Endovascular repair of acute juxtarenal and

thoracoabdominal aortic aneurysms with

surgeon-modified fenestrated endografts
Maciej T. Juszczak, PhD, FRCS, Massimo Vezzosi, MD, Mashuk Khan, FRCS, Jorge Mascaro, MD, FRCS,
Martin Claridge, MD, FRCS, and Donald Adam, MD, FRCS, Birmingham, United Kingdom

ABSTRACT
Objective: The objective of this study was to report the short- and medium-term outcome of surgeon-modified fenes-
trated endovascular aneurysm repair (SM-FEVAR) for acute complex aortic aneurysms.
Methods: Interrogation of a prospectively maintained database identified consecutive patients who underwent SM-
FEVAR for acute complex aortic aneurysms (including mycotic aneurysms treated with rifampicin-soaked endografts)
in a single institution between October 2009 and November 2018.
Results: A total of 54 patients (37 men; median age, 73 years [range, 50-85 years]; aneurysm diameter, 76 mm [inter-
quartile range, 58-90 mm]) with acute thoracoabdominal aortic aneurysms (n ¼ 50; 40 symptomatic, 10 ruptured; 19
extent I-III, 31 extent IV) or symptomatic type IA endoleaks after infrarenal endovascular aneurysm repair (n ¼ 4) un-
derwent SM-FEVAR. Seven of the patients had adjunct chimney and periscope stent grafts or surgical bypasses. A total of
187 vessels (mean, 3.4 [range, 1-5] per patient) were targeted for preservation; nine occluded intraoperatively or within
30 days. The 30-day/in-hospital mortality was 16.7% (n ¼ 9; symptomatic, 7.4%; rupture, 50%) and fell significantly from
29.6% (n ¼ 8) in the first 27 patients to 3.7% (n ¼ 1) in the most recent 27 patients (P ¼ .0243). Spinal cord ischemia
occurred in one patient (1.9%) who died within 30 days. No survivors required permanent renal dialysis. Estimated survival
at 12 and 24 months was 73.2% (standard error [SE], 6.2%). Eight patients underwent 12 late aorta- or graft-related
reinterventions. Estimated freedom from reintervention at 12 months and 24 months was 87.9% (SE, 5.2%) and 81.6%
(SE, 6.4%), respectively.
Conclusions: In patients with acute complex aneurysms, SM-FEVAR provides a customized solution that is associated
with good medium-term survival and durability. The knowledge and skills to perform safe SM-FEVAR should be within
the capabilities of high-volume specialist aortic centers. (J Vasc Surg 2019;-:1-10.)
Keywords: Aortic aneurysm; Acute aneurysm; Fenestrated endovascular aortic aneurysm repair; Surgeon-modified
fenestrated endovascular aneurysm repair; Physician-modified graft

In patients presenting with acute complex aortic aneu-
rysms, open repair is often associated with poor out-
comes, particularly for thoracoabdominal aortic
aneurysms (TAAAs),1 and endovascular aneurysm repair
(EVAR) is usually considered the first-line treatment op-
tion where possible. An off-the-shelf endograft with a
four-branch design (t-Branch; Cook Medical, Blooming-
ton, Ind) is available but may have limited applicability
in the emergent setting without the use of adjunctive
maneuvers, which can prolong the procedure and in-
crease the risk of adverse outcomes, such as spinal cord
ischemia (SCI).2-5 This compromise may be acceptable
in patients who are not suitable for open repair, but other
endovascular techniques also exist, such as surgeon-
modified fenestrated devices,6-10 chimney and periscope
endografts,11-15 or a combination of both.16,17 These ap-
proaches have the advantage of being customized with
regard to, for example, length of aortic coverage or pres-
ervation of upward- or downward-oriented renovisceral
vessels. They do, however, have their relative limitations,
such as an increased risk of occlusion of the parallel
target vessel stent grafts, type IA endoleaks, and lack of
regulatory approval.
The aim of this study was to report the early and
medium-term outcome of consecutive patients under-
going surgeon-modified fenestrated endovascular aneu-
rysm repair (SM-FEVAR) with and without adjunct
chimney and periscope endografts or surgical

From the Complex Aortic Team, Birmingham Heartlands Hospital and Queen
Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust.
Author conflict of interest: D.A. and M.C. have received educational grants from
Cook Inc and Atrium-Maquet.
Correspondence: Mr Donald Adam, MD, FRCS, Department of Vascular Surgery,
Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust,
Birmingham B9 5SS, UK (e-mail: donald.adam@heartofengland.nhs.uk).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc.
https://doi.org/10.1016/j.jvs.2019.10.056

1
2 Juszczak et al
renovisceral bypass for acute symptomatic and ruptured
complex aortic aneurysms in a high-volume specialist
aortic center.
