Anatomical Suitability of the T-Branch Stent-Graft in Patients With Thoracoabdominal Aortic Aneurysms Treated Using Custom-Made Multibranched Endografts

Purpose: To describe a new custom-made thoracic device able to seal against the aortic wall and occlude intercostal arteries for spinal cord preconditioning during the first thoracic stage of a thoracoabdominal endovascular repair. Technique: The custom-made device, based on the Zenith Alpha stent-graft, combines different features from 2 previously described devices: the outer part is designed with a bell-bottom configuration similar to the “Embo” stent-graft, while the inner part mimics the “2 in 1” design. The outer stent-graft is designed to span the entire length of the thoracic aorta and cover as many intercostal arteries as possible during the first stage to effectively precondition the spinal cord. The sutured inner component is customizable in diameter and 20 to 40 mm shorter than the outer stent-graft. The technique has been used in 5 patients. Conclusion: The use of this new custom-made thoracic stent-graft might represent an additional tool for effectively preconditioning the spinal cord during fenestrated and branched staged procedures whenever a proximal thoracic proximal component is needed.

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Intraoperative Proximal Endoleaks during AAA Stent-Graft Repair: Evaluation of Risk Factors and Treatment with Palmaz Stents

Journal of Endovascular Therapy ◽

10.1177/152660280100800306 ◽

2001 ◽

Vol 8 (3) ◽

pp. 268-273 ◽

Cited By ~ 33

Author(s):

Nuno V. Dias ◽

Timothy Resch ◽

Martin Malina ◽

Bengt Lindblad ◽

Krassi Ivancev

Keyword(s):

Stent Graft ◽

Therapeutic Option ◽

Balloon Dilation ◽

Aortic Aneurysms ◽

Type I ◽

Aneurysm Neck ◽

Custom Made ◽

Type I Endoleak ◽

Stent Graft Repair ◽

Palmaz Stents

Purpose: To study factors that might contribute to intraoperative proximal type I endoleak and to evaluate the placement of giant Palmaz stents as a therapeutic option. Methods: Thirty-three patients (30 men; median age 72 years, range 50–85) with abdominal aortic aneurysms underwent implantation of fully supported Gianturco Z-stent—based endografts (12 custom-made aortomonoiliac and 21 bifurcated Zenith devices). Ten (30%) patients were treated for intraoperative proximal endoleaks. Stent-graft oversizing and neck angulation, length, and shape were compared between patients with and without leaks. Results: In 9 cases, the endoleaks were successfully treated with intraoperative placement of Palmaz stents without complications. In 1 patient, a leak that was resolved intraoperatively with balloon dilation reappeared 1 month later; a Palmaz stent was deployed successfully. Stent-graft oversizing did not differ significantly between patients who developed proximal endoleaks and those who did not (median 4.0 mm in both groups, p = 0.47). Median neck length was 21.0 mm in patients with endoleak and 28.0 mm in those without (p > 0.99). Median neck angulation was 30° in both groups (p = 0.33), and the presence of a conical aneurysm neck was not significantly different (2/10 versus 6/23, p > 0.99). All aneurysms remained excluded at a median follow-up of 13 months (range 6–24). Conclusions: Stent-graft oversizing and neck morphology (length, angulation, and conical shape) do not seem to correlate with the incidence of proximal type I endoleaks. Palmaz stent placement appears to be a feasible and safe treatment option for this complication.

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Single Centre Experience with Anaconda Custom-made Fenestrated Stent Graft in the Endovascular Repair of the Juxtarenal Aneurysms

The Open Cardiovascular Medicine Journal ◽

10.2174/1874192401913010031 ◽

2019 ◽

Vol 13 (1) ◽

pp. 31-36

Author(s):

Milan Lisy ◽

Guenay Kalender ◽

Guido Rouhani ◽

Matthias Schwarzbach ◽

Wolf Stelter

Keyword(s):

