Purpose: To report preliminary outcomes of Viabahn Balloon-Expandable Endoprosthesis (VBX) stent-graft as bridging stent for renal arteries in fenestrated endovascular aneurysm repair (FEVAR). Materials and Methods: Between 2018 and 2019, patients undergoing FEVAR at 3 referral Italian university hospitals were prospectively collected. During the study period, VBX was the first-line choice as bridging stent for renal arteries. Procedural and anatomical data were analyzed, including renal artery (RA) configuration. A dedicated software (3Mensio, Vascular Imaging, Bilthoeven, The Netherlands) was used and RA anatomy classified as follow: upward-oriented in case of any angle >30° above the horizontal or transverse axis perpendicular to the aortic axis, downward-oriented if there was an angle >30° measured below the transverse axis and downward + upward in case of an angle 90°. Primary endpoints were technical success, defined as complete deployment of the fenestrated endograft without target vessel (TV) loss, limb stenosis or occlusion and type I or III endoleak, and freedom from target artery instability (TAI), defined by target vessel-related death, occlusion, rupture or reintervention for stenosis, endoleak or disconnection. Secondary endpoints were target artery patency rate and freedom from reinterventions. Results: A total of 26 elective FEVAR for juxta/pararenal aneurysm (20), thoracoabdominal type II (3) and type IV (3) were included. Fifty-one RA were planned for revascularization. Of these, 32 were downward, 10 horizontal, 6 upward, 4 were downward + upward. Technical success was achieved in 88.5% (23/26) of patients and 94.2% (48/51) of the TVs. One occlusion (2.1%) occurred within 30 days in a patient with previous endovascular aortic repair and suprarenal fixation. During follow-up (median 10 months), there was 1 type IC endoleak after 6 months (2.1%) in a patient with upward plus downward arterial orientation. Freedom from TAI was 96.1% (CI = 0.89 to 1.04) at first month and 92.3% (CI = 0.82 to 1.03) at 6 months. No aneurysm-related mortality and renal insufficiency occurred during follow-up. Conclusion: The use of VBX as bridging stent of RA in FEVAR is safe and feasible. Previous EVAR and tortuosity of RA may be a challenging on target vessel fate.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.