Fenestrated and branched stent grafts

It is estimated that 50% of patients with abdominal aortic aneurysms are not candidates for endovascular repair using the currently commercially available devices because of unfavorable anatomy. This includes patients with short or angulated necks, aneurysmal extension into either internal iliac artery, or complex aneurysmal involvement of the juxtarenal, paravisceral, and thoracoabdominal aorta. Good surgical candidates may tolerate open conventional repair of the aneurysm, but patients with large aneurysms and poor cardiac, pulmonary, or renal performance have limited options. Fenestrated and branched stent grafts were designed toextend the proximal sealing zone from the infrarenal segment to the juxta and suprarenal aorta, thereby circumventing the limitation of short or absent aortic necks. Since the first implantation of a fenestrated graft in 1996, there has been tremendous advancement in the development and technology of these devices. It is now possible to treat pathology of the entire aorta via a completely endovascular approach, with short-term results that compare favorably with those of open surgery. This review presents the current world experience with fenestrated and branched stent grafting. It encompasses the historical background of these devices, describes the techniques of fenestrated and branched grafting, summarizes the intermediate-term results for endovascular repair of pararenal, juxtarenal, thoracoabdominal, and aortoiliac aneurysms, and discusses the role of surgeon-modified fenestrated and branched devices.