Mateus P. Correa

Technical aspects of repair of juxtarenal abdominal aortic aneurysms using the Zenith fenestrated endovascular stent graft

Fenestrated endovascular aortic repair has been used with increasing frequency to treat complex aortic aneurysms. The Zenith fenestrated stent graft system (Cook Medical Inc, Brisbane, Queensland, Australia) was approved for commercial use in the United States in April 2012, offering a custom-made design with up to three fenestrations to treat short-neck infrarenal and juxtarenal abdominal aortic aneurysms. This report and the Video presentation (online only) summarize the preoperative planning, stent graft design, and technique of implantation of a Zenith fenestrated stent graft using a totally percutaneous approach in an 80-year-old female patient with a 6-cm juxtarenal abdominal aortic aneurysm. The patient was dismissed home the next day without complications, and a computed tomography angiography at 12 months showed no endoleak or stent graft complications.

Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm using a physician-modified branched stent graft

Branched stent grafts have been widely applied to treat complex aortic aneurysms. The technique often requires brachial or axillary approach to provide antegrade access to directional branches, which are bridged to target visceral arteries by self-expandable stent grafts. Preloaded guidewire catheterization may facilitate access into directional branches, decreasing or eliminating catheter manipulations required during this step of the procedure. We describe the use of a physician-modified branched stent graft using preloaded guidewire catheterization to treat a patient with recurrent, type III thoracoabdominal aortic aneurysm. The procedure was performed with no complications, and total operative time was 300 minutes, fluoroscopy time was 81 minutes, and iodinated contrast dose was 210 mL. Computed tomographic angiography revealed no endoleak and widely patent branches at 2 months.

Pelvic Revascularization During Endovascular Aortic Aneurysm Repair

Endovascular repair of aortic aneurysms (EVAR) has gained widespread acceptance in the treatment of abdominal aortic aneurysms (AAAs). Prospective studies have shown advantages compared with open surgical repair, including decreased blood loss, operating time, hospital stay, morbidity, and mortality. Approximately 30% of patients treated by EVAR have ectatic or aneurysmal common iliac arteries not suitable for distal sealing zones. In these patients, one of the most commonly utilized options is exclusion of the internal iliac artery (IIA). Decreased pelvic perfusion carries the risk of ischemic complications, including buttock claudication, sexual dysfunction, and other devastating complications such as spinal cord injury, ischemic colitis, and gluteal muscle necrosis. This article summarizes the methods of pelvic revascularization in patients with aortoiliac aneurysms involving one or both common iliac arteries.

Non-atherosclerotic Causes of Mesenteric Arterial Disease

The most common cause of occlusive mesenteric artery disease is ostial atherosclerosis. Non-atherosclerotic causes account for 5–10 % of all cases of chronic mesenteric ischemia (CMI). The vasculitides consist in a varied group of conditions characterized by an inflammatory response of vessel wall, with or without associated necrosis and granulomas, affecting 20 individuals per million a year. These diseases have different etiologies and pathogenic mechanisms, albeit most of them are not completely understood. Chronic inflammation can weaken the media and thin the arterial wall leading to aneurysm, or it can cause thickening of the arterial wall, resulting in stenosis and occlusions.

Endovascular Repair of Complex Aortic Pathology

Aortic aneurysms are classified as complex based on their extent and involvement of side branches. Complex aortic aneurysms include arch, thoracoabdominal, juxtarenal and suprarenal aortic aneurysms. Open surgical repair carries high morbidity and mortality beyond large tertiary care centers. During the last decade, numerous technological advances have allowed incorporation of side branches using hybrid and total endovascular techniques. Fenestrated and branched endografts have been widely applied to treat patients with complex aneurysm anatomy. Newer stent graft designs are currently under clinical investigation offering an off-the-shelf alternative to custom-made stent grafts for patients with complex aortic aneurysms. Alternatively, a number of endovascular techniques have been described including chimney, snorkel, periscope and sandwich stent grafts. This article summarizes the current status of hybrid and total endovascular techniques to repair of thoracoabdominal, juxtarenal and suprarenal aortic aneurysms.