Anatomical applicability of ‘’No-cross’’ concept in FEVAR

Abstract Introduction Fenestrated endovascular aortic repair (FEVAR) is a preferred treatment for complex aneurysms, offering lower morbidity and mortality, especially in high-risk patients. However, challenges remain, including anatomical limitations and reintervention rates up to 25% due to endoleaks and target vessel complications. Some arise intraoperatively when the distal component’s dilator tip conflicts with bridging stents while crossing the narrow renovisceral aorta, potentially causing damage. To address this, a novel “no-cross” concept using short dilator tips was introduced to avoid fenestration crossing. This study evaluates the anatomical applicability of various endograft combinations to achieve the "no-cross" principle. Method Preoperative CTA scans from 182 of 282 patients who underwent elective FEVAR at our center between January 2015 and June 2024 were reviewed. Only primary repairs were included. A 3D software was used to measure aortic and iliac anatomy. Applicability of the no-cross approach was assessed using various COOK and Gore distal component combinations. Result Standard Cook components led to nearly universal fenestration crossing. In contrast, the no-cross approach showed high anatomical applicability with all short-tip devices. Absolute applicability was achieved using Gore with a contralateral Gore leg from the right. COOK short tips combined with contralateral Gore limbs yielded 97% applicability from the right and 98% from the left. Discussion The no-cross concept appears anatomically applicable in most FEVAR cases using short-tip dilator systems. It may reduce intraoperative bridging stent complications. Prospective studies are needed to confirm clinical benefits and assess long-term outcomes. These findings could influence future endograft designs, improving safety in complex aortic aneurysm repair.