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Purpose Radiation safety performance is often evaluated using dose parameters measured by personal dosimeters and/or the C-arm, which provide limited information about teams' actual radiation safety behaviors. This study aimed to develop a rating scale to evaluate team radiation safety behaviors more accurately and investigate its reliability. Materials and Methods A modified Delphi consensus was organized involving European vascular surgeons (VS), interventional radiologists, and interventional cardiologists. Initial items and anchors were drafted a priori and rated using five-point Likert scales. Participants could suggest additional items or adjustments. Consensus was defined as >= 80% agreement (rating >= 4) with Cronbach's alpha >= .80. Two VS with expertise in radiation safety evaluated 15 video-recorded endovascular repairs of infrarenal aortic aneurysms (EVAR) to assess usability, inter and intrarater reliability. Results Thirty-one of 46 invited specialists completed three rating rounds to generate the final rating scale. Five items underwent major adjustments. In the final round, consensus was achieved for all items (alpha = .804; agreement > 87%): 'Pre-procedural planning', 'Preparation in angiosuite/operating room', 'Shielding equipment', 'Personal protective equipment', 'Position of operator/team', 'Radiation usage awareness', 'C-arm handling', 'Adjusting image quality', 'Additional dose reducing functions', 'Communication/leadership', and 'Overall radiation performance and ALARA principle'. All EVARs were rated, yielding excellent Cronbach's alpha (.877) with acceptable interrater and excellent intrarater reliability (ICC = .782; ICC = .963, respectively). Conclusion A reliable framework was developed to assess radiation safety behaviors in endovascular practice and provide teams with formative feedback. The final scale is provided in this publication.

Objective To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry. Methods For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak. Results Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904). Conclusions Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.

Background The benefits of endovascular repair of ruptured abdominal aortic aneurysm remain controversial, without any strong evidence about advantages in specific subgroups. Methods An individual‐patient data meta‐analysis of three recent randomized trials of endovascular versus open repair of abdominal aortic aneurysm was conducted according to a prespecified analysis plan, reporting on results to 90 days after the index event. Results The trials included a total of 836 patients. The mortality rate across the three trials was 31·3 per cent for patients randomized to endovascular repair/strategy and 34·0 per cent for those randomized to open repair at 30 days (pooled odds ratio 0·88, 95 per cent c.i. 0·66 to 1·18), and 34·3 and 38·0 per cent respectively at 90 days (pooled odds ratio 0·85, 0·64 to 1·13). There was no evidence of significant heterogeneity in the odds ratios between trials. Mean(s.d.) aneurysm diameter was 8·2(1·9) cm and the overall in‐hospital mortality rate was 34·8 per cent. There was no significant effect modification with age or Hardman index, but there was indication of an early benefit from an endovascular strategy for women. Discharge from the primary hospital was faster after endovascular repair (hazard ratio 1·24, 95 per cent c.i. 1·04 to 1·47). For open repair, 30‐day mortality diminished with increasing aneurysm neck length (adjusted odds ratio 0·69 (95 per cent c.i. 0·53 to 0·89) per 15 mm), but aortic diameter was not associated with mortality for either type of repair. Conclusion Survival to 90 days following an endovascular or open repair strategy is similar for all patients and for the restricted population anatomically suitable for endovascular repair. Women may benefit more from an endovascular strategy than men and patients are, on average, discharged sooner after endovascular repair., Strong evidence of equivalence

Background The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. Methods An individual-patient data meta-analysis of four multicentre randomized trials of EVARversus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. Results The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0–6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. Conclusion The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.

Endovascular repair of dissecting thoracoabdominal aneurysms (TAAA) is challenging and often requires multiple procedures. A 61-year-old man with a dissecting type-II TAAA treated first by placement of a thoracic endograft, and subsequently implantation of a fenestrated endograft. Six months postoperatively, a 10-mm increase of the aorta was observed. A reentry tear in left external iliac artery (EIA) was perfusing the false lumen in a retrograde fashion connecting with the endoleak caused by the inferior mesenteric artery and lumbar arteries. False lumen embolization of the left EIA and outflow vessels was performed. Thrombosis and rapid decrease of false lumen diameter was then observed. This case illustrates the complexity of endovascular management of extensive chronic aortic dissections.

