While early reports demonstrated OSR of complex AAAs to be associated with increased morbidity and mortality rates compared to infrarenal AAAs [5–7], recent data suggest that OSR of such complex AAAs can be performed with clinical outcomes that are equivalent to those of open infrarenal AAA repair [8–11]. In a retrospective study by Kabbani and colleagues [9] at Henry Ford Hospital, a 30-day mortality of 2.9 % was achieved in a cohort of 245 patients undergoing OSR of pararenal and paravisceral AAAs. Major complications were reported in nearly two-thirds of patients, with acute kidney injury (60 %) and pulmonary complications (22 %) serving as the most common form of perioperative morbidity. Long-term survival rates at 5 and 10 years were 70 % and 43 %, respectively, and compare favorably to those reported in other series involving patients undergoing OSR of infrarenal AAAs. Congestive heart failure, chronic obstructive pulmonary disease, and increased aneurysm size at presentation were associated with worse survival. In addition, the Mayo Clinic group recently reported that OSR of juxtarenal AAAs remains a safe option in the current era of complex EVAR, citing a 0.8 % 30-day mortality rate in their consecutive series of 126 patients undergoing elective OSR requiring suprarenal aortic clamping between 2001 and 2006 [10]. No independent risk factors for mortality were identified in their analysis. One-, three-, and five-year cumulative survival rates were 93.9 %, 78.3 %, and 63.8 %, respectively, and were not significantly different than age or gender-matched normative data of the U.S. population.

Complex EVAR using either the snorkel or fenestrated technique has been performed with excellent technical success and with low morbidity and mortality rates in multiple retrospective and observational studies from high volume referral centers and national registries (Table 5.2). The relative superiority of one technique over the other is unclear at the present time due to a paucity of reports directly comparing these two advanced EVAR techniques. Available data to date have shown no reliable difference in these two approaches pertaining to cannulation failure, target branch vessel patency, early mortality, type I endoleak, postoperative renal dysfunction, or need for secondary intervention [11, 27, 42, 43]. We recently sought to compare the early learning curve at our institution with both techniques [42]. Consistent with previous reports, our investigation demonstrated comparable postoperative outcomes between ch- and f-EVAR with respect to mortality, perioperative complications, and short-term branch vessel patency. Additional studies have reported a wide range of 30-day mortality rates following f-EVAR, with a pooled 30-day mortality of 2.1 % noted in a recent systematic review that included 9 studies encompassing 629 patients [47]. Wilson et al. [48] conducted a similar systematic review of 14 studies involving 176 patients with complex AAA treated with ch-EVAR and noted an overall pooled 30-day mortality of 3.4 %.