Management of type I endoleaks—Extension fenestrated cuffs

After endovascular aortic aneurysm repair (EVAR) with last generation endografts, up to 22% of patients have persistent sac perfusion.1–3 Such technical failure of the endovascular repair4 exposes the patient to aortic rupture.5 According to recent guidelines, when technically feasible, high-flow endoleaks should be managed promptly.6,7 Type III and distal type I (or Ib) endoleaks are usually easy to fix, but the treatment of proximal type I (or Ia) endoleaks may pose significant technical challenges requiring complex procedures. Indications for standard infrarenal EVAR are challenged by individual patient anatomy and clinical urgency leading to increasing numbers of patients treated outside instructions for use.8,9 In practice this increases the risk of proximal type I endoleaks. When no sealing zone is available for an infrarenal cuff extension, options include:10–12 • Conversion to open surgery, which often requires supracoeliac aortic clamping • Chimney, periscope and snorkel techniques (CHIMPS) • Fenestrated aortic extension cuffs to reposition the proximal sealing and fixation zones in a non-diseased segment of the aorta above the aneurysm In our experience, fenestrated aortic cuff extension is the preferred option over open surgery with CHIMPS reserved as a bailout option in emergency cases. Successful implantation of fenestrated cuffs requires thorough analysis of pre- and post-implantation imaging, reconstruction on 3D workstations and large experience with fenestrated endografting. In this chap