Stent Graft ◽

Covered Stent ◽

Aortic Aneurysms ◽

Release Mechanism ◽

Type I ◽

Aortic Pathology ◽

Single Centre Experience ◽

Custom Made ◽

Fenestrated Stent Graft ◽

The Mean

Aim: The fenestrated Anaconda custom-made stent graft is one of the recently widely accepted fenestrated devices for managing complex juxta- and pararenal aortic pathology. This study showed its feasibility for treatment of challenging juxtarenal anatomy of the abdominal aorta. Methods: Over the period of 12 months, 9 patients with juxtarenal aortic aneurysm underwent fenestrated stent graft implantation in our institution. The graft fenestrations were customized on the basis of computerized tomography (CT-Angiography; CTA). Selected visceral ostia were protected with covered balloon-expandable stents after partial stent graft deployment. The perioperative and short term data were collected prospectively. Results: The mean aneurysm diameter was 58.4 mm (range 46-73 mm). The mean infrarenal neck length was 3.5 mm (range 0-7 mm), no patient had a severe (>60°) angulation of proximal neck. 18 fenestration for renal arteries, 1 for SMA and 3 for coeliac´s were treated with Advanta V12 covered stent. All the target vessels were cannulated successfully through fenestrations and all the stent grafts were successfully deployed in patients with no technical issue in the release mechanism. All the patients have undergone 6 month follow-up, no aneurysm related or aneurysm-unrelated deaths were reported. On the CTA scan, 3 of the patients had a weak type IIb endoleak; no type I or Type III endoleak was demonstrated. All target vessels were open without an instance of branch-stent stenosis/occlusion. No reintervention was needed. Conclusion: The usage of custom-made Anaconda fenestrated stent graft for endovascular treatment of juxtarenal aortic aneurysms is feasible with acceptable intermediate-term results.

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Measurement of Frictional Properties of Aortic Stent Grafts and Their Delivery Systems

Journal of Medical Devices ◽

10.1115/1.4043292 ◽

2019 ◽

Vol 13 (2) ◽

Cited By ~ 2

Author(s):

Tianhao Chen ◽

Michael Lancaster ◽

Dawn S. Y. Lin ◽

Matthew G. Doyle ◽

Thomas L. Forbes ◽

...

Keyword(s):

Stent Graft ◽

Outer Surface ◽

Computational Models ◽

Endovascular Aneurysm Repair ◽

Aortic Aneurysms ◽

Stent Grafts ◽

Frictional Properties ◽

Custom Made ◽

Inner Surface

Stent grafts are medical devices used to treat abdominal aortic aneurysms (AAAs) in endovascular aneurysm repair (EVAR). Computational and experimental models have been developed to study stent graft delivery and deployment during EVAR; however, frictional properties have not been taken into account in most previous studies. The objective of this study was to determine the coefficients of friction of three commercially available stent grafts (Cook Zenith, Medtronic Endurant, and Vascutek Anaconda), their delivery sheaths, a porcine aorta, and two mock arterial materials. Stent grafts were obtained and separated into stents, graft fabric, and sheaths. Using a custom-made friction measurement apparatus, the coefficients of friction were measured between five material pairs: (i) the stents and inner surface of the sheath, (ii) the graft fabric and inner surface of the sheath, (iii) the outer surface of the sheath and a porcine aorta, (iv) the outer surface of the sheath and three different polyvinyl alcohol (PVA) cryogels, and (v) the outer surface of the sheath and a polydimethylsiloxane (PDMS) sheet. The results show that the coefficients of friction between the graft fabric and the sheath were higher than those between the stents and the sheath. The PVA cryogels showed more comparable frictional properties to the porcine aorta than did the PDMS sheet, suggesting that PVA cryogels provide a more accurate approximation for the in vivo frictional properties. These results can be used to improve the accuracy of computational models for stent graft delivery and deployment and to select appropriate materials for vascular phantoms.

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Clinical Application and Technical Details of Cook Zenith Devices modification to treat Urgent and Elective Complex Aortic Aneurysms

10.21203/rs.3.rs-369695/v1 ◽

2021 ◽

Author(s):

Jesse Manunga ◽

Lia Jordan ◽

Aleem K. Mirza ◽

Xiaoyi Teng ◽

Nedaa Skeik ◽

...

