Abstract
The Zenith (Cook Medical, Brisbane, Australia) fenestrated stent-graft (FSG) was developed based on individual patient aneurysm and renal vessel morphology. It is a Conformité Européenne (CE) mark–approved product, with the corresponding preclinical and clinical testing and has the largest published evidence. The use and application of FSGs require advanced technical skills and radiologic imaging. The present chapter demonstrates the procedure step by step highlighting the challenging issues during the deployment.
Keywords
advanced EVAR, fenestrated endografting, fenestrated endografts, juxtarenal pathologies, pararenal aneurysms
The Zenith (Cook Medical, Brisbane, Australia) fenestrated stent-graft (FSG) was developed based on individual patient aneurysm and renal vessel morphology. It is a Conformité Européenne (CE) mark–approved product, with the corresponding preclinical and clinical testing. Despite widespread commercial availability, the use and application of FSGs require advanced technical skills, radiologic imaging and the largest published experience.
Particularly demanding parts of the procedure are the catheterization of the target vessels through the fenestrations and subsequent advancement of the 6-French (6F) to 8F sheaths into each vessel. In addition, in patients with calcified and tortuous access vessels, the use of a 22F sheath for the main body and large-bore sheaths through the contralateral iliac artery may be hazardous. Sheath-related complications culminating in lower-limb ischemia are more common in patients with small or diseased iliac and femoral arteries.
To overcome such technical difficulties, a new, modified fenestrated endograft was developed. The new system includes a preloaded wire for easier catheterization of both renal arteries through a lower-profile delivery system (20F instead of 22F).
Case Presentation
A 74-year-old male patient presented with a juxtarenal aortic aneurysm 65 mm in diameter ( Fig. 10.1 ). The patient had severe comorbidities, including cardiac disease with previous coronary artery bypass, severe chronic obstructive pulmonary disease (COPD), and a history of nicotine abuse and arterial hypertension.
Fig. 10.2 illustrates the preloaded, single, extra-length nitinol wire and its path from the control handle through the center of the stent-graft. The wire passes through the “pusher” directly into the lumen of the graft at its distal end. It then exits from the renal fenestration, passes through the fabric to the other side and then through the contralateral renal fenestration, returning into the delivery system. In addition, the company provides a specific 4.1F braided beacon-tip catheter (Curly-Q, Cook Medical) that facilitates easy catheterization of both renal arteries by keeping the preloaded wire in place, thus stabilizing the introducer sheath.
The procedure was performed in a hybrid operating room under fluoroscopic control (Axiom Artis FA; Siemens Medical Solutions, Forchheim, Germany). Under general anesthesia a percutaneous approach was used with the Prostar XL 10F vascular closure device (Abbott Vascular, Redwood City, California, USA). In case of small or stenotic iliac vessels, a 10-mm bypass from the common iliac to the superficial femoral artery can facilitate stent-graft insertion and implantation.
A 20F sheath was passed into the femoral artery for introduction of the main body. Before delivery of the main stent-graft, a 14F sheath was advanced into the contralateral external iliac artery, and three 5F sheaths were introduced through its valve ( Fig. 10.3 ). Through each 5F sheath, a separate Shepherd Hook catheter (Mayo Healthcare, Rosebery, Australia) was parked into each target vessel: superior mesenteric artery (SMA) and both renal arteries. Fig. 10.4 shows the precannulation of the left renal artery. In our experience, this maneuver facilitates orientation and correct positioning of the main graft without repeated angiography for target-vessel catheterization.
