Severe infolding of fenestrated-branched endovascular stent graft

Abstract

Infolding of a fenestrated-branched stent graft is an infrequent complication due to excessive oversizing. We report the case of an 89-year-old man who underwent a four-vessel fenestrated-branched endovascular aortic repair for a pararenal aortic aneurysm. Computed tomography angiography revealed severe infolding across the mesenteric-renal vessels. The patient was treated by angioplasty and placement of Palmaz stent. Cone-beam computed tomography confirmed patent visceral vessels with resolution of the infolding. This case illustrates an uncommon complication that can be prevented by modifications in the stent design and by immediate assessment using intraoperative cone-beam computed tomography.

Type IA endoleak caused by interlocked suprarenal bare-metal stents after endovascular abdominal aortic aneurysm repair with successful endovascular rescue

“…Balloon-expandable Palmaz stents have been used successfully as an adjunct to EVAR to improve the proximal seal with hostile aortic neck anatomy and to treat type IA endoleak 19 and also in the case of infolding of a fenestrated endograft. 18 Placement of a Palmaz stent in our case could not disentangle the suprarenal stents but provided sufficient apposition of the endograft to the aortic wall to obtain a proximal seal, which has been maintained for >1 year of follow-up. In our case, open conversion with explantation of the endograft was not an option in the event of endovascular failure because of the patient's advanced age.…”

“…This finding is more commonly described in the context of thoracic endografts placed in a normal-sized aorta, in which oversizing of the graft in a nonaneurysmal aorta may prevent complete expansion of the prosthesis and lead to invagination of the stent graft. 3 Stent infolding has also been observed with the use of fenestrated EVAR to treat juxtarenal 17 and pararenal 18 AAA. This complication may be due to significant disparity between the size of a tapered infrarenal neck and a larger, more proximal sealing zone at the visceral segment, leading to relative oversizing at the infrarenal aorta.…”

Utility of dual longitudinal diameter-reducing ties in aortic arch thoracic endovascular aortic repair

“…It is expected that one diameter reducing tie will reduce the endograft diameter by about 20-30% [4]. Attempts to increase the reduction further with a single tie can lead to endograft infolding and endoleak [7]. In our experience with the use of PMEGs in the aortic arch, as long as we used one diameter reducing tie, we seldom managed to find a suitable place for making fenestrations appropriate for the anatomy of the arch vessels.…”