METHODS
Study cohort. Interrogation of a prospective database
identified 54 consecutive patients who underwent ur-
gent/emergent SM-FEVAR in a single institution between
October 2009 and November 2018. During this time, a total
of 598 patients underwent elective or nonelective fenes-
trated, branched, or chimney-periscope endovascular
repair for juxtarenal abdominal aortic aneurysms (JRAAAs)
and TAAAs. The off-label nature of SM-FEVAR was disclosed
in all cases, and institutional approval was granted for use of
this technique when patients were considered unsuitable
for other treatments. Twenty-four patients treated be-
tween September 2012 and November 2015 have been
included in a previous publication.4
This study was conducted as part of an institutional
audit assessing the use of medical devices outside
instructions for use. As patient identifiers were removed
at the time of data export for analysis, specific ethical
approval by the Institutional Review Board was not
required and patients’ consent not sought.
Data collection and definitions. The following data
were retrieved: demographics, comorbidity, endograft
design, operative duration and adjunctive procedures,
30-day/in-hospital mortality, target vessel loss, major
complications, unplanned reinterventions, and total
hospital and critical care length of stay, and patient sur-
vival and reintervention during follow-up. Follow-up
ended and data were exported for analysis on January
15, 2019.
TAAAs were categorized using the Crawford classifica-
tion for anatomic extent. All patients were considered
unsuitable for open repair because of a combination of
anatomic and physiologic reasons assessed in a multidis-
ciplinary setting. Acute presentation was defined by
symptoms (new-onset back or abdominal pain associ-
ated with aneurysm diameter $6 cm or rapid enlarge-
ment) and radiographic evidence of aneurysm rupture
or a mycotic aneurysm. The diagnosis of mycotic aneu-
rysm18 was based on combinations of clinical presenta-
tion, laboratory markers, and computed tomography
(CT) findings after discussion with infectious disease phy-
sicians and microbiologists. Primary mycotic aneurysm
affected the native aorta, and secondary mycotic aneu-
rysm occurred in the presence of prior open or endovas-
cular prosthetic aortic repair. Urgent repair was
performed for acute symptomatic nonruptured aneu-
rysms, and emergent repair was performed for ruptured
aneurysms.
Preoperative imaging and endovascular technique.
Aneurysm morphology was assessed by CT angiography
(CTA) of the entire aorta from arch vessels to femoral
Journal of Vascular Surgery
--- 2019
ARTICLE HIGHLIGHTS
d
Type of research: Retrospective cohort study
d
Key Findings: Fifty-four surgeon-modified fenes-
trated endovascular aneurysm repairs for acute com-
plex aortic aneurysms had a 16.7% in-hospital
mortality, 1.9% incidence of spinal cord ischemia,
and 73.2% 2-year survival. Reintervention was
frequent but rarely related to the fenestration-
bearing component of the device.
d
Take Home Message: Surgeon-modified fenestrated
endovascular aneurysm repair is a valuable custom-
ized solution for acute complex aneurysms when it
is performed in an aortic center with expertise in
endovascular techniques.
heads with 1-mm slices. Postprocessing evaluations
(multiplanar, three-dimensional, center lumen line
reconstructions) were performed using dedicated soft-
ware for vessel analysis (Aquarius 3D; TeraRecon, Foster
City, Calif), and the endovascular treatment was planned
accordingly.
Procedures (n ¼ 28) were initially performed in an oper-
ating room equipped with mobile C-arm (OEC 9900 Plus;
General Electric, Salt Lake City, Utah) and from October
2015 (n ¼ 26) in a hybrid operating room (Discovery IGS
730; GE Healthcare, Chalfont St Giles, UK). All procedures
were performed under general anesthesia by one or both
of two experienced endovascular surgeons (D.A., M.C.). In
nonruptured cases, a 5000-unit bolus of heparin was given
intravenously before introduction of the endograft, and
further 1000-unit boluses were given every hour if the pro-
cedure was prolonged for >2 hours. In patients with
rupture, either no intravenous administration of heparin
or a 3000-unit bolus was given before introduction of the
endograft, according to the lead surgeon’s preference.
The intraoperative activated clotting time was not
measured.
Cook devices were used in all patients: TX2 device (n ¼ 45;
Fig 1), Zenith Flex device (n ¼ 2), and the unibody device (n ¼
1) for a 16-mm-diameter abdominal aorta. Reinforced fen-
estrations were created, and permanent diameter-
reducing ties were used in the area of the fenestrations in
a small number of patients with a narrow aortic lumen
when a double-tapered TX2 device was not available or a
shorter tapered device was required to limit aortic
coverage. Temporary diameter-reducing ties were not
used. The repair was extended proximally or distally as
required with a variety of CE-marked unmodified devices.
