Suprarenal vs Infrarenal Fixation

Recent decades have been illuminating for the establishment of endovascular aneurysm repair as the treatment of choice for elective and urgent patients with infrarenal abdominal aortic aneurysm. Devices have been constantly developing leading to improved device durability and clinical outcomes. One of the most important issues is the conformability of the endograft to proximal aortic neck anatomy and the suitability of each device to achieve proximal sealing minimizing complications such as migration, endoleak type Ia, and potentially rupture, re-intervention, and death. The proximal fixation systems can be either suprarenal or infrarenal. Devices achieve fixation with multiple features, including active fixation (using barbs or hooks), columnar strength, outward radial force, and fibrotic reaction with prosthetic materials. Some devices may incorporate more than one of these features. Controversy exists on whether the suprarenal bare-metal stents are associated with long-term renal dysfunction, with most recent meta-analysis showing similar outcomes between supra- and infrarenal endografts. There is also a controversy on whether the type of fixation plays a role in migration or neck remodeling-enlargement. In conclusion, there is no available strong evidence to show superiority of any type of fixation, and therefore an individualized strategy respecting the instructions for use of each endograft may provide the most favorable outcome. Finally, proper follow-up is of paramount importance in any device.