The Snorkestrated Technique of Combined Parallel Endografts and Fenestrated Endovascular Aneurysm Repair
Michael Bounds, MD, Nathan Orr, MD, Eleftherios S. Xenos, MD, Joseph Bobadilla, David J. Minion, MD.
University of Kentucky Medical Center, Lexington, KY, USA.
While many consider Parallel Endografts and Fenestrated Endovascular Aneurysm Repair competitive strategies, both similarly allow for preservation of branch vessels that would otherwise be covered during complex endovascular aneurysm repair. In addition, there is a 3-vessel design limitation to the only currently approved fenestrated device in the United States. The purpose of this study was to review our experience with the use of both strategies as a combined approach in the same patient.
A retrospective review of all cases utilizing a combined approach of Parallel Endografts and Fenestrated Endovascular Aneurysm Repair was undertaken. Eleven cases were identified (Table.)
Seven were planned 4-vessel repairs for thoracoabdominal aneurysms, adding an antegrade Celiac parallel graft or Celiac/SMA parallel grafts to a 3-vessel Fenestrated design. Two of these patients had Type III thoracoabdominal aneurysms, and the celiac snorkel was deployed in a thoracic endograft as a sandwich configuration (Figure). The four unplanned cases included two for intra-operative Type IA endoleak, one for intra-operative IIIb endoleak, and one for a fenestrated device that was maldeployed with a 180-degree rotation covering the SMA. A total of two antegrade celiac snorkels, three antegrade SMA snorkels, and 3 retrograde renal sandwich grafts were required to overcome the various complications of these four cases.
Technical success was 100% with no endoleaks at the completion of the case and preservation of all branch vessels. There were no peri-operative deaths or major morbidity. In follow up from 1 to 12 months, no late endoleaks, branch vessel occlusion, sac growth, or aneurysm related death has been identified.
Parallel endografts and fenestrated endovascular aneurysm repair are complimentary strategies for complex aneurysm repair. The two can be combined to allow a planned 4-vessel repair in selective cases of thoracoabdominal aneurysms or to correct unplanned endoleaks or maldeployment issues.
|Indication||n||Fenestrated Device Design||Parallel Grafts|
|Type IV TAA||4||SMA large fenestration/2 renal small fenestrations||Antegrade Celiac|
|Type IV TAA||1||SMA scallop/2 renal small fenestrations||Antegrade Celiac/SMA|
|Type III TAA||2||SMA large fenestration/2 renal small fenestrations||Antegrade Celiac Sandwich|
|Intra-operative Type IA||1||SMA scallop/2 renal small fenestrations||Antegrade Celiac/SMA|
|Intra-operative Type IA||1||SMA scallop/2 renal small fenestrations||Antegrade Celiac/SMA, Retrograde Renal Sandwiches|
|Intra-operative Type IIIB||1||One renal small fenestration||Retrograde Renal Sandwich|
|Maldeployed ZFen||1||SMA scallop/2 renal small fenestrations||Antegrade SMA|
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