step. The sequential catheterization amid progressive endograft deployment technique for fenestrated endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 66Issue 1PreviewFenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms. Despite promising short-term results, the technical complexities of this procedure remain a considerable challenge. The risk of technical failure with loss of visceral or renal arteries is ubiquitous even in the most experienced hands, and thus many patients with unfavorable anatomy are frequently denied FEVAR. We have adopted a new technique for FEVAR that involves retrograde brachial artery access and stepwise deployment of the endograft during target vessel catheterization, overcoming many anatomic limitations encountered from a transfemoral approach. Full-Text PDF Open Archive