Modified Fenestrated Stent Grafts: Device Design, Modifications, Implantation, and Current Applications

Abstract

Patients with aneurysms with short or angulated necks and those with involvement of the renal, visceral, and hypogastric arteries may not be candidates for endovascular treatment using infrarenal stent graft. Fenestrated stent grafts with reinforced fenestrations permit the incorporation of the visceral and renal arteries into the endovascular repair enabling an adequate proximal sealing zone. These devices require a 6-week to 8-week period for customization and are not currently commercially available in the United States. Modified fenestrated stent grafts may have a future role in the compassionate treatment of selected high-risk patients with complex aneurysms who otherwise would not have access to a manufactured fenestrated stent graft, or for those in need of urgent or emergent repair because of impending or contained ruptured, rapidly expanding or excessively large aneurysm. The authors have used modified fenestrated stent grafts selectively in patients with large aortoiliac, juxtarenal, pararenal, or thoracoabdominal aortic aneurysms. In this article, the authors summarize the principles applied for device design and procedure planning, as well as the technique for device modification and implantation.

The transition from custom-made to standardized multibranched thoracoabdominal aortic stent grafts

“…Meanwhile, surgeons in the United States, with patients in need of multibranched thoracoabdominal stent grafts, have little choice but to add cuffs and fenestrations themselves. 15 It is much harder to study a family of customized devices, as evidenced by the long delayed approval of the fenestrated Zenith stent graft. 2.…”

Early Results of Physician Modified Fenestrated Stent Grafts for the Treatment of Thoraco-abdominal Aortic Aneurysms

“…This could potentially lead to an increased risk of target vessel cannulation failure and longterm branch occlusion. While awaiting the arrival of reliable and universal off the shelf stent grafts and on the basis of previous reports from pioneering centres, 9,11 PMSGs constitute a valid option for the treatment of TAAA in selected patients.…”

Endovascular Repair of Juxtarenal Aneurysms

“…These characteristics of the study support the concept that these results provide insight into the real-world experience with this approach to endovascular aneurysm repair, in contrast to modified stent grafts prepared on the back table in the operating room. 14,15 A significant finding in this series is the 5 patients whose procedure was complicated by spinal ischemia, a wellrecognized complication with thoracoabdominal repairs, but less well described in the fenestrated literature or in association with repair for type IV or juxtarenal aortic aneurysms. There is concern that endovascular repair associated with fenestrated grafts in the juxtarenal aorta result in coverage of both lumbar vessels in the visceral aorta and concomitant closure/obstruction of the hypogastric vessels, which might increase the risk of spinal cord ischemia by interruption of collateral pathways in the pelvis.…”