In patients with suspected mycotic aneurysms, the endog-
rafts were flushed with rifampicin antibiotic.
Postoperative details and follow-up. All patients were
admitted to the critical care unit after the procedure. A
spinal cord protection protocol that has been described
Journal of Vascular Surgery
Volume -, Number -
Fig 1. Triple-vessel surgeon-modified fenestrated endog-
raft for a patient with an acute extent IV thor-
acoabdominal aortic aneurysm (TAAA) and an occluded
celiac axis (CA).
previously19 was used. In brief, this involved minimizing
perioperative blood loss, limiting lower limb ischemia-
reperfusion, maintaining a mean arterial pressure above
80 to 90 mm Hg, optimizing oxygen delivery, and
promptly correcting coagulopathy. Prophylactic cere-
brospinal fluid (CSF) drainage and spinal cord neuro-
monitoring were not used, but salvage CSF drains were
used. Patients were followed up after discharge with CTA
at 1 month, 6 months, and 12 months and annually
thereafter. All patients with suspected mycotic aneu-
rysms were discharged on intravenous antibiotic therapy
through a peripherally inserted central catheter; the
duration of intravenous therapy and subsequent oral
therapy was decided after discussion with infectious
disease physicians and microbiologists.
No patients were lost to follow-up. The primary
outcome (survival status) was verified by cross-
referencing the local electronic patient record with the
National Health Service (NHS)-wide mortality database
(Primary Care Mortality Database, Spine, NHS Digital)
derived from death records from the Office for National
Statistics. Patients who lived far from our institution
were followed up by the referring center, which informed
us of any late complications or reinterventions and trans-
ferred CTA images electronically for assessment.
Statistical analysis. This was performed using R envi-
ronment (version 3.4.1; R Foundation for Statistical
Computing, Vienna, Austria; https://www.r-project.org).
The cohort was characterized using descriptive statistics.
Continuous variables were presented as mean (standard
deviation) or median (range or interquartile range [IQR])
as appropriate, and categorical data were presented as
proportions. Fisher exact test was used to analyze cate-
gorical data. Median follow-up was reported as the
observed follow-up in all subjects (irrespective of
outcome). Overall survival and freedom from reinter-
vention were assessed by calculating Kaplan-Meier
product limit estimator with right censoring of survival
data. A P value of <.05 was considered significant.
Juszczak et al 3
RESULTS
Patient characteristics. A total of 54 patients (37 men;
median age, 73 years [range, 50.0-84.6 years]; aneurysm
diameter, 76 mm [IQR, 58-90 mm]) with acute TAAAs
(n ¼ 50; 40 symptomatic, 10 ruptured; 19 extent I-III, 31
extent IV) or symptomatic type IA endoleaks after infrare-
nal EVAR (n ¼ 4) underwent SM-FEVAR. All patients
treated for rupture were hemodynamically stable. In
seven patients, adjunct chimney-periscope stent grafts
or surgical bypasses were employed. Forty patients were
referred from 14 UK vascular centers as they were
considered unsuitable for open repair by the referring
surgical team. Comorbidity data are shown in Table I. The
median estimated glomerular filtration rate was 78 mL/
min/1.73 m2 (IQR, 11-90 mL/min/1.73 m2).
Three patients had postchronic type B dissection TAAA.
No patients had connective tissue disease. Twenty-eight
(52%) patients had suspected mycotic TAAA (19 primary,
9 secondary; 6 extent I-III, 22 extent IV), and the diagnosis
was reached by the referring team before transfer to our
institution in 23 of these patients. All patients presented
with combination of back and abdominal pain, and 16
had been pyrexial (although none were pyrexial in the
48 hours before repair). All patients had an elevated pre-
operative C-reactive protein level (median, 105 mg/L; IQR,
42-178, mg/L), and seven (25%) had positive venous blood
cultures.
The first 27 patients in the series were treated during a
69-month period, and the subsequent 27 were treated in
40 months. More patients were treated for extent I to
extent III TAAAs in the second half of the series (12/27
(44%) vs 7/27 (26%) in early experience; P ¼ .254). The me-
dian time interval between admission to our institution
and repair was 41.5 hours (IQR, 12-87 hours).
Endograft configuration and operative approach.
