Stent graft modification with mini-cuff reinforced fenestrations for urgent repair of thoracoabdominal aortic aneurysms Gustavo S. Oderich, MD, Javairiah.

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Presentation transcript:

Stent graft modification with mini-cuff reinforced fenestrations for urgent repair of thoracoabdominal aortic aneurysms Gustavo S. Oderich, MD, Javairiah Fatima, MBBS, Peter Gloviczki, MD Journal of Vascular Surgery Volume 54, Issue 5, Pages 1522-1526 (November 2011) DOI: 10.1016/j.jvs.2011.06.023 Copyright © 2011 Terms and Conditions

Fig 1 Computed tomography angiography shows a 10-cm type IV thoracoabdominal aortic aneurysm (A) on a patient with prior aortic repair and left renal artery bypass graft (B). Repeat computed tomography angiography after urgent endovascular repair with modified fenestrated endograft showed successful aneurysm exclusion, no endoleak, and patent branched stent grafts (C). Journal of Vascular Surgery 2011 54, 1522-1526DOI: (10.1016/j.jvs.2011.06.023) Copyright © 2011 Terms and Conditions

Fig 2 Technique of stent graft modification with mini-cuff reinforced fenestration. A 3- to 5-mm mini-cuff is fashioned from a Viabahn stent graft, which is cut using scissors in a straight, up-going or down-going fashion to accommodate the desired side branch configuration. The mini-cuff and a gold radio-opaque wire, which is obtained from the Amplatz Goose Snare Kit, are sewn into the fenestration with locking 5-0 Ethibond sutures (A). This technique provides excellent suture handling, hemostasis, and attachment, and is the technique of choice by the manufacturer for reinforcement of fenestrations. Note that the modified TX2 stent graft included two mini-cuff reinforced fenestrations for the celiac and superior mesenteric artery, and a standard fenestration for the left renal bypass graft (B). The mini-cuff reinforced fenestrations are bridged using iCAST-covered stents (C). Journal of Vascular Surgery 2011 54, 1522-1526DOI: (10.1016/j.jvs.2011.06.023) Copyright © 2011 Terms and Conditions

Fig 3 A diameter-reducing wire is added to facilitate implantation of the modified TX2 stent graft. The nitinol wire used for the diameter-reducing wire is obtained from the inner cannula of the stent graft, which is opened with a scalpel (A, inset). One of the three nitinol wires is retrieved and rerouted posteriorly through and through the fabric of the stent graft using a long 22-gauge spinal needle (B). Once the wire is in place (C), the Z stents are constrained using loops of prolene. The first loop is placed around the stainless steel wire (D), and the second loop is routed around the first prolene loop (E), with careful attention not to place the suture through the first prolene loop (F, inset). The nitinol wire is then relocated into the cannula (G). Journal of Vascular Surgery 2011 54, 1522-1526DOI: (10.1016/j.jvs.2011.06.023) Copyright © 2011 Terms and Conditions

Fig 4 Illustration of the modified fenestrated stent graft (A) with two mini-cuff reinforced fenestrations and a standard fenestration. Note that the superior mesenteric artery required a combination of self-expandable stent distally and a balloon-expandable stent proximally because of significant angulation (B). The mini-cuff reinforced fenestration was bridged with a balloon-expandable stent graft, which was flared to optimize seal, similar to what is performed using standard fenestrations (C). Journal of Vascular Surgery 2011 54, 1522-1526DOI: (10.1016/j.jvs.2011.06.023) Copyright © 2011 Terms and Conditions

Fig 5 Placement of bridging stents in the superior mesenteric artery (SMA) using a self-expandable Fluency stent graft distally (A) and a balloon-expandable iCAST stent proximally (B) into the mini-cuff reinforced fenestration. Selective SMA angiography (B) and completion aortography confirmed widely patent stent grafts without endoleak (C). Journal of Vascular Surgery 2011 54, 1522-1526DOI: (10.1016/j.jvs.2011.06.023) Copyright © 2011 Terms and Conditions