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Background: Fenestrated-Branched stent-grafts have been developed as an endovascular alternative for the treatment of complex aortic aneurysms. However, it can take as much as 6-12 weeks to manufacture these devices, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified fenestrated-branched stent-grafts (sm-FBSG) in high-risk patients who presented emergently with ruptured or symptomatic complex aortic aneurysms.
Methods: Retrospective review of all patients treated with sm-FBSG at our institution. Patients presenting with acute symptoms or emergent indication for repair were analyzed.
Results: Thirteen high-risk patients (8 ASA class IV and 5 ASA class III) (10 male, mean age 71 years) presented with symptomatic(n=5) or ruptured(n=8) aortic aneurysms with an average size of 8 cm (range 5-12 cm). Twelve patients (92%) had prior aortic surgery or a hostile abdomen, 77% had heart failure with an ejection fraction of < 35%, and 85% had severe pulmonary dysfunction. Four aneurysms were para-renal and 9 were thoracoabdominal. The average number of visceral vessels treated per patient was 3 (range 2-4) with 37 total branches performed. Endografts were successfully implanted in all patients. There were no cases of paraplegia, no intra-operative deaths, and one death occurred within 30 days (7%). Re-intervention was necessary in two cases; one for a type 3 endoleak and another for a retroperitoneal hematoma. Morbidity included 1 myocardial infarction, 2 patients with transient respiratory failure, and two with transient renal insufficiency not requiring dialysis. Mean postoperative stay in ICU was 3 days, and in-hospital 9 days. At a mean follow-up of 5 months (range 0-12), 3 patients died of non-aneurysm related causes. Branch vessel patency was 100%, and no late re-interventions were necessary. No type I or III endoleaks occurred, and one type II endoleak is under observation.
Conclusion: Sm-FBSG may play an important role in the treatment of select patients with symptomatic or ruptured complex aortic aneurysms that are prohibitive risks for open surgery and in whom endovascular repair cannot be delayed to allow implantation of a custom made commercial device. Until an “off the shelf” fenestrated-branched device is created that does not require a prolonged waiting period, this may be the best option to treat patients with symptomatic or ruptured complex aneurysms that are at excessively high surgical risk.