Adjunct procedures were required in seven patients: iliac
surgical conduit/reconstruction (n ¼ 3), iliac endoconduit
(n ¼ 1), left carotid-subclavian bypass (n ¼ 1), and com-
mon femoral artery reconstruction (n ¼ 2). Axillary or
brachial access was required in 13 patients.
All patients were treated with endograft sealing in the
supraceliac aorta (Society for Vascular Surgery classifica-
tion zones 2-5), and median length of supraceliac
coverage was 59 mm (IQR, 32-174 mm). A total of 187 ves-
sels (celiac axis [CA], n ¼ 39; superior mesenteric artery
[SMA], n ¼ 54; and renal artery [RA], n ¼ 94) were tar-
geted for preservation (mean, 3.4 [range, 1-5] per patient)
with 171 fenestrations, 3 scallops, 11 chimney-periscopes,
and 2 surgical bypasses. The fenestration-scallop config-
uration was as follows: single, n ¼ 4; double, n ¼ 8; triple,
n ¼ 15; and quadruple or more, n ¼ 27 (Fig 2). The CA was
occluded or severely stenosed on presentation in 15 pa-
tients and intentionally sacrificed in 1 patient. Unilateral
RAs were occluded on presentation in nine patients,
bilateral RAs were occluded in one patient who was
4 Juszczak et al Journal of Vascular Surgery
--- 2019

Table I. Cohort characteristics IV TAAA) had a solitary kidney with RA stenosis and un-
No. derwent a staged approach with a right external iliac
Previous aortic intervention 26
artery-RA bypass followed by single-vessel SM-FEVAR
with CA chimney 1 week later. Patient 7 (extent IV
Open ascending alone 2
TAAA after previous open repair with unilateral compro-
Open ascending and total arch 2
mised access) had severe (>90-degree) angulation above
Thoracic EVAR 5
the SMA and an occluded CA and underwent simulta-
Open thoracoabdominal 2 neous common-external iliac bypass, iliac graft-SMA
Open abdominal 8 bypass, and two-vessel SM-FEVAR.
Abdominal EVAR 9 Seven patients underwent SM-FEVAR with nine adjunct
ASA class chimney (n ¼ 6; all CA) or periscope endografts (n ¼ 3; all
2 3 RA). All of these techniques were planned and per-
3 26 formed intentionally. None of these patients had intrao-
4 25 perative or postoperative gutter-related type IA
Hypertension 37 endoleaks.
COPD 14
The procedure was intentionally performed in two
stages during the same acute admission in four patients
CAD 18
with symptomatic TAAA and was completed in three:
CKD stage 3A-5 13
patient 3 described before; patient 20 (extent III TAAA
Permanent renal dialysis 1
with chronic type B dissection), who underwent first-
Preoperative eGFR, mL/min/1.73 m2, 80 (11-90) stage two-vessel SM-FEVAR with left RA fenestration
median (range)
unstented for spinal cord perfusion and was completed
Diabetes 4
on day 8; and patient 33 (extent II TAAA), who underwent
CVD 3 first-stage thoracic endovascular aortic repair and was
Prior cancer 6 completed with four-vessel SM-FEVAR on day 3. One pa-
Preoperative hemoglobin level, mg/ 11.3 (7.9-16.3) tient (patient 8; visceral aortic patch aneurysm) had a left
dL, median (range) iliac endoconduit to deliver a three-vessel SM-FEVAR and
Aneurysm extent the single RA fenestration was unstented to perfuse a
JRAAA with type IA endoleak 4 large patent intercostal artery, but the patient required
TAAA extent IV 31 resection for an ischemic colonic perforation (most likely
TAAA extent I-III 19 due to a combination of mesenteric ischemia and
Aortic disease coverage of the ipsilateral internal iliac artery) and died
Acute symptomatic 40 before completion. The median operating time was
Ruptured 10 224 minutes (IQR, 186-294 minutes).
Mycotic 28
Early outcomes. The 30-day/in-hospital mortality was
Nonmycotic 26
16.7% (n ¼ 9; symptomatic, 7.4%; rupture, 50%) and fell
ASA, American Society of Anesthesiologists; CAD, coronary artery dis-
ease; CKD, chronic kidney disease (stage 3A-5 represents significantly from 29.6% (n ¼ 8) in the first 27 patients to
eGFR <60 mL/min/1.73 m2); COPD, chronic obstructive pulmonary 3.7% (n ¼ 1) in the most recent 27 patients (P ¼ .0243).
