Published on November 01, 2016

Fenestrated EVAR Offers Abdominal Aortic Aneurysm Alternative

James Foster, MD

James F. Foster, III, MD

Dr. Foster attended medical school and completed his residency at the University of Missouri-Kansas City. He completed a fellowship program at the University of Iowa Hospitals and Clinics, Iowa City, IA.

Patients in need of abdominal aortic aneurysm repair but are poor candidates for standard endovascular procedure (EVAR) because of their aneurysmal anatomy may benefit from fenestrated endovascular aneurysm repair (FEVAR). The innovative alternative treats patients with short-necked abdominal aortic aneurysms who do not meet the anatomical criteria for using infrarenal stent grafts. “Open repair is still the gold standard,” James F. Foster, III, MD, a vascular surgeon with Midwest Aortic and Vascular Institute, said. “However, sometimes it’s not an option for patients with complex pathologies. With FEVAR, we can treat patients with abdominal aortic necks that are ≥4 mm.”

Men and women with aortic necks <1 cm do not meet EVAR criteria. Only a small subset of patients require a complex endovascular repair, and of those, the majority do not meet endovascular repair criteria. “This is fairly new technology we are starting to offer at North Kansas City Hospital,” Dr. Foster said. “It’s another option for this patient population.”

The Procedure

Fenestrated abdominal aortic aneurysm promixal
body graft

The fenestrated grafts used in endovascular repair consist of a customized proximal body generated from preoperative computer tomography imaging of the aorta and visceral arteries. It also has a distal bifurcated body with iliac limb components. The endograft has two fenestrations, one for each renal artery, and a scalloped top that facilitates the superior mesenteric artery (SMA), the arterial supply to the small intestine and colon.

The surgeon accesses the aneurysm using a transfemoral approach, which requires a small incision and general anesthesia. “Once the fenestrations are aligned with the renal arteries, the graft is deployed and a stent is placed inside each fenestration, creating a seal from the SMA to the distal iliac arteries,” Dr. Foster explained. The procedure eliminates pressure on the aneurysm sac, preventing rupture. After the repair, the sac remains in place, but is no longer a health risk.

FEVAR Benefits

Fenestrated graft with stented renal arteries.

Patient-specific fenestrated graft
with stented renal arteries

Dr. Foster noted that recent studies comparing FEVAR to open repair for difficult aortic aneurysms demonstrate equivalent mortality rates. “When compared with the gold standard of open repair, FEVAR technology is par for the course,” he said. “However, the long-term outcomes are uncertain at this time. When a patient’s anatomy is suitable for either approach, the decision requires an in-depth conversation between the surgeon and the patient.”

In the short-term, FEVAR reduces a patient’s length of stay to 1-2 days versus 5-7 days for open repair. It also shortens the recovery period by eliminating a stay in the intensive care unit and reducing the post-operative course of treatment. However, endovascular repair often requires more postoperative monitoring such as frequent CT scans.

Silent Pathology

Fenestrated abdominal aortic aneurysm in complex
infrarenal anatomy

Abdominal aortic aneurysms are asymptomatic and are often found incidentally in intra-abdominal testing conducted when a patient presents in the Emergency Room with abdominal pain.

Primary care physicians can identify the presence of an abdominal aortic aneurysm early by acting on clinical suspicions derived from common risk factors. If physicians observe any of the following risk factors, they should order an abdominal ultrasound.

  • Family history of aneurysms
  • History of smoking
  • Age (60 years old)
  • Pulsation during an abdominal exam

About 20% of patients with a ruptured aneurysm will make it to the hospital alive, and that is only because the retroperitoneum contained the rupture,” Dr. Foster noted. “Only about 50% of those patients will be released from the hospital. Early detection is essential.”