Pascal Delsart1, Marco Midulla2, Jonathan Sobocinski3, Charles Achere4, Stephan Haulon3, Gonzague Claisse1, Claire Mounier-Vehier11Vascular Medicine and Hypertension Department, Cardiology Hospital, CHRU Lille, 2Radiology and Cardiovascular Imaging Department, Cardiology Hospital, CHRU Lille, 3Vascular Surgery Department, Cardiology Hospital, CHRU Lille, 4Cardiology Department, Cardiology Hospital, CHRU Lille, FranceAbstract: The chronic management of post-acute aortic dissection (AD) of the descending aorta (Type B) is based on optimal control of blood pressure (BP), with a target BP < 135/80 mmHg. The aim of our study was to determine and verify effective blood pressure control with an objective measurement method and to identify predicting factors.Methods: We collected data from 26 patients hospitalized in the acute phase of a Type B AD between 2006 and 2009. Two groups were defined according to 24 hour BP monitoring results at follow-up. Group 1 consisted of patients with a controlled BP (< 130/80 mmHg), and Group 2 consisted of patients with an uncontrolled BP.Results: Thirty four percent of patients showed an uncontrolled BP at checkup. Vascular history before AD (P = 0.06), high baseline BP trend (P = 0.01 for systolic and P = 0.08 for diastolic), and greater diameter of the descending aorta (P = 0.02) were associated with poor BP control.Conclusion: Prognosis after AD is associated with BP control. Therefore, 24 hour BP monitoring can be made.Keywords: acute aortic syndrome, blood pressure monitoring, hypertension

Type A aortic dissection remains the last challenge of endovascular repair due to the complex anatomy of the ascending aorta and its proximity to the heart and the supra-aortic trunks that makes precise deployment of endografts an extremely difficult procedure. Currently, there are no endovascular devices specifically developed for this aortic region. Thus, open repair is the gold standard approach, but high-risk patients are not eligible for cardiac surgery because of the significant morbidity and mortality associated with these procedures. Therefore, development of a less invasive treatment is an issue that must be addressed. To our best knowledge, there are only a few cases of type A aortic dissections reported in the literature which have been successfully treated with a totally endovascular approach. Two recent CT-based practicability-studies encourage this new approach, describing it as a suitable option for 31-39% of patients. Although the available literature is scant and the experience limited, endovascular repair appears as a treatment option for type A aortic dissections, but further evaluation is mandatory.

The aim of this study was to compare the results of complex aneurysm (hostile neck anatomies) repair in high-risk patients with two minimally invasive techniques, fenestrated endografting (f-EVAR where EVAR stands for endovascular aneurysm repair) and minilaparotomy.All high-risk patients (N.=50, group 1) with hostile neck abdominal aortic aneurysms (AAAs) operated in the vascular surgery department of the "Policlinico Universitario G. Martino" of Messina (Italy) during a 5-year period (January 2006-December 2010) were cross-matched with 50 similar patients (group 2) treated in the Vascular Surgery Department of the "Hopital Cardiologique" University of Lille (France) with similar anatomies, comorbidities and risk factors. The patients in group 1 underwent open minilaparotomy surgery, and the patients in group 2 were treated with f-EVAR. The aim of our study was to compare perioperative complications, survival and reintervention rates.Perioperative cardiac complications occurred in 5 patients (10%) in group 1, and 1 patient (2%) in group 2 (P0.092). Renal impairment not requiring permanent hemodialysis was significantly higher in group 1 (14% vs. 2% P0.027), as well as respiratory complications (32% vs. 2% P0.0001). Five patients (10%) in group 1 underwent reintervention vs. 4 patients in group 2 (P0.7268). There was no statistically significant difference for survival rates at 30 days (92% in group 1 and 96% in group 2; P=0.399); at six months (90% vs. 96%; P=0.239); at one year (90% vs. 96%; P=0.239); and at two years (84% vs. 94%; P=0.110). However, we observed statistically significant differences in survival rates at three years (74% vs. 94%; P0.006); at four years (70% vs. 86%; P0.005); and at five years (65% vs. 68%; P0.003).Our results showed that both techniques are effective in the treatment of AAA with hostile neck in high-risk patients. Although operative mortality rate was not statistically different, f-EVAR showed better results in terms of early complications and late survival.

