# Preoperative Planning for Superior Messetric Artery Aneurysm
## 3 Results
### Planning Follow-Up for Surgery Procedures
#### 3.2.2 Endovascular Aneurysm Repair (EVAR) of Superior Mesenteric Artery Aneurysm  
Endovascular treatment is safer than open surgery in patients with multiple comorbidities, such as severe cardiac or pulmonary disease. However, it should not be used when the cause of the aneurysm is suspected to be infectious. Alternative options include covered stent placement, coil embolization, liquid embolic agents, and thrombin injections [6]. Surgical options include an aneurysm with grafting and/or transposition, aneurysm, and ligation [24].  
The vascular interventional radiologist must consider several vascular factors, in addition to bowel viability, when reviewing a CT scan before the treatment of an SMA aneurysm. A femoral arterial approach is the most common, although a radial approach may be more direct when the aortic- mesenteric angle established in CT angiography is acute. Determining the number of aneurysms is important because individuals may have more than one aneurysm. The presence or absence of aneurysmal wall calcification can help to determine the patient's risk of rupture. [PERSON] et al. [25] found that all ruptures in their study occurred in noncalcified aneurysms. An aneurysm with a small neck, distal to the SMA origin, can be treated safely with coil embolization. The aneurysm must be packed tightly with coils to promote thrombosis. With a wide-necked aneurysm, stent-assisted coil placement, in which a bare-metal stent is deployed in the parent vessel and coils are delivered into the aneurysm sac via a microcatheter passed through the interstices of the stent, is an option.  
The location of the aneurysm in the SMA must be considered, because it may be difficult to place a stent in an aneurysm near the point of origin owing to the lack of an adequate landing zone [6]. The stent should extend at least 1 cm proximally and distally to the aneurysm [6]. Large aneurysms may not be conducive to the use of a covered stent owing to instability in a large lumen and/or inadequate landing zones. The diameter and length of the stent can usually be determined accurately from the preoperative CT angiogram and may be compared with the diagnostic angiogram obtained before endovascular intervention. Self-expanding stents are available in various sizes of 5-16 mm and may require different sizes of sheaths, ranging from 5 F to 10 F [6].  
For vessels with a smaller diameter, lower-profile stents are available and can be placed over a 0.018-inch wire. Covered stents are preferred, to completely exclude the aneurysm and prevent an endoleak, but bare metal stents can also be used successfully [26]. The stent should extend past the aneurysm neck without covering too many jejun or ileal branches [24]. Branches arising from the aneurysm itself also must be considered. The tortuosity of the vessel at pre-procedure CT angiography should also be noted because self-expanding covered stents are effective in tortuous vessels but balloon-expandable stents may be used in proximal straight segments [6]. CT angiography with MPR and 3D rendering helps to delineate the proximity of branch vessels to the aneurysm. Studies by [24] have reported covering up to three jejun branches without bowel ischemia. Careful consideration of clinical presentation, gastrointestinal and/or vascular multidetector CT findings, and patient comorbidities is crucial for proper patient selection and treatment.  
Another option for the side branches is to use fenestrated endovascular aortic aneurysm repair (f-EVAR), which gives more options for the endovascular treatment of pararenal aortic aneurysms. The devices are individually customized to the patient's vascular anatomy, especially to the morphology of the visceral vessels. In a typical fenestrated endovascular device design, the superior mesenteric artery (SMA) is involved, either having a large non-strut fenestration or a single wide scallop (10 mm in diameter).