1. Endovascular Treatment of Juxta-renal AAA
Sohail Choksy
Consultant Vascular Surgeon
Five Rivers Vascular Network
(Colchester and Ipswich Hospitals)

2. Juxtarenal AAA Approx 15% AAA are juxtarenal
No agreed definition for juxta renal AAA
Complex aneurysm with short or no infrarenal neck
Broad spectrum of morphology
No reporting standards
Makes comparison between studies difficult
From endovascular view includes any aneurysm that is less than 10mm in length

3. Aim of FEVAR
In FEVAR extend sealing zone above the renal arteries into visceral segment and beyond whilst maintaining organ perfusion

4. Fenestrated EVAR (F-EVAR)
Aneurysms in close proximity to renal arteries classed as juxta renal
Neck < 1 cm
10-15% of all AAA
Insufficient sealing zone to achieve a seal
Sealing zone extended above the renal arteries to healthy portion of aorta
Holes or “fenestrations” made in fabric to allow perfusion of renal and visceral arteries
Range in complexity from 2 fen (for renal) to 4 fenestrations
A balloon-expandable covered stent e.g. atrium placed through the fen, balloon inflated and stent deployed
Most are custom made devices take 6 weeks to manufacture

5. FEVAR Aneurysm progression following open repair Degenerative aneurysm
Endograft migration

8. Devices
Vascutek Anaconda FEVAR
Cook Zenith FEVAR

9. FEVAR planning Accurate planning is crucial As a minimum 1mm CT slices
Requires post processing of images using software such as Terarecon, 3 Mensio, Vitrea
Multiplanar reconstruction (MPR), straightened MPR
Centre line flow
Accurate measurements of length between vessels and and angles of visceral vessels on clock face
Distance between fenestrations and of length device itself
Orientation of fenestration (Angles measured in angles or clock face)

12. Angles for fenestrations

13. Clinical case
Mr MG 74 y.o. man with juxtarenal AAA not suitable for conventional EVAR
CPEX test showed predicted open AAA mortality >7%
Preop imaging

14. Case 1: Cook Device Mr MG preop imaging

15. Planning Case planned with planning centre in London
Case suitable for a “CE marked device”
Two fenestrations and one scallop

16. Planning images

17. Clock position renal arteries
Right renal artery
Left renal artery

18. Clock position SMA/coeliac

20. Cook Device Two part body
Proximal body = contains the fenestration and scallop, straight tube
Rigid design, fenestrations between the struts
Bare metal fixation (barbs)
Distal bifurcated body (conventional EVAR) which docks into the main body)
Long track record
Rigid stent and so more easily rotated and vertically without fabric “rucking up”
Branched grafts and thoracic grafts also available

21. Deployment Cook Access
Femoral access usually (if access difficult axillary access e.g. downward facing renals, SMA)
Main body inserted via ipsilateral side
Graft is orientated and fenestrations of main body lined up with the target vessel
20F/24F sheath for bridging stents inserted on contralateral side
Proximal body is deployed and target vessels cannulated
Bridging stents (covered balloon expandable) are inserted and left in position
Diameter reducing ties and top cap released
Bridging stents are deployed and flared
Distal body and limbs inserted

22. Operative images

27. Post op CT

28. Vascutek FEVAR (anaconda)
First case 2010
Very different design
Unsupported body (fens can be placed anywhere)
Seal achieved by two rings 5mm apart
Single body system
No bare metal stent
Can be collapsed easily and repositioned
No top cap so can be cannulated easily from above

29. Case 2 Anaconda 3 fenestration

32. Measurements

34. Prototype (Vascutek) Allows practice on 3 D model
Allows adjustment of final graft

36. Limitations of FEVAR No level one evidence
Limited anatomical suitability
Concerns about long term durability
Technically difficult operations can last for 6 hours +
Expensive graft itself costs 15,000 GBP, each bridging stent 2000 GBP
Manufacturing since custom made delay 6 weeks plus therefore not for acute use
Off the shelf devices not available at present

