A Simple Target Will Save the Day and the Kidney: This Is How We Perform Our Endovascular Fenestrated Graft Procedure

With the advent of state-of-the-art imaging modalities, increasing population age, and advanced preventive medical treatments, medical device design attempts to keep up with procedural demand. An abdominal aortic aneurysm (AAA) is a recognized, potentially fatal disease process where strides have been made in screening, detection, and treatment since its discovery. With the introduction of percutaneous endograft procedures in 1991, open surgical treatment is nearly a lost art. Endovascular aortic repair is now the gold standard. However, short landing zone necks, hostile angulation, and markedly dilated seal zones present challenges for one size fits all endovascular aortic devices. Suprarenal and juxtarenal fenestrated aortic grafts are the most advanced individually customized grafts invented to date. Subsequently, proper placement of these complex devices still presents challenges. We present a method for preoperative renal stent placement for target purposes. This article includes a pictorial guide and describes the tips and pitfalls for easy proper AAA exclusion with a fenestrated aortic graft. We were successful in the deployment of the fenestrated graft device and the exclusion of an aortic aneurysm while preserving the patency of the renal arteries. The patient had no postoperative complications. During 18-month postoperative surveillance, imaging demonstrated proper graft positioning without evidence of an endoleak. In fenestrated endovascular aortic repair, preoperative renal stenting is paramount for targeting purposes. This allows for the precise and timely deployment of the renal limbs through the fenestrations while minimizing the risk of postoperative complications, including renal artery occlusion.