Open Repair of Proximal Abdominal Aneurysms Analyzed According to the Anatomy, Clamping Site, and Theoretical Fenestrated Endovascular Design

Background: To report our experience with the open repair (OR) of hostile-necked, juxtarenal, pararenal, and suprarenal (SR) aortic aneurysms (proximal abdominal aortic aneurysms) and stratify the results according to the equivalent endovascular repair. Methods: Data from all patients treated between 2010 and 2015 were prospectively collected and retrospectively reviewed. Preoperative computed tomographic (CT) scans were analyzed to plan a hypothetical equivalent endovascular approach (2, 3, and 4 fenestrations [FENs]). Postoperative results were recorded based on the cross-clamping level: supraceliac (SC), SR, and infrarenal (IR). Major adverse events (MAEs) were defined as the presence of one of the following: all-cause mortality, bowel ischemia, myocardial infarction, paraplegia, respiratory failure, stroke, and renal insufficiency. Results: One hundred fifty-seven patients were treated; 93 met the CT scan criteria (slice thickness, <1.5 mm) and were included in the study. Thirty-day mortality was 2.2% (SC, 7.4%; SR, 0%; IR, 0%) and MAE was 31.2% (SC, 51.9%; SR, 27.3%; IR, 13.6%) in the entire cohort. After endovascular planning, 11 (11.8%) patients would have been treated with a 2-FEN device, 20 3-FEN (21.5%), and 62 4-FEN (66.7%). Only 35.5% of the 4-FEN patients received an SC aortic cross-clamping, whereas 43% SR and 21% IR. Renal/visceral perfusion was performed in 45 (72.5%) 4-FEN patients, and in 20 (64%) 2/3-FEN patients (P < 0.001); renal/visceral revascularization was needed in 23 (37.1%) 4-FEN and 5 (19.2%) 2/3-FEN patients (P = 0.054). Conclusions: Implementing a fenestrated endovascular aortic repair (FEVAR) endovascular program could reduce MAEs, but it must be clear that FEVAR for juxtarenal disease may overcomplicate treatment and include manipulation of visceral vessels that would not need to be affected if IR clamping is possible in OR, when it gives excellent results.