CLINICAL STUDY Endovascular Treatment Options for Complex Abdominal Aortic Aneurysms Sonia Ronchey, MD, Eugenia Serrao, MD, Holta Kasemi, MD, Felice Pecoraro, MD, Stefano Fazzini, MD, Vittorio Alberti, MD, and Nicola Mangialardi, MD ABSTRACT Purpose: To report short-term and midterm outcomes of endovascular aneurysm repair (EVAR) of complex aneurysms requiring revascularization of visceral arteries. Materials and Methods: Prospective data were collected from patients deemed unsuitable for conventional EVAR and conventional surgery who were treated with different endovascular approaches according to the clinical presentation of the aneurysm. Custom-made fenestrated endovascular aneurysm repair (CM f-EVAR) was used in the elective setting, homemade fenestrated endovascular aneurysm repair (HM f-EVAR) or HM f-EVAR combined with chimney endovascular aneurysm repair (ch-EVAR) was used in the emergent setting in patients with hemodynamic stability, and ch-EVAR was used in unstable cases. The study included 34 consecutive patients. Primary outcomes measured were perioperative mortality and morbidity, renal function impairment (RFI), target vessel patency, and survival at mean follow-up. Results: In the CM f-EVAR group (7 of 34 patients; 20.6%), an intraoperative type III endoleak (1 of 7 patients; 14%) sealed spontaneously. At 8.9 months of follow-up, one (1 of 7 patients; 14%) death and one (1 of 7 patients; 14%) episode of transient RFI were documented. Visceral vessel patency rate was 95.2%. In the HM f-EVAR group (4 of 34 patients; 11.7%) and the combination of HM f-EVAR and ch-EVAR group (3 of 34 patients; 8.8%), no complications were observed at 17.3 months of follow-up. In the ch-EVAR group (20 of 34 patients; 58.8%), visceral patency was 95% at 30.9 months of follow-up. Two cases of transient RFI and 2 cases of permanent RFI were registered (2 of 20 patients; 10%). One asymptomatic renal artery branch occlusion was observed at 11 months of follow-up. No endoleaks were documented. Conclusions: EVAR techniques including CM f-EVAR, HM f-EVAR or HM f-EVAR in combination with ch-EVAR, and ch- EVAR are valid tools to maintain blood flow in visceral arteries during treatment of complex aortic aneurysms. The proposed interventional protocol based on clinical presentation was feasible in all cases. ABBREVIATIONS ch-EVAR = chimney endovascular aneurysm repair, CM f-EVAR = custom-made fenestrated endovascular aneurysm repair, EVAR = endovascular aneurysm repair, HM f-EVAR = homemade fenestrated endovascular aneurysm repair, RA = renal artery, RFI = renal function impairment, SMA = superior mesenteric artery Conventional endovascular aneurysm repair (EVAR) is not feasible in a complex aortic aneurysm with inadequate landing zone, and open surgery is still the gold standard (1,2). In patients who are not considered to be candidates for conventional surgery, different endovascular tools have been reported to exclude com- plex aortic aneurysms while maintaining blood flow into visceral arteries (3–6). The purpose of this study was to report our short-term and midterm results with fenes- trated and chimney techniques using an interventional protocol based on clinical presentation. MATERIALS AND METHODS Patients and Treatment Selection From April 2007 to March 2013, data from pati- ents treated with custom-made fenestrated endovascular & SIR, 2015 J Vasc Interv Radiol 2015; XX:]]]–]]] http://dx.doi.org/10.1016/j.jvir.2015.02.021 None of the authors have identified a conflict of interest. From the Department of Vascular Surgery (S.R., E.S., H.K., S.F., V.A., N.M.), San Filippo Neri Hospital, Rome; and Vascular Surgery Unit (F.P.), AOUP “P. Giaccone,” University of Palermo, Via Liborio Giuffrè, 5, Palermo 90100, Italy. Received September 16, 2014; final revision received February 2, 2015; accepted February 21, 2015. Address correspondence to F.P.; E-mail: felice. pecoraro@unipa.it