Treatment for thoracoabdominal aortic aneurysm by fenestrated endovascular aortic repair with physician-modified stent graft

Abstract

Despite being widely used for several years, the endovascular aortic repair (EVAR) of a thoracoabdominal aneurysm (TAAA) remains challenging, particularly the revascularization of the abdominal aortic visceral branches. A 66-year-old male was admitted to hospital with abdominal bloating and pain. Computed tomographic angiography (CTA) confirmed a Crawford type III TAAA from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery. Fenestrated-EVAR was performed successfully and 1 week later CTA showed a type III endoleak, which had resolved 3 months later, without stent migration or visceral artery occlusion. In this present case, the surgeons preferred to perform the procedure in three surgical stages, postponing the deployment of a covered stent in the CA fenestration to provide additional time for the development of collateral circulation to the spinal cord as a possible means of preventing postoperative paraplegia.

Physician-Modified Endovascular Gore Excluder Graft (Handmade Modified) for Complex Abdominal Aortic Aneurysm: A Step-by-Step Approach

“…The role of the EVAR for noncomplex aortic aneurysms is well established, but not all aneurysms have the ideal anatomy for endovascular treatment; technology evolved to treat complex aneurysm, including pararenal, juxtarenal, or thoracoabdominal aneurysms, to the point of becoming the first choice of treatment with great results. [1][2][3] There are custom-made fenestrated devices with excellent reported results 4,5 ; some of the limiting features of these devices are the cost and the time of production. The PMEGs for complex aneurysm emerged as a bridge or as an urgent method for treating emergency cases as well as patients in whom the time of development of the custom prosthesis is too long.…”

“…The role of the EVAR for noncomplex aortic aneurysms is well established, but not all aneurysms have the ideal anatomy for endovascular treatment; technology evolved to treat complex aneurysm, including pararenal, juxtarenal, or thoracoabdominal aneurysms, to the point of becoming the first choice of treatment with great results. 1 -3…”

“…1 These devices are currently an off-the-shelf option treatment; however, these techniques could be helpful in cases where no other option is feasible. 2 Currently, there are well-established indications for PMEG: the first scenario is in high-risk patients, particularly in the context of elderly and multiple comorbidities, making an open repair a challenge or even not feasible because of the morbidity and mortality associated with the open surgical repair, and in the setting of no availability to a manufactured fenestrated stent-graft or because the urgency of the presentation cannot wait the required time for graft customization. 3 The second indication and scenario is the presence of a hostile neck, making it not feasible for standard EVAR.…”