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Superior Mesenteric Artery Outcomes After Large Fenestration Strut Relocation With The Zenith Fenestrated Endoprosthesis
Aleem K. Mirza, MD, Timothy Sullivan, MD, Jason Alexander, MD, Nedaa Skeik, MD, Elliot Stephenson, MD, Senthil Jayarajan, MD, Jessica Titus, MD, Joseph Karam, MD, Xiaoyi Teng, MD, Jesse Manunga, MD.
Minneapolis Heart Institute, Minneapolis, MN, USA.

OBJECTIVES: The Zenith Fenestrated (ZFen) stent-graft is frequently configured with a strut spanning large fenestration for superior mesenteric artery (SMA) incorporation, which may hinder future endovascular interventions. This has led some to bend and suture crossing struts to the side, creating a strut-free fenestration (Figure). However, technical success and long-term outcomes of these patients remain underreported. The aim of this study was to compare SMA outcomes with and without large fenestration stent relocation.
METHODS: We performed a retrospective review of a prospectively maintained database of all patients undergoing fenestrated endovascular aortic repair (FEVAR) with ZFen between 2013 and 2019 at our institution. Those who had SMA incorporation with large fenestrations were included and separated into stent strut relocation (SR) and no relocation (NR) groups. Endpoints included procedural metrics, technical success, major adverse events (MAE), and target vessel instability.
RESULTS: A total of 121 patients (77% male; mean age 76.17.1 years) met inclusion criteria, including 94 patients (78%) with SR and 27 patients (22%) with NR. There were no differences in comorbidities between groups. A total of 369 target vessels were incorporated, with a mean of 3.00.2 per patient, and no differences between the two groups. The mean operating room time, contrast volume, estimated blood loss, fluoroscopy time and radiation dose were lower (p<0.001) in the SR group, and was attributed to increased experience with time. The overall technical success (SR: 100%, NR: 96%, p=0.22), defined as implantation of the device without target vessel loss, was 99%. At a mean follow up time of 32 months, there were two attempted endovascular interventions for mesenteric ischemia. One resulted in SMA dissection requiring bypass in the NR group, and other was successful ballooning of the bridging stent with subsequent resolution of mesenteric angina in 1 patient in the SR group.
CONCLUSIONS: Minor modications of the large fenestration by relocating the spanning stent struts is safe and does not negatively impact procedural metrics, long-term device integrity, or branch instability. To the contrary, it facilitates future endovascular SMA interventions if needed.


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