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In this issue, Le Houerou and colleagues 1 Le Houerou T. Alvarez-Marcos F. Gaudin A. Bosse C. Costanzo A. Vallee A. et al. Midterm outcomes of antegrade in situ laser fenestration of polyester endografts for urgent treatment of aortic pathologies involving visceral and renal arteries. Eur J Vasc Endovasc Surg. 2023; 93: 720-727 Abstract Full Text Full Text PDF Scopus (1) Google Scholar report the early and midterm outcomes of urgent endovascular aortic aneurysm repair using commercially available polyester endografts modified using an antegrade in situ laser fenestration technique (LFEVAR). A number of endovascular approaches are available for patients with acute complex aortic aneurysms who are not candidates for open repair, and include off the shelf commercially manufactured devices, back table physician modification of standard endografts, and parallel grafts. 2 Mascoli C. Vezzosi M. Koutsoumpelis A. Iafrancesco M. Ranasinghe A. Clift P. et al. Endovascular repair of acute thoraco-abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2018; 55: 92-100 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In the present study, the authors demonstrate that LFEVAR may be an acceptable alternative approach, reporting high technical and clinical success. Using this approach, fenestrations are not reinforced, and this is one of the potential compromises of the technique. 3 DiBartolomeo A.D. Han S.M. Techniques of antegrade in situ laser fenestration for endovascular aortic repair of complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg Cases Innov Tech. 2022; 8: 787-793 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Indeed, the first fenestrated aortic stent grafts had unsupported fenestrations, 4 Anderson J.L. Berce M. Hartley D.E. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther. 2001; 8: 3-15 Crossref PubMed Scopus (225) Google Scholar and these were quickly superseded by the devices with reinforced fenestrations which are in use today. Reassuringly, there was a low incidence of fenestration related endoleaks during a median follow up of 24 months which, in part, may be related to patient selection: the authors advocate that the technique should ideally be reserved for those pathologies where there will be contact between the endograft and the aortic wall. Physician modified fenestrated and off the shelf branch endografts remain a better option in patients presenting acutely with extent I–IV thoraco-abdominal aneurysms (TAAA) where there will be no contact between the endograft and the renovisceral segment of the aortic wall. 5 Juszczak M.T. Vezzosi M. Khan M. Mascaro J. Claridge M. Adam D. Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts. J Vasc Surg. 2020; 72: 435-444 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The potential value of this technique may, therefore, be in the treatment of patients with ruptured short necked infrarenal and juxtarenal abdominal aortic aneurysm (AAA) who are anatomically unsuitable for temporary ‘damage limitation’ off IFU infrarenal endovascular repair, and where a proximal seal in aortic zone 6 or 7 may suffice. Compared with acute TAAA, these patients present far more frequently and are more likely to be salvageable even if there is an element of haemodynamic instability. The authors assert that back table physician modification of standard endografts may be unsuitable for unstable patients because of the time taken for modification, but pre-stenting of the renovisceral target vessels prior to LFEVAR may also be associated with an inherent delay. If LFEVAR is to have a role in the management of ruptured AAA, then an alternative approach to pre-stenting of target vessels may be needed which will allow more rapid proximal aortic control while facilitating subsequent renovisceral stent grafting. However, the learning curve and logistical challenges of delivering this technique in the emergency setting should not be underestimated: although over 40% of patients in this series presented acutely, only two patients were treated for aortic rupture. The authors of the present study are to be commended for developing their LFEVAR technique, refining patient selection criteria, and delivering good early and midterm outcomes in a physiologically and anatomically complex cohort. Further studies are required in patients with ruptured complex AAA to elucidate the potential of this approach. Midterm Outcomes of Antegrade In Situ Laser Fenestration of Polyester Endografts for Urgent Treatment of Aortic Pathologies Involving the Visceral and Renal ArteriesEuropean Journal of Vascular and Endovascular SurgeryVol. 65Issue 5PreviewAortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for the emergency repair of complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article was to evaluate the midterm results of LFEVAR performed with polyester endografts. Full-Text PDF