Abstract:

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.

Key words: fenestrated endovascular aortic repair, complex abdominal aortic aneurysms, evidence-based medicine

摘要：

腔内治疗（EVAR）作为治疗腹主动脉瘤（AAA）的首选方式已获得了越来越广泛的认可，但高达40%的AAA病人不符合传统标准EVAR的治疗指征。大多数不适合标准EVAR的病人都是因为近端锚定区不足或动脉瘤累及内脏动脉，这些病人通常也是高外科风险的病人。超适应证应用标准EVAR治疗非常规AAA却成为了一种趋势，但这些技术治疗短瘤颈病变的安全性和有效性仍有争议。多项研究的早期结果显示使用辅助技术（例如平行支架等）扩大标准EVAR适用性仍存在较高失败率和再干预率等问题。另一些研究的长期随访结果亦显示：与开放性手术相比，接受标准EVAR+辅助技术治疗的AAA病人再干预和晚期AAA破裂的风险也有所增加。自1999年首次报道以来，开窗腔内修复术（F-EVAR）在治疗近肾AAA方面获得了广泛的应用。F-EVAR的基本理念是将锚定区跨过分支动脉，同时通过开窗保留分支动脉。这是EVAR技术质的飞跃，它标志着腔内重建分支血管时代的到来，也为后来腔内修复技术重建弓上分支动脉提供了参考。目前在我国注册的针对内脏动脉的开窗器材主要有COOK公司生产的ZFEN开窗支架型血管。ZFEN可用于高外科风险和正常风险的近肾AAA病人。也可用于修复先前开放手术或EVAR失败的病人。定制ZFAN开窗直径分为开窗主体和分叉主体与分支两部分，完全根据病变解剖直径和长度数据设计。对径路血管条件良好的病人一般采用经皮穿刺完成手术。近端开窗主体植入体内前应在X线下仔细确认每个标记物所代表的位置。植入体内后首先确认主体支架的前后方向正确，然后将开窗部位推进至目标血管附近。肾动脉重建是ZFEN手术最关键和困难的步骤，图像融合技术有利于手术操作的顺利进行。肾动脉支架选择以球扩式覆膜支架为宜，在肾动脉下有一定瘤颈的病变可用球扩性裸支架, 植入分叉支架主体和对侧支。大量研究证实了ZFEN技术重建内脏动脉的有效性和安全性。

关键词: 定制开窗, 复杂腹主动脉瘤, 循证医学