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Physician Modification Of Zenith Fenestrated Endovascular Graft For Management Of Type Ia Endoleak
Andre Critsinelis, MD, Rahul Rodrigues, BS, Kumudini Myla, BS, Brandon Madris, MD, Prashanth Palvannan, MD, Payam Salehi, MD, Shivani Kumar, MD.
Tufts Medical Center, Boston, MA, USA.
DEMOGRAPHICS: A 74-year-old female, current smoker, previously underwent endovascular repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA) with a 23 mm Gore EXCLUDER.
HISTORY: The patient presented with a persistent type Ia endoleak associated with proximal graft infolding, refractory to ballooning. Centerline imaging demonstrated a distance of 36mm from the flow divider to the lowest renal artery, 56mm to the bottom of the superior mesenteric artery (SMA), and 74mm to the bottom of the celiac. The shortest available Zenith Fenestrated (ZFEN) graft with two proximal sealing stents measures 94 mm, which exceeded the distance to the flow divider.
PLAN: A ZFEN graft with 2 small fenestrations for the renal arteries, and one large fenestration for the SMA was created. Back-table modification of the ZFEN graft was performed to shorten its length. The device was partially reverse-unsheathed to expose the distal-most stent (Figure 1a). A wire cutter and scalpel were used to excise the stent struts and circumferential fabric (Figure 1b and 1c). The remaining distal fabric edge was sutured to the distal fixation trigger wire with Prolene to maintain graft stability and turnability (Figure 1d), then re-sheathed with umbilical tape. Deployment of the modified ZFEN graft with renal artery stenting was successful. Completion angiography demonstrated complete resolution of the type Ia endoleak without evidence of a type III endoleak at the junction with the prior graft. The patient tolerated the procedure without complication.
DISCUSSION: Management of type Ia endoleaks after infra-renal EVAR can be challenging, particularly in the setting of high bifurcation of the prior endograft, which limits available length for fenestrated grafts to build up coverage. In this case, modification of the ZFEN graft created a shorter graft segment, enabling deployment within a short landing zone. This technique expands the utility of the ZFEN platform for complex reinterventions such as in this case with a type 1a endoleak, where the short distance from fabric edge to flow divider of certain EVAR grafts precludes use of standard ZFEN proximal body lengths.
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