Introduction: Endovascular approach to abdominal aortic aneurysm has increased in frequency over the last decade and is preferred by many practitioners and patients alike. However, its role in "complex" aneurysms with challenging anatomy, short neck length, or borderline landing zone for grafts is less well understood. Additionally, the endovascular role in complex urgent or emergent repairs has not been adequately studied. Several techniques have been developed in order to address these concerns and further the endovascular approach. This article seeks to describe incidents in which an endovascular approach may be challenging, describe the most popular techniques now available for approaching these cases, and present the best literature available for considering these techniques.
Evidence acquisition: Medline searches were performed with the key words "complex endovascular aneurysm repair," "fenestrated endovascular aneurysm repair," "chimney grafts" and "snorkel grafts" to gain access to available data.
Evidence synthesis: Articles were reviewed for results and technical considerations.
Conclusions: By employing increasingly complex endovascular techniques, complex pararenal aneurysms can be successfully treated in an endovascular fashion.