Thrombotic occlusion after vascular reconstructive surgery is a frequent complication, specially when low-flow arteries and arterial prostheses are involved. Heparin therapy is usually administered in acute arterial insufficiency, and also during the perioperative period, in order to limit thrombus formation or propagation at the surgical or the cross-clamp application sites. The overall benefit of antiplatelet agents, specially aspirin, during the pre, peri and postoperative periods has been clearly demonstrated for arterial prostheses, and is probably useful in venous bypasses. Aspirin therapy also prevents thrombotic complication in other vascular beds, and reduces long-term cardiovascular morbidity and mortality. Oral anticoagulation by vitamin K antagonists, alone or combined with aspirin is perhaps an appropriate choice in selected patients with high risk of graft thrombosis, but cannot be recommended for routine treatments because of an increased risk of hemorrhage.

Background Acute occlusion of renal bridging stent grafts after fenestrated/branched endovascular aortic repair (F/B-EVAR) is an acknowledged complication with high morbidity that often results in chronic dialysis dependence. The feasibility and effect of timely or late (≥6 hours of ischemia) renal artery revascularization has not been adequately reported. Methods We performed a retrospective, multicenter study across 11 tertiary institutions of all consecutive patients who had undergone revascularization of renal artery stent graft occlusions after complex EVAR. The end points were technical success, association between ischemia time and renal function salvage, interventional complications, mortality, and mid-term outcomes. Results From 2009 to 2019, 38 patients with 46 target vessels (TVs; eight bilateral occlusions) were treated for renal artery occlusions after complex EVAR (mean age, 63.5 ± 10 years; 63.2% male). Six patients had a solitary kidney (15.8%). Of the 38 patients, 16 (42.1%) had undergone FEVAR and 22 (57.9%) had undergone BEVAR. The technical success rate was 95.7% (44 of 46 TVs). The recanalization technique used was sole aspiration thrombectomy in 5.3%, aspiration thrombectomy and stent graft relining in 52.6%, and sole stent graft relining in 36.8%. The median renal ischemia time was 27.5 hours (range, 4-720 hours; interquartile range, 4-36 hours). Most patients (94.4%) had been treated after ≥6 hours of renal ischemia time, and 55.6% had been treated after 24 hours. In 14 patients (36.8%), renal function had improved after intervention (mean glomerular filtration rate improvement, 14.2 ± 9 mL/min/1.73 m2). However, 24 patients (63.2%) showed no improvement. Improvement of renal function did not correlate with the length of renal ischemia time. Of the 14 patients with bilateral renal artery occlusion or a solitary kidney, 9 experienced partial recovery of renal function and no longer required hemodialysis. In-hospital mortality was 2.6%. The cause of renal stent graft occlusion could not be identified in 50% of the TVs (23 of 46). However, in 19 (41.3%), significant stenosis or a kink of the renal stent graft was found. The median follow-up was 11 months (interquartile range, 0-28 months). The estimated 1-year patient survival and patency rate of the renal stent grafts was 97.4% and 83.8%, respectively. Conclusions Revascularization of occluded renal bridging stent grafts after F/B-EVAR is a safe and feasible technique and can lead to significant improvement of renal function, even after long ischemia times (>24 hours) of the renal parenchyma or bilateral occlusion, as long as residual perfusion of the renal parenchyma has been preserved. Also, the long-term patency rates justify aggressive management of renal artery occlusion after F/B-EVAR.

The authors regret that the name of one of the co-author has been incorrectly spelt. Dr. Melina Vega de Ceniga should have been cited as “Vega de Ceniga M” The authors would like to apologise for any inconvenience caused.

