Anatomic Feasibility of Off-the-Shelf FEVAR Devices: An Anatomic Study

Abstract Objective Fenestrated endovascular aneurysm repair (FEVAR) enables treatment of complex aortic aneurysms involving visceral branches but is limited by patient-specific anatomical variability. Off-the-shelf (OTS) devices could reduce manufacturing delay; however, their feasibility depends on anatomic compatibility across populations. Design A large multicenter dataset was analysed to evaluate the anatomic feasibility of standardized OTS fenestrated stent-graft configurations for juxtarenal and pararenal abdominal aortic aneurysms (AAAs) in this retrospective anatomic study. Methods Computed tomography angiography (CTA) data from a sample of 8,238 patients evaluated for FEVAR between January 2018 and December 2023 were analysed. Measurements of the celiac axis (CA), superior mesenteric artery (SMA), left renal artery (LRA), and right renal artery (RRA) included ostial distance and branching angle relative to the CA. A greedy set-cover algorithm identified the smallest number of OTS configurations achieving fenestration target vessel alignment (FTVA). Cumulative coverage and clustering by aortic diameter were assessed. Analyses were exploratory and descriptive. Results Anatomic data were available in 57.1% of cases for the SMA, 96.1% for the LRA, and 96.8% for the RRA. The CA served as the reference point for all analyses. Eight configurations covered 81.9% of SMA, 49.7% of LRA, and 52.9% of RRA anatomies. SMA coverage exceeded 90% with 16 designs, while 20 configurations were required for each renal artery to reach 80% coverage. No clustering of vessel origin by aortic diameter (median 28 mm; interquartile range 26–30.5 mm) was observed. Below 70% coverage for three-vessel and <25% for four-vessel combinations was achieved with the top 100 configurations. Conclusion A standardized dual-fenestrated OTS platform incorporating the CA and SMA appears anatomically feasible for most patients, whereas renal artery variability limits multi-vessel standardization. Dual-fenestrated devices with renal branches could also circumvent these constraints fully.