IMAC 2019 : Fenestrated EVAR for chronic dissection thoracoabdominal aortic aneurysm

This didactic procedure concerns a 58 years old man with a history of hypertension, severe COPD and marfanoid syndrome. The patient had a symptomatic aneurysmal evolution of thoracoabdominal aortic dissection treated 4 years earlier with an open-air surgery (59mm). Decision was made to treat the patient by endovascular technique.

Educational objectives

• Plan a step-by-step fenestrated EVAR procedure.
• How to manage access through false and true lumen to secure aortic branches?
• How to proceed to a safe and successful catheterization of the aortic branches?
• Materials choice: guidewires, catheter, balloons and stent: sizing and shaft length.
• How advance and position a fenestrated endograft?
• Tips and tricks to avoid endo-leaks.
• Importance of a good imaging.
  
  Step-by-step procedure
  

  1) Vascular imaging : CT

• Identifying the endograft into the true lumen in addition to a perfused large false lumen.
• Right renal artery is perfused by the false lumen while the left one is perfused by the true lumen.
• The dissection is extended to the right common iliac artery.
  

  2) Sizing and procedure preparation

• Sizing the endograft with the fenestration at the level of the communication between false and true lumen.
• Positioning the graft in the true lumen with 4 fenestrations.
• The graft design should include an iliac branch to exclude the false lumen until the external iliac artery without compromising the internal iliac branch.
• Choice of the bridging stents for the four fenestrations (CT, SMA, L+R Renal arteries) and the right hypogastric artery.
  

  3) Step by step procedure

• Right and left common femoral puncture under US with preclosing with 2 ProGlides.
• Check that guidewires positions are in the true lumen from both accesses.
• Catheterization of IMA and position a plug into the AMI.
• Access to the right renal from true lumen and position a wire as a marker.
• Advancement of the thoracic component of the graft.
• Advancement of the Fenestrated component of the graft with is carefully positioned using the image fusion.
• Positioning of the fenestrated grafts.
• Perform an angio to check that fusion mask is correctly positioned.
• Opening of the fenestrated endo graft.
• Access to left renal artery with a 90cm sheath to the left renal fenestration.
• Catheterization of the right renal artery.
• Advancement of the 6*27mm BeGraft stent 6 Fr compatible until the final parking position (used with the preloaded system). (Long sheath and long shaft for the stent).
• Access to the lumen of the endograft from the opposite side (left femoral access).
• Catheterization of the SMA on Lateral view.
• Advancement of the sheath on a Rosen wire in order to avoid the risk of dissection while maintain a good support then advance the stent into the SMA in its parking position.
• Catherization and position the parking stent into the CT. Release the CT stent.
• SMA stenting with a 10*27mm BeGraft (exchange with a floppy wire to avoid the kinking between the end edge stent and the vessel). In case of a severe kinking an additional nitinol stent may be added to ensure a smooth transition.
• Stenting the right then left renal artery with post-dilatation to flare the stent and ensure a good apposition.
• Ensure a good seal with an angio check then balloon post dilatation if an endo-leak is noticed.
• Advancement of the iliac branch to the right iliac to exclude the lumen.
• Removing the renal sheaths and remove the nose of the delivery device to the sheath.
• Advancement of the iliac delivery device using a snare at the opposite side to catch the wire and advance it from the right side.
• Release of the iliac branch device.
• Positioning of the 12 Fr sheath above the iliac bifurcation then into the internal iliac
• Positioning of the bridging stent into the internal iliac artery.
• Release of the stent then releasing the remaining part of the iliac endo-graft.
• Maintain a balloon inflation to stabilize the all system while removing the nose.
• Positioning and releasing the bifurcated component.
• Performing a kissing balloon angioplasty.
• Balloon opening of the graft
• Final combine CT with image fusion to control the position of all the fenestration and the iliac bifurcation.
  
  Bibliography
  
  

  1.Suckow BD, Goodney PP, Columbo JA, Kang R, Stone DH, Sedrakyan A, et al. National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients. J Vasc Surg. juin 2018;67(6):1690-1697.e1.
  
  2. D’Oria M, Oderich GS, Tenorio ER, Kärkkäinen JM, Mendes BC, Macedo TA, et al. Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg. juill 2020;72(1):44‑54.
  
  3. Petit P, Hertault A, Mesnard T, Bianchini A, Lopez B, Patterson BO, et al. Outcomes of Preventive Embolization of the Inferior Mesenteric Artery during Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Interv Radiol. sept 2021;32(9):1360-1370.e2.
  
  4. Spanos K, Kölbel T, Kubitz JC, Wipper S, Konstantinou N, Heidemann F, et al. Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms. J Vasc Surg. févr 2019;69(2):357‑66.
  
  5. Varkevisser RRB, O’Donnell TFX, Swerdlow NJ, Liang P, Li C, Ultee KHJ, et al. Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms. J Vasc Surg. juin 2019;69(6):1670‑8.
  
  6. Schanzer A, Beck AW, Eagleton M, Farber MA, Oderich G, Schneider D, et al. Results of fenestrated and branched endovascular aortic aneurysm repair after failed infrarenal endovascular aortic aneurysm repair. J Vasc Surg. sept 2020;72(3):849‑58
  
  7. Michel M, Becquemin J-P, Marzelle J, Quelen C, Durand-Zaleski I. Editor’s Choice – A Study of the Cost-effectiveness of Fenestrated/branched EVAR Compared with Open Surgery for Patients with Complex Aortic Aneurysms at 2 Years. Eur J Vasc Endovasc Surg. juill 2018;56(1):15‑21.
  
  8. Jones DW, Stangenberg L, Swerdlow NJ, Alef M, Lo R, Shuja F, et al. Image Fusion and 3-Dimensional Roadmapping in Endovascular Surgery. Ann Vasc Surg. oct 2018;52:302‑11.