Keyword(s):

Stent Graft ◽

Hospital Length ◽

Aortic Aneurysms ◽

Hospital Length Of Stay ◽

Safe Alternative ◽

Nitinol Wire ◽

Estimated Blood Loss ◽

Contrast Volume ◽

Custom Made ◽

Technical Details

Abstract Purpose: To describe technical details of modifying four different Cook Zenith devices to treat complex aortic aneurysms.Material: In the first three cases, the modification process involved complete stent graft deployment on a sterile back table. Fenestrations were created using an ophthalmologic cautery and reinforced with a radiopaque snare using a double-armed 4-0 Ethibond locking suture based on measurements obtained on centerline of flow. In each instance, a nitinol wire was withdrawn and redirected through and through the fabric and used as a constraining wire. In the fourth patient, modification involved partial stent graft deployment and creation of additional two fenestrations to accommodate renal arteries. The devices are resheathed and implanted in the standard fashion.Results: Four patients underwent exclusion of their aneurysms, including thoracoabdominal aneurysms (n=2), a contained ruptured juxtarenal aneurysm (n=1), and a ruptured failed previous endovascular repair (n=1). Fifteen fenestrations were successfully bridged with Atrium iCAST stent grafts. Average graft modification time, operative time, contrast volume, radiation dose, estimated blood loss, and hospital length of stay were 89 minutes, 155.25 minutes, 58.8 mL, 2451 mGy, 175 mL, and 4.3 days, respectively. One patient required a secondary intervention to treat a type Ib endoleak. During an average follow-up of 25 months, aneurysm sacs progressively shrank without additional intervention.Conclusion: Physician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program.

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Clinical application and technical details of cook zenith devices modification to treat urgent and elective complex aortic aneurysms

CVIR Endovascular ◽

10.1186/s42155-021-00233-7 ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Jesse Manunga ◽

Lia Jordano ◽

Aleem K. Mirza ◽

Xiaoyi Teng ◽

Nedaa Skeik ◽

...

Keyword(s):

Stent Graft ◽

Hospital Length ◽

Aortic Aneurysms ◽

Hospital Length Of Stay ◽

Safe Alternative ◽

Nitinol Wire ◽

Estimated Blood Loss ◽

Contrast Volume ◽

Custom Made ◽

Technical Details

Abstract Purpose To describe technical details of modifying four different Cook Zenith devices to treat complex aortic aneurysms. Material In the first three cases, the modification process involved complete stent graft deployment on a sterile back table. Fenestrations were created using an ophthalmologic cautery and reinforced with a radiopaque snare using a double-armed 4–0 Ethibond locking suture based on measurements obtained on centerline of flow. In each instance, a nitinol wire was withdrawn and redirected through and through the fabric and used as a constraining wire. In the fourth patient, modification involved partial stent graft deployment and creation of additional two fenestrations to accommodate renal arteries. The devices are resheathed and implanted in the standard fashion. Results Four patients underwent exclusion of their aneurysms, including thoracoabdominal aneurysms (n = 2), a contained ruptured juxtarenal aneurysm (n = 1), and a ruptured failed previous endovascular repair (n = 1). Fifteen fenestrations were successfully bridged with Atrium iCAST stent grafts. Average graft modification time, operative time, contrast volume, radiation dose, estimated blood loss, and hospital length of stay were 89 min, 155.25 min, 58.8 mL, 2451 mGy, 175 mL, and 4.3 days, respectively. One patient required a secondary intervention to treat a type Ib endoleak. During an average follow-up of 25 months, aneurysm sacs progressively shrank without additional intervention. Conclusion Physician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program.

