Advancing Endovascular Solutions for Complex Abdominal Aortic Aneurysms: Patient Selection, Imaging, and Device Innovations

Abstract

BACKGROUND Abdominal aortic aneurysm (AAA) poses a significant health risk, with a prevalence of 4.8%, and becomes a surgical concern when the diameter exceeds 5.5 cm due to the heightened risk of rupture. Endovascular aneurysm repair (EVAR) has emerged as the primary approach, especially for infrarenal AAAs, offering advantages over traditional open surgery. However, complex anatomies challenge standard EVAR, leading to the development of innovative endografts. This study reviews the literature on treating complex abdominal aortic aneurysms (C-AAAs), focusing on patient selection, preoperative imaging, and available devices. METHODS A comprehensive literature review was conducted on C-AAAs, encompassing treatment options, patient selection criteria, and preoperative imaging. Searches in Pubmed and Google Scholar utilized keywords such as "complex abdominal aortic aneurysm", "fenestrated endovascular aortic repair (FEVAR)", "branched endovascular aortic repair (BEVAR)", "Chimney endovascular aortic repair (chEVAR)" and "patient selection." Additional relevant articles were included through cross-referencing. RESULTS Patient selection for C-AAA endovascular treatment involves assessing rupture risk, operative mortality, life expectancy, and anatomical considerations. The impact of age on outcomes remains inconclusive across different studies. Preserving renal function is crucial, particularly in patients with renal anomalies, which require careful evaluation. Precise measurements guide decisions, considering factors like aortic tortuosity. Preoperative imaging, particularly computed tomography angiography (CTA), is vital, providing comprehensive anatomical information. Intraoperative fusion imaging enhances real-time assessment, contributing to procedural precision. Device selection, including FEVAR, BEVAR, and Chimney endovascular aortic repair, is tailored to individual anatomy, with custom-made, off-the-shelf, and physician-modified devices offering diverse options. CONCLUSION The endovascular treatment of C-AAAs has undergone significant advancements, transforming therapeutic approaches. Optimal outcomes hinge on meticulous patient selection, comprehensive preoperative imaging, and tailored device selection. The evolution from traditional to innovative endografts reflects a paradigm shift. Ongoing research should refine risk assessment, optimize device modifications, and expand endovascular interventions' applicability for C-AAAs.