Technical specification and matters needing attention for rebuilding visceral artery by fenestrated endovascular aortic aneurysm repair        LIU Jie，GUO Wei. Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing 100853, China
Corresponding author：GUO Wei, E-mail: pla301dml@vip.sina.com
Abstract    Up to 40% of AAA patients are ineligible for treatment with currently standard devices for EVAR, though EVAR has been accepted as the preferred treatment for infra-renal AAA. The majority excluded criteria are based on inadequate landing zones or involvement of the visceral arteries, and many of them are ineligible for open surgery. The safety and efficiency of conventional EVAR in the short or hostile infra-renal proximal neck remains controversial. Several studies have showed promising early outcomes with parallel grafts or endoluminal screws, to broaden the use of standard EVAR in the hostile neck, other studies have reported high rates of treatment failure and re-intervention. Moreover, the adjunctive technics to EVAR showed an increased rate of re-intervention and risk of late aneurysm-related rupture in patients treated with EVAR compared to open repair in a long-term follow-up. Since FEVAR first described in 1999, it has been widely used in the treatment of juxtarenal AAA. The fundamental concept of FEVAR was to extend the proximal sealing zone to treat complex AAA unsuitable for standard EVAR while maintaining visceral arteries perfusion. This is a leap in EVAR, which marks the arrival of the era for the visceral branches reconstruction. It also provides a milestone for the reconstruction of the aortic arch by endovascular repair. Two fenestrated devices to treat complex AAA available including the Zenith fenestrated aortic stent-graft. The most commonly used devices includes small fenestrations for the RAs and a scallop for the SMA. The RAs are always stented and the scallop usually is not stented. Access and blood flow to the limbs become more important. The fenestrated tube is correctly oriented before deployed after angiography. All fenestrations are easily visualized by four markers. It is advised to position the graft slightly high and repositioning and reorientation is easier downward than upward. Target vessel reconstruction is performed sequentially, starting with the easiest RA. Target vessel stenting should start with the highest RA to prevent damage to the contralateral lower renal stent during ballooning and flaring. Bifurcated component deployment and catheterization of contralateral limb. Published studies dating back to 2004 have showed the safety and efficacy of the FEVAR.