International audience; ObjectiveProximal para-anastomotic aneurysms, or aneurysmal degeneration of the native aorta above a previous open abdominal aortic repair (Pr-AAAs), are challenging scenarios. The aim of this study was to report the early and mid term outcomes of endovascular repair of Pr-AAAs by fenestrated and branched endovascular aneurysm repair (FB-EVAR).MethodsFrom 2006 to 2017, pre-operative, intra-operative, and post-operative data from patients undergoing FB-EVAR for Pr-AAAs at two European vascular surgery units were prospectively collected and retrospectively analysed. Early results were considered in terms of technical success (target visceral vessel cannulation and stenting, absence of type I – III endoleak, iliac limb occlusion and 24 h mortality); spinal cord ischaemia (SCI) and 30 day and in hospital mortality. Survival, target visceral vessel (TVV) patency, and freedom from re-interventions were also considered at the mid term follow up.ResultsFive hundred and forty-four patients underwent FB-EVAR to treat juxta/pararenal or thoraco-abdominal aneurysms. Of these patients, 108 (19.8%) cases were Pr-AAAs (94% male; mean ± standard deviation [SD] age 71 ± 4 years; American Society of Anesthesiologists’ grade 3–4 in 74% and 26%, respectively). The previous open aortic repair (OR) was performed 10 ± 2 years before FB-EVAR. It was a tubular aorto-aortic repair in 63 (58.3%) cases, a bifurcated aortobi-iliac repair in 37 (34.2%) cases, and an aortobifemoral bypass repair in eight (7.4%) cases. A previous thoracic endovascular aneurysm repair (TEVAR) had been performed in seven patients (6.5%). The aortic lesion at the time of FB-EVAR was, according to the Crawford classification, a type I – III in 69 (63.9%) or a type IV 39 (36.1%) thoraco-abdominal aneurysm. The mean ± SD aneurysm diameter was 64 ± 6 mm. Overall, 390 TVVs (3.6 ± 1 TVV/case) were revascularised by an endograft with fenestrations (n = 63 [58.3%]), with branches (n = 26 [24.1%]), or with both fenestrations and branches (n = 19 [17.6%]). Tubular, trimodular, or aorto-uni-iliac implants were planned in 68 (63.0%), 38 (35.2%), and two (1.8%) patients, respectively. Proximal TEVAR, carotid–subclavian bypass, and iliac branch devices were planned as adjunctive procedures in 41 (38.0%), five (4.6%), and three (2.8%) cases, respectively. Overall technical success was 93%, with technical failures including five TVV losses (coeliac trunk, n = 1; renal arteries, n = 4) and three deaths within 24 h. Post-operative SCI occurred in seven patients (6.5%), four of which (3.7%) were permanent. SCI was more frequent in category I – III TAAAs (p = .042) and in endografts incorporating both fenestrations and branches (p = .023). Cardiac, pulmonary, and renal complications (reduction in glomerular filtration rate of ≥30% compared with baseline) occurred in 9%, 10%, and 20%, respectively. Bowel ischaemia was seen in three (2.8%) patients. Thirty day mortality was 4% and was associated with pre-operative chronic renal failure (p = .034), post-operative cardiac morbidity (p = .041), and bowel ischaemia (p = .003). Overall in hospital mortality was 5.5% (n = 6). Mean ± SD follow up was 38 ± 18 months. Survival was 82%, 64%, and 54% at one, three, and five years, respectively, and target visceral vessel patency was 93%, 91%, and 91%, respectively. Permanent haemodialysis was needed in four patients (3.7%). There was no late aneurysm related mortality. Survival during follow up was statistically significantly affected by pre-operative chronic renal failure (p = .022), post-operative cardiac morbidity (p = .042), SCI (p = .044), and bowel ischaemia (p = .003). Freedom from re-intervention at one, three, and five years was 89%, 77%, and 74%, respectively.ConclusionEndovascular treatment of aneurysmal aortic degeneration above a previous open abdominal repair with FB-EVAR is safe and effective. If those promising results are confirmed at later follow up, FB-EVAR should be considered a prominent therapeutic option, especially in high risk patients.

Improvements in endovascular technologies and development of custom-made fenestrated and branched endografts currently allow clinicians to treat complex aortic lesions such as thoraco-abdominal and aortic arch aneurysms once treatable with open repair only. These advances are leading to an increase in the complexity of endovascular procedures which can cause long operation times and high levels of radiation exposure. This in turn places pressure on the vascular surgery community to display more superior interventional skills and radiological practices. Advanced imaging technology in this context represents a strong pillar in the treatment toolbox for delivering the best care at the lowest risk level. Delivering the best patient care while managing the radiation and iodine contrast media risks, especially in frail and renal impaired populations, is the challenge aortic surgeons are facing. Modern hybrid rooms are equipped with a wide range of new imaging applications such as fusion imaging and cone-beam computed tomography (CBCT). If these technologies contribute to reducing radiation, they can be complex and intimidating to master. The aim of this review is to discuss the fundamentals of good radiological practices and to describe the various imaging tools available to the aortic surgeon, both those available today and those we anticipate will be available in the near future, from equipment to software, to perform safe and efficient complex endovascular procedures.