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Passing a Mechanical Aortic Valve With a Short Tip Dilator to Facilitate Aortic Arch Endovascular Branched Repair

Journal of Endovascular Therapy ◽

10.1177/15266028211002506 ◽

2021 ◽

pp. 152660282110025

Author(s):

Nikolaos Konstantinou ◽

Sven Peterss ◽

Jan Stana ◽

Barbara Rantner ◽

Ramin Banafsche ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Arch ◽

Stent Graft ◽

Mechanical Valve ◽

Valve Prosthesis ◽

Proper Position ◽

Mechanical Aortic Valve ◽

Aortic Replacement ◽

Custom Made ◽

Aortic Valve Prosthesis

Purpose To present a novel technique to successfully cross a mechanical aortic valve prosthesis. Technique A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels. Conclusion Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

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Endovascular repair of de novo post-stenotic aortic coarctation aneurysms with complex collateral supply: two cases with long and medium term follow-up

CVIR Endovascular ◽

10.1186/s42155-020-00193-4 ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Omar Abdel-Hadi ◽

John Thomson ◽

Simon J. McPherson

Keyword(s):

Stent Graft ◽

Endovascular Repair ◽

Aortic Coarctation ◽

De Novo ◽

Aortic Aneurysms ◽

Medium Term ◽

First Case ◽

Case Presentations ◽

Selective Embolisation

Abstract Purpose To report the technical details and outcomes of the endovascular repair of two cases of de novo post-stenotic aortic coarctation aneurysms complicated by complex collateral supply. Case presentations Two patients with thoracic aortic aneurysms complicated by complex aneurysm sac collaterals distal to a previously untreated thoracic aortic coarctation have been treated at our institution. Open surgical intervention was deemed to carry a high risk of haemorrhage due to the degree and complexity of arterial collateralisation. In the first case, selective embolisation of collateral vasculature was performed prior to successful exclusion of the aneurysm with a thoracic endovascular stent-graft and then balloon-expandable stent dilatation of the coarctation stenosis. In the second case, the additional technique of using a jailed sheath within the aneurysm sac allowed for selective embolisation of previously inconspicuous collaterals after deployment of the stent-graft and stent combination. Results Technical success was achieved in both patients with successful occlusion of the aneurysm, with no recorded complications or aneurysm sac perfusion in the long and medium term follow up periods respectively. Conclusion De novo post stenotic aortic coarctation aneurysms are rare. Endovascular repair is a safe and durable technique that provides a less invasive alternative to open surgical repair. The use of a jailed sheath allows for complete selective embolisation of complex collaterals avoiding a type II aneurysm endoleak.

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The first commercial use of the Valiant Navion stent graft system for endovascular repair of a descending thoracic aortic aneurysm

Vascular ◽

10.1177/1708538120981127 ◽

2020 ◽

pp. 170853812098112

Author(s):

Cassra N Arbabi ◽

Navyash Gupta ◽

Ali Azizzadeh

Keyword(s):

Stent Graft ◽

Standard Of Care ◽

Aortic Aneurysms ◽

Descending Thoracic Aortic Aneurysm ◽

Thoracic Aortic Aneurysms ◽

Commercial Use ◽

Early Results ◽

Multiple Configuration ◽

One Year

Objectives Thoracic endovascular aortic repair (TEVAR) is the standard of care for descending thoracic aortic aneurysms (DTAA), and newer generation stent grafts have significant design improvements compared to earlier generation devices. Methods We report the first commercial use of the Medtronic Valiant Navion stent graft for treatment of an 85-year-old woman with a 5.8 cm DTAA and a highly tortuous thoracic aorta. Results A percutaneous TEVAR was performed using a two-piece combination of the Valiant Navion FreeFlo and CoveredSeal stent graft configurations for zones 2–5 coverage. The devices were successfully delievered through highly tortuous anatomy and deployed, excluding the entire length of the aneurysm with precise landing, excellent apposition and no evidence of endoleak. The patient tolerated the procedure well and has had no stent graft-related complications through one-year follow-up. Conclusions Design enhancements such as a lower profile delivery system, better conformability, and a shorter tapered tip are some of the improvements to this third-generation TEVAR device. Coupled with the multiple configuration options available, this gives physicians a better tool to treat thoracic aortic pathologies in patients with challenging anatomy. The early results are encouraging, and evaluation of long-term outcomes will continue.

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