Fenestrated and branched endograft repair of juxtarenal aneurysms after previous open aortic reconstruction

Customized fenestrated endografts are manufactured based on the patient's preoperative 3-dimensional (3D) computerized tomographic angiography (CTA). The preferred method of repair is a composite fenestrated endograft (A), but certain clinical scenarios warrant repair using a fenestrated bifurcated graft (B) or a fenestrated tube graft (C). A, Demonstrates the composite graft components with the lower bifurcated portion of the graft within the upper fenestrated tube portion. A Jomed covered stent is demonstrated inside of a left renal fenestration (arrow). B, Demonstrates a fenestrated bifurcated device with an internal/external (Int/Ext) docking limb. C, Demonstrates a custom fenestrated tube with its celiac artery scallop (thick black arrow), a fenestration for the superior mesenteric artery (SMA) (thin black arrow), an internal/external low profile caudally oriented branch (arrow) for the left renal artery.

A 20F sheath is often introduced into the contralateral groin to allow simultaneous guiding sheath access to multiple fenestrations via direct puncture of the diaphragm at the hub (black arrow). Access to up to three fenestrations can be gained with two 7F guiding sheaths plus a third bare wire, if necessary (white arrow).

Repair of a juxta-renal aneurysm above a previous aorto-bi-iliac graft. A, Demonstrates the short working distance between the lowest (left) renal artery and the neobifurcation. B, Demonstrates a sharp angle (arrow) in the left renal artery that proved difficult to traverse with an Atrium iCAST. C, This was eventually revascularized with a Wallgraft followed by an extension with an EV3 Everflex bare metal stent to ease the distal transition (arrow).

Kaplan-Meier survival curve demonstrating patient survival after fenestrated endograft repair. Patients at risk are listed under the curve.

Kaplan-Meier curve demonstrating vessel patency after fenestrated endograft repair. Overall vessel patency was 94%. Vessels at risk are listed under the curve.