Fenestrated stent-grafting after previous endovascular abdominal aortic aneurysm repair

Aim. The aim of this study was to present their experience and highlight the technical difficulties associated with the use of fenestrated stent-grafts to treat juxta and pararenal abdominal aortic aneurysms (AAA) in patients having undergone a previous infrarenal endovascular aneurysm repair (EVAR). Methods. A prospectively held database maintained at the University Medical Center of Groningen including 162 patients who have undergone branched and fenestrated stent-grafting for AAA, was queried for patients treated with this technology after previous EVAR. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality and morbidity were evaluated. Results. A total of 9 patients underwent repair with a fenestrated endograft after previous EVAR. All patients had aneurysmal degeneration of the juxta- and pararenal aorta not suitable to standard endovascular techniques. We encountered various intraoperative complications including iliac and renal artery access problems, intraoperative previous graft migration, and dislocation of previous graft limb. In one patient, immediate conversion was needed because a twisted graft limb prevented retrieval of the top cap of the fenestrated graft. The remaining eight patients were successfully treated by endovascular means. For these patients, target vessel success rate was 100% (20/20) and mean hospital stay 6.0 days (range 3-12 days). Thirty-day and one-year mortality were 0%. Mean follow up was 31 months (range 1-76 months). No aneurysm related death occurred during follow-up. Conclusion. Fenestrated endovascular stent-grafts can be used to repair juxta- and pararenal AAA after previous EVAR. However, several technical challenges have to be overcome due to the presence of a previous stent-graft.