Aim: To evaluate contrast-enhanced ultrasound (CEUS) as an effective alternative to CT-angiography (CTA) for endoleak detection and aneurismal sac diameter measurement in the follow-up after endovascular abdominal aortic aneurysm repair (EVAR). Methods: From January 2006 to December 2010, 395 patients underwent EVAR follow-up with both CTA and CEUS. The diameter of the aneurismal sac and the presence of endoleaks were evaluated in all the 395 paired examinations. Results: Bland-Altman plots showed a good agreement in aneurismal sac diameter evaluation between the two imaging modalities. The mean diameter was 54.93 mm (standard deviation (SD) ±12.57) with CEUS and 56.01 mm (SD ± 13.23) with CTA. The mean difference in aneurismal sac diameter was -1.08 mm ± 3.3543 (95% confidence interval (CI), -0.75 to -1.41), in favour of CTA. The number of observed agreement in endoleak detection was 359/395 (90.89%). The two modalities detected the same type I and type III endoleaks. McNemar's χ 2 test confirmed that CTA and CEUS are equivalent in endoleak detection. Conclusions: CEUS demonstrated to be as accurate as CTA in endoleak detection and abdominal aortic aneurysm diameter measurements during EVAR follow-up, without carrying the risks of radiation exposure or nephrotoxicity. Even if it cannot be proposed as the sole imaging modality during follow-up, our analysis suggests that it should have a major role. © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective The purpose of this study is to report updated clinical and aortic remodeling results from the Study for the Treatment of complicated Type B Aortic Dissection using Endoluminal repair (STABLE) trial, a prospective, multicenter study evaluating safety and effectiveness of a pathology-specific endovascular system (proximal stent graft and distal bare metal stent) for the treatment of complicated type B aortic dissection. Methods All 86 enrolled patients (mean age, 59 years; 73.3% men) were treated within 90 days of symptom onset (55 with acute dissections and 31 with nonacute dissections). Inclusion criteria were branch vessel obstruction/compromise, impending rupture as evidenced by periaortic effusion/hematoma, resistant hypertension, persistent pain/symptoms, or aortic growth ≥5 mm within 3 months (or transaortic diameter ≥40 mm). Remodeling of the dissected aorta, including thrombosis of the false lumen and changes in the true lumen, false lumen, and transaortic diameter, were assessed in patients with available computed tomographic imaging through 2 years. Results The 30-day mortality rate was 4.7% (4/86) in the overall patient group (5.5% in acute patients and 3.2% in non-acute patients). Freedom from all-cause mortality was 88.3% at 1 year and 84.7% at 2 years (no significant difference between acute and nonacute patients). From baseline to 2 years, the true lumen diameter increased significantly in the descending thoracic aorta and the more distal abdominal aorta, along with a decrease in the false lumen diameter in both aortic segments. A majority of patients had either a stable or shrinking transaortic diameter in the thoracic (80.3% at 1 year and 73.9% at 2 years) or abdominal aorta (79.1% at 1 year and 66.7% at 2 years). Transaortic growth (>5 mm) occurred predominantly in acute dissections. Consistently, a shorter time from symptom onset to treatment was found to predict transaortic growth in the abdominal aorta ( P = .03). Conclusions Endovascular repair of complicated type B aortic dissection with the use of a composite construct demonstrates favorable early clinical outcomes and aortic remodeling. However, patients treated in the acute setting may be prone to aortic growth and may require close observation. Follow-up through 5 years is ongoing.

Introduction: The revascularisation of large (>3 mm) renal arteries emerging from the proximal sealing zone or off the aneurismal wall can be challenging during endovascular aortic aneurysm repair. In this article, we describe various endovascular techniques using custom-made endografts to treat these complex variant anatomies. Cases: Nine patients deemed unfit for open repair with unusual renal vascularisation associated with aortic aneurysms were treated by endovascular means. After three-dimensional (3D) reconstructions on a dedicated workstation, custom-made devices were designed and manufactured. The revascularisation of multiple renal arteries and aberrant origins of renal arteries, associated or not with pelvic kidney or horseshoe kidney, was managed using fenestrated and branched endografts. Results: All target vessels were patent on computed tomography (CT) scan and contrast-enhanced ultrasound evaluation before discharge as well as on the 6-month follow-up. One patient presented a decrease of postoperative glomerular filtration rate over 30% but did not require dialysis. No sac enlargement was depicted, and no reintervention was performed during follow-up. Three type 2 endoleaks were diagnosed. Conclusion: Endovascular treatment with fenestrated and branched endografts should be considered in challenging renal artery anatomies in patients unfit for open repair. © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

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