disease; CVD, cerebrovascular disease; eGFR, estimated glomerular
filtration rate; EVAR, endovascular aneurysm repair; JRAAA, juxtarenal With regard to anatomic extent of aneurysm, the 30-day/
abdominal aortic aneurysm; TAAA, thoracoabdominal aortic aneurysm. in-hospital mortality for extent IV TAAA and type IA
endoleaks was 14.3% (5/35) compared with 21% (4/19) for
extent I to extent III TAAA (P ¼ .704). With regard to
already on renal dialysis, and unilateral RAs were inten- disease, the 30-day/in-hospital mortality for suspected
tionally sacrificed in two patients. Five RAs in four pa- mycotic aneurysms was 10.7% (3/28) compared with 23%
tients were not involved in the landing zone of the (6/26) for nonmycotic aneurysms. The mortality accord-
endograft. ing to the fenestration/scallop configuration was as fol-
Intraoperatively, five (3%) target vessels occluded in four lows: single, 25% (1/4); double, 37% (3/8); triple, 13% (2/15);
patients: the RA successfully stent grafted but occluded and quadruple or more, 11% (3/27). With the exception of
in ruptured TAAA treated without heparinization; previ- rupture status, there was no statistically significant dif-
ously stented RA misaligned in postchronic type B ference in any of the preoperative demographics (Table I)
dissection TAAA; stenosed CA in mycotic TAAA; and ste- between survivors and nonsurvivors.
nosed CA and RA in failed infrarenal EVAR with type IA SCI occurred in one patient (1.9%) who presented with a
endoleak. ruptured extent II TAAA. This patient also required dial-
Early in our experience, two patients were treated with ysis, underwent reoperation for groin hemorrhage,
adjuvant open surgical bypass. Patient 3 (mycotic extent demonstrated no neurologic recovery with salvage CSF
Journal of Vascular Surgery
Volume -, Number -
Fig 2. Intraoperative images of two-vessel (A), three-vessel (B), four-vessel (C), and five-vessel (D) surgeon-modified
fenestrated endovascular aneurysm repair (SM-FEVAR) devices.
drainage, and died after requesting withdrawal of treat-
ment. One patient (patient 8, described before) required
ventilator support for >48 hours and died of sepsis after
colonic resection for an ischemic perforation. No survi-
vors developed a stroke or required new permanent
renal dialysis.
Three (5.6%) patients returned to the operating room
during the index admission for nonaorta- or nongraft-
related complications and none survived: the two pa-
tients described before (for groin hemorrhage and
colonic perforation) and another patient with a second-
ary mycotic aneurysm who had a negative laparotomy
for suspected hemorrhage and subsequently died of
sepsis. Another three (5.6%) patients required an un-
planned aorta- or graft-related reintervention within
30 days, one during the initial admission and two on
readmission to the hospital (Table I). One of these pa-
tients (SM-FEVAR for mycotic ruptured extent IV TAAA)
was readmitted on postoperative day 25 with small
bowel ischemia due to SMA stent graft occlusion and un-
derwent ilio-SMA bypass but did not survive. In addition
Juszczak et al 5
to this patient, another three target vessels occluded in
two patients within the first 30 days postoperatively
with no clinical consequences (CA chimney and RA
fenestration in 10-cm mycotic extent III TAAA; RA peri-
scope in 9-cm ruptured extent I TAAA). The median
duration of critical care stay was 2 days (IQR, 1-3 days),
and overall hospital stay was 9 days (IQR, 6-15 days). No
patients developed abdominal compartment syndrome,
and none of the patients with suspected mycotic aneu-
rysms required adjunct procedures (such as an aneurysm
sac drainage). Two patients with ruptured TAAA required
an intercostal chest drain and none required late lung
decortication.
Medium-term outcomes. Median observed follow-up
was 19.8 months (IQR, 4.5-44.2 months). Estimated sur-
vival at 12 and 24 months was 73.2% (standard error [SE],
6.2%; Fig 3). Eight patients underwent 12 late (>30 days)
aorta- or graft-related reinterventions (Table II), and the
fenestration-bearing component of the repair was
responsible for the reintervention in two patients.
6 Juszczak et al
Fig 3. Kaplan-Meier curve representing overall survival. SM-FEVAR, Surgeon-modified fenestrated endovascular
aneurysm repair.
Estimated freedom from reintervention at 12 months
and 24 months was 87.9% (SE, 5.2%) and 81.6% (SE, 6.4%),
respectively (Fig 4). There were no recurrent graft in-
fections in patients treated for suspected mycotic
aneurysms.
