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

Authors

  • Fábio Pais Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-3058-7303
  • Anita Quintas Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Gonçalo Alves Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Joana Catarino Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-1559-5479
  • Ricardo Correia Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-0509-3715
  • Rita Bento Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Rita Garcia Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-5135-0196
  • Rita Ferreira Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Maria Emília Ferreira Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal

DOI:

https://doi.org/10.48750/acv.426

Keywords:

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

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.

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References

Dua A, Kuy S, Lee CJ, Upchurch GR, Desai SS. Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010. J Vasc Surg. 2014;59:1512-17.

Schaik T, Meekel J, Hoksbergen A, Vries R, Blankensteinjn J, Yeung K. Systematic review of embolization of type I endoleaks using liquid embolic agents. J Vasc Surg 2021;74:1-9.

Veith F, Baum R, Ohki T, Amor M, Adiseshiah M, Blankensteinjn J et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at international conference. J Vasc Surg 2002;35:1029-35.

Rosen R, Green R. Endoleak management following endovascular aneurysm repair. J Vasc Interv Radiol. 2008;19:37-43.

Harris P, Vallabhaneni S, Desgranges P, Becquemin J, Marrewijk C, Laheij R. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. J Vasc Surg. 2000;32:739-49.

Reddy N, Ham S, Weaver F, Rowe V, Ziegler K, Han S. Repair of Delayed Type 1a Endoleak using Fenestrated and Parallel Endografts. Ann Vasc Surg. 201849:309.e7–e15

Chaikof E, Brewster D, Dalman R, Makaroun M, Illig K, Sicard G et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg. 2009,50:880-96.

Rosen R, Green R. Endoleak management following endovascular aneurysm repair. J Vasc Interv Radiol. 2008;19:37-43.

Schwarze M, Shen Y, Hemmerich J, Dale W. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg. 2009;50:722-9.

Katsargyris A, Yazar O, Oikonomou K, Bekkema F, Tielliu I, Verhoeven E. Fenestrated stent-grafts for salvage of prior endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2013;46:49-56

Doumenc B, Mesnard T, Patterson B, Azzaoui R, Préville A, Haulon S et al. Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021;61:571-8.

Verhoeven E, Muhs B, Zeebregts C, Tielliu I, Prins T, Bos W et al. Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery. Eur J Vasc Endovasc Surg 2007;33:84-90.

Wang S, Drucker N, Sawchuk A, Lemmon G, Dalsing M, Motaganahalli R et al. Use of the Zenith fenestrated platform to rescue failing endovascular and open aortic reconstructions is safe and technically feasible. J Vasc Surg. 2018;68:1017–22.

Kasprzak P, Pfister K, Kuczmik W, Schierling W, Sachsamanis G, Oikonomou K. Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. J Endovasc Ther. 2021;4:519-23.

Paludetto G, Meulen S, Ouriel K, Patarca R. Physician Modified Low Profile Endograft for Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms in Patients with Small Access Vessels. EJVES Vasc Forum. 2021;51:9-12

Starnes BW. Physician-modified endovascular grafts for the treatment of elective, symptomatic, or ruptured juxtarenal aortic aneurysms. J Vasc Surg. 2012;56:601-7

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Published

2022-09-11

How to Cite

1.
Pais F, Quintas A, Alves G, Catarino J, Correia R, Bento R, Garcia R, Ferreira R, Ferreira ME. On-table Zenith® CE Fenestrated Stent Graft modification for the treatment of delayed type Ia Endoleak. Angiol Cir Vasc [Internet]. 2022 Sep. 11 [cited 2022 Sep. 25];18(2):90-4. Available from: https://acvjournal.com/index.php/acv/article/view/426

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Section

Clinical Case