Use of 3D Printing to Guide Creation of Fenestrations in Physician-Modified Stent-Grafts for Treatment of Thoracoabdominal Aortic Disease

Abstract

Purpose: To summarize the experience and outcomes of total endovascular repair of thoracoabdominal aortic disease using 3-dimensional (3D) printed models to guide on-site creation of fenestrations in aortic stent-grafts. Materials and Methods: From April 2018 to March 2019, 34 patients (mean age 58±14 years; 24 men) with thoracoabdominal aortic disease were treated in our department. Nineteen patients had thoracoabdominal aortic dissection and 15 had thoracoabdominal aortic aneurysm. Preoperatively, a 3D printed model of the aorta was made according to computed tomography images. In the operating room, the main aortic stent-graft was completely released in the 3D printed model, and the position of each fenestration or branch was marked on the stent-graft. The fenestrations were then made using an electric pen. Wires were sewn to the edge of the fenestrations using nonabsorbable sutures. After customization, the aortic stent-graft was reloaded into the delivery sheath and deployed. Results: The printing process took ~5 hours (1 hour for image reconstruction, 3 hours for printing, and 1 hour for postprocessing). The physician-modified stent-grafts had a total of 107 fenestrations secured by 102 bridging stent-grafts, including 73 covered stents and 29 bare stents. The average procedure time was 5.6±1.2 hours, including a mean 1.3 hours for stent-graft customization. No renal insufficiency or paraplegia occurred. Two branch arteries were lost during the operation. One patient (3%) died 1 week after surgery from a retrograde dissection rupture. One patient developed a minor cerebral infarction postoperatively. The mean follow-up time was 8.5 months. There was 1 endoleak from a fenestration (coil embolized) and 4 distal ruptures of the aortic dissection (3 treated and 1 observed). Conclusion: Three-dimensional printing can be used to guide creation of fenestrated stent-grafts for the treatment of thoracoabdominal aortic diseases involving crucial branches. This technique appears to be more accurate than the traditional measurement method, with short-term follow-up demonstrating the safety and reliability of the method. However, further research and development are needed.

Clinical Applications of Patient-Specific 3D Printed Models in Cardiovascular Disease: Current Status and Future Directions

“…All of the bridged visceral vessels were patent with no enlargement of the aneurysm during the follow-up [77]. This study proves the clinical value of 3D printed aortic models in guiding treatment of aortic disease by Tong et al expanded the application of 3D printing aorta models to guide surgical planning of fenestration for treatment of patients with thoracoabdominal aortic aneurysm (TAAA) [77]. Their retrospective study comprised 34 patients who received fenestrated endovascular stent graft repair (fEVAR) for thoracoabdominal aortic disease (19 had aortic dissection and 15 had thoracic abdominal aortic aneurysms).…”

“…Similar to other aortic disease, the 3D printed models allow for surgical simulation of complex endovascular repair of aortic dissection, although further research is needed to test its clinical value in more cases. Tong et al expanded the application of 3D printing aorta models to guide surgical planning of fenestration for treatment of patients with thoracoabdominal aortic aneurysm (TAAA) [77]. Their retrospective study comprised 34 patients who received fenestrated endovascular stent graft repair (fEVAR) for thoracoabdominal aortic disease (19 had aortic dissection and 15 had thoracic abdominal aortic aneurysms).…”

“…Tong et al expanded the application of 3D printing aorta models to guide surgical planning of fenestration for treatment of patients with thoracoabdominal aortic aneurysm (TAAA) [ 77 ]. Their retrospective study comprised 34 patients who received fenestrated endovascular stent graft repair (fEVAR) for thoracoabdominal aortic disease (19 had aortic dissection and 15 had thoracic abdominal aortic aneurysms).…”

“…Results showed the successful treatment of these complicated thoracoabdominal aortic disease by customized fenestrated stent grafts with a mean follow-up of 8.5 months in this case series. All of the bridged visceral vessels were patent with no enlargement of the aneurysm during the follow-up [ 77 ]. This study proves the clinical value of 3D printed aortic models in guiding treatment of aortic disease by fEVAR, although further research on a large sample size with long follow-up of clinical outcomes is warranted.…”

Commentary: Three-Dimensional Printed Aortic Templates for Physician-Modified Stent-Grafts: Another Boost to the Quality of These Devices

“…Initial case reports described 3D print–assisted implantations in the aortic arch region 1 and renovisceral segment, 8 but until recently major observational studies were lacking. In the June 2020 issue of the JEVT , Tong et al 9 presented a group of 34 patients with thoracoabdominal aortic lesions requiring implantation of a modified device. In each case, patient-specific aortic models were used as a template to fabricate PMSGs with a total of 107 fenestrations.…”