The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique for Aorto-Iliac Occlusive Disease

Endovascular treatment options of aorto-iliac occlusive disease have emerged, leading to better outcomes in more complex pathology, which typically involves a reconstruction of the aortic bifurcation. The Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB) configuration was introduced in 2013, in an attempt to optimize outcomes, when compared to the kissing stent configuration, which was traditionally the preferred endovascular technique for this pathology. CERAB aims to optimize geometry, and with that the arterial flow patterns that are associated with loss of patency. In CERAB, the aortic bifurcation is reconstructed using three balloon-expandable covered stents in a tight connection with each other and with an appropriate wall apposition, thereby minimizing geometrical mismatch (Fig. 1a-c). The reconstruction can be extended on both sides and could be combined with chimney, or parallel, grafts in aortic side branches that need to be preserved. In the current paper, the details of the CERAB technique are described and supported by evidence derived from pre-clinical studies that confirm the more optimal geometry and flow patterns compared to kissing stents. Also, a summary is provided of published clinical evidence, including technical and clinical outcomes of the technique. These data show promising early results, with patency rates in line with those achieved with open surgery, also in patients with extensive disease. Finally, the potential modes of failures and future developments are discussed.