Procedural and Mid-term Outcomes of Stented, Unstented Fenestrations and Scallop Configurations for Celiac Axis Incorporation in Fenestrated Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND

Incorporation of the celiac axis (CA) during fenestrated endovascular aneurysm repair (FEVAR) can be achieved using stented fenestrations, unstented fenestrations, or scallop configurations. Comparative evidence supporting one strategy over another remains limited. This study aimed to evaluate procedural efficiency, visceral-vessel durability, aneurysm sac behavior, endoleak incidence, and secondary intervention rates across these three CA management strategies.

METHODS

A retrospective single-center study was conducted of consecutive patients undergoing FEVAR with CA incorporation between 2007 and 2024 using only custom-made Zenith Fenestrated devices. Patients were grouped according to CA configuration: stented fenestration, unstented fenestration, or scallop. Peri-operative metrics, mortality, endoleaks, CA patency, aneurysm sac evolution, and secondary interventions were analyzed. Between-group comparisons were performed using appropriate nonparametric or categorical statistical tests.

RESULTS

A total of 129 patients were included (58 stented, 26 unstented, 45 scallop), with a median follow-up of 23.4 months [IQR 9.6-59.4]. Baseline demographics and comorbidity profiles were comparable. Operative time, fluoroscopy time, radiation dose, contrast volume, and estimated blood loss did not differ significantly between CA strategies (all P > 0.05). Thirty deaths (23.3%) occurred during follow-up, with no significant survival difference between groups after adjustment for follow-up duration (P = 0.12); 30-day mortality remained below 2%. Endoleak incidence during follow-up was similar across strategies (P = 0.48), predominantly type II, with no excess of type I or III endoleaks in any configuration. Aneurysm sac behavior was comparable, with no significant difference in sac diameter change or rates of ≥5 mm regression. Loss of CA patency and CA-related re-interventions were uncommon and did not differ between groups. Overall secondary intervention rates were similar across CA strategies (P = 0.77).

CONCLUSION

In this large single-center FEVAR cohort, CA incorporation using stented fenestrations, unstented fenestrations, or scallops resulted in comparable procedural efficiency, visceral-vessel durability, aneurysm sac behavior, and re-intervention rates. These findings support an anatomy-driven, individualized approach to CA management during FEVAR without compromising mid-term outcomes.