A Systematic Review of Fenestrated Endovascular Repair for Juxtarenal and Short-Neck Aortic Aneurysm: Evidence So Far.

BACKGROUND: Fenestrated endovascular repair is an alternative to open repair in the management of juxtarenal aortic aneurysms and short-neck abdominal aortic aneurysms (AAAs). The aim of this article is to examine the evidence in published literature on the use of fenestrated endovascular stent grafts in the treatment of juxtarenal and short-neck AAAs.

METHODS: Systematic review was formulated under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Articles published from January 1996 to October 2014 in English language were included. Published studies on fenestrated endovascular stent grafts in treating juxtarenal and short-neck AAAs were systematically searched and reviewed through a computerized search of PubMed and Ovid MEDLINE and cross-referenced. Title key words include "fenestrated", "juxtarenal", and "short neck". All relevant published articles up to first October 2014 were reviewed.

RESULTS: A total of 529 nonduplicated publications were identified but only 15 articles were eligible for our qualitative analysis, with 763 patients and 2,040 target vessels. Twelve studies were included in cohort studies with a short or medium follow-up period (median range, 6-67 months). The mean 30-day and late follow-up mortality were 1.7% (range, 0-4%) and 20.1% (range, 4-50%), respectively, with 5.3% aneurysm-related late deaths. A total of 74 target vessels (3.6%) were lost in all the studies with 65 of them (87.8%) lost postoperatively. Overall, 28.8% patients endured renal dysfunction postoperatively, whereas 2.5% of patients required dialysis. Target vessel events and endoleaks were the 2 major indications for reintervention, accounting for 63.8%. Fourteen aneurysm sacs (1.8%) were enlarged continuously during follow-up and a half were due to type II endoleaks. Migration of the proximal fenestration component was reported with 3.0%. One registry study reported 4.1% of early mortality, higher than any cohort studies, whereas the target vessel loss was relatively low (1.6%). Freedom of late secondary intervention decreased from 90% at year 1 to 70% at year 3. Two nonrandom controlled comparative studies showed no definitive superiority of fenestrated repair over the open surgery.

CONCLUSIONS: Contemporary published literature does not produce a high enough level of evidence that leads to a change in treatment guidelines for juxtarenal or short-neck aneurysm. Fenestrated endovascular repair is a safe and efficacious treatment, particularly for those deemed surgically high risk. Growing experience and innovation of stent graft are essential for the advancement of fenestrated grafting.