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 VS1. Two-Vessel Fenestration of Gore C3 Excluder Endograft for Treatment of AAA in a High-Risk Patient with Unfavorable Anatomy for Conventional EVAR

Amy Coulter, Tze-Woei Tan, Wayne W. Zhang
LSU Health Sciences Center Shreveport, Shreveport, LA.
BACKGROUND: High-risk patients with AAA and anatomy not suited for conventional endovascular repair have limited options for treatment. The Gore Excluder endograft can be reconstrained after deployment with the development of the C3 delivery system and now can be utilized for physician-modified fenestrated endovascular repair.
  1. Preoperative planning for fenestration of a Gore C3 Excluder aortic endograft using 3-D reconstruction of a CT angiogram. A clock-face orientation is used.
  2. A 20F sheath is loaded onto the delivery catheter for the aortic endograft.
  3. The endograft is partially deployed in a sterile fashion on a back table.
  4. The location of the fenestrations are measured and marked. Fenestrations should be cut to precisely the size of the renal artery orifices or slightly smaller.
  5. The fenestrations are made. This was initially attempted with an aortic punch; however, it was much simpler to simply cut the PTFE sharply. Wire-cutters may be needed to cut any stent struts that impinge on the fenestrations.
  6. Radio-opaque snare wires are sutured around the fenestrations, and additional markers are sutured to the endograft for orientation.
  7. The fenestrations are pre-cannulated with 0.014 wires.
  8. The endograft is reconstrained using silk ties and umbilical tape and loaded into the 20F sheath on the delivery catheter. A Freer elevator is helpful in loading the superior portion of the main body, which has metal anchors that project out from the endograft.
  9. The renal arteries and SMA are identified with angiography.
  10. The main body is advanced to the level of the SMA, and the renal arteries are cannulated through the fenestrations with the 0.014 wires. The wires are then exchanged for stiff wires and 6F guiding sheaths are placed in the renal arteries.
  11. The main body is deployed.
  12. Covered stent-grafts are deployed in the renal arteries and flared into the aortic endograft.
  13. The remainder of the procedure is finished in a conventional fashion.
AUTHOR DISCLOSURES: A. Coulter: Nothing to disclose; T. Tan: Nothing to disclose; W. W. Zhang: Nothing to disclose.
Posted April 2013

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