DISCUSSION
This study describes a large single-center series of
SM-FEVAR for acute JRAAA and TAAA. The approach
accounted for <10% of our complex EVAR practice, but
the heterogeneity of the acute aortic presentation (acute
symptomatic and ruptured) and the associated disease
(chronic dissection, degenerative and mycotic aneu-
rysms; TAAA and type IA endoleaks) demonstrate that
it is a broadly applicable technique. The in-hospital mor-
tality (16.7% overall and 7.4% for acute nonruptured
cases) and paraplegia rate (1.9%) are encouraging and
comparable to other reports of EVAR for acute complex
aortic disease. The low incidence of SCI in this series may
be explained by a combination of factors including our
spinal cord protection protocol, which has been in
routine practice since September 2012,19 and the fact
that almost 65% of the patients had JRAAA or extent
IV TAAA and the median extent of supraceliac aortic
coverage was 59 mm. Staging of the endovascular repair
with temporary aneurysm sac perfusion has been
employed to reduce the risk of SCI in elective complex
EVAR, but its use is limited in the nonelective setting.
We have previously reported using temporary aneurysm
sac perfusion in patients with symptomatic nonruptured
TAAA using, among other methods, an unstented
Journal of Vascular Surgery
--- 2019
directional branch.4 In this study, we took an unconven-
tional approach by using an unstented fenestration in
two patients who were considered high risk for SCI and
where no other staging option existed.
Medium-term survival in this series (73% at 2 years) was
similar to that reported in large elective series of
fenestrated-branched EVAR for TAAA,20,21 and although
late reinterventions were frequent, rarely were they
related to the fenestration-bearing component of the
modified device. Importantly, there was evidence of an
improvement in perioperative mortality over time, which
was likely due to multiple factors including our learning
curve, increased frequency of procedures in the second
half of the series, improved imaging in a hybrid operating
room with three-dimensional fusion, and fewer patients
treated for rupture in the second half of the series
(despite the fact that no patients referred to our institu-
tion with hemodynamically stable ruptures were turned
down for anatomic reasons). Some might consider that
the 50% mortality for ruptured TAAA calls into question
whether these patients should be treated. This nihilistic
viewpoint stifles progress and innovation, and it is only
by attempting to treat these patients that one can refine
the selection criteria and endovascular techniques
required to optimize patient outcomes. If a patient
with ruptured TAAA survived the procedure, the survival
at 1 and 2 years was good.
Our institution is a high-volume aortic center providing
a comprehensive range of open and endovascular tech-
niques for elective and emergency repair of the entire
aorta. In patients with acute TAAA and no evidence of
Journal of Vascular Surgery Juszczak et al 7
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Table II. Early and late aorta- and graft-related reinterventions

Prior aortic Type of
Case TAAA Mycotic repair Endograft Indication reintervention Interval
7 III No OR AAA SM-FEVAR (RRA, LRA RA type IB EL Redo RA stent grafting 13 months
fenestration) þ SMA
bypass
9 IV Yes No SM-FEVAR (CA, SMA, Distal AAAa Infrarenal EVAR 43 months
RRA, LRA fenestration)
13 IV Yes No SM-FEVAR (SMA, RRA, SMA stent graft CIA-SMA bypass 25 days
LRA fenestration) occlusion
19 II No No SM-FEVAR (CA, SMA Type IA EL TEVAR þ LCCA chimney 4 months
fenestration; RRA Type IB EL Renal þ SMA 32 months
scallop) debranching
25 II No OR AAA SM-FEVAR (SMA, RRA, SMA type IB EL Redo SMA stent grafting 17 months
LRA fenestration)
26 II No OR arch, SM-FEVAR (SMA, RRA, Type IB EL Infrarenal EVAR 12 months
TEVAR LRA fenestration)
28 II Yes No SM-FEVAR (CA, SMA, New proximal mycotic TEVAR IP 8 days
RRA, LRA fenestration) aneurysm
30 II/CTBD Yes TEVAR SM-FEVAR (CA, SMA, Type II EL Embolization 8 months
RRA, LRA fenestration) Type IB EL Limb extension (left) 12 months
Type IB EL Limb extension (right) 18 months
35 III No Ascending OR SM-FEVAR (CA, SMA, Distal AAAb Infrarenal EVAR þ coil 2 months
RRA, LRA fenestration) left IIA, right EIA-IIA
bypass
44 IA No EVAR SM-FEVAR (CA, SMA, Type IB EL Limb extension (right) 3 months
RRA, LRA fenestration) Limb extension (left) 6 months
47 IV Yes No SM-FEVAR (CA, SMA, New distal mycotic Infrarenal EVAR 21 days
RRA, LRA fenestration) aneurysm
AAA, Abdominal aortic aneurysm; CA, celiac axis; CIA, common iliac artery; CTBD, chronic type B dissection; EIA, external iliac artery; EL, endoleak;
EVAR, endovascular aneurysm repair; IIA, internal iliac artery; IP, inpatient; LCCA, left common carotid artery; LRA, left renal artery; OR, open surgical
repair; RA, renal artery; RRA, right renal artery; SMA, superior mesenteric artery; SM-FEVAR, surgeon-modified fenestrated endovascular aneurysm
repair; TAAA, thoracoabdominal aortic aneurysm; TEVAR, thoracic endovascular aortic repair.
a
Known 45-mm AAA at time of SM-FEVAR and monitored until planned intervention at 60 mm.
b
Known 75-mm AAA at time of SM-FEVAR and planned intervention once patient has recovered from SM-FEVAR.

