Abstract
PurposeTo describe technical details of modifying four different Cook Zenith devices to treat complex aortic aneurysms.MaterialIn the first three cases, the modification process involved complete stent graft deployment on a sterile back table. Fenestrations were created using an ophthalmologic cautery and reinforced with a radiopaque snare using a double-armed 4–0 Ethibond locking suture based on measurements obtained on centerline of flow. In each instance, a nitinol wire was withdrawn and redirected through and through the fabric and used as a constraining wire. In the fourth patient, modification involved partial stent graft deployment and creation of additional two fenestrations to accommodate renal arteries. The devices are resheathed and implanted in the standard fashion.ResultsFour patients underwent exclusion of their aneurysms, including thoracoabdominal aneurysms (n = 2), a contained ruptured juxtarenal aneurysm (n = 1), and a ruptured failed previous endovascular repair (n = 1). Fifteen fenestrations were successfully bridged with Atrium iCAST stent grafts. Average graft modification time, operative time, contrast volume, radiation dose, estimated blood loss, and hospital length of stay were 89 min, 155.25 min, 58.8 mL, 2451 mGy, 175 mL, and 4.3 days, respectively. One patient required a secondary intervention to treat a type Ib endoleak. During an average follow-up of 25 months, aneurysm sacs progressively shrank without additional intervention.ConclusionPhysician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program.
Highlights
Ruptured abdominal aortic aneurysm is commonly a lethal condition; lower mortality has been observed in patients treated at high volume centers offering endovascular intervention. (Karthikesalingam et al, 2014) a number of patients have aneurysms not amenable to approved infrarenal devices, and exclusion requires incorporation of visceral arteries
Physician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program
To aide understanding of Physician modified endovascular grafts (PMEG) procedural planning and execution, we describe our approach to the management of diverse complex aortic aneurysmCMDcustom made devices (cAAA) pathology with PMEGs using four different Cook Zenith devices
Summary
Ruptured abdominal aortic aneurysm is commonly a lethal condition; lower mortality has been observed in patients treated at high volume centers offering endovascular intervention. (Karthikesalingam et al, 2014) a number of patients have aneurysms not amenable to approved infrarenal devices, and exclusion requires incorporation of visceral arteries. Ruptured abdominal aortic aneurysm is commonly a lethal condition; lower mortality has been observed in patients treated at high volume centers offering endovascular intervention. (Karthikesalingam et al, 2014) a number of patients have aneurysms not amenable to approved infrarenal devices, and exclusion requires incorporation of visceral arteries. Compared to open repair, fenestrated/branched endografts (f/b-EVAR) confer lower mortality in patients with complex aortic aneurysm (cAAA). The technique is shown to be effective for patients treated with two snorkels. Branched thrombosis is higher especially when three or more snorkels are used For this reason, the European Society for Vascular and Endovascular Surgery does not recommend the use of more than two chimney grafts, limiting the use of this technique in patients requiring seal above the superior mesenteric artery (SMA). The European Society for Vascular and Endovascular Surgery does not recommend the use of more than two chimney grafts, limiting the use of this technique in patients requiring seal above the superior mesenteric artery (SMA). (Gupta et al, 2017)
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