On-table Zenith® CE Fenestrated Stent Graft modification for the treatment of delayed type Ia Endoleak

Abstract

Introduction: Delayed type Ia endoleaks are often associated with proximal extension of the aneurysmal degeneration to the juxtarenal aortic segment. Endovascular treatment of type Ia endoleaks secondary to aortic neck dilatation can raise many technical challenges related to the previous implanted stent graft. Methods: It is presented the endovascular treatment of a delayed type Ia endoleak using a physician-modified Zenith® fenestrated stent graft and two parallel aortic covered stents. Results: The patient was a 84-years old man, with a past medical history of atrial fibrillation, acute ischemic stroke, hypertension and dyslipidemia, that initially underwent an EVAR for a 5.5.cm infrarenal AAA with a TREO Bolton® endograft. After 3 years of follow-up, the Angio-CT scan showed a delayed type Ia endoleak secondary to aortic neck dilatation with significant growth of the aneurysmatic sac. It was planned an endovascular proximal extension with a fenestrated cuff ZFEN platform (Zenith Fenestrated (ZFEN; Cook Medical, Bloomington, Ind) but the short distance to the previous EVAR bifurcation unenable the implantation of a standard 94cm Zenith® CE Fenestrated Stent Graft. To overcome this challenge, it was planned an on-table modification of the fenestrated stent graft (Zenith® CE with 1 large strut fenestration SMA, 2 small fenestrations renal) by cutting the distal aortic stent. Under general anaesthesia, the fenestrated endograft was partially deployed on-table, the distal stent was cut with thermocautery, and the device was resheathed. The fenestrated cuff was implanted in the standard fashion with target vessel catheterization and renal stenting. Two aortic covered stents (Aortic Begraft Bentley® 18mm) were implanted inside each iliac limb of the previous EVAR and sealed proximally in a parallel graft configuration on the fenestrated cuff. The final completion angiogram demonstrated perfusion of bilateral renal arteries, resolution of IA and without further endoleaks, as well perfusion of both hypogastric arteries. At two months of follow up, the patient remains asymptomatic and the angio-CT scan showed resolution of type Ia endoleak but the presence of a late type II endoleak. Conclusion: Delayed type Ia endoleaks associated with proximal extension of the aneurysmal degeneration to the juxtarenal aortic segment, can raise some technical difficulties related to the previous implanted stent graft. Careful evaluation of patient anatomy and previous endografts should be done in planning for these procedures. On table physician modification of stent grafts is a valid solution to overcome challenging cases limitations. Further long-term follow-up is needed.

Keywords

• Type Ia endoleak
• fenestrated stent graft
• abdominal aortic aneurysm
• juxtarenal
• physician modified stent grafts