Purpose: Early results of endovascular aortic arch aneurysm repair with fenestrated/branched endografts are promising. However, access to these devices in many regions of the world remains limited to a handful of centers participating in government-approved trials. This leaves patients living out of reach of these centers with limited or no treatment options. We describe a technique of treating aortic arch aneurysms with surgeon-modified fenestrated stent graft.
Technique: The technique is demonstrated in an 80-year-old patient with a symptomatic 5.5 cm saccular aortic arch aneurysm that was successfully excluded with a surgeon-modified fenestrated Cook alpha proximal thoracic stent graft. The device comes with laser cut 3.5 mm barbs that do not permit retrograde resheathing. To overcome this, it was deployed, completely removed from its delivery system and a fenestration created to accommodate the left subclavian artery. A nitinol wire was withdrawn and used as a diameter-reducing wire that allowed for the device to be constrained posteriorly. Now mounted on its delivery system, the device was transitioned from a 24 French (Fr) sheath to a 20 Fr sheath to an 18 Fr sheath before advancing it into its original sheath. Under general anesthesia, the device was delivered into the thoracic aorta via a lunderquist wire placed from the right common femoral artery. The fenestration was cannulated from the left brachial artery access following partial device deployment and bridged with an Atrium iCAST stent graft.
Conclusion: Endovascular repair of aortic arch aneurysms with surgeon-modified fenestrated Cook alpha proximal stent graft is feasible. The procedure has a potential for significant complications and should be performed in conjunction with an experienced cardiac surgery team.
Jesse Manunga and Benjamin Sun
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