connective tissue disease, endovascular repair is consid-
ered the technique of choice rather than open surgery,
and this includes extent IV aneurysms. A large proportion
of patients in this series had confirmed or suspected
mycotic aneurysms. Whereas open surgery with exten-
sive débridement and tissue sampling to guide antimi-
crobial treatment is arguably the standard of care for
mycotic infrarenal aortoiliac aneurysms, this is not neces-
sarily the case for patients with mycotic paravisceral and
thoracoabdominal aneurysms, where the magnitude of
open surgery is considerable and many patients are de-
nied intervention because of significant comorbidity,
coexisting infection, or poor condition on presentation.
In our practice, these cases are discussed with our cardio-
thoracic aortic surgeons to determine whether open
repair is a reasonable option, but almost invariably an
endovascular-first approach is favored. In the absence
of rupture, surgery is performed if the patient is systemi-
cally stable and once antibiotic therapy has had suffi-
cient time to render the patient apyrexial.
Once the decision has been reached to proceed with
an endovascular repair, the clinical dilemma then
involves balancing the risks and benefits of SM-FEVAR,
the t-Branch device, and chimney and periscope endog-
rafts. SM-FEVAR accounted for 57% of acute JRAAA and
TAAA endovascular repairs. During the study period,
another 41 patients were treated with chimney and peri-
scope endografts alone (n ¼ 17), the t-Branch device (n ¼
17), or custom-made fenestrated-branched devices
already available in the hospital and intended for the
same or another patient (n ¼ 7). The in-hospital mortality
for SM-FEVAR was similar to these other techniques,
particularly in the case of acute TAAA (SM-FEVAR, 18%;
chimney and periscope endografts, t-Branch, and
custom fenestrated-branched devices, 21.4%).
The SM-FEVAR technique provides a quick customized
solution with minimal compromise. Specifically, the
length of supraceliac coverage can be tailored to mini-
mize the risk of SCI; narrow aortic lumen is no obstacle,
and the technique is feasible in postchronic type B
dissection TAAA; and upward-oriented target vessels
can be accommodated by appropriately placed fenes-
trations. However, a high level of knowledge of device
planning is required, graft modification can be
8 Juszczak et al
Fig 4. Kaplan-Meier curve representing freedom from reintervention. SM-FEVAR, Surgeon-modified fenestrated
endovascular aneurysm repair.
time-consuming (although rarely taking longer than
60 minutes), and durability is unknown as published se-
ries are scarce. Early experience of the technique was in
North America,7-9 where it was developed before
custom-manufactured devices became available. Only
recently have there been reports from Europe, but the
number of patients treated is small. Cochennec et al6 re-
ported a 9% mortality in 11 patients with acute TAAA; and
Tsilimparis et al10 reported a 14% mortality in 21 patients
(11 with acute thoracoabdominal aortic disease) with,
reassuringly, no device-related complications at a mean
follow-up of 11 months. This series dealt almost exclu-
sively with acute TAAA, and despite increased
complexity with all repairs extending into zone 5 or
above, the early outcomes during the entire study period
were similar to those of the two smaller European
reports.
Acute complex aneurysms are often unsuitable for the
t-Branch according to the instructions for use, thereby
necessitating adjunctive techniques that prolong the
procedure and may contribute to the increased risk of
SCI.2-5 The majority of patients treated with this device
in our institution have been outside the instructions for
use. In our opinion, there are two principal compromises
with t-Branch: the length of supraceliac coverage can be
excessive, especially if it is deployed more proximally to
accommodate all of the target vessels, and this exposes
the patient to a higher risk of SCI; and deployment in a
narrow aortic lumen, as is often the case in extent IV
TAAA and saccular paravisceral aneurysms, risks failure
to catheterize a target vessel or target vessel stent graft
Journal of Vascular Surgery
--- 2019
compression and occlusion during follow-up.3 The pub-
lished outcomes of nonelective t-Branch are difficult to
compare with large asymptomatic aneurysms included
alongside symptomatic and ruptured aneurysms. The
Bologna group2 reported 1 (12.5%) death in 8 patients
with acute symptomatic or ruptured TAAA, whereas
the Malmö group3 had 3 (27%) deaths in 11 patients
with ruptured TAAA, with SCI in 3 (27%) patients (2 pa-
tients treated for extent IV TAAA). The Hamburg group5
reported a 10% 30-day mortality in 30 patients with
acute symptomatic or ruptured TAAA, with SCI devel-
oping in 8 (27%) patients (1 patient treated for extent IV
TAAA), of whom 4 patients (13%) had permanent
paraplegia.
