Clinical research study Thoracoabdominal and complex aortic aneurysms| Volume 72, ISSUE 6, P1891-1896, December 01, 2020

Maximizing proximal seal zone in fenestrated endografting: Evolution in the approach to graft configuration

Published:April 21, 2020DOI:



      Fenestrated endografting for juxtarenal and pararenal abdominal aortic aneurysms affords the ability to seal stent grafts in normal aorta at and above the renal arteries. The Zenith fenestrated graft (ZFEN; Cook Medical, Bloomington, Ind) is custom-made to surgeon specifications, subject to certain manufacturing limitations. The most common configuration in the pivotal trial and in commercial use after approval has been as a scallop for the superior mesenteric artery (SMA) and two small fenestrations for the renal arteries (configuration A). An alternative configuration to maximize the seal zone length, consisting of a large fenestration for the SMA and two small fenestrations for the renal arteries (configuration B) has been routinely adopted at our institutions to potentially prevent type IA endoleak.


      The present retrospective cohort study examined 100 consecutive ZFEN grafts designed for patients at two university centers from 2012 through 2019. The proximal seal length, measured from the top of the graft to the beginning of the aneurysm, was determined from the preoperative computed tomography angiograms. Alternative configurations were evaluated to determine whether they would have provided a longer proximal seal length.


      The two most common configurations were B (n = 45) and A (n = 38). For the cases in which A had been chosen but B could have been built, 5.8 ± 1.9 mm of seal zone length was lost. For the cases in which B was chosen but A could have been built, 5.8 ± 2.8 mm of seal zone length was gained. Owing, in part, to the increased proximal seal length with configuration B, this configuration has been used more frequently in the past 4 years of the present study compared with the first four (53% vs 25%; P = .004). Of 95 patients who had completed surgery and follow-up, type IA endoleaks were observed in 12 (13%) on completion angiography, all of which had resolved on follow-up imaging without intervention. No SMA was compromised by misalignment of the large fenestration in configuration B.


      A significantly longer proximal seal length can be obtained using a ZFEN with a large fenestration for the SMA and two small fenestrations for the renal arteries. Whenever possible, surgeons should consider this configuration to maximize the proximal seal length and potentially reduce the risk of proximal endoleak. An additional advantage of this approach is that stenting of the SMA to prevent shuttering will be unnecessary or impossible, making the procedure more technically facile.


      To read this article in full you will need to make a payment
      SVS Member Login
      Society Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schanzer A.
        • Greenberg R.K.
        • Hevelone N.
        • Robinson W.P.
        • Eslami M.H.
        • Goldberg R.J.
        • et al.
        Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.
        Circulation. 2011; 123: 2848-2855
        • Jordan Jr., W.D.
        • Ouriel K.
        • Mehta M.
        • Varnagy D.
        • Moore Jr., W.M.
        • Arko F.R.
        • et al.
        Outcome-based anatomic criteria for defining the hostile aortic neck.
        J Vasc Surg. 2015; 61: 1383-1390
        • Oderich G.S.
        • Greenberg R.K.
        • Farber M.
        • Lyden S.
        • Sanchez L.
        • Fairman R.
        • et al.
        Results of the United States multicenter prospective study evaluating the Zenith fenestrated endovascular graft for treatment of juxtarenal abdominal aortic aneurysms.
        J Vasc Surg. 2014; 60: 1420-1428.e1-1428.e5
        • Simons J.P.
        • Shue B.
        • Flahive J.M.
        • Aiello F.A.
        • Steppacher R.C.
        • Eaton E.A.
        • et al.
        Trends in use of the only Food and Drug Administration-approved commercially available fenestrated endovascular aneurysm repair device in the United States.
        J Vasc Surg. 2017; 65: 1260-1269
        • Swerdlow N.J.
        • McCallum J.C.
        • Liang P.
        • Li C.
        • O’Donnell T.F.X.
        • Varkevisser R.R.B.
        • et al.
        Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously.
        J Vasc Surg. 2019; 70: 381-390
        • O’Donnell T.F.X.
        • Corey M.R.
        • Deery S.E.
        • Tsougranis G.
        • Maruthi R.
        • Clouse W.D.
        • et al.
        Select early type IA endoleaks after endovascular aneurysm repair will resolve without secondary intervention.
        J Vasc Surg. 2018; 67: 119-125
        • Diehm N.
        • Dick F.
        • Katzen B.T.
        • Schmidli J.
        • Kalka C.
        • Baumgartner I.
        Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution.
        J Vasc Surg. 2008; 47: 886-892
        • Diehm N.
        • Di Santo S.
        • Schaffner T.
        • Schmidli J.
        • Volzmann J.
        • Juni P.
        Severe structural damage of the seemingly non-diseased infrarenal aortic aneurysm neck.
        J Vasc Surg. 2008; 48: 425-434
        • O’Callaghan A.
        • Greenberg R.K.
        • Eagleton M.J.
        • Bena J.
        • Mastracci T.M.
        Type Ia endoleaks after fenestrated and branched endografts may lead to component instability and increased aortic mortality.
        J Vasc Surg. 2015; 61: 908-914
        • McFarland G.
        • Tran K.
        • Virgin-Downey W.
        • Sgroi M.D.
        • Chandra V.
        • Mell M.W.
        • et al.
        Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure.
        J Vasc Surg. 2019; 69: 385-393
        • Pintoux D.
        • Chaillou P.
        • Azema L.
        • Bizouarn P.
        • Costargent A.
        • Patra P.
        • et al.
        Long-term influence of suprarenal or infrarenal fixation on proximal neck dilatation and stent graft migration after EVAR.
        Ann Vasc Surg. 2011; 25: 1012-1019
        • Avci M.
        • Vos J.A.
        • Kolvenbach R.R.
        • Verhoeven E.L.
        • Perdikides T.
        • Resch T.A.
        • et al.
        The use of endoanchors in repair EVAR cases to improve proximal endograft fixation.
        J Cardiovasc Surg. 2012; 53: 419-426
        • Manunga J.M.
        • Oderich G.S.
        Endovascular training and learning curve for complex endovascular procedures.
        in: Oderich G. Endovascular Aortic Repair. 1st ed. Springer, Cham, Switzerland2017: 245-256
        • Wang S.K.
        • Drucker N.A.
        • Dalsing M.C.
        • Sawchuk A.P.
        • Gupta A.K.
        • Motaganahalli R.L.
        • et al.
        Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair.
        J Vasc Surg. 2018; 68: 1688-1695
        • Mastracci T.M.
        • Greenberg R.K.
        • Eagleton M.J.
        • Hernandez A.V.
        Durability of branches in branched and fenestrated endografts.
        J Vasc Surg. 2013; 57: 926-933
        • Lala S.
        • Knowles M.
        • Timaran D.
        • Shadman Baig M.
        • Valentine J.
        • Timaran C.
        Superior mesenteric artery outcomes after fenestrated endovascular aortic aneurysm repair.
        J Vasc Surg. 2016; 64: 64692-64697
        • Ullery B.W.
        • Lee G.K.
        • Lee J.T.
        Shuttering of the superior mesenteric artery during fenestrated endovascular aneurysm repair.
        J Vasc Surg. 2014; 60: 900-907