Since the introduction of endovascular aortic aneurysm repair (EVAR) 30 years ago in 1991,1Volodos N.L. Karpovich I.P. Troyan V.I. Kalashnikova Yu V. Shekhanin V.E. Ternyuk N.E. et al.Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction.Vasa Suppl. 1991; 33: 93-95PubMed Google Scholar,2Parodi J.C. Palmaz J.C. Barone H.D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2955) Google Scholar EVAR has emerged as the first-choice treatment of elective abdominal aortic aneurysms, accounting for >80% of repairs performed in the United States.3Lederle F.A. Freischlag J.A. Kyriakides T.C. Padberg Jr., F.T. Matsumura J.S. Kohler T.R. et al.Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.JAMA. 2009; 302: 1535-1542Crossref PubMed Scopus (849) Google Scholar, 4Buck D.B. van Herwaarden J.A. Schermerhorn M.L. Moll F.L. Endovascular treatment of abdominal aortic aneurysms.Nat Rev Cardiol. 2014; 11: 112-123Crossref PubMed Scopus (71) Google Scholar, 5Dua A. Kuy S. Lee C.J. Upchurch Jr., G.R. Desai S.S. Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010.J Vasc Surg. 2014; 59: 1512-1517Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar Many institutions have adopted EVAR as the preferred treatment option, independent of patient age or clinical risk, relegating open surgical repair to patients with unsuitable anatomy. As the number of EVAR procedures has grown, as many as 41% of repairs have been reported to fail in the long term because of ongoing aortic aneurysm sac enlargement.6Schanzer A. Greenberg R.K. Hevelone N. Robinson W.P. Eslami M.H. Goldberg R.J. et al.Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.Circulation. 2011; 123: 2848-2855Crossref PubMed Scopus (572) Google Scholar,7Holt P.J. Karthikesalingam A. Patterson B.O. Ghatwary T. Hinchliffe R.J. Loftus I.M. et al.Aortic rupture and sac expansion after endovascular repair of abdominal aortic aneurysm.Br J Surg. 2012; 99: 1657-1664Crossref PubMed Scopus (33) Google Scholar When evaluated in a large cohort of 39,996 Medicare beneficiaries who had undergone EVAR, 2160 patients (5.4%) had experienced EVAR failure and aortic aneurysm rupture.8Schermerhorn M.L. Buck D.B. O'Malley A.J. Curran T. McCallum J.C. Darling J. et al.Long-term outcomes of abdominal aortic aneurysm in the Medicare population.N Engl J Med. 2015; 373: 328-338Crossref PubMed Scopus (319) Google Scholar One potential alternative to pushing the limits of use for conventional infrarenal EVAR devices is to swing the pendulum back and perform more open repairs. Sadly, I believe that “train has left the station.” Patients and providers desire and expect minimally invasive treatment. Furthermore, with the current precipitous decline in the volume of open aortic surgery performed by vascular surgery trainees, comfort levels with open repair have been decreasing.9Dua A. Upchurch Jr., G.R. Lee J.T. Eidt J. Desai S.S. Predicted shortfall in open aneurysm experience for vascular surgery trainees.J Vasc Surg. 2014; 60: 945-949Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 10Sachs T. Schermerhorn M. Pomposelli F. Cotterill P. O'Malley J. Landon B. Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm.J Vasc Surg. 2011; 54: 881-888Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 11Fonseca A.L. Reddy V. Longo W.E. Gusberg R.J. Are graduating surgical residents confident in performing open vascular surgery? Results of a national survey.J Surg Educ. 2015; 72: 577-584Crossref PubMed Scopus (22) Google Scholar We might not like to say it (I definitely do not), but if we are honest, that is the truth. In this month's JVS, Teter et al12Teter K. Li C. Ferreira L.M. Ferrer M. Rockman C. Jacobwitz G. et al.Fenestrated endovascular aortic aneurysm repair promotes positive infrarenal neck remodeling and greater sac shrinkage compared with endovascular aortic aneurysm repair.J Vasc Surg. 2022; 76: 344-351Abstract Full Text Full Text PDF Scopus (1) Google Scholar have presented data that might suggest another viable alternative to pushing the limits on the use of conventional infrarenal EVAR devices. In their study, they compared sac remodeling differences observed after treatment of infrarenal aortic aneurysms with EVAR (n = 90) vs fenestrated EVAR (FEVAR; n = 30).12Teter K. Li C. Ferreira L.M. Ferrer M. Rockman C. Jacobwitz G. et al.Fenestrated endovascular aortic aneurysm repair promotes positive infrarenal neck remodeling and greater sac shrinkage compared with endovascular aortic aneurysm repair.J Vasc Surg. 2022; 76: 344-351Abstract Full Text Full Text PDF Scopus (1) Google Scholar The cohorts were similar with regard to demographics. However, despite the FEVAR group clearly having a greater number of disadvantaged infrarenal aortic necks for sealing, aortic aneurysm sac regression was significantly improved in the FEVAR group compared with that in the EVAR group. In contrast, FEVAR was associated with less sac enlargement (eg, treatment failure) than was EVAR. The study was hypothesis generating and did leave important questions unanswered: (1) what was the comparative morbidity and mortality between groups; (2) would the observed aortic remodeling difference be more or less pronounced in long-term follow-up beyond their mean of 30 months; (3) what was the difference in costs between groups; and (4) did the decision to have all imaging measurements performed by employees of the company that manufacture the FEVAR graft (they did not participate in data analysis or writing of the report), introduce the potential for implicit and/or explicit bias? As a specialty, did we get this 30-year EVAR experiment wrong? Is FEVAR a better solution than EVAR for the treatment of infrarenal aneurysms (I can already hear the hammer and nail comments…)? Yes and no. In the setting of a parallel, nondiseased, 2-cm infrarenal aortic neck, conventional EVAR is a good solution, supported by strong evidence. Otherwise, if it is my aorta, please do not use an infrarenal EVAR graft. Add a couple of renal fenestrations, seal durably, leverage the relative stability of the pararenal aortic tissue, and monitor me annually to ensure sac regression. When FEVAR procedures are planned and executed well at high-volume centers, we know that the associated morbidity and mortality from adding renal fenestrations are extremely low and likely not different from those with conventional infrarenal EVAR. Would this approach be reasonable at high-volume aortic centers? Yes. Could the necessary FEVAR skill set be disseminated broadly or would that result in a trade-off of fewer EVAR complications for an increased new array of FEVAR complications? It is time we answer that question because pushing the limits for conventional EVAR is not the right answer. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Fenestrated endovascular aortic aneurysm repair promotes positive infrarenal neck remodeling and greater sac shrinkage compared with endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 76Issue 2PreviewEndovascular aortic aneurysm repair (EVAR) has become the standard of care for abdominal aortic aneurysms (AAAs) in the modern era. Although numerous devices exist for standard infrarenal AAA repair, fenestrated EVAR (fEVAR) offers a minimally invasive alternative to traditional open repair for patients with a short infrarenal neck. Over time, aortic neck dilation can occur, leading to loss of the proximal seal, endoleaks, and AAA sac growth. In the present study, we analyzed aortic remodeling after EVAR vs fEVAR and further evaluated whether fEVAR confers a benefit in terms of sac shrinkage. Full-Text PDF