Chimney and periscope endografting represents an
alternative off-the-shelf customized option that may
also avoid excessive supraceliac coverage. Acceptable
outcomes can be achieved when up to two target vessels
are stent grafted,22 representing an acceptable option for
JRAAA, but parallel endograft occlusion, stroke, and mor-
tality rates all increase as the number of target vessels in-
creases,23,24 and there are few data on acute TAAA, for
which preservation of three or four target vessels is invari-
ably required.11-15 As with t-Branch, in patients with
extent IV TAAA and saccular paravisceral aneurysms,
the native aortic lumen is often too narrow to accommo-
date three or four parallel endografts. Chimney endog-
rafts are, however, useful adjuncts to SM-FEVAR for
challenging target vessels.16,17 Early in our experience,
we chose to use adjunct chimney and periscope endog-
rafts in 4 of the first 12 patients because of relative
Journal of Vascular Surgery
Volume -, Number -
inexperience with multivessel SM-FEVAR; surgical reno-
visceral bypasses were performed in two patients for
the same reason. The main indication for chimney and
periscope endografts in these early repairs was a steeply
downward-facing and compressed CA, and this remains
a relative indication for its use in our current practice.
One important exception was a patient with a ruptured
extent I TAAA who underwent single-vessel (SMA)
SM-FEVAR with bilateral renal periscope endografts as
extreme pararenal tortuosity precluded accurate posi-
tioning of the renal fenestrations. Although there were
no gutter endoleaks in the small group of patients
treated in this manner in this study, our concerns about
durability remain, with two of nine chimney and peri-
scope endografts occluding within 30 days of repair,
albeit without clinical consequences.
SM-FEVAR appears to be an extremely useful addition
to the armamentarium for tackling acute JRAAA and
TAAA, particularly where the required aortic coverage is
less than with t-Branch, the aortic lumen is narrow, and
target vessels are upward oriented. The technique is
more forgiving than one might expect, with some
degree of tolerance in the position of the fenestrations
if they are placed in the interstent gaps. Indeed, the
target vessels that occluded intraoperatively in this series
would have been challenging with custom-
manufactured devices. Whereas there is little in the
way of data on durability when the devices are used in
the acute setting, this series and another series10 have
demonstrated no significant issues arising from the
modified section of the devices within the first year after
implantation, indicating that the devices appear to be
robust enough to treat the acute patient who has no
open surgical option and an extremely short life expec-
tancy without intervention.
Limitations. Although we have reported good out-
comes in terms of early morbidity and mortality,
medium-term survival, and endograft durability, the
number of patients described is relatively small, the cohort
is heterogeneous, and the follow-up is relatively short so
that it is not possible to reach robust conclusions. A
multicenter study with longer follow-up would be
required to demonstrate the role and efficacy of
SM-FEVAR in the management of acute JRAAA and TAAA.
CONCLUSIONS
Despite its versality, the endovascular community has
been slow to adopt the technique, and the number of
acute aneurysms reported in the world literature is small.
One hurdle may be concerns about the lack of regulatory
approval, but this can be overcome by working with the
institutional ethics and governance departments to
create clear guidelines to justify its use. Whereas there
is no doubt that the technique requires an in-depth
knowledge of complex device planning and advanced
Juszczak et al 9
endovascular skills, these attributes are within the capa-
bility of specialist centers that will have the experience to
plan, to modify, and to implant what is currently, in our
opinion, an extremely valuable customized endovascular
solution for patients with acute complex aneurysms.
AUTHOR CONTRIBUTIONS
Conception and design: MJ, JM, MC, DA
Analysis and interpretation: MJ, JM, MC, DA
Data collection: MJ, MV, MK, DA
Writing the article: MJ, DA
Critical revision of the article: MJ, MV, MK, JM, MC, DA
Final approval of the article: MJ, MV, MK, JM, MC, DA
Statistical analysis: MJ
Obtained funding: Not applicable
Overall responsibility: DA
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Submitted Mar 9, 2019; accepted Oct 5, 2019.