Technique for treating complex aneurysms with Hercules stent graft modified by the surgeon Márcio Fernando Costa Medeiros, MD, Ângelo Mário de Sá Bomfim.

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Presentation transcript:

Technique for treating complex aneurysms with Hercules stent graft modified by the surgeon Márcio Fernando Costa Medeiros, MD, Ângelo Mário de Sá Bomfim Filho, MD, Dominique Rodas Costa, MD, Daniel Florencio Ferro, MD Journal of Vascular Surgery Cases and Innovative Techniques Volume 2, Issue 4, Pages 184-189 (December 2016) DOI: 10.1016/j.jvscit.2016.05.003 Copyright © 2016 The Author(s) Terms and Conditions

Fig 1 Computed tomography angiography with three-dimensional image in a patient with juxtarenal aortic aneurysm (A). Landing zone diameter is measured in detail right above the celiac trunk (CT) origin (B), and the aneurysm is further evaluated by centerline flow analysis for measurement of length (C and D). RRA, Right renal artery; SMA, superior mesenteric artery. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions

Fig 2 Modification of the stent graft. A, Strengthening of the fenestration with nitinol wire and continuous suture of 5-0 polypropylene. B, Scallop to the celiac artery (white arrow) and fenestration to the superior mesenteric artery (black arrow), left renal artery (yellow arrow), and right renal artery (not shown). C, Positioning of diameter-reducing wire. D, Reduction of the stent graft's original diameter. Hercules T stent graft of 34 × 34 × 160 mm, with diameter reduced to 20 mm (40% of the original diameter). Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions

Fig 3 Schematic picture of diameter-reducing technique. A, Endoprosthesis fully released. B, The first loop enclasps the main wire and extends to the side to wrap two stent segments and is fixed in the stent graft fabric. C, The second loop passes through the first loop without going through the support wire and heads to the second segment of the contralateral stent, also fixed in the stent graft fabric. D, The metal structures are approximated. E, In detail, loops surrounding the support wire and knots are apart after wire removal. F, Endoprosthesis prepared to be resheathed. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions

Fig 4 A and B, Fenestrated stent graft with 0.014-inch guidewires already in place. C, The stent graft is resheathed, and guidewires from each fenestration end out through holes along the stent graft sheath. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions

Fig 5 Fluoroscopy image after release of the stent graft: scallop to celiac trunk (CT) and stents for superior mesenteric artery (SMA), right renal artery (RRA), and left renal artery (LRA). Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions

Fig 6 Computed tomography angiography: 30-day control in frontal (A) and lateral (B) views and 8-month control (C). Imaging confirms successful aneurysm exclusion, no endoleak, and preserved visceral perfusion. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 184-189DOI: (10.1016/j.jvscit.2016.05.003) Copyright © 2016 The Author(s) Terms and Conditions