VESS25 - A Fenestrated, Double Barrel Technique for Proximal Reintervention After Open or Endovascular Abdominal Aortic Aneurysm Repair

Objectives: Proximal endovascular reintervention after prior EVAR or open AAA repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow use of the commercially available ZFEN device using a double barrel, kissing-limb technique.

Methods: Patients undergoing fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πDLIMB = πDZFEN + 2DZFEN (Figure 1).

Results: Of 235 patients undergoing ZFEN from 2012-2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 using the double barrel technique (8 EVAR, 5 OR). Distance from the flow divider to the lowest renal artery was 67±24.4 mm (range 39-128), and to the SMA was 87±30.5 mm (range 60-164). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal/SMA to accommodate a standard ZFEN build was 56/60 mm, respectively. Four patients required adjunctive snorkel grafts and 2 required laser fenestrations. Two patients had small gutter leaks at one month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72% and 48% at 1-, 2- and 3-years.

Conclusions: This double barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.