Experience with fenestrated endovascular aortic endograft (FEVAR) in the treatment of post dissection aneurysms remains challenging. A 49-year-old male with a history of type A dissection repair (ascending tube graft) presented with a residual 6-cm expanding extent III thoracoabdominal aortic aneurysm (TAAA). Our objective was to perform a 3-vessel FEVAR with a custom-made endograft with preloaded wires for each fenestration. Serial deployment technique was utilized. This technique allowed us to cannulate each target artery from above while keeping the rest of the fenestrated endograft below each fenestration still in the sheath. by keeping the endograft constrained, creates space outside of the endograft which is key to facilitate catheter/wire mobility and subsequent target artery cannulation.
A custom-made fenestrated endovascular aortic endograft was designed on the basis of measurements obtained from high-resolution CTA images on a three-dimensional workstation using standard centerline flow orthogonal techniques (TeraRecon, Foster City, Calif). The graft design included fenestrations to the celiac artery, SMA, and right renal artery (RRA). The main body fenestrated graft was designed with a modified preloaded delivery system with a single diameter reduction tie. Intraoperative 3D-3D fusion imaging was performed. We utilized IVUS to confirm true lumen presence. Proximal and distal seal were obtained in non-dissected vessels proximal and distal to the dissection. Main body fenestrated graft was delivered via groin using serial deployment technique. Cannulation of all target arteries was performed without use of any reentry device or needle puncture of the septum. Balloon-expandable bridging stent grafts were deployed through the fenestrations to the celiac, SMA and RRA. Completion angiography showed expansion of true lumen and patent visceral branches. The 1-month surveillance imaging demonstrated excellent stent graft architecture, no evidence of endoleak and favorable aortic remodeling.
FEVAR is feasible option for patients with chronic type B aortic dissections with TAAAs. Serial deployment, by keeping the endograft constrained, creates space outside of the endograft which facilitates target artery cannulation in narrowed true lumen.
Publication stageIn Press Journal Pre-Proof
Presented at the 47th Annual Meeting of the New England Society for Vascular Surgery, Boston, MA, Sept 2020
The authors would like to acknowledge the patient in this case report for providing consent to
The authors would like to acknowledge Dr. Gustavo Oderich for providing permission to include images in our video from the book Endovascular Aortic Repair.
© 2021 The Author(s). Published by Elsevier Inc. on behalf of Society for Vascular Surgery.