37. Results from FEVAR
No randomised trials comparing open juxtarenal AAA repair and FEVAR

38. Systematic review Chinese study studies to Oct 2014
12 studies included, 763 patients, 2040 target vessels
30d mortality 1.7% (0-4%)
Late mortality 20.1% (4-50%)
74 target vessels lost
28.8% renal dysfunction, 2.5% dialysis
Freedom of late secondary intervention decreased from 90% at year 1 to 70% at year 3
2 non random studies compared the two methods. No differences in mortality
Ann Vasc Surg Nov;29(8):1680-8

39. Registry data
Globalstar registry : Early results of Fenestrated repair of juxta renal AAA in the UK Circulation 2012
All patients who underwent FEVAR in experienced institutions (>10 cases)
318 patients from 14 centres
Procedural success in 99%
Target vessel loss in 0.6% (5 vessels)
Spinal cord ischaemia in 5 patients
Perioperative mortality was 4.1% (11 deaths)
Vpossum scores indicated these were high risk patients
Predicated mortality for open repair 11%
Tentative risk reduction 7%

40. Kaplan–Meier analysis of target vessel (TV) patency.
Kaplan–Meier analysis of target vessel (TV) patency. Cum indicates cumulative; surv., survival.
On behalf of the British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry Circulation. 2012;125:
Copyright © American Heart Association, Inc. All rights reserved.

41. Kaplan–Meier analysis of overall survival.
Kaplan–Meier analysis of overall survival. Cum indicates cumulative; surv., survival.
On behalf of the British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry Circulation. 2012;125:
Copyright © American Heart Association, Inc. All rights reserved.

42. Kaplan–Meier analysis of freedom from late secondary intervention.
Kaplan–Meier analysis of freedom from late secondary intervention. Cum indicates cumulative; surv., survival.
On behalf of the British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry Circulation. 2012;125:
Copyright © American Heart Association, Inc. All rights reserved.

43. Open Vs FEVAR Norden et al 2009, St Georges Group
Systematic review of comparison of studies for open Vs FEVAR for juxtarenal aneurysms
Identified 8 FEVAR studies = 368 cases
12 studies for open repair = 1164 cases
Main findings: Mortality FEVAR = 1.4% ( ) and Open 3.6% ( )
Renal impairment greater in open group but no difference in dialysis
Reintervention in EVAR group higher (15% vs 2.6%)
Eur J Vasc Endovasc Surg : 35-41

44. Open Vs FEVAR
Rao et al 2015
Meta-analysis of case series compared of open and FEVAR for juxtarenal AAA
35 Studies to April 2013
21 open 1575 patients
14 FEVAR 751
Mortality 4.1 % in both groups
FEVAR patients were older (by 5 years) and had more comorbidities (cardiorespiratory and renal)
FEVAR patients
More reinterventions
Higher rate of renal impairment
Lower long term survival
Open surgery patients more serious complications
Considerable heterogeneity between groups
Selection bias higher risk patients in FEVAR group

46. Chimneys
Involves placing a stent parallel to the main aortic stent graft maintain vessel patency
If good conformability between the ch. Stent, main stent and aortic wall then good seal but gutters can lead to endoleak
No lead time (customised grafts lead time 6-8 weeks)
Chimneys grafts can be used in urgent or emergency situations
Useful in bail out (if branch vessel overstented, emergency setting and patients unfit for open repair)

47. ChEVAR Classification

48. Access Will require axillary artery access and long sheaths
Ch. Stents (covered)
Fluency (self expanding)
Atriums (balloon expandable)
Viabahn (self expanding)
Requires “kissing technique” of simultaneous balloon inflation in ch stent and EVAR for moulding
Inferior to FEVAR in terms of type 1 endoleak, stroke risk and renal artery perforation
No long term data

50. Conclusions
Both FEVAR and open repair are safe treatments for juxtarenal AAAA
Limitations of FEVAR should be considered when planning treatment
Open repair remains favourable option for younger fitter patients whilst FEVAR is the best option for older patient with greater comorbidity
Reintervention and progression to renal insufficiency should be considered
A classification system for juxta renal AAA and reporting criteria required to be able to compare results
A Randomised control trial is required to compare open Vs FEVAR for juxtarenal aneurysms