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We thank Dr Roy and colleagues for their comments to our article.1Katsargyris A, Oikonomou K, Kouvelos G, Mufty H, Ritter W, Verhoeven EL. Comparison of outcomes for double fenestrated endovascular aneurysm repair versus triple or quadruple fenestrated endovascular aneurysm repair in the treatment of complex abdominal aortic aneurysms [published online ahead of print February 8, 2017]. J Vasc Surg http://dx.doi.org/10.1016/j.jvs.2016.11.043.Google Scholar The main finding of this study was that complex fenestrated endovascular aneurysm repair (FEVAR), mainly with three fenestrations (3× FEVAR) was not associated with a higher perioperative risk than standard FEVAR with two fenestrations (2× FEVAR). Therefore, a liberal approach toward adding one extra fenestration whenever needed to achieve a durable proximal sealing zone was suggested. We agree with Roy et al that a type II statistical error cannot be excluded given the low complication rate observed, and this is clearly acknowledged in our report.1Katsargyris A, Oikonomou K, Kouvelos G, Mufty H, Ritter W, Verhoeven EL. Comparison of outcomes for double fenestrated endovascular aneurysm repair versus triple or quadruple fenestrated endovascular aneurysm repair in the treatment of complex abdominal aortic aneurysms [published online ahead of print February 8, 2017]. J Vasc Surg http://dx.doi.org/10.1016/j.jvs.2016.11.043.Google Scholar We also agree that these results may not be reproducible in centers with less experience that are still in the learning curve phase. This is, however, more an argument toward centralization of FEVAR rather than keeping FEVAR simple (2× FEVAR) in order to make it feasible also in smaller centers, at a potential cost of inferior durability.2Verhoeven E.L. Katsargyris A. Haulon S. Caveat emptor: lessons learned from the endovascular treatment of complex aortic pathologies.Eur J Vasc Endovasc Surg. 2015; 49: 363-365Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Our report did not show a significant long-term benefit for patients treated with a 3× FEVAR vs patients treated with a 2× FEVAR, probably as a result of the short follow-up period and the low event rate. Long-term results from Cleveland Clinic have shown that a 2× FEVAR design was complicated by an increased risk of proximal type I endoleak during follow-up (10.4% for 2× FEVAR vs 1.9% for 3×/4× FEVAR; P < .01). This resulted over time to increased use of 3× and 4× FEVAR for treatment of the same anatomy.3Mastracci T.M. Eagleton M.J. Kuramochi Y. Bathurst S. Wolski K. Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms.J Vasc Surg. 2015; 61: 355-364Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar The groups of Malmö and Lille have also demonstrated a trend toward more fenestrations for better proximal sealing, without this resulting in an increase of perioperative mortality.4Sveinsson M. Sobocinski J. Resch T. Sonesson B. Dias N. Haulon S. et al.Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm.J Vasc Surg. 2015; 61: 895-901Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Looking at our data, it appears that we have moved toward creation of a longer sealing zone over time, as in our hands, 3× FEVAR has become a standard procedure with accumulated experience. We understand that this striving for longer sealing with the aim of increased durability seems odd in a world where short-neck and sometimes juxtarenal aneurysms are treated with standard EVAR outside the instructions for use or new concepts without proof of evidence. Our purpose was to incite people to use 3× FEVAR instead of 2× FEVAR whenever required to achieve long-term durability. In addition, 3× FEVAR offers the option of a double-width scallop for the celiac artery and more options for the location of the three fenestrations. In our opinion, 2× FEVAR should be reserved only for short-neck aneurysms and probably to replace the other techniques mentioned above in a number of patients. We understand the limitations discussed by Roy et al, but 2× FEVAR in borderline suitable anatomy, even with a good perioperative result, may lead to long-term complications that are difficult to repair. Regarding “Comparison of outcomes for double fenestrated endovascular aneurysm repair versus triple or quadruple fenestrated endovascular aneurysm repair in the treatment of complex abdominal aortic aneurysms”Journal of Vascular SurgeryVol. 66Issue 2PreviewWe read with interest the comparison by Katsargyris et al of fenestrated endovascular aneurysm repair (FEVAR) with one or two fenestrations against FEVAR with three or four fenestrations in their center. They observed no significant difference in outcomes in the postoperative period or in the early follow-up. They concluded that more complex FEVAR is as safe as less complex FEVAR and advocated more liberal use of complex FEVAR. These results differ from our similar analysis,1 and as such we suggest that the applicability of this conclusion is compromised for the following reasons. Full-Text PDF Open Archive