Dataset Information

Emergency Endovascular Repair of Symptomatic Post-dissection Thoraco-abdominal Aneurysm Using a Physician Modified Fenestrated Endograft During the Waiting Period for a Manufactured Endograft.

ABSTRACT:

Introduction

Fenestrated branched endovascular aortic repair with custom manufactured devices (CMDs) has been applied to treat post-dissection thoraco-abdominal aortic aneurysms (TAAA), but the long waiting period for device manufacture limits its application in symptomatic or contained ruptured aneurysms.

Report

A 59 year old female presented with a 7 cm chronic post-dissection extent II TAAA. The patient underwent first stage total arch repair with the elephant trunk technique. At the time of the initial placement of the thoracic stent graft a fenestration was created in the septum to perfuse the right renal artery, which originated from the false lumen. A second stage procedure was planned with a CMD, but the patient presented with severe chest pain and lower extremity weakness, which was attributed to compression of the true lumen below the renal arteries due to increased flow into a pressurised false lumen. The patient underwent successful repair using a physician modified endograft (PMEG) with four fenestrations and preloaded guidewires. Follow up at 21 months showed no complications and a widely patent stent graft.

Discussion

The Zenith Alpha has several advantages over the TX2 platform for modification, notably lower profile fabric and wider Z tents, which provide greater flexibility for the creation of fenestrations or branches. In this case, the creation of a larger fenestration during the first stage procedure probably contributed to pressurisation of the false lumen. PMEGs remain a valuable option for TAAA repair, including chronic post-dissection aneurysms. Their application is particularly useful in symptomatic patients who are not candidates for an off the shelf endograft and cannot wait for a device to be manufactured.

SUBMITTER: Mirza AK

PROVIDER: S-EPMC8077236 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:IntroductionAlarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks.ReportA 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome.DiscussionTotal explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care.

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