The Zenith fenestrated endovascular graft may be designed with single-wide scallops or large fenestrations to address the superior mesenteric artery (SMA). Misalignment of the SMA with an unstented scallop or large fenestration is possible. The purpose of this study was to assess SMA outcomes after fenestrated endovascular aortic aneurysm repair (FEVAR). Over an 18-month period, 47 FEVARs were performed at a single institution. For analysis, patients were divided in two groups: unstented (n = 23) vs stented (n = 24) SMA scallops/fenestrations. Technical success for FEVAR was 100%. The median follow-up period was 7.7 months (range, 1-16 months). In the unstented group, nine of 23 patients (39%) had some degree of misalignment of the SMA (range, 9%-71%; Fig). Among these, four of 23 patients (17%) developed complications: 3 SMA stenoses and 1 occlusion. The mean peak systolic velocity (PSV) in patients with and without SMA misalignment was 317.8 cm/s vs 188.4 cm/s (P < .08), respectively. In the stented group, no misalignment occurred and only one of 24 patients (4%) developed an SMA stenosis that required angioplasty. Overall, patients with unstented SMAs had significantly more adverse events directly attributable to SMA misalignment compared with the stented group (44% vs 4%, respectively; P < .05). Misalignment of the SMA with the use of unstented scallops or fenestrations occurs frequently. Routine stenting of single-wide and large fenestrations, when feasible, may be a safer option for patients undergoing FEVAR.